Refined balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension - reference center experience.

Introduction: Chronic thromboembolic pulmonary hypertension (CTEPH), characterized by thromboembolic changes affecting the pulmonary bed, leads to ventricular function deterioration and premature death. The introduction of balloon pulmonary angioplasty (BPA) has significantly improved the prognosis of CTEPH patients. Aim: The authors of this article decided to summarize the experience of the BPA program, conducted between 2014 and 2022, at the reference center. Material and methods: Among 111 CTEPH patients, 55 were included in the analysis. A total of 226 sessions were performed, with a significant percentage of intravascular imaging and pressure catheter use. Results: Mean pulmonary pressure decreased significantly from 42 (22-66) to 26.5 mm Hg (11-54) (p < 0.05). Pulmonary vascular resistance and natriuretic peptide concentration decreased from 6.67 (1.66-14) to 3.295 Wood units (1.09-11.11), respectively, and from 1934 (60-16963) to 296 (21-9901) ng/ml (p < 0.05). There was also an improvement in the functional class (WHO) from 2.85 ±0.61 to 2.15 ±0.62 and an increase in the 6-minute walking distance from 300 ±131 to 367 ±154 m (p < 0.05). There were no in-hospital deaths or within 30 days of the procedure. Arterial damage occurred during nine sessions (n = 9/226, 4%), while 0.9% (n = 2/226) were complicated by acute right ventricular failure. Post-reperfusion pulmonary edema (RPE 0 - none) was observed in almost 90% of the sessions, grade 1 to 3 RPE occurred in 10.2%, and grade 4 RPE was not noted. Conclusions: BPA programs conducted in experienced centers are a safe and effective treatment option for inoperable CTEPH patients.

Plasma Troponins Identify Patients with Very Low-Risk Acute Pulmonary Embolism.

INTRODUCTION: Although in the non-vitamin K oral anticoagulants (NOAC) era majority of low-risk acute pulmonary embolism (APE) patients can be treated at home, identifying those at very low risk of clinical deterioration may be challenging. We aimed to propose the risk stratification algorithm in sPESI 0 point APE patients, allowing them to select candidates for safe outpatient treatment. MATERIALS AND METHODS: Post hoc analysis of a prospective study of 1151 normotensive patients with at least segmental APE. In the final analysis, we included 409 sPESI 0 point patients. Cardiac troponin assessment and echocardiographic examination were performed immediately after admission. Right ventricular dysfunction was defined as the right ventricle/left ventricle ratio (RV/LV) > 1.0. The clinical endpoint (CE) included APE-related mortality and/or rescue thrombolysis and/or immediate surgical embolectomy in patients with clinical deterioration. RESULTS: CE occurred in four patients who had higher serum troponin levels than subjects with a favorable clinical course (troponin/ULN: 7.8 (6.4-9.4) vs. 0.2 (0-1.36) p = 0.000). Receiver operating characteristic (ROC) analysis showed that the area under the curve for troponin in the prediction of CE was 0.908 (95% CI 0.831-0.984; p < 0.001). We defined the cut-off value of troponin at >1.7 ULN with 100% PPV for CE. In univariate and multivariate analysis, elevated serum troponin level was associated with an increased risk of CE, whereas RV/LV > 1.0 was not. CONCLUSIONS: Solely clinical risk assessment in APE is insufficient, and patients with sPESI 0 points require further assessment based on myocardial damage biomarkers. Patients with troponin levels not exceeding 1.7 ULN constitute the group of "very low risk" with a good prognosis.

Electrocardiogram, Echocardiogram and NT-proBNP in Screening for Thromboembolism Pulmonary Hypertension in Patients after Pulmonary Embolism.

Background: The annual mortality of patients with untreated chronic thromboembolism pulmonary hypertension (CTEPH) is approximately 50% unless a timely diagnosis is followed by adequate treatment. In pulmonary embolism (PE) survivors with functional limitation, the diagnostic work-up starts with echocardiography. It is followed by lung scintigraphy and right heart catheterization. However, noninvasive tests providing diagnostic clues to CTEPH, or ascertaining this diagnosis as very unlikely, would be extremely useful since the majority of post PE functional limitations are caused by deconditioning. Methods: Patients after acute PE underwent a structured clinical evaluation with electrocardiogram, routine laboratory tests including NT-proBNP and echocardiography. The aim of this study was to verify whether the parameters from echocardiographic or perhaps electrocardiographic examination and NT-proBNP concentration best determine the risk of CTEPH. Results: Out of the total number of patients (n = 261, male n = 123) after PE who were included in the study, in the group of 155 patients (59.4%) with reported functional impairment, 13 patients (8.4%) had CTEPH and 7 PE survivors had chronic thromboembolic pulmonary disease (CTEPD) (4.5%). Echo parameters differed significantly between CTEPH/CTEPD cases and other symptomatic PE survivors. Patients with CTEPH/CTEPD also had higher levels of NT-proBNP (p = 0.022) but concentration of NT-proBNP above 125 pg/mL did not differentiate patients with CTEPH/CTEPD (p > 0.05). Additionally, the proportion of patients with right bundle brunch block registered in ECG was higher in the CTEPH/CTED group (23.5% vs. 5.8%, p = 0.034) but there were no differences between the other ECG characteristics of right ventricle overload. Conclusions: Screening for CTEPH/CTEPD should be performed in patients with reduced exercise tolerance compared to the pre PE period. It is not effective in asymptomatic PE survivors. Patients with CTEPH/CTED predominantly had abnormalities indicating chronic thromboembolism in the echocardiographic assessment. NT-proBNP and electrocardiographic characteristics of right ventricle overload proved to be insufficient in predicting CTEPH/CTEPD development.

A Novel Doppler TRPG/AcT Index Improves Echocardiographic Diagnosis of Pulmonary Hypertension after Pulmonary Embolism.

BACKGROUND: We hypothesized that a Doppler index, the ratio of tricuspid regurgitation peak gradient (TRPG) to pulmonary ejection acceleration time (AcT), improves the assessment of the echocardiographic probability of pulmonary hypertension in the identification of CTEPH and chronic thromboembolic pulmonary disease (CTED) in symptomatic patients after PE. Doppler echocardiography is recommended as the initial imaging tool for the diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH) after acute pulmonary embolism (PE). METHODS: We analyzed the data from 845 consecutive PE (468 women; 61 ± 18 years) survivors who completed at least 6 months of anticoagulation therapy. Here, 555 patients (325 women; 66 ± 16 years) reporting functional impairment (FI) underwent transthoracic echocardiography. We included 506 patients (297 women; age 63.4 ± 16.6 years) in whom both AcT and TRPG were available into the current study. The presence of a minimum of intermediate echocardiographic probability of PH necessitated the diagnosis of CTEPH. RESULTS: Echocardiography revealed a high echocardiographic probability of PH in 69 (13.6%) and intermediate echocardiographic probability in 109 (21.5%) patients. CTEPH was diagnosed in 35 (6.9%) patients and CTED in 22 (4.3%) patients. TRPG/AcT was significantly higher in the combined CTEPH + CTED group than in those with other causes of FI (0.412 (0.100-2.197) vs. 0.208 (0.026-0.115), p < 0.001), and the area under the receiver operating characteristic curve of the TRPG/AcT for CTEPH + CTED was 0.804 (95% confidence interval (CI): 0.731-0.876). Importantly, multiple logistic regression showed that TRPG/AcT is a significant predictor of CTEPH + CTED after considering echocardiographic probability (odds ratio = 1.51, 95% CI: 1.25-1.91, p < 0.001). Conditional inference trees analysis revealed that TRPG/AcT > 0.595 identified patients with CTEPH or CTED with a positive predictive value of 78.6% and negative predictive value of 92.7%. CONCLUSIONS: A Doppler index TRPG/AcT improves the assessment of symptomatic PE survivors. TRPG/AcT > 0.6 indicates a high probability of CTEPH or CTED, whereas TRPG/AcT < 0.6 allows for the safe exclusion of CTEPH + CTED in patients with a low echocardiographic probability of PH.

Defining right ventricular dysfunction by echocardiography in normotensive patients with pulmonary embolism.

INTRODUCTION: Although the prognostic value of various echocardiographic parameters of right ventricular dysfunction (RVD) was reported in normotensive patients with acute pulmonary embolism (PE), there is no generally accepted definition of RVD. OBJECTIVES: The aim of the study was to compare echocardiographic parameters for the prediction of an adverse 30­day outcome and create an optimal definition of RVD.                                     Patients and methods: Echocardiographic parameters including the right ventricular to left ventricular diameter ratio (RV to LV ratio) and tricuspid annular plane systolic excursion (TAPSE) to predict PE­related mortality, hemodynamic collapse, or rescue thrombolysis within the first 30 days were directly compared in 490 normotensive patients with PE. RESULTS: An adverse outcome (AO) was present in 31 patients (6.3%); 8 of them (1.6%) died due to PE. Systolic blood pressure, RV to LV ratio, and TAPSE were independent predictors of AO. The receiver operator characteristic yielded an area under the curve of 0.737 (0.654-0.819; P <0.001) for the RV to LV ratio and 0.75 (0.672-0.828; P <0.001) for TAPSE with regard to an AO. The hazard ratio for AO was 2.5 for the RV to LV ratio of more than 1 (95% CI, 1.2-5.7; P <0.03) and 3.8 for TAPSE of less than 16 mm (95% CI, 1.74-8.11; P = 0.001). A combined RVD criterion (TAPSE <16 mm and RV to LV ratio >1) was present in 60 patients (12%), and showed a positive predictive value of 23.3% with a high negative predictive value of 95.6% regarding an AO (HR, 6.5; 95% CI, 3.2-13.3; P <0.001). CONCLUSIONS: Defining RVD on echocardiography by the RV to LV ratio of more than 1 combined with TAPSE of less than 16 mm identified patients with an increased risk of 30­day PE­related mortality, hemodynamic collapse, or rescue thrombolysis, while patients without this sign had a very good 30­day prognosis.

Peak systolic velocity of tricuspid annulus is inferior to tricuspid annular plane systolic excursion for 30 days prediction of adverse outcome in acute pulmonary embolism.

BACKGROUND: Tricuspid annular plane systolic excursion (TAPSE) is an established index of right ventricular (RV) systolic function and a significant predictor in normotensive patients with pulmonary embolism (PE). Recently, Doppler tissue imaging-derived tricuspid annular systolic velocity (TV S'), a modern parameter of RV function was reported to be useful in the diagnosis and prognosis of a broad spectrum of heart diseases. Therefore, herein, is an analysis of the prognostic value of both parameters in normotensive PE patients. METHODS: One hundred and thirty nine consecutive PE patients (76 female, age 56.4 ± 19.5 years) were included in this study. All patients were initially anticoagulated. Transthoracic echocardiography was performed on admission. The study endpoint (SE) was defined as PE-related 30-day mortality and/or need for rescue thrombolysis. RESULTS: Seven (5%) patients who met the criteria for SE presented more severe RV dysfunction at echocardiography. Univariable Cox regression analysis showed that RV/LV ratio predicted SE with hazard risk (HR) 10.6 (1.4-80.0; p = 0.02); TAPSE and TV S' showed HR 0.77 (0.67-0.89), p < 0.001, and 0.71 (0.52-0.97), p = 0.03, respectively. Area under the curve for TAPSE in the prediction of SE was 0.881; 95% CI 0.812-0.932, p = 0.0001, for TV S' was 0.751; 95% CI 0.670-0.820, p = 0.001. Multivariable analysis showed that the optimal prediction model included TAPSE and systolic blood pressure (SBP showed HR 0.89 95% CI 0.83-0.95, p < 0.001 and TAPSE HR 0.67, 95% CI 0.52-0.87, p<0.03). Kaplan-Meier analysis showed that initially PE patients with TAPSE ≥ 18 mm had a much more favorable prognosis that patients with TAPSE < 18 mm (p < 0.01), while analysis of S' was only of borderline statistical significance. CONCLUSIONS: It seems that TV S' is inferior to TAPSE for 30 day prediction of adverse outcome in acute pulmonary embolism.

"The post-pulmonary syndrome - results of echocardiographic driven follow up after acute pulmonary embolism".

INTRODUCTION: The concept of post Pulmonary Embolism syndrome includes various combinations of functional, haemodynamic or imaging abnormalities in patients after pulmonary embolism (PE). Although residual obstruction of pulmonary vascular bed is suggested to be a major cause of post Pulmonary Embolism syndrome (post-PE syndrome) other cardiopulmonary abnormalities can be responsible for functional impairment. Therefore, we analyzed the frequency of post-PE syndrome and its potential causes. MATERIAL AND METHODS: We report data of consecutive 845 PE survivors (468 F, aged 62 ± 18 yrs) who were anticoagulated, and followed for at least 6 months. All symptomatic subjects at follow up underwent diagnostic workup. RESULTS: 35% (290/845) of PE survivors recovered functionally, while 65% patients reported a decreased exercise tolerance compatible with post-PE syndrome. One hundred and five symptomatic cases were lost to follow up. After diagnostic workup, chronic thromboembolic pulmonary hypertension (CTEPH) was diagnosed in 38 of 450 (8.4%) symptomatic subjects and chronic thromboembolic pulmonary disease (CTED) was diagnosed in 15/450 (3.3%) of them. Chronic heart failure with reduced ejection fraction (EF) was found in 6.9% (31/450) of patients and 154 patients (34.2%) had leftsided diastolic dysfunction. Valve heart disease was detected in 6.2% (28/450), atrial fibrillation in 31/450 (6.9%), Other causes of reduced exercise tolerance include coronary artery disease in 31/450 (6.9%), pulmonary disease 42/450 (9.3%), morbid obesity 15/450 (3.3%), neoplasms 15/450 (3.3%), psychiatric disorders 1%, rheumatoid disease 1%, anemia 1%. CONCLUSIONS: Approximately 65% of PE survivors report functional impairment, despite at least 6 months of anticoagulation. Persistent pulmonary artery thromboemboli resulting in CTEPH or CTED were detected in 7.2% of PE survivors and 11.8% of symptomatic patients. Leftsided diastolic dysfunction was the most prevalent echocardiographic abnormality, and remained the most common cause of functional limitation affected 34.2% of symptomatic cases.

Stress echocardiography. Part I: Stress echocardiography in coronary heart disease.

Stress echocardiography (stress echo) is a method in which various stimuli are used to elicit myocardial contractility or provoke cardiac ischemia with simultaneous echocardiographic image acquisition of left ventricular function and valvular flow, if needed. The technique is a well-recognized, safe and widely available stress test used for the diagnosis and assessment of prognosis in coronary heart disease, but may also prove valuable in valvular heart disease. The stressors used include physical exercise, pharmacological agents (dobutamine, vasodilators) and pacing stress, most often with the use of a permanent pacemaker. Two operators should perform the test: a physician experienced in stress echocardiography (at least 100 tests completed under supervision of an expert) and a trained nurse or another doctor. The laboratory should feature a defibrillator and a resuscitation kit with a set of pharmaceuticals, an intubation kit and an AMBU bag. Pacing stress echo requires an external programmer for the implanted permanent pacemaker. Exercise should be the preferred stressor for the diagnosis of ischemic heart disease with alternative of high-dose dobutamine test in cases of contraindications to physical stress. Pacing stress echo is recommended for patients with pacemakers, and dipyridamole test for the assessment of coronary flow reserve. Chest pain in patients with intermediate probability of coronary artery disease, inability to perform physical exercise and non-diagnostic resting or exercise electrocardiography are indications for stress echo. The test is also used in symptomatic patients after revascularization or patients qualified for revascularization for functional assessment of coronary artery stenosis. Low-dose dobutamine test is usually performed in patients after myocardial infarction or with moderate-to-severe left ventricular dysfunction to assess myocardial viability before potential revascularization.Stress echocardiography (stress echo) is a method in which various stimuli are used to elicit myocardial contractility or provoke cardiac ischemia with simultaneous echocardiographic image acquisition of left ventricular function and valvular flow, if needed. The technique is a well-recognized, safe and widely available stress test used for the diagnosis and assessment of prognosis in coronary heart disease, but may also prove valuable in valvular heart disease. The stressors used include physical exercise, pharmacological agents (dobutamine, vasodilators) and pacing stress, most often with the use of a permanent pacemaker. Two operators should perform the test: a physician experienced in stress echocardiography (at least 100 tests completed under supervision of an expert) and a trained nurse or another doctor. The laboratory should feature a defibrillator and a resuscitation kit with a set of pharmaceuticals, an intubation kit and an AMBU bag. Pacing stress echo requires an external programmer for the implanted permanent pacemaker. Exercise should be the preferred stressor for the diagnosis of ischemic heart disease with alternative of high-dose dobutamine test in cases of contraindications to physical stress. Pacing stress echo is recommended for patients with pacemakers, and dipyridamole test for the assessment of coronary flow reserve. Chest pain in patients with intermediate probability of coronary artery disease, inability to perform physical exercise and non-diagnostic resting or exercise electrocardiography are indications for stress echo. The test is also used in symptomatic patients after revascularization or patients qualified for revascularization for functional assessment of coronary artery stenosis. Low-dose dobutamine test is usually performed in patients after myocardial infarction or with moderate-to-severe left ventricular dysfunction to assess myocardial viability before potential revascularization.

Echocardiography in adults.

Transthoracic echocardiography is the primary non-invasive modality for anatomical and functional cardiac assessment. All one-, two-dimensional and Doppler modes use the same phenomenon, i.e. the piezoelectric effect, to visualize mobile cardiac structures and blood flow in cardiac cavities. Novel techniques for myocardial imaging, such as tissue Doppler and acoustic marker tracing, allow for the assessment of regional myocardial contractility of the left and the right ventricle. Cardiac assessment is performed in standard views characterized by an optimal acoustic window. The goal of each cardiac echo is to assess cardiac function and morphology using all available imaging modes. The evaluation of acquired valvular heart diseases should include morphological and functional changes indicative of the type (stenosis, regurgitation, complex defect) and the mechanism (Carpentier's classification of mitral regurgitation) of the defect, as well as its stage (mild, moderate, severe). The assessment of left and right ventricular function should involve the measurement of global and regional parameters. An echocardiographic report should also include information on septal continuity and the presence of additional structures or intracardiac masses.Transthoracic echocardiography is the primary non-invasive modality for anatomical and functional cardiac assessment. All one-, two-dimensional and Doppler modes use the same phenomenon, i.e. the piezoelectric effect, to visualize mobile cardiac structures and blood flow in cardiac cavities. Novel techniques for myocardial imaging, such as tissue Doppler and acoustic marker tracing, allow for the assessment of regional myocardial contractility of the left and the right ventricle. Cardiac assessment is performed in standard views characterized by an optimal acoustic window. The goal of each cardiac echo is to assess cardiac function and morphology using all available imaging modes. The evaluation of acquired valvular heart diseases should include morphological and functional changes indicative of the type (stenosis, regurgitation, complex defect) and the mechanism (Carpentier's classification of mitral regurgitation) of the defect, as well as its stage (mild, moderate, severe). The assessment of left and right ventricular function should involve the measurement of global and regional parameters. An echocardiographic report should also include information on septal continuity and the presence of additional structures or intracardiac masses.

Balloon pulmonary angioplasty - efficient therapy of chronic thromboembolic pulmonary hypertension in the patient with advanced sarcoidosis - a case report.

BACKGROUND: Approximately a quarter of patients with advanced sarcoidosis develop pulmonary hypertension (PH), which affects their prognosis. We report unusual case of confirmed chronic thromboembolic pulmonary hypertension (CTEPH) in a patient with stage IV sarcoidosis successfully treated with balloon pulmonary angioplasty (BPA). CASE PRESENTATION: A 65 years old male with a history of colitis ulcerosa, and pulmonary sarcoidosis diagnosed in 10 years before, on long term oral steroids, with a history of deep vein thrombosis and acute pulmonary embolism chronically anticoagulated was referred to our center due to severe dyspnea. On admission he presented WHO functional class IV, mean pulmonary artery pressure (mPAP) in right heart catheterization (RHC) was elevated to 54 mmHg. Diagnosis of CTEPH was definitely confirmed with typical V/Q scan, and with selective pulmonary angiography (PAG) completes by intravascular imagining (intravascular ultrasound, optical coherent tomography). The patient was deemed inoperable by CTEPH team and two sessions of BPA with multimodal approach resulted in significant clinical and haemodynamical improvement to WHO class II and mPAP decrease to 27 mmHg. CONCLUSIONS: Balloon pulmonary angioplasty, rapidly developing method of treatment of inoperable CTEPH patients, is also extremely useful therapeutic tool in complex PH patients.

Tricuspid Regurgitation Peak Gradient (TRPG)/Tricuspid Annulus Plane Systolic Excursion (TAPSE)　- A Novel Parameter for Stepwise Echocardiographic Risk Stratification in Normotensive Patients With Acute Pulmonary Embolism.

BACKGROUND: Patients with intermediate-risk acute pulmonary embolism (APE) are a heterogeneous group with an early mortality rate of 2-15%. The tricuspid annulus plane systolic excursion (TAPSE) and tricuspid regurgitation peak gradient (TRPG) can be used for risk stratification, so we analyzed the prognostic value of a new echo parameter (TRPG/TAPSE) for prediction of APE-related 30-day death or need for rescue thrombolysis in initially normotensive APE patients.Methods and Results:The study group consists of 400 non-high-risk APE patients (191 men, age: 63.1±18.9 years) who had undergone echocardiography within the first 24 h of admission. The TRPG/TAPSE parameter was calculated. The clinical endpoint (CE) was a combination of 30-day APE-related death and/or rescue thrombolysis. The CE occurred in 8 (2%) patients. All patients with TAPSE ≥20 mm (n=193, 48.2%) had a good prognosis. Among 206 patients with TAPSE <20 mm, 8 cases of the CE occurred (3.9%). NPV and PPV for TRPG/TAPSE >4.5 were 0.2 and 0.98, respectively. The CE was significantly more frequent in 19 (9.2%) patients with TRPG/TAPSE >4.5 than in 188 (90.8%) with TRPG/TAPSE ≤4.5 (4 (21.1%) vs. 4 (2.1%), P=0.0005). Among normotensive APE patients with TAPSE <20 mm, TRPG/TAPSE >4.5 was associated with 21.1% risk of APE-related death or rescue thrombolysis. CONCLUSIONS: TRPG/TAPSE, a novel echocardiographic parameter, may be useful for stepwise echocardiographic risk stratification in normotensive patients with APE, and it identifies patients with a poor prognosis.

Management of high risk pulmonary embolism - a single center experience.

BACKGROUND AND AIM: Patients with acute pulmonary embolism (APE) associated with hemodynamic instability, i.e. high-risk APE (HR-APE), are at risk for early mortality and require urgent reperfusion therapy with thrombolysis or embolectomy. However, a considerable proportion of HR-APE subjects is not reperfused but only anticoagulated due to high bleeding risk. The aim of the present study was to assess the management of HR-APE in a single large-volume referral center. METHODS: A single-center retrospective study of 32 HR-APE subjects identified among 823 consecutive patients hospitalized for symptomatic APE. RESULTS: Out of 32 subjects with HR-APE (19 women, age 69 ± 19 years), 20 patients were unstable at admission and 12 subsequently deteriorated despite on-going anticoagulation. Thrombolysis was applied in 20 (62.5%) of HR-APE subjects, limited mainly by classical contraindications in the remainder. Percutaneous pulmonary embolectomy was performed in 4 patients. In-hospital PE-related mortality tended to be higher, albeit insignificantly, in the patients who developed hemodynamic collapse during the hospital course compared to those unstable at admission (67% vs. 40%, p = 0.14). Also, survival was slightly better in 22 patients treated with thrombolysis or percutaneous embolectomy in comparison to 10 subjects who received only anticoagulation (54% vs. 40%, p = 0.2). Major non-fatal bleedings occurred in 7 of 20 patients receiving thrombolysis (35%) and in 2 (17%) of the remaining non-thrombolysed 12 HR-APE subjects. CONCLUSIONS: Hemodynamically instability, corresponding to the definition of HR-APE, affects about 4% of patients with APE, developing during the hospital course in approximately one-third of HR-APE subjects. As almost 40% of patients with HR-APE do not receive thrombolytic therapy for fear of bleeding, urgent percutaneous catheter-assisted embolectomy may increase the percentage of patients with HR-APE undergoing reperfusion therapy. Further studies are warranted for a proper identification of initially stable intermediate-risk APE subjects at risk of hemodynamic collapse despite appropriate anticoagulation.

Improvement of left ventricular diastolic function and left heart morphology in young women with morbid obesity six months after bariatric surgery.

BACKGROUND: Obesity contributes to left ventricular (LV) diastolic dysfunction (LVDD) and may lead to diastolic heart failure. Weight loss (WL) after bariatric surgery (BS) may influence LV morphology and function. Using echocardiography, this study assessed the effect of WL on LV diastolic function (LVDF) and LV and left atrium (LA) morphology 6 months after BS in young women with morbid obesity. METHODS: Echocardiography was performed in 60 women with body mass index ≥ 40 kg/m², aged 37.1 ± ± 9.6 years prior to and 6 months after BS. In 38 patients, well-controlled arterial hypertension was present. Heart failure, coronary artery disease, atrial fibrillation and mitral stenosis were exclusion criteria. Parameters of LV and LA morphology were obtained. To evaluate LVDF, mitral peak early (E) and atrial (A) velocities, E-deceleration time (DcT), pulmonary vein S, D and A reversal velocities were measured. Peak early diastolic mitral annular velocities (E') and E/E' were assessed. RESULTS: Mean WL post BS was 35.7 kg (27%). A postoperative decrease in LV wall thickness, LV mass (mean 183.7 to 171.5 g, p = 0.001) and LA parameters (area, volume) were observed. LVDD was diagnosed in 3 patients prior to and in 2 of them subsequent to the procedure. An improvement in LVDF Doppler indices were noted: increased E/A, D and E' lateral, and decreased S/D and lateral E/E'. None of the patients showed increased LV filling pressure. No significant correlations between hypertension and echo-parameters were demonstrated. CONCLUSIONS: Six months after BS weight loss resulted in the improvement of LVDF and left heart morphology in morbidly obese women. (Cardiol J 2018; 25, 1: 97-105).

Favourable pregnancy outcome in a woman with secondary pulmonary hypertension complicating mitral stenosis.

Pulmonary hypertension (PH) is a rare condition with a high incidence of maternal and perinatal mortality (30-56% and 10-13%, respectively). Pulmonary hypertension is a contraindication to pregnancy because of high risk of maternal death, therefore the World Health Organisation (WHO) advises to discuss a termination in the event of pregnancy with women suffering from PH.

Refined balloon pulmonary angioplasty-A therapeutic option in very elderly patients with chronic thromboembolic pulmonary hypertension.

INTRODUCTION/OBJECTIVES: Balloon pulmonary angioplasty (BPA) is a developing treatment for inoperable chronic thromboembolic pulmonary hypertension (CTEPH). However, to our knowledge there are no published data on BPA in CTEPH subjects aged 75 or over. The aim of the study was to analyze clinical and hemodynamic outcomes of sequential BPA in very elderly patients disqualified from pulmonary endarterectomy (PEA). PATIENTS AND METHODS: We enrolled 10 patients (4 male, 6 female, median age 81 [75-88]) with confirmed CTEPH, mPAP > 30 mmHg, and WHO class > II, disqualified from PEA. Overall, 10 patients underwent 39 BPA sessions (mean 3.9 sessions per patient, range 1-9), and 70 pulmonary arteries were dilated, (mean 6.5 vessels per patient, range 1-14). RESULTS: Pulmonary angioplasty resulted in significant clinical and hemodynamic improvement in every patient: 6 MWT distance increased from a median of 221 m (80-320) to 345 (230-455) and plasma NT-proBNP levels decreased (P < 0.01). Sequential BPA resulted in normalization of mPAP (<25 mmHg) in 6 of 10 patients and mPAP decreased to 25-30 mmHg in three others. In the whole group mPAP decreased from 41 (31-53) mmHg to 23 (17-33) mmHg (P < 0.01). Overall, mean PAP and PVR decreased significantly in all cases, while CO and CI increased (P < 0.01). No severe complications occurred during BPA and over a median follow-up of 553 days (range 81-784), and all patients are still alive and in good general health. CONCLUSION: This study demonstrated the safety and efficacy of refined BPA in CTEPH patients aged 75 or over, disqualified from PEA. Refined BPA may emerge as an alternative therapeutic strategy in very elderly CTEPH patients who are suitable for surgery, but this requires further validation in a large prospective study.

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.

High prevalence of severe coronary artery disease in elderly patients with non-operable chronic thromboembolic pulmonary hypertension referred for balloon pulmonary angioplasty.

INTRODUCTION: Balloon pulmonary angioplasty (BPA) is a new emerging catheter-based alternative treatment option for patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH). AIM: To show that all elderly CTEPH patients referred for BPA are at higher risk of obstructive coronary artery disease and that, in daily practice, they should undergo invasive coronary angiography. MATERIAL AND METHODS: Eleven patients at the age of at least 65 years (6 males, 5 females, 77.2 ±5.9 years) with confirmed non-operable type II or type III CTEPH, considered for BPA, underwent elective coronary angiography. Severe obstructive coronary artery disease (CAD) was diagnosed when stenosis of left main coronary artery ≥ 50% or stenosis of ≥ 70% of epicardial arteries was angiographically confirmed. We also screened for CAD consecutive age- and sex-matched 114 PE survivors (52 males, 62 females, 74.8 ±7.2 years) with excluded CTEPH. RESULTS: Severe CAD was more frequent in elderly patients with non-operable type II or type III CTEPH candidates for BPA than in elderly acute PE survivors with excluded CTEPH (54.5% vs. 16.7%, p < 0.01), and therefore elderly CTEPH patients referred for BPA were at higher risk of CAD (OR = 5.9, 95% CI: 1.64-21.46, p = 0.007) when compared to elderly survivors after acute PE with excluded CTEPH. CONCLUSIONS: All elderly CTEPH patients referred for BPA are at higher risk of severe CAD and should routinely undergo invasive coronary angiography before BPA.