Early echocardiographic results of transapical off-pump mitral valve repair with the NeoChord DS1000 device in patients with severe mitral regurgitation due to posterior leaflet prolapse: first experiences in Poland.

INTRODUCTION: Minimally invasive techniques of mitral valve (MV) repair have been increasingly used in recent years. Transapical implantation of artificial chordae on a beating heart under 2D/3D transesophageal echocardiographic guidance with the NeoChord DS1000 device is a new surgical treatment of degenerative mitral regurgitation (MR). AIM: To evaluate early results of MV repair with the NeoChord DS1000 device in the first group of consecutive patients operated on in Poland. MATERIAL AND METHODS: Twenty-one patients with severe MR due to posterior leaflet prolapse (81% male; mean age: 60.7 ±12.7 years) underwent MV repair with the NeoChord DS1000 system. There were 12 (57.1%) patients with type A (an isolated central prolapse/flail), 8 (38.1%) patients with type B (multisegment disease/flail) and 1 (4.8%) patient with type C (posterior/paracommisural area) MV prolapse. A flail leaflet was present in 12 (57.1%) patients. The median number of neochords was 3 (2-6). We assessed by echocardiography left-sided heart morphology and evaluated MR degree before and 6 months after chords implantation. RESULTS: Early procedural success was achieved in 100% of patients. At the 6-month follow-up nonsignificant MR (trace and mild) was detected in 17 (81.0%) patients, while moderate MR was detected in 4 (19.0%) patients; mean values of left-sided heart dimensions and volumes, mitral E and E' velocity of lateral MV annulus significantly decreased. CONCLUSIONS: A novel procedure with the NeoChord DS1000 device is feasible in properly selected patients, and results in a significant reduction of MR degree and left ventricle and left atrium reverse remodeling at the 6-month follow-up.

Transapical beating heart mitral valve repair with the NeoChord system: early outcomes of a single-center experience.

INTRODUCTION: Trans-apical beating heart off-pump mitral valve (MV) repair is a novel surgical technique for treating mitral regurgitation (MR) caused by degenerative flail/prolapse (DLP). AIM: To present early outcomes of a single-center experience with transapical beating heart mitral valve repair with the NeoChord system. MATERIAL AND METHODS: Thirty-seven patients with severe symptomatic MR were treated with the NeoChord technique between September 2015 and December 2018 (78% men; mean age: 62.3 ±13.4 years). We evaluated standard cardiac surgery perioperative complications as well as those related to the NeoChord technique as well as early surgical success as defined by the reduction of MR to less than moderate by implantation of at least 2 neochordae. RESULTS: During this series we had no hemodynamic instability due to bleeding or arrhythmia. There were no transapical technique-related adverse events such as a leaflet perforation or tear, a major native chord rupture, which would require implantation of a new chord, ventricular apex rupture, or left atrial perforation. There were no major adverse events including death, stroke or acute myocardial infarction. Nine (24%) patients developed an episode of perioperative atrial fibrillation. We were able to conclude the operation in 98% of our patients with less than moderate MR. One (2%) patient had moderate MR at the conclusion of the operation. CONCLUSIONS: Trans-apical off-pump MV repair with the NeoChord system is a safe, minimally invasive procedure, with few minor complications. In well-selected candidates it provides successful treatment of degenerative MR. Results are anatomy dependent, so preoperative patient selection is crucial.

Transapical off-pump mitral valve repair. First experience with the NeoChord system in Poland (report of two cases).

BACKGROUND: Artificial chord implantation to repair a flail or prolapsing mitral valve leaflet requires open heart surgery and cardiopulmonary bypass. AIM: Transapical off-pump artificial chordae implantation is a new surgical technique proposed to treat degenerative mitral valve regurgitation. The procedure is performed using the NeoChord DS1000 system (NeoChord, Inc., St. Louis Park, MN, USA), which facilitates both implantation and lenght adjustment of the artificial chordae under two (2D)- and three (3D)-dimensional transoesophageal echocardiographic (TEE) guidance on a beating heart. METHODS: Two male patients aged 60 and 55 years with severe mitral regurgitation due to posterior leaflet prolapse underwent transapical off-pump artificial chordae implantation on September 3, 2015. The procedure was performed by left minithoracotomy under general anaesthesia in a cardiac surgical theatre, using 2D and 3D TEE guidance. RESULTS: Early procedural success as confirmed by 3D TEE was achieved in both patients, with implantation of 6 artificial chordae in the first patient and 3 artificial chordae in the second patient. Both procedures were uneventful, and no postoperative complications were noted. The patients were discharged home on the 8th and 6th postoperative day, respectively. CONCLUSIONS: The NeoChord DS1000 system allows both implantation and lenght adjustment of artificial chordae under 2D and 3D TEE guidance on a beating heart. Our initial experience in 2 patients with posterior mitral leaflet prolapse indicates that the procedure is feasible and safe.

Evaluation of brain lesions in patients after coronary artery bypass grafting using MRI with the emphasis on susceptibility-weighted imaging.

INTRODUCTION: Patients undergoing coronary artery bypass grafting (CABG) are at risk of strokes and neurocognitive disorders. THE AIM OF THE STUDY: The aim of the study was to assess the clinical utility of susceptibility-weighted imaging (SWI) MRI in detection of new brain lesions in patients after CABG. We assessed the incidence and types of brain lesions and correlated the data with neurological examinations in groups of patients who underwent on-pump and off-pump CABG. MATERIAL AND METHODS: Patients underwent a neurological examination and MRI before, 6-20 days after and 6 months after the CABG. Fifty-one patients (43 men, mean age 63.12 years) were analyzed. RESULTS: Fifteen (29.4%) patients underwent on-pump CABG, 36 (70.6%) off-pump CABG. On postoperative scans new lesions were detected in 12 (23.5%) patients. Ischemic lesions (visible on diffusion-weighted imaging [DWI]) were detected in 4 patients, in 6 lesions were visible on SWI, in 1 case lesions were visible on SWI and DWI. Hemorrhagic stroke was observed in 1 patient. In the group of patients who underwent on-pump CABG, new brain lesions were observed in 60.0% of patients vs. 8.3% of those who underwent off-pump CABG (p < 0.0001); these changes more frequently were multiple (p < 0.0013) and located infratentorially (p < 0.0218). Lesions visible on SWI were observed only in patients undergoing on-pump CABG (p = 0.00005). In all patients (except for 1 with stroke), lesions visible in MRI were clinically silent. CONCLUSIONS: The use of SWI enables one to detect lesions occurring in the brain after CABG, invisible in other sequences. On-pump CABG is associated with a greater risk of clinically silent brain damage compared to off-pump CABG.

PPAR Gamma Expression Levels during Development of Heart Failure in Patients with Coronary Artery Disease after Coronary Artery Bypass-Grafting.

Genetic research has elucidated molecular mechanisms of heart failure (HF). Peroxisome proliferator-activated receptors (PPARs) seem to be important in etiology of HF. The aim of study was to find the correlation between PPARγ expression during development of HF in patients and coronary artery disease (CAD) after coronary artery bypass-grafting (CABG). Methods and Results. We followed up 157 patients (mean age 63) with CAD without clinical, laboratory, or echo parameters of HF who underwent CABG. Clinical and laboratory status were assessed before CABG and at 1, 12, and 24 months. During CABG slices of aorta (Ao) and LV were collected for genetic research. HF was defined as LVEF <40% or NT-proBNP >400 pg/mL or 6MWT <400 m. Patients were divided into 2 groups: with and without HF. PPARγ expression in Ao and LV was not increased in both groups at 2-year follow-up. Sensitivity of PPARγ expression in Ao above 1.1075 in detection of HF was 20.5% (AUC 0.531, 95% CI 0.442-0.619). Positive predictive value (Ppv) was 85.7%. Sensitivity and specificity of PPARγ expression in the LV in detection of HF were 58% and 92.9%, respectively (AUC 0.540, 95% CI 0.452-0.626). Ppv was 73.2%. Conclusion. PPARγ expression in Ao and LV was comparable and should not be used as predictive factor for development of HF in patients with CAD after CABG.

Coronary computed tomographic angiography for prediction of procedural and intermediate outcome of bypass grafting to left anterior descending artery occlusion with failed visualization on conventional angiography.

Conventional coronary angiography (CCA) has considerable limitations regarding visualization of distal vessel segments in chronic total occlusion. We assessed the ability of coronary computed tomographic angiography (CCTA) to predict the success of coronary artery bypass grafting (CABG) to the chronically occluded left anterior descending coronary artery (LAD) incompletely visualized on CCA. Thirty symptomatic patients rejected for CABG on the basis of the CCA findings underwent preoperative CCTA before intended transmyocardial laser revascularization. The LAD was explored operatively in all patients, and CABG to the LAD was attempted if the distal vessel was suitable for anastomosis. The procedural outcome of CABG and the 6-month patency of the left internal mammary artery graft at follow-up CCTA were defined as the primary and secondary end point, respectively. The primary and secondary end points were achieved in 80% and 77% of patients, respectively. We found a significant correlation between the intraoperative and computed tomographic measurement of distal LAD diameter (R = 0.428, p = 0.037). On multivariate analysis, the maximum diameter of the distal LAD by CCTA (odds ratio 8.16, p = 0.043) was the only independent correlate of procedural success of CABG. A cutoff value of 1.5 mm for the mean distal LAD diameter predicted left internal mammary artery graft patency with 100% specificity and 83% sensitivity. Successful CABG resulted in significant improvements in angina class and left ventricular function in LAD segments at 6 months of follow-up. In conclusion, CCTA predicted both the procedural and the intermediate outcome of CABG to chronic LAD occlusion with failed visualization on CCA.

Computed tomography to predict surgical revascularization of a left anterior descending artery occlusion incompletely visualized by conventional angiography.

PURPOSE: Previous studies demonstrated that failure to visualize distal chronic total occlusion in conventional coronary angiography (CCA) does not preclude procedural success of coronary artery bypass grafting (CABG). We assessed the utility of computed tomography angiography (CTA) in guiding CABG to the occluded left anterior descending artery (LAD) incompletely visualized by CCA. MATERIALS AND METHODS: Twenty-four symptomatic patients rejected for revascularization of an occluded LAD on the basis of CCA underwent a preoperative CTA before intended transmyocardial laser revascularization. Off-pump CABG to the LAD was attempted in all patients depending on the intraoperative findings. The primary outcome was defined as procedural success of CABG to the LAD. RESULTS: The success rate for CABG was 79.2%. By CCA, Rentrop 0/1 was present in 6 patients (25%), whereas Rentrop 2 was present in 18 patients (75%). By CTA, Rentrop 3 was seen in all patients. Compared with the CABG-failure group, the CABG-success group showed a larger mean distal LAD diameter (1.7 ± 0.2 mm vs. 1.3 ± 0.1 mm; P=0.001). By receiver-operating curve analysis, a cutoff value of 1.5 mm for the mean distal LAD diameter predicted CABG availability with 100% specificity and 95% sensitivity. The distal LAD short length and intramyocardial course were other significant correlates of CABG failure compared with CABG success (60% vs. 5.3%, P=0.018; 80% vs. 0%, P<0.001). CONCLUSIONS: Noninvasive CTA is not only superior to CCA in delineating distal coronary occlusion but also very precisely predicts the procedural success of CABG. CTA represents a robust evaluation tool for coronary mapping of chronic total occlusion with doubtful distal anatomy in CCA.

Coronary artery fistula in a 70 year-old woman with myocardial infarction.

Coronary artery fistulas are infrequent congenital malformations. We present the case of a patient with acute coronary syndrome and fistula between the proximal left anterior descending artery (LAD) and the pulmonary artery. The fistula was diagnosed during coronary angiography. Its presence and morphology was confirmed by a 64-slice computer tomography scan. The patient underwent a successful coronary artery bypass grafting procedure with surgical closure of the fistula.

Does contrast agent injection during trans-catheter aortic valve implantation negatively affect kidney function?

BACKGROUND: Trans-catheter aortic valve implantation (TAVI) has recently emerged as an alternative to conventional surgery in high-risk surgical patients with haemodynamically significant aortic valve stenosis. However, patients referred for TAVI are usually elderly individuals (> 80 years) who frequently also suffer from renal impairment. Trans-catheter valve therapies require extensive use of contrast injections with a risk of nephrotoxicity. AIM: To evaluate post-TAVI renal function and to determine whether the exposure to contrast injections might cause reduced kidney function and contrast-induced nephropathy. METHODS: From January 2009 to September 2010, TAVI was performed in 39 patients (26 women and 13 men). The mean age of the patients was 81.43 ± 7.39 years, and the mean volume of contrast material administered was 187.95 ± 91.34 mL. Serum creatinine and glomerular filtration rate (GFR, acc. to the MDRD formula) were estimated in all patients prior to and 1, 2, and 5-8 days after TAVI. RESULTS: Two female patients died on postoperative day 1. Other patients did not show clinically significant reduction in renal function following the procedure (mean creatinine concentration 104.46 vs 99.77 vs 94.56 vs 93.64 mmol/L, NS and mean GFR 52.37 vs 56.63 vs 60.18 vs 61.34 mL/min/1.73 m², NS). CONCLUSIONS: 1. The TAVI procedure, which includes contrast injection does not seem to cause a clinically significant decrease of renal function. 2. None of our elderly patients with severe aortic valve stenosis, multiple co-morbidities, and pre- TAVI renal compromise developed contrast-induced nephropathy.

Transcatheter aortic valve implantation using transfemoral/transsubclavian or transapical approach: 30-day follow-up of the initial 30 patients.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is a new method for the treatment of aortic stenosis (AS). AIM: To evaluate early results of TAVI using transfemoral/transsubclavian approach (TFA/TSA) or transapical approach (TAA) in patients with severe AS and high risk for surgical aortic valve replacement. METHODS: Between January 2009 and May 2010, 30 high-risk patients underwent TAVI. The primary treatment option was TFA, and TAA was used if contraindications to TFA were present; one patient underwent the procedure using TSA. Reasons for selecting TAA were as follows: small diameter (<7 mm) and/or severe calcification of the iliofemoral arteries, peripheral atherosclerosis, "porcelain" aorta and a horizontal course of the ascending aorta. Edwards-Sapien or CoreValve devices were used in all cases, and procedures were performed without the use of cardiopulmonary bypass in a cardiac catheterisation laboratory. RESULTS: Mean patient age was 82.46 ± 5.79 years, mean NYHA class was 3.23 ± 0.41, and predicted mean surgical mortality using logistic Euroscore was 29.18 ± 16.9% (22.72 ± 12.07% in the TFA/TSA group vs 34.6 ± 15.4% in the TAA group; p = 0.031). Eleven patients were treated using TAA. The valve was implanted successfully in 96% of patients. Inhospital mortality was 3.3%. Mean 30-day mortality was 6.6% in the entire cohort, 0% in the TFA/TSA group and 18% in the TAA group. There were no cases of periprocedural myocardial infarction (MI), cardiogenic shock, stroke/transient ischaemic attack, or need for cardiopulmonary resuscitation. One patient died suddenly three weeks after the procedure; except for this case, there were no major adverse cardiovascular events (MACCE: MI, cerebrovascular accident, re-do procedure) at 30-day follow-up. The TAVI was associated with a significant reduction in the mean maximal aortic gradient in both groups (from 99.6 ± 22.07 mm Hg to 21.83 ± 9.38 mm Hg post-procedure and to 23.25 ± 9.22 mm Hg at 30-day follow up), with no cases of severe aortic valve regurgitation. The NYHA class at 30 days improved from 3.23 ± 0.41 to 1.72 ± 0.52 (p = 0.03). CONCLUSIONS: Our results demonstrate lower 30-day complication rate and mortality in the TFA/TSA group. The availability of several techniques of valve implantation in the group of non-surgical patients with severe AS potentially broadens the patient population with indications for this treatment.

Coronary computed tomography angiography without catheter angiography before bypass surgery in a patient with diffuse aortic atherosclerosis.

Patients with atheromatous plaques of the thoracic aorta undergoing coronary angiography are subjected to a substantial risk of catheter-related stroke or peripheral embolism. We describe a 49-year-old male patient with class III angina symptoms and extensive aortic plaque burden referred for coronary computed tomography angiography due to a high risk of catheterization-related cerebrovascular complications. On the basis of computed tomography angiography findings, the final decision on coronary artery bypass grafting with a modification of the surgical approach was made.

Computed tomography angiography for visualisation of distal coronary arteries and selection for surgical revascularisation in a patient with acute myocardial infarction.

Patients with symptomatic multivessel coronary artery disease rejected for coronary revascularisation have adverse prognosis. We describe a 61 year-old male with non-ST-elevation myocardial infarction who was considered unsuitable for coronary revascularisation based on the conventional angiography findings. Unlike conventional angiography, computed tomography angiography visualised distal coronary segments and the patient underwent successful coronary artery bypass grafting.

Giant metastatic intrapericardial tumor 20 years after nephrectomy.

We present a rare case of giant, metastatic renal cell carcinoma of the pericardium diagnosed 20 years after nephrectomy. An endovascular procedure was used to place coils preoperatively in the large collateral vessels supplying the tumor to achieve mass reduction and reduce intraoperative bleeding. The tumor was resected through a median sternotomy, and the patient's recovery was uneventful. Preoperative coil placement in the tumoral arteries enabled a safe and bloodless resection in this rare presentation.

[POL-TAVI First--Polish report on transcatheter aortic valve implantation (TAVI) of Edwards-Sapien prosthesis in the first 19 high risk patients with severe aortic stenosis and comorbidities]. / Nasze forum--kardiolodzy i kardiochirurdzy razem Raport POL-TAVI FIRST z zastosowania przezcewnikowej implantacji zastawki aortalnej typu Edwards-Sapien u pierwszych w Polsce 19 chorych z grupy bardzo duzego ryzyka, z ciezka stenoza aortalna i chorobami obciazajacymi rokowanie.

Patients with severe symptomatic aortic stenosis, who from November 2008 to March 2009 were treated with Edwards-Sapien transcatheter aortic valve implantation (TAVI) within the POL-TAVI First Polish Registry, were included in the analysis. Nineteen patients aged 78+/-4.8 years with high operation risk and Logistic EuroSCORE 25+/-7.6% were reported (74% were females). In 15 (79%) patients the valve was implanted transapically (TA), in the other four (21%)--via the femoral arterial access (TF). The valve was successfully implanted in 16 (84%) patients, in one patient aortic valvuloplasty alone was performed. During in-hospital period two patients died (one during periprocedural period and another one--two months after the implantation). During the mean follow-up of 5+/-1.5 months (except for one patient who is still in hospital) all patients are in NYHA class I or II. Results of the initial series of 19 TAVI patients in Poland are satisfactory, and the trial will be continued with careful medical and economical analysis.