Problematika trombotických mikroangiopatií (TMA) představuje, nejen v porodnictví, velmi závažný patologický stav, který je spojen s tvorbou trombóz na úrovni kapilár i arteriol v důsledku poškození endotelu a aktivace komplementu. Je pro- vázen mikroangiopatickou hemolytickou anémií (MAHA), trombocytopenií a dysfunkcí různých orgánů. Relativně často je navíc spojen se sekundárními systémovými změnami srážlivosti. TMA zahrnují velmi nesourodou skupinu syndromů a sta- vů, kdy ke konečné diagnóze docházíme postupným vylučováním jednotlivých příčin („per exclusionem“). V porodnické praxi se nejčastěji setkáváme s tím, že těhotné/rodičky/nedělky se prezentují pod obrazem preeklampsie/HELLP syndromu (hemolysis, elevated liver enzymes, low platelets). Tento všem porodníkům jinak dobře známý stav zahrnuje obraz MAHA (dynamické snižování hladiny hemoglobinu, zvyšování hladiny bilirubinu, snížení haptoglobinu, přítomnost schistocytů v periferním nátěru krve), periportální ischémie jater (elevace transamináz) a trombocytopenie v důsledku vyšší agregace trombocytů v poškozené periferní mikrocirkulaci. HELLP syndrom se řadí mezi TMA také, měl by však spontánně odezní- vat přibližně do 48-72 hodin po porodu. Pakliže se tak nestane, je velmi důležité pomýšlet na jiné příčiny TMA, které často představují ještě vážnější ohrožení života než HELLP syndrom. Důkladná znalost diferenciální diagnostiky je proto velmi důležitá. Problematiku tedy musí dobře ovládat každý poskytovatel zdravotní péče těhotným ženám, a proto ji kolektiv autorů předkládá ve formě tohoto doporučeného postupu.

The issue of thrombotic microangiopathy (TMA) represents, not only in obstetrics, a serious pathological condition that is associated with the formation of thromboses at the level of capillaries and arterioles due to endothelial damage and complement activation. It is accompanied by microangiopathic haemolytic anaemia (MAHA), thrombocytopenia and dysfunction of various organs. In addition, it is relatively often associated with secondary systemic changes in coagulation. TMAs comprise a very heterogeneous group of syndromes and conditions, where the final diagnosis is reached by sequential exclusion of the individual causes (‚per exclusionem‘). In obstetric practice, we most often encounter pregnant/parturient/ pregnant women presenting with a picture of pre-eclampsia/HELLP syndrome (haemolysis, elevated liver enzymes, low platelets). This condition, otherwise well known to all obstetricians, includes the picture of MAHA (dynamic decrease in hemoglobin, increase in bilirubin, decrease in haptoglobin, presence of schistocytes in the peripheral blood smear), periportal hepatic ischemia (elevation of transaminases) and thrombocytopenia due to increased platelet aggregation in the damaged peripheral microcirculation. HELLP syndrome is also classified as a TMA, but should resolve spontaneously within approximately 48-72 hours after delivery. If this does not happen, it is very important to think about other causes of TMA, which often represent an even more serious threat to life than HELLP syndrome. A thorough knowledge of differential diagnosis is therefore very important. The issue therefore needs to be well understood by every provider of health care to pregnant women, which is why the team of authors presents it in the form of this recommended practice.

BACKGROUND: The effect of dexmedetomidine on regional splanchnic blood flow remain unclear. OBJECTIVES: We hypothesized, that there is no difference in regional rectal perianastomotic perfusion and oxygenation when using non-opioid dexmedetomidine-isoflurane anesthesia when compared to fentanyl-isoflurane anesthesia. METHODS: Ten female pigs were randomly divided into two groups (Dexmedetomidine, DEX, Fentanyl, FNT). Analgesia was provided by either dexmedetomidine (0.7-1.0 μg/kg/h) or fentanyl (6-10 μg/kg/h). The model of rectosigmoid resection in pigs was used. Two combined Laser Doppler flowmetry (LDF) and oxymetry probes were fixed on the antimesenterial site of the rectosigmoid, one orally and the second distally to resection zone. At the end of the experiment all animals were woken up and extubated. The healing of the anastomosis was controlled seven days after the operation. RESULTS: All experimental animals were hemodynamically stable throughout the experiment. No anastomotic leakage was detected. All animals survived until the seventh postoperative day. In the DEX group the median of the LDF signal on aboral site at the end of experiment was 35% (23-49%), in FNT group the median of the LDF signal was 19% (12-28%), which was statistically significantly lower (p < 0,05). CONCLUSIONS: This study has shown some protective effects of dexmedetomidine-isoflurane based anesthesia on perianastomotic microcirculation when compared to fentanyl-isoflurane based anesthesia.

• MeSH
• Anastomosis, Surgical methods   MeSH
• Anesthesia methods   MeSH
• Dexmedetomidine * pharmacology   MeSH
• Fentanyl * pharmacology   MeSH
• Colorectal Surgery methods   MeSH
• Swine MeSH
• Animals MeSH
• Check Tag
• Female MeSH
• Animals MeSH
• Publication type
• Journal Article MeSH

Angina pectoris bez obstrukce koronárních tepen je častý nález u pacientů s bolestmi na hrudi, v jehož patofyziologii se uplatňují zejména dva mechanismy – strukturální nebo funkční poškození mikrocirkulace či funkční poškození epikardiálních tepen, případně jejich kombinace. Souhrnný článek se zabývá dia- gnostikou koronární mikrovaskulární dysfunkce se zaměřením na kontinuální termodiluci jako bezpečnou, jednoduchou, rychlou a na operatérovi nezávislou metodu. Popisuje teoretický základ i praktické aspekty s grafickými ukázkami měření.

Angina with non-obstructive coronary artery disease is a frequent finding in patients with chest pain. Its pathophysiology involves two main mechanisms: structural and functional dysfunction of microcircula- tion, functional dysfunction of epicardial arteries, and their combination. The review article focuses on the diagnostics of microvascular dysfunction, particularly continuous thermodilution, as a safe, easy, fast, and operator-independent method. It describes both theoretical background and practical aspects with graphical examples of measurements.

• Keywords
• koronární průtok,
• MeSH
• Angina Pectoris * diagnosis   classification   physiopathology   MeSH
• Hemodynamic Monitoring methods   MeSH
• Coronary Vessels pathology   MeSH
• Humans MeSH
• Microvessels pathology   MeSH
• Microcirculation MeSH
• Pericardium physiology   MeSH
• Thermodilution * methods   MeSH
• Check Tag
• Humans MeSH
• Publication type
• Research Support, Non-U.S. Gov't MeSH
• Review MeSH

BackgroundThe ischemia-reperfusion injury (IRI) is unavoidable in vascular surgery. Damage to the microcirculation and endothelial glycocalyx might set up a shock with loss of circulatory coherence and organ failure. Sulodexide may help to protect endothelial glycocalyx and alleviate the ischemia-reperfusion injury.MethodsTwenty female piglets underwent surgery with a 30-min-long suprarenal aortic clamp, followed by two hours of reperfusion. Ten piglets received sulodexide before the clamp, and 10 received normal saline. Blood and urine samples were taken at baseline and in 20-min intervals until the 120th minute to analyze the serum syndecan-1, E-selectin, and thrombomodulin. Albumin and glycosaminoglycans were examined in the urine. The kidney biopsies before and after the protocol were examined by light microscopy with hematoxylin-eosin staining. The sublingual microcirculation was recorded by side-stream dark field imaging at the time as blood and urine.ResultsBased on the 2-way ANOVA testing, there was no statistically significant difference in the parameters of sublingual microcirculation. Serum markers of endothelial cell activation and damage (E-selectin and thrombomodulin) did not show any statistically significant difference either. Syndecan-1, a marker of glycocalyx damage, showed statistically significantly higher values based on the 2-way ANOVA testing (p < 0.0001) with the highest difference in the 80th minute: 7.8 (3.9-44) ng/mL in the control group and 1.8 (0.67-2.8) ng/mL in the sulodexide group. In the urine, the albuminuria was higher in the control group, although not statistically significant. Glycosaminoglycans were statistically significantly higher in the sulodexide group based on the mixed-effect analysis due to the intervention itself. Histological analysis of the renal biopsies showed necrosis in both groups after reperfusion.ConclusionAdministering sulodexide significantly reduced the level of endothelial markers of IRI. The study results support further research into using preemptive administration of sulodexide to modulate IRI in clinical medicine.

• MeSH
• E-Selectin blood   MeSH
• Glycocalyx MeSH
• Glycosaminoglycans * pharmacology   therapeutic use   MeSH
• Kidney pathology   blood supply   MeSH
• Microcirculation drug effects   MeSH
• Disease Models, Animal MeSH
• Swine MeSH
• Reperfusion Injury * prevention & control   MeSH
• Syndecan-1 blood   MeSH
• Thrombomodulin blood   MeSH
• Animals MeSH
• Check Tag
• Female MeSH
• Animals MeSH
• Publication type
• Journal Article MeSH

BackgroundSulodexide is a glycosaminoglycan-based drug prescribed to patients with angiopathy. We performed a pilot study to investigate whether sulodexide positively modulates the endothelial glycocalyx (EG) layer and the microcirculation in a porcine model of EG enzymatic damage. The EG is a sugar-based endothelial lining that is involved in the physiology of the capillary wall and the pathogenesis of many diseases.MethodsEG damage was induced in eight piglets by hyaluronidase III and heparanase I given intravenously. Four animals received sulodexide 600 IU intravenously before the enzymes and four animals after the enzymes were administered. Four animals constituted a control group. Sublingual microcirculation by side-stream dark field imaging and plasmatic concentration of syndecan-1 by ELISA were measured at baseline, 20 min after intervention, and at the 40th, and 60th minute onwards. The statistics were performed with a one-way ANOVA test with Turkey's correction for multiple comparisons testing. Timepoint comparison was performed by Student t-test or Mann-Whitney test.ResultsAt baseline, there were no statistically significant differences between the animal groups. After the intervention, the levels of syndecan-1 were significantly lower in the control group. While there were no differences between the two intervention groups. The sublingual microcirculation analysis showed that the DeBacker score was significantly higher in the control group. At 60 min, there was also a statistically significant difference in DeBacker score between the groups (8.1 ± 1.6 mm-1 in the group with enzymes given first and 11 ± 0.92 mm-1 in the group with sulodexide given first, p = 0.03). The analysis of the proportion of perused vessels did not show any statistically significant differences.ConclusionThe results of the study demonstrated a working model of EG damage but no specific action of sulodexide on EG modulation. In the sublingual microcirculation analysis, the sulodexide reduced the fall in absolute tissue perfusion in 60 min.

• MeSH
• Endothelium, Vascular * drug effects   MeSH
• Glycocalyx * drug effects   metabolism   MeSH
• Glycosaminoglycans * pharmacology   MeSH
• Hyaluronoglucosaminidase MeSH
• Microcirculation drug effects   MeSH
• Disease Models, Animal MeSH
• Pilot Projects MeSH
• Swine MeSH
• Syndecan-1 blood   MeSH
• Animals MeSH
• Check Tag
• Animals MeSH
• Publication type
• Journal Article MeSH

BACKGROUND: Excess fluid in the interstitium can adversely affect the microcirculation. We studied how gradual dilution of the blood plasma by crystalloid fluid influences microcirculatory variables and capillary filtration in 20 patients undergoing surgery. METHODS: Video recordings of the sublingual mucosal were made on four occasions during the surgery and compared with quasi-measurements of the capillary filtration rate using retrospective volume kinetic data collected over 5-10-minute periods during 262 infusion experiments with crystalloid fluid. RESULTS: The number of crossings (vessel density) increased up to plasma dilution of 15-20 % whereafter it decreased. The proportion of the vessels that were perfused (PPV) decreased and reached a nadir of -15 % at a dilution of 20-30 %. Changes in the number of crossings and the PPV correlated (r = 0.62, P < 0.001) but the curve was displaced so that crossings showed no change when PPV had decreased by approximately 10 %. However, the PPV of vessels with a thickness of ≤25 μm increased or remained constant in the dilution range of up to 20 %. The volume kinetic analysis showed that the capillary filtration was greater than expected from proportionality with the volume expansion up to a plasma dilution of 15 %, the greatest difference (+89 %) being for plasma dilution up to 5 %. CONCLUSION: Plasma dilution of up to 15 % increased the vessel density, and the capillary filtration increased by more than suggested by the volume expansion. Dilution >15 % had a negative influence on these variables.

• MeSH
• Video Recording MeSH
• Time Factors MeSH
• Adult MeSH
• Hemodilution * MeSH
• Isotonic Solutions administration & dosage   MeSH
• Capillary Permeability MeSH
• Capillaries physiopathology   MeSH
• Kinetics MeSH
• Crystalloid Solutions * administration & dosage   MeSH
• Middle Aged MeSH
• Humans MeSH
• Microcirculation * MeSH
• Regional Blood Flow MeSH
• Retrospective Studies MeSH
• Blood Flow Velocity MeSH
• Aged MeSH
• Mouth Mucosa blood supply   MeSH
• Mouth Floor blood supply   MeSH
• Check Tag
• Adult MeSH
• Middle Aged MeSH
• Humans MeSH
• Male MeSH
• Aged MeSH
• Female MeSH
• Publication type
• Journal Article MeSH
• Research Support, Non-U.S. Gov't MeSH

UNLABELLED: Retinal microcirculation reflects retinal perfusion abnormalities and retinal arterial structural changes at relatively early stages of various cardiovascular diseases. Wall-to-lumen ratio (WLR) may represent the earliest step in hypertension-mediated organ damage.Our objective was to compare functional and structural parameters of retinal microcirculation in a randomly selected urban population sample, in hypertensive and normotensive individuals. DESIGN AND METHOD: A total of 398 randomly selected individuals from an urban population aged 25-65 years, residing in Pilsen, Czech Republic, were screened for major cardiovascular risk factors. Retinal microcirculation was assessed using scanning laser Doppler flowmetry, with data evaluable in 343 patients. Complete data were available for 342 individuals divided into four groups based on blood pressure and control status of hypertension: normotensive individuals ( n = 213), treated controlled hypertensive individuals ( n = 30), treated uncontrolled hypertensive individuals ( n = 26), and newly detected/untreated hypertensive individuals ( n = 73). RESULTS: There was a tendency to higher wall thickness in treated but uncontrolled hypertensive patients (compared to normotensive and treated controlled hypertensive individuals). WLR was significantly increased in treated but uncontrolled hypertensive patients as well as in individuals with newly detected thus untreated hypertension or in patients with known but untreated hypertension. There was no difference in WLR in treated, controlled hypertensive patients compared with normotensive individuals. CONCLUSION: Our results show that an increased WLR, reflecting early vascular damage, was found in newly detected individuals with hypertension and in untreated hypertensive patients, reflecting early hypertension-mediated vascular damage. Early initiation of hypertension treatment may be warranted.

• MeSH
• Arterioles MeSH
• Hypertension * MeSH
• Blood Pressure MeSH
• Humans MeSH
• Microcirculation MeSH
• Retinal Vessels diagnostic imaging   MeSH
• Check Tag
• Humans MeSH
• Publication type
• Journal Article MeSH
• Geographicals
• Czech Republic MeSH

AIM: To propose a standardized, high-resolution ultrasound (US) protocol to assess the patellar tendon-Hoffa fat pad interface (PTHFPI) in patients with (proximal) patellar tendinopathy (PPT). METHODS: Using a high-frequency transducer and a high-level machine, we matched the cadaveric and histological microarchitecture of the PTHFPI with multiple sonographic patterns of patients with PPT. Likewise, high-sensitive color/power Doppler assessments were also performed to evaluate the microcirculation of the soft tissues beneath the patellar tendon. RESULTS: Modern US equipment allows for detailed assessment of the potential pain generators located inside the PTHFPI in patients with PPT. They include anterosuperior portion of the Hoffa body and the loose connective tissue of the deep paratenon with its microvascular plexus. CONCLUSIONS: In patients with PPT, accurate sonographic assessment of the PTHFPI can be performed using adequate technological equipment. Accordingly, tailored ultrasound-guided interventions can also be planned if/when clinically indicated.

• MeSH
• Knee Joint diagnostic imaging   MeSH
• Middle Aged MeSH
• Humans MeSH
• Patellar Ligament * diagnostic imaging   MeSH
• Cadaver MeSH
• Aged MeSH
• Tendinopathy * diagnostic imaging   pathology   MeSH
• Adipose Tissue * diagnostic imaging   MeSH
• Ultrasonography methods   MeSH
• Check Tag
• Middle Aged MeSH
• Humans MeSH
• Male MeSH
• Aged MeSH
• Female MeSH
• Publication type
• Journal Article MeSH

Trombotická trombocytopenická purpura (TTP) je vzácné, život ohrožující onemocnění patřící do skupiny trombotických mikroangiopatií (TMA). Je charakterizováno přítomností mikroangiopatické hemolytické anemie, těžké trombocytopenie a ischemického postižení cílových orgánů. Podstatou onemocnění je závažný deficit metaloproteázy štěpící von Willebrandův faktor (vWF). Deficit enzymu způsobuje hromadění velkých multimerů vWF, na které se aktivně váží trombocyty, s následným vznikem mikrotrombů v cévním řečišti. Stěžejním vyšetřením pro diagnostiku TTP je prokázání snížené aktivity enzymu ADAMTS13 pod 10 % (0,1 IU/ml). Léčba TTP by měla být zahájena co nejdříve, již při vyslovení podezření na TTP, často ještě před znalostí výsledků aktivity enzymu ADAMTS13. Současný standard léčby akutní ataky získané TTP zahrnuje výměnnou plazmaferézu, imunosupresi a kaplacizumab. O úspěšnosti léčby rozhoduje rychlá diagnostika TTP vč. vyšetření aktivity ADAMTS13 a včasné zahájení komplexní léčby. Nedílnou součástí léčby je také dlouhodobé sledování aktivity onemocnění, vč. monitorace aktivity ADAMTS13.

Thrombotic thrombocytopenic purpura (TTP) is a rare, life-threatening disease belonging to the group of thrombotic microangiopathies (TMA). It is characterised by the presence of microangiopathic haemolytic anaemia, severe thrombocytopenia, and ischaemic end-organ damage. The underlying cause of the disease is a severe deficiency of von Willebrand factor (vWF) cleaving metalloprotease. The enzyme deficiency causes the accumulation of large multimers of vWF to which platelets bind actively, with subsequent formation of microthrombi in the microcirculation. The most important test for the diagnosis of TTP is reduced ADAMTS13 enzyme activity below 10% (0.1 IU/ml). Treatment of TTP should be initiated as early as possible when it is suspected, often before the ADAMTS13 activity results are known. The current standard of care for acute attacks of acquired TTP includes therapeutic plasma exchange, immunosuppression, and caplacizumab. A rapid diagnosis of TTP, including ADAMTS13 activity testing, and early initiation of comprehensive treatment are critical to treatment success. Long-term monitoring of disease activity, including monitoring of ADAMTS13 activity, is also a necessary part of the treatment

• Keywords
• kaplacizumab,
• MeSH
• Adrenal Cortex Hormones therapeutic use   MeSH
• Single-Domain Antibodies therapeutic use   MeSH
• Humans MeSH
• Antibodies, Monoclonal therapeutic use   MeSH
• Plasmapheresis MeSH
• ADAMTS13 Protein metabolism   MeSH
• Rituximab administration & dosage   therapeutic use   MeSH
• Purpura, Thrombotic Thrombocytopenic * diagnosis   therapy   MeSH
• Check Tag
• Humans MeSH
• Publication type
• Review MeSH

Krátkodobá mortalita pacientů s akutním infarktem myokardu (AIM), kteří jsou léčeni perkutánní koronární intervencí bez kardiogenního šoku (KŠ) je 5%, mortalita těch s komplikujícím KŠ je desetinásobně vyšší. Rychlá a efektivní kombinovaná protidestičková léčba (kyselina acetylsalicylová a inhibitor P2Y12) má zásadní význam pro časné obnovení průtoku v koronární tepně a perfuzi mikrocirkulace, a tím pro prognózu nemocných. Pacienti s KŠ jsou populací s nejvyšším trombotickým rizikem. Přesto je KŠ vyřazovacím kritériem pro účast v randomizovaných studiích. Relevantní evidence o srovnání efektivity protidestičkových léků u této subpopulace pacientů zcela chybí. Projekt je randomizovanou multicentrickou dvojitě zaslepenou studií srovnávající efektivitu cangreloru a ticagreloru. Vychází z předpokladu, že cangrelor, parenterální a přímý inhibitor P2Y12, má potenciál být optimálním lékem pro pacienty s AIM komplikovaným iniciálně KŠ, kteří podstupují PCI. Vzhledem k hypoperfuzy splanchnika je totiž preferovanou aplikací intravenózní a z léků mají přednost ty, jež nevyžadují metabolizaci.; A short-term mortality of patients with acute myocardial infarction (AMI) without cardiogenic shock (CS) and treated with PCI is 5%, mortality of those with CS is 10 times higher. Rapid and effective antiplatelet therapy (acetylsalicylic acid and P2Y12 inhibitor) is of essential importance for an early coronary flow renewal and perfusion of microcirculation, and is as such highly important for patient’s prognosis. Patients with CS are the population with the highest thrombotic risk. CS is an exclusion criterion for participation in randomized studies. Relevant evidence resulting from comparison of antiplatelets in these patients is entirely missing. The project is a randomized study, comparing efficacy of cangrelor and ticagrelor. It is based on an assumption that cangrelor, parenteral and direct-acting P2Y12 inhibitor, has a potential to be an optimal drug for patients with AMI complicated with CS. With regards to hypoperfusion of the splanchnic area, the preferred drug application is the parenteral route while in case of drugs, those not requiring metabolisation, are being preferred.

• Keywords
• prognóza, mortalita, mortality, Outcome, akutní infarkt myokardu, kardiogenní šok, protidestičková léčba, velké kardiovaskulární příhody, cardiogenic shock, antiplatelet therapy, major cardiovascular events, acute myocardial infartion,

• NML Publication type
• závěrečné zprávy o řešení grantu AZV MZ ČR