Gender Differences in Survival after Coronary Artery Bypass Grafting-13-Year Results from KROK Registry.

The influence of gender on both early and long-term outcomes of coronary artery bypass grafting (CABG) is not clearly defined. Objectives: This study aimed to assess the impact of gender on early and long-term mortality after CABG using data from the KROK Registry. Methods: All 133,973 adult patients who underwent CABG in Poland between 1 January 2009 and 31 December 2019 were included in the Polish National Registry of Cardiac Surgical Procedures (KROK Registry). The study enrolled 90,541 patients: 68,401 men (75.55%) and 22,140 women (24.45%) who met the inclusion criteria. Then, 30-day mortality, 1-year mortality, and long-term mortality rates were compared. Results: Advanced age, higher Canadian Cardiovascular Society (CCS) and New York Heart Association (NYHA) grade, diabetes, hypercholesterolemia, arterial hypertension, body mass index BMI > 35 kg/m2, and renal failure, before the propensity matching, were more frequently observed in women. Women more frequently underwent urgent surgery, including single and double graft surgery, and off-pump CABG (OPCAB) (p < 0.001). In propensity-matched groups, early mortality (30 days) was significantly higher in women (3.4% versus 2.8%, p < 0.001). The annual mortality remained higher in this group (6.6% versus 6.0%, p = 0.025). However, long-term mortality differed significantly between the groups and was higher in the male group (33.0% men versus 28.8% women, p < 0.001). Conclusions: There are no apparent differences in long-term mortality between the two sexes in the entire population. In propensity-matched patients, early mortality was lower for men, but the long-term survival was found to be better in women.

Beneficial and harmful effects of CB1 and CB2 receptor antagonists on chronotropic and inotropic effects related to atrial ß-adrenoceptor activation in humans and in rats with primary hypertension.

We have previously shown that cannabinoid CB1 and CB2 receptor antagonists, AM251 and AM630, respectively, modulate cardiostimulatory effects of isoprenaline in atria of Wistar rats. The aim of the present study was to examine whether such modulatory effects can also be observed (a) in the human atrium and (b) in spontaneously hypertensive rats (SHR) and normotensive Wistar Kyoto rats (WKY). Inotropic effects of isoprenaline and/or CGP12177 (that activate the high- and low-affinity site of ß1 -adrenoceptors, respectively) were examined in paced human atrial trabeculae and rat left atria; chronotropic effects were studied in spontaneously beating right rat atria. AM251 modified cardiostimulatory effects more strongly than AM630. Therefore, AM251 (1 µM) enhanced the chronotropic effect of isoprenaline in WKY and SHR as well as inotropic action of isoprenaline in WKY and in human atria. It also increased the inotropic influence of CGP12177 in SHR. AM630 (1 µM) decreased the inotropic effect of isoprenaline and CGP12177 in WKY, but enhanced the isoprenaline-induced inotropic effect in SHR and human atria. Furthermore, AM251 (0.1 and 3 µM) and AM630 (0.1 µM) reduced the inotropic action of isoprenaline in human atria. In conclusion, cannabinoid receptor antagonists have potentially harmful and beneficial effects through their amplificatory effects on ß-adrenoceptor-mediated positive chronotropic and inotropic actions, respectively.

Effectiveness of surgical closure of left atrial appendage during minimally invasive mitral valve surgery.

BACKGROUND: Left atrial appendage closure (LAAC) reduces the risk of stroke in patients with atrialfibrillation. It can be performed surgically from the inside of the left atrium or from the outside. Stapling or clipping devices can also be used from the outside. Despite providing an excellent interior view of the appendage, those techniques cannot be implemented during minimally invasive mitral valve surgery conducted through right­sided minithoracotomy. AIMS: This study aimed to assess the effectiveness of surgical closure of the left atrial appendage from the inside during minimally invasive mitral valve surgery. METHODS: A total of 50 patients with mitral valve disease and atrial fibrillation who underwent minimallyinvasive mitral valve surgery and LAACbetween 2012 and 2017 were included in this study. The appendagewas closed from the inside using a continuous suture. After a median follow­up of 1.6 years after surgery, 19 patients were examined by transthoracic and transesophageal echocardiography (TEE). Transesophageal echocardiography was performed to assess whether the appendage had been effectively closed. When any leakage was suspected, cardiac computed tomography was performed. RESULTS: In 19 patients, TEE was performed at 0.5 to 5 years after the surgery. A single patient did not tolerate TEE, and minimal leakage was suspected in 2 patients. All 3 individuals underwent computed tomography examination, which confirmed leakage in a single patient. CONCLUSIONS: Surgical LAACduring minimally invasive mitral valve surgery through right minithoracotomyis an effective technique that provides durable results.

Perioperative thrombocytopenia predicts poor outcome in patients undergoing transcatheter aortic valve implantation.

PURPOSE: To determine the time point at which thrombocytopenia after TAVI procedure is an indicator of the worst prognosis, with special consideration of perioperative platelet and coagulation activation as its potential causes. METHODS: Thirty two patients (mean age 78.5±7.9years, 62% females) qualified for TAVI procedure were prospectively evaluated. Platelet counts were assessed at baseline and for the next three postoperative (POD) days. Platelet activation was evaluated by P-selectin (PS, serum, ELISA) and platelet factor 4 (PF-4, CTAD plasma), and blood coagulation activation by prothrombin fragments 1+2 (F1+2, plasma, ELISA). Composite end point (CEP) including death and the need of cardiovascular rehospitalization was assessed after a mean of 14.1±6.7months. RESULTS: During the follow up period half of the patients reached CEP. Thrombocytopenia was more profound and frequent in patients with CEP as compared to those without (p<0.05). No differences regarding either the biomarkers of platelet (PS, PF-4) or coagulation (F1+F2) activation between the groups with and without CEP were found. Patients with moderate-to-severe thrombocytopenia at baseline had worse prognosis (log-rank test, p=0.0003). Based on the receiver operating characteristic curve analysis, the differences between platelet count on each postoperative day and the baseline count did not have any predictive value in CEP occurrence. CONCLUSIONS: Patients with thrombocytopenia following TAVI procedure have poor prognosis, however, the changes on the particular days are not more important than initial platelet count. Further studies are needed to evaluate platelet and blood coagulation activation as potential causes of thrombocytopenia and impaired prognosis related to it.

The causes of thrombocytopenia after transcatheter aortic valve implantation.

INTRODUCTION: Even though thrombocytopenia following transcatheter aortic valve implantation (TAVI) has been described, further investigation of this phenomenon is needed. AIMS: To determine which factors may explain the fall in platelet count that occurs after implantation of a TAVI device, including markers of platelet and blood coagulation activation. MATERIAL AND METHODS: 32 patients without previous indications for dual antiplatelet therapy (mean age 78.5±7.9 years, 62% females) with severe aortic valve stenosis (mean gradient 54.6±16.9mmHg) who qualified for TAVI procedure (Edwards Sapien XT) were prospectively analyzed. Platelet counts were analyzed before the surgery, on the day of the procedure and for the three following postoperative days (POD 1 to 3). To assess platelet activation P-selectin (PS, serum) and platelet factor 4 (PF-4, CTAD plasma) were measured, whereas for the evaluation of coagulation activation prothrombin fragments 1+2 (F1+2, plasma) were assessed before the procedure, on POD-1 and POD-3 (ELISA). RESULTS: During the postoperative period a significant platelet count drop, the most evident on POD-2, was observed followed by a platelet count raise. The platelet count drop correlated directly with the amount of iodinated contrast agent (r=0.42, p=0.016) and inversely with baseline mean platelet volume (r=-0.37, p=0.046). Neither clinical nor perioperative parameters, except contrast medium, influenced platelet count decrease. No significant differences regarding the concentration of the evaluated markers in patients with and without thrombocytopenia were found. PF-4 and F1+2 significantly changed during the study (p<0.05). Greater acute PF-4 decrease correlated with greater acute platelet count drop (r=0.48, p=0.043), and during the study slower PF-4 increase correlated with higher platelet count increase on POD-3 (r=-0.505, p=0.032). Lower baseline PS correlated with lower baseline platelet count and higher platelet count increase on POD-3 (r=0.45, p=0.04 and =-0.55, p=0.02, respectively). No significant correlations between F1+2 concentrations and platelet count changes have been found. CONCLUSIONS: Platelet reduction shortly after TAVI procedure is related to the amount of contrast agent applied during the procedure. Platelet activation and blood coagulation along with impaired baseline platelet renewal might be the mechanisms of thrombocytopenia following TAVI procedure.

Thrombocytopenia associated with TAVI-The summary of possible causes.

Thrombocytopenia (TP) following transcatheter aortic valve implantation (TAVI) procedure is a common phenomenon but the underlying mechanisms are neither well known nor described. Postinterventional severe TP is related to worse early and late outcome. Moreover, the statement of enhanced platelet and coagulation activation might justify even stronger antiplatelet and anticoagulation therapy following TAVI procedure. Thus, the examination of the pathomechanisms responsible for TP post TAVI seems to be crucial. Several hypotheses have been raised. TP can be caused by insufficient production or impaired platelet renewal. On the other hand, increased platelet activation, consumption and destruction might also be responsible for TP. These findings, mostly related to the procedure alone, need further investigation. Here, we summarize the potential multifactorial causes of post TAVI thrombocytopenia.

Single-centre experience in surgery of acute aortic type A dissection and true aortic arch aneurysm.

BACKGROUND: Surgery of the aortic arch is challenging. AIM: To assess the results of aortic arch surgery. METHODS: Analysis of 172 patients operated on arch dissection (emergency group: 97 patients) or aneurysm (elective group: 75 patients) between 2007 and 2014. Arch surgery was defined as a procedure requiring circumferential anastomosis at the level of the aortic arch or the descending aorta with the use of techniques of brain protection (deep hypothermic circulatory arrest [DHCA] or selective antegrade cerebral perfusion [SACP]) and/or debranching of at least one supra-aortic vessel. RESULTS: Men predominated in both groups (> 70%). Men were younger in the emergency group (55 vs. 66 years; p < 0.008). The operative risk was higher in the emergency group (19.2% vs. 12.5%; p < 0.001). Forty-nine per cent of the patients from the emergency group and 5% from the elective group were operated with antiplatelet therapy (p < 0.001). Extended hemiarch procedure was performed in 79% (n = 77) in the emergency and 76% (n = 57) in the elective group. Total arch replacement was performed in 19 (21%) patients from the emergency and 18 (24%) patients from the elective group. In these patients debranching was performed in 68% of the emergency patients group and in 67% of the elective group. Elephant trunk procedure (classic/frozen) was performed in 53% (n = 10) from the emergency and in 78% (n = 14) of patients from the elective group. Aortic valve sparing surgery was performed in 20% of patients from the emergency and 9% from the elective group (p = 0.063). DHCA was performed in 58% (n = 43) of patients from the elective group and 39% (n = 37) from the emergency group. SACP was performed in 61% (n = 58) of patients from the emergency and 42% (n = 31) from the elective group. Thirty-day mortality in the emergency group reached 33% (n = 32), and in the elective group 15% (n = 11; p = 0.007). In multivariate analysis, predictors of death in the emergency group were: Logistic EuroSCORE above 19.5%, extracorporeal circulation time above 228 min, and postoperative acute renal failure (ARF); and in the elective group: DHCA time above 26 min, rethoracotomy due to bleeding, and ARF. Follow-up was completed in 100% of patients in terms of vital status. The mean follow-up time of the patients from the emergency group was 24.3 ± 27.10 (min 0, max 92) months, and from the elective group 30.3 ± 24.5 (min 0, max 99) months. During the follow-up period all-cause mortality in the emergency group was 43% (n = 42/97), and in the elective group it was 36% (n = 27/75). CONCLUSIONS: Early mortality in the emergency group was higher, while long-term mortality did not differ among the groups. Postoperative ARF is a critical predictor of mortality in both groups.