Left atrial strain rate: marker of hemodynamically significant coronary artery stenosis?

Aim: To assess the diagnostic value of left atrial deformation parameters during dobutamine stress echocardiography to predict significant coronary artery stenosis in patients with moderate pretest probability of coronary artery disease (CAD). Materials & methods: Rest and stress echocardiography were performed on 61 patients with a moderate and high probability of CAD. Based on presence of CAD patients were divided into pathological and nonpathological groups. Results: Early diastolic strain rate (LAe SR) was significantly lower among the pathological group at high dobutamine doses. LAe SR was evaluated with receiver operating characteristic curve and threshold prognostic value was set of -2.05 (sensitivity 78%, specificity 50%, area under the curve 0.638; p = 0.026). Conclusion: Measuring LAe SR has predictive value and might be a helpful parameter in assessing ischemia.

Value of myocardial deformation parameters for detecting significant coronary artery disease.

Introduction: The study aimed to evaluate the diagnostic value of global and regional myocardial deformation parameters derived from two-dimensional speckle-tracking echocardiography to detect functionally significant coronary artery stenosis. Methods: Dobutamine stress echocardiography and cardiac magnetic resonance myocardial perfusion imaging (CMR-MPI) were performed on 145 patients with a moderate and high probability of coronary artery disease (CAD) and LVEF≥55%. Significant CAD was defined as>50% stenosis of the left main stem,>70% stenosis in a major coronary vessel, or in the presence of intermediate stenosis (50-69%) validated as hemodynamically significant by CMRMPI. Patients were divided in two groups: non-pathological (48.3%) vs pathological (51.7%), according to CAG and CMR-MPI results. Afterwards, off-line speckle-tracking analysis was performed to analyse myocardial deformation parameters. Results: There were no differences in myocardial deformation parameters at rest between groups, except global longitudinal strain (GLS) and global radial strain (GRS) were significantly lower in the CAD (+) group: -21.3±2.2 vs.-16.3±2.3 (P<0.001) and 39.7±23.2 vs. 24.5±15.8 (P<0.001). GLS and regional longitudinal strain rate (SR) had the highest diagnostic value at high dobutamine dose with AUC of 0.902 and 0.878, respectively. At early recovery, GLS was also found to be the best myocardial deformation parameter with a sensitivity of 78%, specificity 67%, AUC 0.824. Conclusion: Global and regional myocardial deformation parameters are highly sensitive and specific in detecting functionally significant CAD. The combination of deformation parameters and WMA provides an incremental diagnostic value for patients with a moderate and high probability of CAD, especially the combination with regional longitudinal SR.

The impact of COVID-19 on adult cardiac surgery.

Background: This study aims to evaluate the impact of the novel coronavirus disease 2019 (COVID-19) pandemic on cardiac surgery in a single cardiac surgery center in Lithuania. Methods: Between November 2018 and March 2021, the data of male COVID-19-negative patients (n=81; mean age: 65.5±8.5 years; range, 46 to 87 years) operated during the pandemic were compared with the data of male COVID-19-positive patients operated during the same period (n=14; mean age: 65.2±10.6 years). The number of patiets, demographic and perioperative data were compared between the patients operated during the pandemic (2020/2021 years; pandemic group) and the prepandemic period (2018/2019 years; control group). Results: A statistically significant difference between the COVID-19-positive and COVID-19-negative patients was found in terms of the frequency of wound infection (n=3, 21.4% vs. n=12, 14.8%; p=0.013), resternotomy due to bleeding (n=2, 14.3% vs. n=0, 0%; p=0.018), and duration of hospitalization after surgery (26.4±20.4 days vs. 15.3±8.9 days; p=0.008). Comparing data of patients who had surgery before and during the pandemic, a significant decrease in the number of cardiac operations (166 vs. 95) was observed. There was significantly increased body mass index (p=0.01) and incidence of diabetes mellitus type 2 (p=0.021) in the pandemic group. Conclusion: Despite a significantly higher rate of complications in patients infected with COVID-19, planned cardiac surgery with the utilization of adequate protective measures during quarantine is still a better option than a complete cessation of elective cardiac surgery.

Prognostic factors of atrial fibrillation following coronary artery bypass graft surgery.

OBJECTIVE: Postoperative atrial fibrillation (POAF) is the most common complication after cardiac surgery. To prevent this complication, routine pharmacological prophylactic drugs could be administered. Our study aimed to analyze the various perioperative factors associated with the development of POAF after coronary artery bypass graft (CABG) surgery. METHODS: This prospective study included 617 patients, who received CABG surgery in the year 2014. RESULTS: There were 429 (69.5%) male and 188 (30.5%) female patients. Mean patient age was 67.2 (9.4) years, and 365 patients (59.2%) were more than 65 years. Incidence of POAF was 24.1% (N = 149). Multivariable analysis showed that independent predictors of POAF after CABG surgery were: age >65 (P  = 0.008; OR 2.089; 95% CI 1.208-3.613), AF in the past (P < 0.001; OR 10.838; 95% CI 5.28-22.247), preoperative hypertrophy or dilation of left atrium (P = 0.002; OR 4.996; 95% CI 1.823-13.691), CABG surgery using 4 or more bypass grafts (P = 0.042; OR 1.669; 95% CI 0.972-2.866), preoperative hypokalemia (P = 0.001; OR 3.317; 95% CI 1.678-6.559), >trivial mitral (P = 0.024; OR 7.556; 95% CI 0.964-20.376), and aortic (P = 0.009; OR 1.937; 95% CI 1.178-3.187) valve regurgitation. CONCLUSIONS: The profile of patients affected by POAF was considerably different with regard to the demographics, preoperative heart condition, history of previous heart rhythm disorders, and operative data. The most important independent factors that predicted POAF after CABG surgery were associated with structural heart defects, advanced age, history of previous AF, and preoperative hypokalemia.

Non-ischaemic mitral valve suture annuloplasty: late follow-up results.

OBJECTIVE: To evaluate late outcomes after posterior mitral valve (MV) annulus double-suture annuloplasty for degenerative (non-ischaemic) MV insufficiency. DESIGN: Between 2005 and 2011, 138 patients underwent MV repair using posterior MV double-suture annuloplasty and an additional 105 patients underwent tricuspid valve repair. The study protocol included operative mortality, reoperation rate and reasons, as well as echocardiographic parameters at pre- and postoperative and follow-up periods (2-9 years). RESULTS: In-hospital mortality was 2/138 (1.45%). Early post operation, no regurgitation was noted in 74/136 (54.4%) patients, I(o) regurgitation was observed in 55/136 (40.4%), II(o) was observed in 6/136 (4.4%) and III(o) was observed in 1/136 (0.7%); during late follow-up (from 2 to 9 years), no regurgitation was observed in 21.6% patients, I(o) was observed in 58%, II(o) was observed in 17% and III(o) was observed in 3.4%. The mean preoperative anterolateral diameter of the MV annulus was 39.02±4.97 mm and, at late follow-up, it was 27.66±3.94 mm (p=0.000); at these same time points, left ventricular end-diastolic diameter (LVEDD) was 55.74±7.29 mm and 49.17±6.01 mm (p=0.000), respectively, and the left ventricular ejection fraction (LVEF) was 53.08±8.93% and 50.92±6.78%, respectively (p=0.007). CONCLUSIONS: This study demonstrates suture annuloplasty to be an effective treatment up to 9 years for degenerative mitral valve disease. This technique enables preservation of the posterior mitral valve annulus diameter with stable long-term (up to 9 years) reduction, a competent (no regurgitation/⩽II(o) regurgitation) MV in 96.6% of cases and positive left ventricular (LV) remodelling.

Do age, diabetes and left ventricular function affect the outcomes of ischemic mitral valve repair?

INTRODUCTION: It is well documented that older age, chronic concomitant diseases (such as diabetes mellitus, chronic obstructive lung disease, etc.), and poor left ventricular function can increase the postoperative complication rate and worsen the general outcomes of coronary artery bypass (CABG) and concomitant repair of ischemic mitral regurgitation (MR). MATERIAL AND METHODS: Retrospective data of 394 patients after CABG and mitral valve (MV) repair (mainly annuloplasty) were analyzed. Patients were grouped according to age, diabetes mellitus (DM), and left ventricular ejection fraction (LVEF). Echocardiography data, the rate of postoperative complications (cardiogenic shock, preoperative myocardial infarction, bleeding from the gastrointestinal tract, cognitive disorders, stroke, sepsis, deep wound infection), and early and late mortality were compared between paired groups. RESULTS: There were no differences between age groups in reverse positive remodeling of LV. A significantly higher incidence of sepsis and deep wound infection in younger patients was observed. Patients with DM had no change in the pre-postoperative NYHA class and a higher rate of perioperative MI (10.3% vs. 3.1% respectively, p < 0.05) in comparison to patients with no DM. In all LVEF groups, MR was significantly decreased, but reverse positive remodeling of LV was pronounced only in those with "poor" and "moderately lowered" LVEF. Postoperative complications did not differ among these three groups. CONCLUSIONS: Elderly age, concomitant DM and lowered LVEF do not influence either early or late mortality, including early postoperative outcomes after MV repair for ischemic MR following CABG. Concomitant DM increases the rate of perioperative MI and impairs reverse remodeling of LV.

Outcome of the first successful heart-lung transplantation in the Baltic countries.

Successful heart-lung complex transplantation was performed in a 48-year-old man. During the postoperative period, M. tuberculosis infection was diagnosed, and the treatment subsequently started. One year after, the patient was urgently hospitalized due to myocardial infarction. However, despite the best efforts, the patient died. Antituberculosis treatment is recommended to all the patients with confirmed active tuberculosis. Treatment of tuberculosis in transplant recipients is similar to that of the general population, with the exclusion of rifamycins in the regimen and longer duration of treatment.

[Ischemic cardiomyopathy: possibilities of surgical treatment]. / Isemine kardiomiopatija. Chirurginio gydymo galimybes.

The high morbidity and mortality in patients with serious heart failure is a therapeutic challenge for current medicine. The leading cause of left ventricular dysfunction remains ischemic heart disease. Coronary artery bypass surgery is a treatment of choice in moderate-to-severe ischemic cardiomyopathy. The scarcity of completed prospective randomized clinical trials and high surgical risks create significant uncertainty concerning the optimal current treatment strategy. The role of imaging techniques of assessment for myocardial viability based on current guidelines may be very important in clinical decision-making. Present paper reviews some of the relevant literature concerning surgical treatment of ischemic cardiomyopathy and current evidence-based recommendations on this method of treatment. In advanced heart failure, coronary revascularization alone is an insufficient treatment modality. In the presence of moderate-to-severe ischemic mitral regurgitation, mitral valve repair or replacement should be considered at coronary artery bypass grafting surgery. One of the most common mechanisms of ischemic mitral regurgitation is Carpentier's type IIIb dysfunction, in which an undersized mitral anuloplasty might be helpful. Surgery of left ventricular shape and volume restoration leads to improvement of left ventricular function in patients with ischemic cardiomyopathy. When the results from three ongoing prospective randomized studies--the Surgical Treatment for Ischemic Heart Disease trial, Heart Failure Revascularization trial, the PET and Recovery Following Revascularization-2 trial--determining outcome of revascularization versus medical therapy are available, clinicians will have reliable data for making decisions concerning the optimum treatment strategy. At present, the choice of management still remains based on the data obtained from available retrospective trials or the state of art in the field.

[The impact of uncorrected mitral insufficiency on left ventricle remodeling]. / Liekamojo iseminio mitralinio nesandarumo itaka kairiojo skilvelio remodeliavimuisi.

UNLABELLED: The aim of our study was to evaluate the influence of residual ischemic mitral insufficiency on patient's functional status and left ventricle remodeling after repair of ischemic mitral insufficiency. MATERIAL AND METHODS: The study group consisted of 95 out of 128 patients who underwent mitral valve repair for ischemic mitral insufficiency at the Department of Cardiac Surgery of the Heart Center of Kaunas University of Medicine in 1996-2002. The study protocol included general clinical data, patients NYHA functional class, pre, peri and postoperative echocardiographic data. RESULTS: In patients with residual MI (MR>or=2 grade) late postoperative left ventricle morphometric parameters, left ventricle ejection fraction and mean pulmonary artery pressure did not change. Size of left ventricle was reduced (left ventricle end diastolic diameter index decreased from 28.9+/-0.4 to 27.7+/-0.4 mm/m(2), p<0.001; left ventricle end systolic diameter index - from 22.2+/-0.6 to 19.7+/-0.7 mm/m(2), p<0.001), left ventricle ejection fraction increased (33.3+/-1.0 and 40.1+/-1.2%, p<0.0001), mean pulmonary artery pressure, NYHA functional class significantly decreased with MR<2 grade late postoperatively. CONCLUSIONS: Residual MR is important factor for further worsening of patient's functional status and progressing of left ventricle remodeling after combined surgery.

[Early complications and changes of left ventricular geometry and volume following two types of ventricular reconstruction: compression of scar zone and modified Dor aneurysmectomy]. / Ankstyvosios komplikacijos, kairiojo skilvelio geometrijos bei turio pokyciai po dvieju tipu skilvelio formos ir turio rekonstrukcijos: randines sienos kompresijos ir modifikuotos Doro aneurizmektomijos.

UNLABELLED: The aim of the study was to evaluate early complication rate and changes of left ventricular geometry and function after two types of left ventricular reconstruction surgery. METHODS: The study included 54 patients with ischemic heart disease and left ventricular aneurysm, who underwent coronary artery bypass grafting and left ventricular reconstruction surgery: I group (31 patients) underwent modified Dor aneurysmectomy and II group (23 patients) underwent infarcted wall compression. The study protocol included operative data, early postoperative complications and evaluation of left ventricular function 10(th)-14(th) day after surgery. RESULTS: Early complication rate had tendency to be higher in I group. Among patients with left ventricular ejection fraction <20%, in I group all 6 patients died, including 5 patients who underwent aneurysmectomy combined with mitral and tricuspid anuloplasty and 2 patients who underwent both apical aneurysmectomy and posterior wall compression, in II group - 1 of 3 patients died. Early changes of left ventricular geometry in I group included decrease in left ventricular diameter, volume, mass, as well as reduction of short axis of left atrium, in II group - decrease in left ventricular diameter, mass and both axis of left atrium. Left ventricular ejection fraction had tendency to increase in both groups: in 41.9% of patients in I group and in 56.5% in II group. CONCLUSIONS: Following different types of left ventricular reconstruction surgery early postoperative complications rate did not differ, except higher mortality rate in patients with left ventricular ejection fraction <20%, who underwent modified Dor aneurysmectomy combined with other surgical procedures. Early changes of left ventricular geometry and volume differed between patients who underwent different types of left ventricular reconstruction.

[Initial results of left ventricular remodelling operations]. / Kairiojo skilvelio remodeliavimo chirurginio gydymo rezultatai.

UNLABELLED: The aim of our study was to evaluate the initial results of left ventricular CABG and left ventricular remodelling operations. Study group consisted of 47 patients (pts) who underwent left ventricular geometry and volume restoration operations at the Kaunas University of Medicine Hospital during 1996 to 2002. Protocol included general clinical data, NYHA functional class, pre- and postoperative echocardiographic data, left ventricular aneurysm repair procedures. Pts mean age was 63.4+/-1.2 years. Men/women ratio 38/9. At admission NYHA functional class was 3.5+/-0.1. Mean left ventricular ejection fraction preoperatively was 24.2+/-0.9%, LV end diastolic diameter - 60.3+/-1.2 mm. Correction of left ventricular aneurysm consisted of: 1) direct aneurysmectomy - 11 pts, 2) endoventricular patch plasty - 7 pts, 3) circular suture - 19 pts, 4) aneurysmal reinforcement - 10 pts. RESULTS: Early postoperative NYHA functional class decreased from 3.5+/-0.1 to 2.8+/-0.1 (p<0.0001) and late postoperative to 2.7+/-0.2 (p<0.0001). Within 2 weeks LV morphometric parameters, left ventricular ejection fraction, mean pulmonary artery pressure didn't change significantly. There was a significant reduction of mitral regurgitation in all survivals from grade 2.5+/-0.1 to 1.4+/-0.2 (p<0.0001). Hospital mortality - 25.5%, late mortality - 22.2%. Late postoperative LV end diastolic and systolic diameters had a tendency to increase. All of the patients showed late postoperative increase in deceleration time from 0.13+/-0.01 to 0.18+/-0.02 s (p<0.05), decrease in degree of MR from 2.6+/-0.1 to 1.8+/-0.3 (p<0.05). LV systolic function has a tendency to increase from 25.6+/-1.4 to 29.1+/-1.4. In conclusion, effective LV surgical remodelling combined with CABG improves pts functional status: NYHA functional class, LV diastolic function. But the results of these combined cardiac operations are not so excellent. The hospital mortality remains high, correction of LV morphometric parameters is not preferable.

[Clinical, functional and prognostic evaluation of ischemic mitral insufficienty surgical correction]. / Iseminio mitralinio nesandarumo chirurginio gydymo velyvuju rezultatu ivertinimas.

UNLABELLED: The aim of our study was to evaluate the patients' (pts) survival, changes of functional status after repair of ischemic mitral insufficiency (IMI) and to determine their prognostic determinants. Study group consisted of 128 pts who underwent mitral valve (MV) repair for IMI at Kaunas University of Medicine hospital during 1996 to 2002. Study protocol included general clinical data, coronary artery involvement, patients NYHA functional class, pre, post and operative echocardiographic data, mitral valve repair procedures. RESULTS: There was a significant reduction of MR in all survivals from grade 2.8+/-0.1 to 1.5+/-0.1 (p<0.0001). All of the patients showed late postoperative increase in LVEF from 32.2+/-1.0 to 37.1+/-1.1% (p<0.0001). Late postoperative NYHA functional class changed significantly from 3.3+/-0.1 to 2.3+/-0.1 (p<0,0001). Two-year years survival without heart failure was 51.6+/-7.9%. Prognostic markers of late postoperative heart failure (II-IV NYHA functional class): LVEF/=II grade late postoperatively. Two-year years survival without residual MR was 51.1+/-7.8%. Predictors of late residual MR are early residual MR>I grade (p<0.0001), LVEF<30% early postoperatively (p<0.0001) and LVEDDI late postoperatively >/=28 mm/m(2) (p<0,01). Hospital mortality - 17.2%, late mortality - 7.9%. Two and four-year years survival after combined heart surgery - 66.7%. CONCLUSIONS: Repair of IMI - effective method in treating ischemic heart disease complicated with MV regurgitation: late postoperatively patients functional status improves, LVEF increase. Prognostic markers of late postoperative heart failure (II-IV NYHA functional class) are: LVEF/=II grade late postoperatively.