Robot-Assisted Minimally Invasive Multivessel Coronary Bypass Guided by Computerized Tomography.

OBJECTIVE: Robot-assisted minimally invasive coronary bypass surgery is one of the least invasive approaches that offers multivessel revascularization and accelerated recovery. We investigated the benefits of computed tomography angiography (CTA) guidance in robotic coronary bypass (RCAB) by analyzing perioperative outcomes. METHODS: Between April 2022 and April 2023, 60 consecutive patients who underwent RCAB under preoperative CTA guidance were included. The intercostal space of the minithoractomy incision was determined based on the distance from the thoracotomy site to the midsection of the left anterior descending artery (LAD) on preoperative CTA. Peripheral vascular findings on preoperative CTA guided the decision for the cannulation site. Perioperative parameters and early outcomes were evaluated. RESULTS: The mean age of the patients was 62.3 ± 10.5 years, and 51 patients were male (85.0%). The mean number of revascularized vessels was 2.9 ± 1.1. Left thoracotomy guided by CTA measurements was performed in the fourth intercostal space in 37 patients (61.7%) and in the third intercostal space in the remaining patients. Axillary cannulation was performed in 28 (46.7%) patients because of prohibitive findings in the iliac vessels and aorta. All target coronary arteries with an indication for bypass were revascularized with CTA-guided RCAB. The left internal mammary artery (LIMA) was anastomosed to the LAD in all patients, and the LIMA was anastomosed sequentially to the diagonal artery in 17 patients (28.3%). No operative mortality or cerebrovascular event was observed. One patient underwent reoperation due to bleeding. CONCLUSIONS: Robot-assisted minimally invasive multiple-vessel coronary bypass under preoperative CTA guidance is safe and can be performed with excellent results.

Robotic-assisted mitral valve surgery without aortic cross-clamping: a safe and feasible technique.

Background: The primary objective of this study was to evaluate the safety and feasibility of robotic-assisted mitral valve surgery without aortic cross-clamping. Methods: From January 2010 to September 2022, 28 patients underwent robotic-assisted mitral valve surgery without aortic cross-clamping in our center using DaVinci Robotic Systems. Clinical data during the perioperative period and early outcomes of the patients were recorded. Results: Most patients were in New York Heart Association (NYHA) class II and III. Mean age and EuroScore II of the patients were 71.5 ± 13.5 and 8.4 ± 3.7 respectively. The patients underwent either mitral valve replacement (n = 16, 57.1%) or mitral valve repair (n = 12, 42.9%). Concomitant procedures were performed including tricuspid valve repair, tricuspid valve replacement, PFO closure, left atrial appendage ligation, left atrial appendage thrombectomy and cryoablation for atrial fibrillation. Mean CPB times were 140.9 ± 44.6 and mean fibrillatory arrest duration was 76.6 ± 18.4. Mean duration of ICU stay was 32.5 ± 28.8 h and mean duration of hospital stay 9.8 ± 8.3 days. One patient (3.6%) underwent revision due to bleeding. New onset renal failure was observed in one (3.6%) patient and postoperative stroke in one (3.6%) patient. Postoperative early mortality was observed in two (7.1%) patients. Conclusions: Robotic-assisted mitral valve surgery without cross-clamping is a safe and feasible technique in high-risk patients undergoing redo mitral surgery with severe adhesions as well as in primary mitral valve cases that are complicated with ascending aortic calcification.

Artificial intelligence in echocardiography: Review and limitations including epistemological concerns.

BACKGROUND AND PURPOSE: In this review we describe the use of artificial intelligence in the field of echocardiography. Various aspects and terminologies used in artificial intelligence are explained in an easy-to-understand manner and supplemented with illustrations related to echocardiography. Limitations of artificial intelligence, including epistemologic concerns from a philosophical standpoint, are also discussed. METHODS: A narrative review of relevant papers was conducted. CONCLUSION: We provide an overview of the usefulness of artificial intelligence in echocardiography and focus on how it can supplement current day-to-day clinical practice in the assessment of various cardiovascular disease entities. On the other hand, there are significant limitations, including epistemological concerns, which need to be kept in perspective.

Comparison of Pericardiocentesis in Post-Cardiac Surgery and Nonsurgical Patients with Pericardial Tamponade.

INTRODUCTION: There are several approaches for pericardiocentesis. However, there is no definite suggestion about puncture location after cardiac surgery. The purpose of this study is to examine whether there is any difference regarding puncture location during pericardiocentesis in postoperative cardiac tamponade comparing to nonsurgical cardiac tamponade. METHODS: We retrospectively analyzed patients who had undergone pericardiocentesis from August 2011 to December 2019. Patients were examined in two groups, nonsurgical and postsurgical, based on the etiology of pericardial tamponade. Clinical profiles, echocardiographic findings, and procedural outcomes were identified and compared. RESULTS: Sixty-eight pericardiocenteses were performed in this period. The etiology of pericardial effusion was cardiac surgery in 27 cases and nonsurgical medical conditions in 41 cases. Baseline demographic variables were similar between the surgical and nonsurgical groups. Loculated effusion was more common in the postsurgical group (48.1% vs. 4.9%, P<0.001). Maximal fluid locations were different between the groups; right ventricular location was more common in the nonsurgical group (36.6% vs. 11.1%, P=0.02), while lateral location was more common in the postsurgical group (12.2% vs. 40.7%, P=0.007). Apical drainage was more frequently performed in the postsurgical group compared to the nonsurgical group (77.8% vs. 53.7%, P=0.044). CONCLUSION: Apical approach as a puncture location can be used more frequently than subxiphoid approach for effusions occurred after cardiac surgery compared to nonsurgical effusions. Procedural success is prominent in this group and can be the first choice of treatment.

A randomized trial of flow-mediated dilation to prevent radial artery spasm during transradial approach.

BACKGROUND: Although transradial approach has been increasingly preferred for percutaneous coronary interventions, radial artery spasm (RAS) is still one of the major disadvantages. Flow-mediated dilation (FMD) is a well-known method for assessing endothelial function through dilation. The aim of this study was to investigate the efficacy of prepuncture flow mediated dilation in preventing RAS during transradial approach. METHODS: The present study prospectively included 222 consecutive patients who underwent transradial coronary intervention. Patients were 1:1 randomized into two groups who underwent prepuncture FMD and who did not (FMD [+] and FMD [-], respectively). RESULTS: In FMD [+] group the incidence of RAS was lower (5.4% vs. 16.2%, P=0.009). Multivariate logistic regression analysis demonstrated that female sex, more than two catheter usage and transradial approach without prepuncture FMD independently predicted RAS (odds ratio [OR]=4.66, 95% confidence interval [CI]: 1.8-12.06, P=0.001, OR=5.73, 95% CI: 2.01-16.39, P=0.001, and OR=5.01, 95% CI: 1.74-14.48, P=0.003; respectively). However, access site crossover number was very low in both groups and not different between groups. CONCLUSIONS: Prepuncture FMD can significantly reduce RAS during transradial coronary interventions. Thus, prepuncture FMD can be used as a simple adjunctive method to prevent RAS.

Comparison of hypertension prevalence and the use of renin-angiotensin-aldosterone system blockers in hospitalized patients with COVID-19 and non-COVID-19 viral pneumonia.

OBJECTIVE: To compare the prevalence of hypertension and pre-existing use of renin-angiotensin-aldosterone system blockers in patients with coronavirus disease (COVID-19) and non-COVID-19 viral pneumonias. METHODS: Real-time polymerase chain reaction confirmed COVID-19 and non-COVID-19 pneumonia patients were retrospectively analyzed. The presence of hypertension, coronary artery disease (CAD), and pre-existing use of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) were compared between the groups. RESULTS: A total of 103 COVID-19 and 91 non-COVID-19 hospitalized viral pneumonia patients were enrolled. Hypertension and CAD were more common in patients with non-COVID-19 viral pneumonia than in patients with COVID-19 (39.6% vs 22.3%, respectively, p=0.012 and 24.2% vs 4.9%, respectively, p<0.001). In our study, 2.9% and 6.8% of patients with COVID-19 were on ACEIs and ARBs, respectively, whereas 13.2% and 19.8% of patients with non-COVID-19 viral pneumonia were on ACEIs and ARBs, respectively (p=0.009 and p=0.013). Neutrophil-to-lymphocyte ratio (p<0.001) was prominent in patients with non-COVID-19 viral pneumonia compared with patients with COVID-19. CONCLUSION: Our study results indicate that hypertension and CAD are more common among patients with non-COVID-19 viral pneumonia than patients with COVID-19. The prevalence of ACEIs and ARBs use was not higher in patients with COVID-19. Our results support that the use of ACEIs and ARBs do not play a specific role in patients with COVID-19.

An analysis of the learning curve for robotic-assisted mitral valve repair.

BACKGROUND: Many cardiac surgeons receive training for sternotomy-based cardiac surgical operations in residency programs and only a few education programs offer training specifically in minimally invasive cardiac surgery. In this report, we aimed to search and analyze the learning curve for robotic-assisted mitral valve (MV) repair in cardiac surgeons. METHOD: Between January 2010 and July 2019, 60 robotic-assisted isolated MV repair surgeries were performed with DaVinci Robotic Systems in our center. Different kinds of surgical techniques were used. The assessment of the learning curve was based on cardiopulmonary bypass (CPB) and transthoracic aortic clamp (CC) times. RESULT: There were 23 (38.3%) men and 37 (61.7%) women with a mean age of 48.3 years. The lesions of the MV were posterior leaflet prolapsus (n = 42, 70.0%), anterior leaflet prolapsus (n = 8, 13.3%), Barlow disease (n = 3, 5%), and annular dilatation (n = 7, 11.6%). The patients underwent notochordal implantation (n = 27, 45%), quadrangular or triangular resection (n = 23, 38.3%), isolated ring annuloplasty (n = 7, 11.7%), resection, and leaflet reduction (n = 2, 3.3%) or edge to edge repair (n = 1, 1.7%). The maturation of the learning curve appeared to be about 30 cases. The statistical analysis showed that the mean CPB and CC times for the first 30 cases were greater compared with the 30 after learning curve (155.3 vs. 118.9 min [p = .00], 102.3 vs. 80 min [p = .00], respectively). There was no case of conversion to open surgery. No perioperative mortality was observed. CONCLUSION: The maturation of the learning curve for robotic-assisted MV repair appeared to be about 30 cases in our group of patients. This study had encouraging results for surgeons who desire to start a robotic mitral surgery program.

Association between renin-angiotensin-aldosterone system inhibitor treatment, neutrophil-lymphocyte ratio, D-Dimer and clinical severity of COVID-19 in hospitalized patients: a multicenter, observational study.

The aim of this study was to investigate the possible relationship between worse clinical outcomes and the use of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) in hospitalized COVID-19 patients. A total of 247 adult patients (154 males, 93 females; mean age: 51.3 ± 14.2 years) hospitalized for COVID-19 as confirmed by polymerase chain reaction (PCR) were retrospectively reviewed. Demographic and clinical characteristics and laboratory parameters were analyzed using various statistical modeling. Primary outcomes were defined as the need for intensive care unit (ICU), mechanical ventilation, or occurrence of death. Of the patients, 48 were treated in the ICU with a high flow oxygen/noninvasive mechanical ventilation (NIMV, n = 12) or mechanical ventilation (n = 36). Median length of ICU stay was 13 (range, 7-18) days. Mortality was seen in four of the ICU patients. Other patients were followed in the COVID-19 services for a median of 7 days. There was no significant correlation between the primary outcomes and use of ACEIs/ARBs (frequentist OR = 0.82, 95% confidence interval (CI) 0.29-2.34, p = 0.715 and Bayesian posterior median OR = 0.80, 95% CI 0.31-2.02) and presence of hypertension (frequentist OR = 1.23, 95% CI 0.52-2.92, p = 0.631 and Bayesian posterior median OR = 1.25, 95% CI 0.58-2.60). Neutrophil-to-lymphocyte ratio (NLR) and D-dimer levels were strongly associated with primary outcomes. In conclusion, the presence of hypertension and use of ACEIs/ARBs were not significantly associated with poor primary clinical outcomes; however, NLR and D-dimer levels were strong predictors of clinical worsening.

Application of cryoablation for the treatment of atrial fibrillation in patients undergoing cardiac surgery: Our mid-term results.

BACKGROUND: In this study, we aimed to present mid-term results of concomitant argon-based cryoablation in patients undergoing cardiac surgery. METHODS: Between August 2014 and May 2016, 33 patients (17 males, 16 females; mean age 63.9 years; range 45 to 82 years) underwent the Maze procedure using cryoablation for the treatment of atrial fibrillation during a concomitant open cardiac operation. Robot-assisted procedures were used in 12 patients. Biatrial or isolated left atrial ablation was performed according to the underlying pathology. The rhythm assessment with 12-lead electrocardiography and 24-hour Holter, and recordings of atrial fibrillation-related medications, stroke or other thromboembolic events were evaluated by the cardiologist at 3 and 12 months postoperatively. RESULTS: Thirty patients (90.9%) were in sinus rhythm and three (9.1%) were in atrial fibrillation at the time of discharge. Cryoablation failed in three patients (n=2, 8.3% in isolated left atrial and n=1, 11.1% in biatrial group) following the operation in the mid-term. Among the patients, there was no in-hospital mortality and no major postoperative complications such as stroke, sepsis, renal failure requiring dialysis, and prolonged respiratory failure. CONCLUSION: Concomitant surgical cryoablation is an effective method for the treatment of atrial fibrillation, when performed concomitantly with other cardiac surgical procedures and results in very low atrial fibrillation recurrence, even in robotic surgery.

Can radial artery pulse grading predict radial artery spasm during transradial approach?

BACKGROUND: Radial artery spasm (RAS) has been defined as one of the major disadvantage of transradial approach. AIM: The aim of this study was to investigate the predictive value of radial artery pulse grading on RAS during transradial approach. METHODS: The present study prospectively included 115 consecutive patients who underwent transradial coronary catheterisation at a single centre. Patients were divided into two groups: those with RAS and those without. RESULTS: The incidence of RAS was 16.5% (n = 19). Multivariate logistic regression analysis demonstrated that female sex, guiding catheter usage, and radial artery pulse grading ≤ 2 independently predicted RAS (odds ratio [OR] 8, 95% confidence interval [CI] 1.8-36.2, p = 0.007, OR 10.6, 95% CI 2.2-51.2, p = 0.03 and OR 25.8, 95% CI 6.1-108.5, p < 0.001, respec-tively). These three variables were weighted proportionally to their respective OR for RAS (female sex [1.5 points], guiding catheter usage [2 points], and radial artery pulse grading ≤ 2 [5 points]). Two risk strata were defined (low risk, score 0-4, high risk, score 5-8.5), and high risk was associated with increased incidence of RAS (n = 13 [61.9%] vs. n = 6 [6.4%], p < 0.001). CONCLUSIONS: Radial artery pulse grading together with female sex and guiding catheter usage are independent predictors of RAS, and by using a simple risk score high-risk patients for RAS can be identified.

Easily measurable, noninvasive, and novel finding for pulmonary hypertension: Hypertrophy of the basal segment of septomarginal trabeculation of right ventricle.

BACKGROUND: Effect of pulmonary hypertension (PH) on right ventricular (RV) geometry constitutes an ideal target to assess both pulmonary artery pressure (PAP) and its physiological importance. In this study, we evaluated the diagnostic power of the basal segment of septomarginal trabeculation (SMT) in predicting the PH and RV hypertrophy by cardiovascular magnetic resonance (CMR) in patients with idiopathic pulmonary arterial hypertension (IPAH) and Eisenmenger's syndrome (ES). METHODS: Eleven patients with IPAH, seven patients with ES, and 20 healthy controls were enrolled. CMR was used to measure the area and the thickness of the basal segment of SMT and right ventricular free wall (RVFW). Pulmonary artery systolic pressures (PASPs) were estimated by transthoracic echocardiography (TTE) with continuous-wave Doppler analysis measuring maximal tricuspid regurgitation (TR) velocity. Late gadolinium enhancement (LGE) findings of CMR and brain natriuretic peptide (BNP) levels were also obtained in all patients and control group. RESULTS: The area and the thickness of the basal segment of SMT were higher in patients with IPAH and ES than control group (P<.001). Pulmonary artery dimension, end-diastolic diameter of RV, RVFW thickness, and BNP levels were found to be significantly correlated with PAP (P<.001). LGE was present at the insertion point of RV only in patients group (P<.001). CONCLUSIONS: Increased area and thickness of the basal segment of SMT are easily measurable noninvasive markers of PH in patients with IPAH and ES.

Elective percutaneous coronary intervention leads to significant changes in serum resistin, leptin, and adiponectin levels regardless of periprocedural myocardial injury: an observational study.

OBJECTIVE: Bioactive roles of adipokines in coronary atherosclerosis and acute coronary syndromes have been demonstrated previously. However, there is a lack of data regarding the relationship between serum adipokines and periprocedural myocardial injury (PMI) following elective percutaneous coronary intervention (PCI). Therefore, we aimed to investigate the association between serum adipokines and PMI related to elective PCI. METHODS: In total, 153 consecutive patients (aged 60.6±8.2 years, 98 men) with stable angina pectoris undergoing elective PCI were enrolled in this observational cross-sectional study. Serum resistin, leptin, adiponectin, and high-sensitive Troponin T (hscTnT) levels were measured immediately before PCI and after 12-h PCI. The no-injury, PMI, and type 4a myocardial infarction (type 4a MI) groups were defined as groups consisting patients with post-procedural hscTnT concentrations <14 ng/L, between 14-70 ng/L, and >70 ng/L, respectively. RESULTS: Serum hscTnT, resistin, and leptin concentrations significantly (p<0.001) increased while serum adiponectin levels decreased (p<0.001) after 12-h elective PCI. However, no correlation was found between post-procedural hscTnT concentrations and resistin, leptin, and adiponectin levels. The no-injury group consisted of 65 patients (42.4%), whereas PMI and type 4a MI were observed in 70 (45.8%) and 18 (11.8%) patients, respectively. The average pre-procedural and post-procedural resistin, leptin, and adiponectin levels did not show any significant difference in the no-injury, PMI, and type 4a MI groups. CONCLUSION: There is no correlation between serum adipokine levels and post-procedural troponin elevations reflecting PMI or type 4a MI. However, serum resistin and leptin levels increase, whereas adiponectin levels decrease significantly after elective PCI.

Safety of Early Discharge After Primary Percutaneous Coronary Intervention.

In contrast to ST-elevation myocardial infarction treatment, there is no clear definition for when and which patient to discharge. Our study's main goal was to test the hypothesis that an early discharge strategy (within 48 to 56 hours) in patients with successful primary percutaneous coronary intervention (PPCI) is as safe as in patients who stay longer. The Early Discharge after Primary Percutaneous Coronary Intervention trial was designed in a prospective, randomized, multicenter fashion and registered with http://clinicaltrials.gov (NCT01860079). Of 900 patients with ST-elevation myocardial infarction, the study randomized 769 eligible patients to the early or the standard discharge group. The study's primary outcomes were all-cause mortality and readmission at 30 days. We considered assessment of functional status and health-related quality of life to be secondary outcomes. The early discharge group had significantly shorter length of hospital stay compared with the standard discharge group (45.99 ± 9.12 vs 114.87 ± 63.53 hours; p <0.0001). Neither all-cause mortality nor readmissions were different between the 2 study groups (p = 0.684 and p = 0.061, respectively). Quality-of-life measures were not statistically different between the 2 study groups. Our study reveals that discharge within 48 to 56 hours after successful PPCI is feasible, safe, and does not increase the 30-day readmission rate. Moreover, the patients perceived health status at 30 days did not differ with early discharge.

Catheter entrapment due to severe radial artery spasm during transradial approach.

BACKGROUND: Catheter entrapment due to severe radial artery spasm (RAS) during transradial coronary catheterization has been rarely reported and its management is not precisely defined. The aim of this study was to determine the incidence, predictors and management of catheter entrapment due to severe RAS. METHODS: A total of 723 patients undergoing transradial coronary catheterization at a single center were retrospectively enrolled in the present study. Patients were divided into two groups: those with catheter entrapment due to severe RAS and those without. RESULTS: The incidence of catheter entrapment was 0.8%. Height (161.2 ± 9.1 cm vs. 169.6 ± ± 10 cm, p = 0.047) and body surface area (1.86 ± 0.04 vs. 1.95 ± 0.18, p = 0.002) were found to be lower, and total procedure time 33.2 ± 13.4 min vs. 15.2 ± 12.3 min, p < 0.001) was longer in the entrapment group. Multivariate logistic regression analysis demonstrated that total procedure time independently predicted catheter entrapment (odds ratio: 1.057, 95% confidence interval [CI] 1.004-1.114, p = 0.035). Receiver-operating characteristic curve demonstrated good diagnostic accuracy for prolonged total procedure time in predicting catheter entrapment (area under curve = 0.8, 95% CI 0.63-0.97, p = 0.01). Patients were effectively treated with stepwise administration of systemic vasodilators, forearm heating, sedation and as a last resort general anesthesia with no significant complication. CONCLUSIONS: Catheter entrapment due to severe RAS during transradial approach was rare and prolonged total procedure time is an independent predictor of catheter entrapment. Treatment with stepwise administration of different treatment modalities is possible with no significant complication.

Rise of serum troponin levels following uncomplicated elective percutaneous coronary interventions in patients without clinical and procedural signs suggestive of myocardial necrosis.

INTRODUCTION: The new definition of periprocedural myocardial infarction (type 4a MI) excludes patients without angina and electrocardiographic or echocardiographic changes suggestive of myocardial ischemia even though significant serum troponin elevations occur following percutaneous coronary intervention (PCI). AIM: To evaluate the incidence and predictors of serum troponin rise following elective PCI in patients without clinical and procedural signs suggestive of myocardial necrosis by using a high-sensitivite troponin assay (hsTnT). MATERIAL AND METHODS: Three hundred and four patients (mean age: 60.8 ±8.8 years, 204 male) undergoing elective PCI were enrolled. Patients with periprocedural angina, electrocardiographic or echocardiographic signs indicating myocardial ischemia or a visible procedural complication such as dissection or side branch occlusion were excluded. Mild-moderate periprocedural myocardial injury (PMI) and severe PMI were defined as post-PCI (12 h later) elevation of serum hsTnT concentrations to the range of 14-70 ng/l and > 70 ng/l, respectively. RESULTS: The median pre-procedural hsTnT level was 9.7 ng/l (interquartile range: 7.1-12.2 ng/l). Serum hsTnT concentration elevated (p < 0.001) to 19.4 ng/l (IQR: 12.0-38.8 ng/l) 12 h after PCI. Mild-moderate PMI and severe PMI were detected in 49.3% and 12.2% of patients, respectively. Post-procedural hsTnT levels were significantly higher in multivessel PCI, overlapping stenting, predilatation and postdilatation subgroups. In addition, post-procedural hsTnT levels were correlated (r = 0.340; p < 0.001) with the stent lengths. CONCLUSIONS: High-sensitivite troponin measurements indicate a high incidence of PMI even though no clinical or procedural signs suggestive of myocardial ischemia exist. Multivessel PCI, overlapping stenting, predilatation, postdilatation and longer stent length are associated with PMI following elective PCI.

Transradial catheterization may decrease the radial artery luminal diameter and impair the vasodilatation response in the access site at late term: an observational study.

The present study aimed to evaluate the late-term changes in radial artery luminal diameter (RAD) and vasodilatation response following transradial catheterization (TRC). TRC-inducing trauma to radial artery intima may trigger chronic phase vascular changes and lead to anatomical and functional impairment. There is controversial data whether the impairment persists or repairs later. Fifty-six consecutive patients undergoing TRC were enrolled prospectively. Baseline RAD, flow-mediated dilatation (FMD) and nitroglycerin-mediated dilatation (NMD) of the radial artery at the access site were measured before TRC by high-resolution ultrasound. Six months later; RAD, FMD and NMD were measured again at the same access site. RAD at the sixth month was reduced compared with pre-procedural measurements (2.85 ± 0.44 versus 2.74 ± 0.42 mm, p = 0.0001).The average FMD decreased to 5.66 ± 5.87 %, which was significantly lower than the observed pre-procedural FMD (9.45 ± 5.01 %) 6 months after TRC (p = 0.0001). Likewise, the average NMD at the sixth month was reduced compared with pre-procedural NMD (9.52 ± 6.77 versus 6.64 ± 6.51 %, p = 0.018). Logistic regression analysis indicated that pre-procedural radial artery diameter to sheath size ratio was the independent predictor of NMD reduction (95 % confidence interval, ß = -9.74, p = 0.024). TRC may lead to a significant luminal diameter reduction and impairment of vasodilatation response in the radial artery at late term.

Pulmonary artery to aorta ratio for the detection of pulmonary hypertension: cardiovascular magnetic resonance and invasive hemodynamics in heart failure with preserved ejection fraction.

BACKGROUND: Previous work indicates that dilatation of the pulmonary artery (PA) itself or in relation to the ascending aorta (PA:Ao ratio) predicts pulmonary hypertension (PH). Whether these results also apply for heart failure with preserved ejection fraction (HFpEF) is unknown. In the present study we evaluated the diagnostic and prognostic power of PA diameter and PA:Ao ratio on top of right ventricular (RV) size, function, and septomarginal trabeculation (SMT) thickness by cardiovascular magnetic resonance (CMR) in HFpEF. METHODS AND RESULTS: 159 consecutive HFpEF patients were prospectively enrolled. Of these, 111 underwent CMR and invasive hemodynamic evaluation. By invasive assessment 64 % of patients suffered from moderate/severe PH (mean pulmonary artery pressure (mPAP) ≥30 mmHg). Significant differences between groups with and without moderate/severe PH were observed with respect to PA diameter (30.9 ± 5.1 mm versus 26 ± 5.1 mm, p < 0.001), PA:Ao ratio (0.93 ± 0.16 versus 0.78 ± 0.14, p < 0.001), and SMT diameter (4.6 ± 1.5 mm versus 3.8 ± 1.2 mm; p = 0.008). The strongest correlation with mPAP was found for PA:Ao ratio (r = 0.421, p < 0.001). By ROC analysis the best cut-off for the detection of moderate/severe PH was found for a PA:Ao ratio of 0.83. Patients were followed for 22.0 ± 14.9 months. By Kaplan Meier analysis event-free survival was significantly worse in patients with a PA:Ao ratio ≥0.83 (log rank, p = 0.004). By multivariable Cox-regression analysis PA:Ao ratio was independently associated with event-free survival (p = 0.003). CONCLUSION: PA:Ao ratio is an easily measureable noninvasive indicator for the presence and severity of PH in HFpEF, and it is related with outcome.

Predictive Value of the No-Reflow Phenomenon and Epicardial Adipose Tissue for Clinical Outcomes After Primary Percutaneous Coronary Intervention.

INTRODUCTION: The determinants of clinical outcomes in patients with acute ST-elevation myocardial infarction (STEMI) are still being debated. The aim of this study was to investigate the prognostic value of the no-reflow phenomenon and epicardial adipose tissue (EAT) thickness for clinical outcomes in patients undergoing primary percutaneous coronary intervention (pPCI) for STEMI. METHODS: The present study prospectively included 114 consecutive patients (mean age 54 ± 10 years, 15 women) who underwent successful pPCI. Patients were divided into two groups according to the occurrence of the no-reflow phenomenon and further subdivided according to the tertile of EAT thickness (Group I <5.1 mm, Group II ≥5.1 mm). We assessed the composite and separate occurrence of major adverse cardiac events. RESULTS: Throughout the 3-year follow up, the number of admissions for heart failure was significantly higher in patients with no-reflow (n=5 [20%] vs. n=1 [1%], p=0.003) and in female patients (n=4 [26%] vs. n=2 [2%], p=0.004). In the subgroup analysis, group I patients with no-reflow showed a higher frequency of admission for heart failure (n=4 [44%] vs. n=1 [6%], p=0.04). However, multivariate logistic regression analysis demonstrated that only no-reflow and female sex independently predicted admission for heart failure (OR: 19.3, 95%CI: 1.4-269.7, p=0.03, and OR: 24.9, 95%CI: 2.2-288.8, p=0.01, respectively). CONCLUSION: No-reflow and female sex are independent predictors of admission for heart failure in the longterm follow up of patients with STEMI. However, EAT thickness is not associated with clinical outcomes after pPCI.

Comparison of Effects of Low- versus High-Dose Heparin on Access-Site Complications during Transradial Coronary Angiography: A Double-Blind Randomized Study.

OBJECTIVES: Although heparin is highly effective in reducing the rate of radial artery occlusion after transradial catheterization, the optimal heparin dose is still controversial. The aim of this study was to evaluate the efficacy and safety of two different heparin doses during transradial coronary angiography. METHODS: 490 consecutive patients undergoing transradial coronary angiography were prospectively enrolled into this double-blind randomized trial. A total of 202 patients enrolled in the low-dose (LD; 2,500 U of heparin) group and 202 patients enrolled in the high-dose (HD; 5,000 U of heparin) group were included in the final analysis. The primary endpoint of the study was radial artery occlusion. Bleeding and hematomas were the secondary outcome measures. RESULTS: At day 7, radial artery occlusion occurred in 5.9% of the patients in the LD group and in 5.4% of the patients in the HD group (p = 0.83). Bleeding during deflation of the transradial band occurred in 6.4% of the patients in the LD group and in 18.3% of the patients in the HD group; the difference was statistically significant (p < 0.001). Higher-dose heparin was found to be an independent predictor of bleeding (p = 0.007). CONCLUSION: A lower dose of heparin (i.e. 2,500 U) decreases bleeding during transradial band deflation without an increase in radial artery occlusion.