Long-term echocardiographic evaluation of asymptomatic patients undergoing minimally invasive valve repair for severe primary mitral regurgitation.

BACKGROUND: Asymptomatic patients with newly diagnosed severe primary mitral regurgitation (MR) may not be candidates for surgery according to clinical guidelines. AIMS: We aimed to determine whether asymptomatic patients with severe primary MR benefit from minimally invasive mitral valve repair. METHODS: This prospective registry study assessed consecutive asymptomatic patients who underwent mitral valve repair using right minithoracotomy. Left ventricular ejection fraction, end­diastolic and end­­systolic volumes, end­diastolic and end­systolic diameters, as well as left atrial (LA) area and volume were measured. Major adverse cardiovascular and cerebrovascular events (MACCEs) were assessed at 6, 12, and 24 months after surgery. RESULTS: The study included 114 patients, of whom 16 (14%) were lost to follow­up (except the endpoint of death). No deaths were reported during follow­up. A comparison of median echocardiographic parameters at baseline and 24 months revealed significant reverse remodeling: left ventricular ejection fraction, 68% vs 60% (P <0.001); end­diastolic volume, 165 cm3 vs 107.5 cm3 (P <0.001); end­systolic volume, 51 cm3 vs 43.5 cm3 (P = 0.02), end­diastolic diameter, 58 mm vs 49 mm (P <0.001); end­systolic diameter, 35 mm vs 30 mm (P <0.001); LA area, 26 cm2 vs 18 cm2 (P <0.001); and LA volume, 96 cm3 vs 49.5 cm3(P <0.001). There were 9 MACCEs (9.2%): 2 reoperations (2%), 1 hospitalization for heart failure (1%), and 6 cases of new­onset atrial fibrillation (6.1%). CONCLUSIONS: Minimally invasive mitral valve repair is safe and effective in asymptomatic patients with severe primary MR. It should be recommended regardless of ventricular and atrial dimensions.

Transcatheter closure of patent foramen ovale using the internal jugular venous approach.

Transcatheter closure of patent foramen ovale is routinely performed using the transfemoral approach, which is safe and technically easy. Our case represents the rare situation where the procedure needs to be performed using the right internal jugular venous approach. According to our best knowledge this is the first report of a patent foramen ovale closure procedure with access through the internal jugular with necessity to advance the guide wire and transseptal sheath into the left ventricle. Developing alternative techniques of transcatheter patent foramen ovale closure seems to be especially important in rare cases where transfemoral access is unavailable.

[Periprocedural and late complications after percutaneous closure of patent foramen ovale: a single centre experience].

BACKGROUND: Patent foramen ovale (PFO) is a potential risk factor for ischaemic stroke in young individuals. An interventional method of secondary stroke prevention in PFO patients is its percutaneous closure. AIM: To assess safety and effectiveness (i.e. lack of residual shunt) of percutaneous PFO closure in patients with history of cryptogenic cerebrovascular event. METHODS: 149 patients (56 men/93 women), aged 39 ± 12 years, underwent percutaneous PFO closure. The implantation was performed under local anaesthesia, guided by trans-oesophageal echocardiography (TEE) and fluoroscopy. Follow-up trans-thoracic echocardiography (TTE) was performed at 1 month and follow-up TEE at 6-months. In cases of residual shunt, additional TEE was performed after ensuing 6 months. RESULTS: Effective PFO closure (no residual shunt) was achieved in 91.3% patients at 6 months and 95.3% patients at 12 months. In 2 patients transient atrial fibrillation was observed during the procedure. In 2 patients, a puncture site haematoma developed and in 1 patient superficial thrombophlebitis was noted. In 1 patient a small pericardial effusion was observed, which resolved at day 3 post-procedurally, after administration of non-steroidal anti-inflammatory drugs. CONCLUSIONS: Percutaneous PFO closure seems to be a safe procedure when performed in a centre with adequate expertise with regard to these procedures.

Impact of atherosclerotic changes of carotid vessels on long-term outcome in relatively young patients with acute coronary syndrome.

BACKGROUND: Complex stenoses of coronary vessels as well as unstable plaques are part of the widespread atherosclerotic process. AIM: The possible association between the incidence of unstable coronary artery disease (CAD) and the morphology of carotid artery wall and cardiovascular events (MACE) was assessed prospectively in a two-year follow-up study. METHODS AND RESULTS: Ninety-seven consecutive patients, aged under 60, admitted to hospital with suspected acute coronary syndrome (ACS) were included. Angiography was performed in all patients. Coronary artery disease was confirmed in 78 patients. This was the CAD(+) group. In 19 patients, coronary arteries were normal. This was the CAD(-) group. In all cases, carotid ultrasound was performed before discharge and at two-year follow-up, with evaluation of carotid arteries wall morphology: carotid intima-media thickness (CIMT) in far distal wall of common carotid artery and the presence of plaques. Carotid atherosclerosis was defined as CIMT > 0.9 mm or incidence of plaques; MACE was defined as death, ACS, stroke or need for urgent coronary revascularisation. Sixty patients from the CAD(+) group met the carotid atherosclerosis criteria. This was named the CAR(+) subgroup; 18 patients with normal carotid morphology comprised the CAR(-) subgroup. During the two years, MACE occurred only in the CAD(+) group (22 events). There was no statistical difference in the MACE-free survival curve of the CAR(+) and CAR(-) subgroups (p = 0.91). CONCLUSIONS: The presence of atherosclerotic process in carotid region coexists well with the incidence of CAD; however, it does not determine prognosis after ACS.

Preoperative quantification of aortic valve stenosis: comparison of 64-slice computed tomography with transesophageal and transthoracic echocardiography and size of implanted prosthesis.

Precise measurements of aortic complex diameters are essential for preoperative examinations of patients with aortic stenosis (AS) scheduled for aortic valve (AV) replacement. We aimed to prospectively compare the accuracy of transthoracic echocardiography (TTE), transoesophageal echocardiography (TEE) and multi-slice computed tomography (MSCT) measurements of the AV complex and to analyze the role of the multi-modality aortic annulus diameter (AAd) assessment in the selection of the optimal prosthesis to be implanted in patients surgically treated for degenerative AS. 20 patients (F/M: 3/17; age: 69 ± 6.5 years) with severe degenerative AS were enrolled into the study. TTE, TEE and MSCT including AV calcium score (AVCS) assessment were performed in all patients. The values of AAd obtained in the long AV complex axis (TTE, TEE, MSCT) and in multiplanar perpendicular imaging (MSCT) were compared to the size of implanted prosthesis. The mean AAd was 24 ± 3.6 mm using TTE, 26 ± 4.2 mm using TEE, and 26.9 ± 3.2 in MSCT (P = 0.04 vs. TTE). The mean diameter of the left ventricle out-flow tract in TTE (19.9 ± 2.7 mm) and TEE (19.5 ± 2.7 mm) were smaller than in MSCT (24.9 ± 3.3 mm, P < 0.001 for both). The mean size of implanted prosthesis (22.2 ± 2.3 mm) was significantly smaller than the mean AAd measured by TTE (P = 0.0039), TEE (P = 0.0004), and MSCT (P < 0.0001). The implanted prosthesis size correlated significantly to the AAd: r = 0.603, P = 0.005 for TTE, r = 0.592, P = 0.006 for TEE, and r = 0.791, P < 0.001 for MSCT. Obesity and extensive valve calcification (AV calcium score ≥ 3177Ag.U.) were identified as potent factors that caused a deterioration of both TTE and MSCT performance. The accuracy of AAd measurements in TEE was only limited by AV calcification. In multivariate regression analysis the mean value of the minimum and maximum AAd obtained in MSCT-multiplanar perpendicular imaging was an independent factor (r = 0.802, P < 0.0001) predicting the size of implanted prosthesis. In patients with AS echocardiography remains the main diagnostics tool in clinical practice. MSCT as a 3-dimentional modality allows for accurate measurement of entire AV complex and facilitates optimal matching of prosthesis size.

The use of myocardial contrast echocardiography in the assessment of left ventricular function recovery after primary percutaneous coronary intervention in the setting of acute myocardial infarction.

BACKGROUND: Despite successful reperfusion therapy of acute myocardial infarction and complete restoration of infarct-related artery patency, the improvement of systolic function in long-term outcome depends on preserved microvasculature integrity. Myocardial contrast echocardiography (MCE) is a useful technique for identification of viable myocardium. AIM: To assess the value of real-time myocardial contrast echocardiography (rt-MCE) in prediction of left ventricular function improvement in patients with anterior wall acute myocardial infarction as well as selection of the optimal cut-off value for the number of dysfunctional segments with preserved complete perfusion, in order to predict the global left ventricular function improvement during one-month observation. METHODS: Rt-MCE was performed in 74 patients (50 men, aged 58+/-11 years) with anterior wall myocardial infarction, treated with primary percutaneous coronary intervention (PCI) within 12 hours from the onset of symptoms. After estimation of regional contractility disturbances and global systolic function of the left ventricle, rt-MCE was performed with contrast assessment of dysfunctional segments (normal contrast pattern=2, heterogeneous=1, lack of contrast=0). Regional perfusion score index (RPSI) was calculated by adding the perfusion indices and dividing by the number of dysfunctional segments. RESULTS: Of a total of 1184 visualised segments, 344 (29.1%) were dysfunctional (189 hypokinetic, 155 akinetic). Contractility improvement was observed in 192 segments (preserved viability in 105 hypokinetic and 37 akinetic segments). In a group of 44 patients with systolic function improvement, 34 of them had preserved viability, and in a group of 30 patients without LVEF improvement, in 22 of them myocardium viability was not observed. Sensitivity, specificity and accuracy of rt-MCE in prediction of left ventricular global improvement were 72.7%, 73.3% and 73%, respectively, whereas in prediction of regional function improvement these values were 73.9%, 77% and 75.5%, respectively. CONCLUSION: Rt-MCE performed in the early phase of myocardial infarction enables the prediction of left ventricular regional and global function improvement in patients treated with primary PCI.

Diagnostic utility of tissue tracking echocardiography for the diagnosis of ischaemic heart disease.

INTRODUCTION: Both the resting electrocardiogram and standard echocardiography have limited value in detecting ischaemic heart disease (IHD) in patients with atypical symptoms or asymptomatic subjects. Tissue tracking (TT) is a novel method based on tissue Doppler echocardiography for the assessment of longitudinal apical myocardial motion. AIM: To assess diagnostic utility of TT mode in the diagnosis of IHD. METHODS: The study was performed in a group of 36 patients (aged 58+/-8 years, 15 males) with good acoustic window, sinus rhythm and normal left ventricular ejection fraction on standard echocardiography who were previously selected for coronary angiography. Systolic displacement of myocardium (TT) was assessed in all patients using apical views (4, 2, and 3-chamber) and 7-colour-coded visualisation expressing various apical displacements of the myocardium during systole. Group IHD(-) consisted of 16 patients with normal coronary angiography or insignificant lesions and group IHD(+) consisted of 20 patients with significant (>70%) coronary lesions. RESULTS: Despite similar prevalence of arterial hypertension and diabetes as well as similar pharmacological treatment patients from the IHD(+) group had a lower TT index (ratio of the sum of regional TT values to the number of analysed segments than the IHD(-) (patients 4.5+/-0.8 mm vs 5.9+/-0.9 mm respectively, p <0.001). CONCLUSIONS: Resting echocardiography with tissue tracking enables fast, non-invasive and semiquantitative evaluation of left ventricular function. This method of assessment of longitudinal layers of the left ventricle may be useful in the diagnosis of ischaemic heart disease.

[Prediction of adverse cardiac events in patients with acute anterior wall myocardial infarction treated with PCI]. / Przewidywanie wystapienia niekorzystnych zdarzen sercowych u chorych ze swiezym zawalem miesnia sercowego sciany przedniej leczonych PCI.

UNLABELLED: Despite common use of reperfusion therapy, particularly primary PCI during acute myocardial infarction, steadily increasing number of patients with low left ventricular ejection fraction, with heart failure (HF), requiring frequent rehospitalisation justifies the study establishing the best indices of prediction of major adverse cardiac events (MACE) occurrence. The aim of the study was to define the frequency of MACE (death, re MI, sVT, rehospitalisation for HF) in patients with acute anterior wall myocardial infarction in 6 month follow up and the factors determinatig its occurence. The 115 consecutive patients (86 males of age 57.7 +/- 11 yrs) with first anterior MI were studied. After successful PCI (TIMI 3) the angiographic assessment was performed (MBG 0-1 - no perfusion, MBG 2-3 - perfusion preserved). During first 48 hours 12-lead ECG was monitored in order to analyse the time to reduction of ST elevation in the lead with the highest elevation (deltatST 50%). On 2nd day LV function (LVEF and WMSI) and dyssfunctional segment perfusion (RPSI) were assessed. On 5th day Holter monitoring with arrhythmia and time domain parameters (SDNN, rMSSD) of heart rate variability were performed, on 30 day TWA test was done. RESULTS: During 180 follow-up 18 MACE occurred (3 death, 2 MI, 11 rehospitalisations for HF). In univariate analysis cigarette smoking, higher maximum troponin I value, LVEDV, LVESV, ST elevation sum, longer time to reduction of ST elevation, lower LVEF and RPSI, lack of microvessel integrity and positive TWA test had significant relationship with occurrence of MACE. The multivariate analysis of Cox proportional risk regression demonstrated that only lower value of RPSI and LVEF, longer time of ST elevation reduction in the lead with the highest ST elevation and positive TWA test were independent indices of MACE prediction. CONCLUSIONS: Cumulative evaluation of LVEF, indices of preserved perfusion and results of TWA test turned out to be the best predictors of MACE occurrence in 6 month follow up in patients after anterior MI treated with PCI.

Circumferential pulmonary vein RF ablation in the treatment of atrial fibrillation: 3-year experience of one centre.

INTRODUCTION: In patients with atrial fibrillation (AF), significantly symptomatic in particular, restoring and maintaining sinus rhythm is one of treatment strategies. Considering the limited efficacy and side effects of anti-arrhythmic agents, growing hopes are attributed to the developing techniques of percutaneous ablation. AIM: To determine the efficacy and safety of circumferential pulmonary vein ablation performed using the CARTO system in patients with paroxysmal or permanent AF. METHODS: The study involved 94 patients (mean age 54 years, males 65%, structural heart disease 29.4%) with symptomatic, recurrent and AF resistant to antiarrhythmic agents (paroxysmal AF 63.8%), selected for circumferential pulmonary vein ablation with the Pappone method. Follow-up examinations were performed after 1, 3, 6, 9, and 12 months. The symptoms, ECG, 24-hour ECG monitoring and complications were recorded. RESULTS: Mean procedure and fluoroscopy durations were 4.5 hours and 22.4 minutes respectively. The long-term follow-up ranged from 3 to 24 months, with median time of 12 months. At six months, 47.8% of patients remained free from AF, and improvement in terms of infrequent arrhythmia occurrence and low incidence of symptoms in an additional 36.7% was observed. Efficacy was lower in patients with permanent AF (12 months 90% vs 70%). Complications were seen in six (6.4%) patients: cardiac tamponade in two patients; and pericardial effusion, retroperitoneal bleeding, stroke, and pulmonary vein thrombosis each in one patient. CONCLUSIONS: Circumferential pulmonary vein ablation leads to resolution of arrhythmia or marked clinical improvement in about 75% of patients with symptomatic, resistant AF. The success rate is lower in patients with permanent rather than paroxysmal AF. As severe complications are not unlikely, the indications for such therapy must be carefully balanced.

Primary direct stenting versus endoscopic atraumatic coronary artery bypass surgery in patients with proximal stenosis of the left anterior descending coronary artery--a prospective, randomised study.

BACKGROUND: The dynamic development of interventional cardiology resulted in an increasing proportion of patients treated with various forms of coronary angioplasty instead of surgery. On the other hand, it has been well established that the results of coronary artery by-pass surgery of the left anterior descending (LAD) coronary artery with the use of the internal mammary artery are excellent. AIM: To compare the results of primary direct stenting (PDS) and endoscopic atraumatic coronary artery bypass (EACAB) surgery in patients with an isolated proximal LAD type A or B1 lesion. METHODS: This prospective and randomised study included 100 patients with an isolated critical (> or =70%) LAD stenosis who underwent PDS (n=50) or EACAB (n=50). RESULTS: After a six-month follow-up period, 32 (64%) PDS patients and 47 (94%) EACAB patients were angina-free. The rate of major cardiac adverse events (MACE) was significantly higher in the PDS group than in surgically treated patients (p<0.05). After one year of follow-up, 40 (80%) PDS-treated patients and all 50 EACAB patients had no recurrences of angina. After two-year follow-period, the survival rate without MACE was significantly higher in the EACAB group than in the PDS-treated patients (94% vs 76%, p<0.05). CONCLUSIONS: Minimally invasive cardiac surgery is an alternative method to direct stenting in the treatment of patients with proximal LAD stenosis.

Prognostic value of troponin I after elective percutaneous coronary interventions.

BACKGROUND: A mild and asymptomatic increase in the troponin level following elective percutaneous coronary interventions (PCI) has been widely reported, however, the prognostic role of this finding has not yet been well established.Aim. To assess prognostic value of troponin I level increase following elective PCI. METHODS: The study group consisted of 90 consecutive patients who underwent elective PCI in our institution. Troponin I level (normal values <0.1 ug/L) was assessed at baseline and 12 as well as 24 hours after the procedure. In addition, CK-MB level was measured 12 and 24 hours following PCI. Left ventricular (LV) systolic performance was assessed echocardiographically at baseline and after 12 months. The incidence of major adverse coronary events (MACE) during one-year follow-up was also evaluated. RESULTS: An increase in troponin I level >0.1 ug/L was observed in 66 (73%) patients; of whom, 8 patients had a marked (>1.0 ug/L) increase of troponin I, with a concomitant significant elevation of the CK-MB level. Patients with a positive troponin test developed systolic LV abnormalities more often than patients with a normal troponin I level following PCI (p<0.001). There were 10 MACE in the troponin-positive group and 2 in the troponin-negative patients (NS). Seven MACE occurred in patients with marked increase in troponin I level (>1.0 ug/L) which was significantly more often than in the troponin-negative patients (p<0.001). CONCLUSIONS: A mild increase in troponin I level following elective PCI was frequent and did not predict poor outcome, however, was associated with the development of LV systolic impairment. A marked (>1.0 ug/L) increase in troponin I level identified patients at risk of MACE. An increase in troponin I level was similar following various types of PCI.

Primary stenting versus MIDCAB: preliminary report-comparision of two methods of revascularization in single left anterior descending coronary artery stenosis.

BACKGROUND: Percutaneous revascularization is a well-accepted method of treatment for a single left anterior descending coronary artery (LAD) stenosis. With the introduction of primary stenting, it has become the treatment of choice for a LAD lesion. In the last few years however, the introduction of minimally invasive cardiac surgery, video-assisted left internal thoracic artery (LITA) harvesting, and robotic surgery have raised the question as to whether minimally invasive surgical revascularization would be competitive with percutaneous coronary interventions in cases of single-vessel stenoses. METHODS: A group of 100 patients with Canadian Cardiovascular Society class II to IV, and angiographically confirmed single critical stenosis of the LAD (type A or B), were treated with direct primary stenting (group 1, n = 50), or with endoscopic atraumatic coronary artery bypass grafting (group 2, n =50). RESULTS: All patients in a group 1, obtained a very good angiographic and clinical effect. No acute postoperative complications were noted at 1 month of follow-up. However, at 1 month of follow-up, 3 patients (6%) developed restenosis of the LAD, and at 6 months follow-up, 6 patients (12%), developed restenosis of the LAD. In these cases, repeated percutaneous coronary interventions of the target vessel were successfully performed. In group 2, very good operative results were observed. In 1 and 6 months of follow-up, all patients remained asymptomatic. Critical stenosis of the left internal thoracic artery-LAD anastomosis was angiographically documented in 1 case (2%). This patient was successfully treated with balloon angioplasty. CONCLUSIONS: The study results document the superiority of endoscopic atraumatic coronary artery bypass grafting over direct primary stenting in LAD revascularization, along with the slightly higher costs of the surgical procedure.