Long-term follow-up in patients with ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention.

Long-term follow-up after primary percutaneous coronary intervention (pPCI) for ST-segment elevation myocardial infarction (STEMI) beyond 5 years is poorly described. There are no risk-stratification systems available for routine use. This retrospective, academic, two-centre analysis included consecutive patients who presented with acute STEMI between March 2008 and December 2019. In total, 5263 patients underwent pPCI; all patients were included in the analysis only once. Baseline characteristics were gathered from prospective local registries and based on initial hospitalization. The study enrolled 5263 patients who had been treated with pPCI; it found that cardiovascular mortality was the most frequent cause of death (65.0%) on long-term follow-up to 12 years. Myocardial infarction associated mortality was 27.2%. Cardiovascular mortality was dominant, including in the landmark analysis beyond 1 year. Multivariate analysis identified significant predictors for long-term cardiovascular mortality: age, history of diabetes mellitus, history of renal insufficiency, history of heart failure, Killip class, and successful pPCI at presentation. A predictive model was built to evaluate the risk of cardiovascular death with a high discrimination value (C-statistic = 0.84). Cardiovascular diseases remain the leading cause of long-term mortality after pPCI in the Central European population. Our novel predictive model provides risk stratification; it could identify patients who would experience the greatest benefit from aggressive secondary prevention measures.

Cholesterol and glucose profiles according to different fasting C-peptide levels: a cross-sectional analysis in a healthy cohort from the Czech Republic.

The relationship between glycaemia and lipoprotein metabolism has not been completely clarified, and slight differences may be found between local authors, trials and evaluated parameters. Therefore this cross-sectional study investigated fasting cholesterol and glucose levels along with the determination of atherogenic index in a cohort of healthy individuals from the Czech Republic in relation to their fasting C-peptide levels. Data were collected between 2009 and 2018 and a total of 3189 individuals were stratified by C-peptide reference range (260-1730 pmol/l) into three groups - below (n = 111), within (n = 2952) and above (n = 126). Total, HDL, LDL cholesterol and atherogenic index were used to compare lipoprotein levels by relevant C-peptide concentrations. Participants using the supplements to affect lipid or glycaemia metabolism were excluded from this study. The evaluation of blood parameters in a fasting state included correlations between C-peptide and cholesterols, differences of variances (F-test) and the comparison of lipoprotein mean values (t-test) between the groups created by the C-peptide reference range. Mean values of total (4.9, 5.1, 5.3 mmol/l), LDL (2.6, 3.1, 3.4 mmol/l) cholesterol and atherogenic index (2.1, 2.8, 3.7) were higher with increasing C-peptide levels, whereas HDL was inversely associated with fasting C-peptide concentration. A positive and negative correlation between atherogenic index (rxy = 0.36) and HDL level (rxy = -0.36) with C-peptide values was found. Differences of HDL, LDL and atherogenic index were, in particular, recorded between the groups below and above the reference range of C-peptide (p ≤ 0.001). Considerable differences (p ≤ 0.001) were also observed for the same lipoprotein characteristics between the groups above and within the C-peptide reference. Generally, the type of cholesterol is crucial for the evaluation of specific changes concerning the C-peptide range. Lipoprotein concentrations differ in relation to C-peptide - not only below and above the physiological range, but also inside and outside of it. Conclusions: Fasting levels of cholesterol, plasma glucose, and atherogenic index were strongly associated with fasting C-peptide levels in healthy individuals. Our data suggest that fasting C-peptide could serve as a biomarker for the early detection of metabolic syndrome and/or insulin resistance prior to the manifestation of type 2 diabetes.

The influence of epicardial and endocardial use of cryoenergy on the completeness of lesions in surgical ablation of atrial fibrillation.

INTRODUCTION: Cryoenergy is the most commonly used method of lesion formation in patients who have undergone surgical ablation of atrial fibrillation. Despite frequent use, the clinical effect of cryoenergy in endocardial and epicardial approaches is unknown. AIM: To compare the effect of various cryoenergy applications on the postoperative incidence of sinus rhythm and completeness of lesions performed. MATERIAL AND METHODS: A total of 55 patients underwent concomitant atrial fibrillation surgical ablation using cryoenergy under various conditions: epicardially during cardiac arrest, epicardially on beating heart, and endocardially. In the postoperative period, patients were invited to attend an electrophysiological examination to assess the completeness of surgical ablation lesions and, if necessary, to complete catheter ablation. RESULTS: Twenty-four patients underwent epicardial ablation on the arrested heart (group 1), 12 patients underwent epicardial ablation on the beating heart (group 2), and 19 patients underwent endocardial ablation (group 3). In the electrophysiological examination, sinus rhythm was present in 71% vs. 83% vs. 89% of patients, respectively. The completeness of pulmonary vein isolation was confirmed in 31% vs. 25% vs. 95% of patients, complete box lesions in 15% vs. 0% vs. 79% of patients, respectively. CONCLUSIONS: Despite the similar clinical effect of surgical ablation in all three approaches, the morphologically most effective use of cryoenergy is endocardial ablation. This approach has a very good result. Our findings further support the endocardial use of cryoenergy during surgical ablation of atrial fibrillation.

How to manage left ventricular embolization of the transcatheter valve.

Transcatheter aortic valve implantation is a treatment alternative for high-risk patients with severe aortic stenosis who are not eligible for conventional open aortic valve replacement. We describe a case of a rare but serious complication in the form of ventricular embolization of an Edwards Sapien-XT aortic valve following its transapical implantation. The valve was successfully captured and reimplanted into the aortic annulus, which did not require conversion to median sternotomy or use of extracorporeal circulation.

Short-term and medium-term outcomes of transapical aortic valve implantation as a single-strategy approach: one center's experience.

INTRODUCTION: Transcatheter aortic valve replacement has been developed as an alternative option for surgical high-risk or inoperable patients with severe symptomatic aortic stenosis. AIM OF THE STUDY: Aim of the study was to evaluate the outcomes of patients undergoing transapical aortic valve replacement as a single-strategy option by a single-center multidisciplinary heart team. MATERIAL AND METHODS: Between June 2009 and December 2014, 41 patients underwent transapical transcatheter aortic valve implantation (TA-TAVI) at our institution. All patients received Edwards SAPIEN balloon expandable pericardial valves (Edwards Lifesciences, Irvine, CA, USA). Our center followed a "clear transapical strategy" for all patients. RESULTS: The mean age of the patients was 79.6 years, and the mean logistic EuroSCORE was 21.06 ± 12.82%. Fifteen patients (36.6%) underwent redo operations. Complications included stroke (n = 1), re-exploration for bleeding or cardiac tamponade (n = 4), renal failure requiring temporary hemodialysis (n = 4) and permanent pacemaker implantation (n = 3). There were no myocardial infarctions or coronary obstruction. The total 30-day mortality rate was 17.1% (7 patients). Postoperative intensive care unit stay was 4.6 ± 5.7 days, and mean hospitalization was 11.6 ± 7.2 days. CONCLUSIONS: The TA-TAVI approach provides good results in terms of early and midterm outcomes. This approach is feasible and safe for patients who have high surgical risk.

Thoracoscopic Occlusion of the Left Atrial Appendage.

OBJECTIVE: Left atrial appendage (LAA) plays a crucial role in the etiopathogenesis and the prevention of the stroke in patients with nonvalvular atrial fibrillation (AF). This paper presents our first experience with thoracoscopic LAA occlusion using an external clip. METHODS: We performed a total of 30 LAA occlusions with the AtriClip from left thoracoscopy approach during the period from July 2012 to July 2013. AtriClip was implanted during the bilateral thoracoscopic radiofrequency (RF) as part of left atrial ablation procedure. RESULTS: Among the 30 procedures, AtriClip was once periprocedurally partially positioned. In the remaining procedures, the implantation was successful without complications. Of the 30 patients, 29 underwent transesophageal echocardiography and computer tomography examination at 3 months after the procedure. Apart from the patient with the partial clip placement, a residual pouch of 18 mm was detected in another patient. In the remaining group (28/30 patients, 93%), the exclusion was complete. No migration or any other clip implantation-related complications occurred during the follow-up. None of the patients experienced an embolization event. CONCLUSIONS: Endoscopic AtriClip implantation appears to be a reproducible and safe method of LAA occlusion, with a minimal risk and a high efficiency. In our opinion, the AtriClip implantation is a reasonable part of thoracoscopic AF treatment and should be considered as an alternative tool for stroke risk reduction in patients with AF.

Sequential hybrid procedure for persistent atrial fibrillation.

BACKGROUND: Catheter ablation of persistent atrial fibrillation yields an unsatisfactorily high number of failures. The hybrid approach has recently emerged as a technique that overcomes the limitations of both surgical and catheter procedures alone. METHODS AND RESULTS: We investigated the sequential (staged) hybrid method, which consists of a surgical thoracoscopic radiofrequency ablation procedure followed by radiofrequency catheter ablation 6 to 8 weeks later using the CARTO 3 mapping system. Fifty consecutive patients (mean age 62±7 years, 32 males) with long-standing persistent atrial fibrillation (41±34 months) and a dilated left atrium (>45 mm) were included and prospectively followed in an unblinded registry. During the electrophysiological part of the study, all 4 pulmonary veins were found to be isolated in 36 (72%) patients and a complete box-lesion was confirmed in 14 (28%) patients. All gaps were successfully re-ablated. Twelve months after the completed hybrid ablation, 47 patients (94%) were in normal sinus rhythm (4 patients with paroxysmal atrial fibrillation required propafenone and 1 patient underwent a redo catheter procedure). The majority of arrhythmias recurred during the first 3 months. Beyond 12 months, there were no arrhythmia recurrences detected. The surgical part of the procedure was complicated by 7 (13.7%) major complications, while no serious adverse events were recorded during the radiofrequency catheter part of the procedure. CONCLUSIONS: The staged hybrid epicardial-endocardial treatment of long-standing persistent atrial fibrillation seems to be extremely effective in maintenance of normal sinus rhythm compared to radiofrequency catheter or surgical ablation alone. Epicardial ablation alone cannot guarantee durable transmural lesions. CLINICAL TRIAL REGISTRATION: URL: www.ablace.cz Unique identifier: cz-060520121617.

[The user´s reporting from the national registry of catheter aortic valve implantations (Czech TAVI Registry): the possibilities of the analytical reports based on the database system TrialDB2]. / Uzivatelské výstupy z národního registru katetrových implantací aortální chlopne (Czech TAVI Registry): moznosti analytických výstupu zalozených na databázovém systému TrialDB2.

Assessment of the treatment procedures and their results is increasingly important in current medicine. The emphasis is put on an effective use of the health technologies (HTA). Unlike randomised studies, which involve strictly selected groups of patients who meet inclusion and exclusion criterias, the multicentre clinical registries provide a real-life picture of the treatment safety and effectiveness. Well prepared registries involve both research database and a friendly user interface enabling collection of parametric and easily analyzable data. Although there are some technological aspects aiming to ensure a maximum quality of entered data, cooperation with the users and data managers is essential. Such a registry, otherwise meaningful, must provide answers to previously defined medical hypotheses. Regular feedback to users (so called benchmarking or reporting) is considered to be of key importance. The Czech TAVI Registry (CTR) is a good example of reaching all of the above defined criterias. This registry contains data of approximately 95 % of all transcatheter aortic valve implantations (TAVI) performed in the Czech Republic. It is based on a general system aimed at the design of clinical trials, namely the TrialDB2 (a database system for clinical registries developed by the Institute of Biostatistics and Analyses at the Masaryk University (IBA MU). CTR has been run as an English-language version under the auspices of the Czech Society of Cardiology and represents one of the top-quality registries maintained by IBA MU. This paper presents the currently available database systems and some reports from this particular registry.

The incidence and outcomes of acute coronary syndromes in a central European country: results of the CZECH-2 registry.

BACKGROUND: The incidence and treatment strategies of acute coronary syndrome (ACS) vary by region. Additionally, the clinical spectrum of ACS is changing and outcomes are improving. AIM: We assessed the incidence, treatment strategies, and outcomes of ACS for a well-defined population within a well-established network of percutaneous coronary intervention (PCI) centers and non-PCI centers. METHODS: The CZECH-2 registry included 1221 consecutive patients (mean age: 68 ± 13 years; 63.4% males) admitted for suspected ACS to 32 hospitals (including 4 PCI centers) within four Czech counties (total population: 2,370,841 inhabitants) during a 2-month period. RESULTS: The estimated incidence of confirmed ACS was 2,149 cases/million/year. In 374 (31%) patients, ACS was ruled out during the hospital stay. Coronary angiography (CAG) was performed in 60% of the patients overall and PCI was performed in 59% of the confirmed ACS patients. Killip classifications II-IV on admission were more common in patients with final diagnosis of non ST-elevation myocardial infarction (NSTEMI) than ST-elevation myocardial infarction (STEMI) (37.1% vs. 22.8%; p<0.001). The 30-day mortality rate was 5.7% for the whole study group, 7.3% for STEMI patients, 8.4% for NSTEMI patients, and 1.6% for patients with unstable angina pectoris (UAP), respectively. CONCLUSIONS: Almost one-third of the patients admitted for suspected ACS had a different final diagnosis. Among those with confirmed ACS, the use of CAG, PCI, CABG, and effective medications is rational. Outcome in NSTEMI patients was equivalent to those in STEMI patients, mainly due to the high-risk population in this group.

Health-related quality of life after cardiac surgery--the effects of age, preoperative conditions and postoperative complications.

BACKGROUND: Factors influencing the postoperative health-related quality of life (HRQOL) after cardiac surgery have not been well described yet, mainly in the older people. The study's aim was to explore differences in clinical conditions and HRQOL of patients before and after cardiac surgery taking into account the influence of age and to describe factors influencing changes of HRQOL in the postoperative period. METHODS: This was a prospective consecutive observational study with two measurements using the SF-36 questionnaire before surgery and 1 year after surgery. It considered main clinical characteristics of participants prior to surgery as well as postoperative complications. RESULTS: At baseline assessment the study considered 310 patients, predominantly male (69%). Mean age was 65 (SD 10.4) years and 101 patients (33%), who were older than 70, constituted the older group. This older group showed greater comorbidity, higher cardiac operative risk and lower HRQOL in the preoperative period as well as a higher prevalence of postoperative complications than the younger group. Thirty-day mortality was 1.4% in the younger group and 6.9% in the older group (p < 0.001). One year mortality was 3.3% in the younger group and 10.9% in the older group (p < 0.001). There was a significant improvement in all 8 health domains of the SF-36 questionnaire (p < 0.001) in the overall sample. There was no significant difference in change in a majority of HRQOL domains between the younger and the older group (p > 0.05). Logistic multivariate analysis identified a higher values of preoperative PCS (Physical component summary) scores (OR 1.03, CI 1.00 - 1.05, p = 0.0187) and MCS (Mental component summary) scores (OR 1.02, CI 0.997 - 1.00, p = 0.0846) as the only risk factors for potential non-improvement of HRQOL after cardiac surgery after correction for age, gender and type of surgery. CONCLUSIONS: Older patients with higher operative risk have lower preoperative HRQOL but show a similar improvement in a majority of HRQOL domains after cardiac surgery as compared with younger patients. The multivariate analysis has shown the higher preoperative HRQOL status as a only significant factor of potential non-improvement of postoperative HRQOL.

Two-staged hybrid treatment of persistent atrial fibrillation: short-term single-centre results.

OBJECTIVES: The treatment of persistent and long-standing persistent atrial fibrillation (AF) has unsatisfactory results using both medical therapy and/or catheter ablation, where incomplete ablation lines remain a significant problem. This study evaluates the feasibility, efficacy and safety of the sequential, two-staged hybrid treatment combining thoracoscopic surgical and transvenous catheter AF ablation. METHODS: Thirty patients with persistent and long-standing persistent AF underwent surgical thoracoscopic radiofrequency (RF) ablation procedure using a predefined protocol (pulmonary veins isolation, box lesion, isthmus line lesion, dissection of the ligament of Marshall, left atrial appendage exclusion with an epicardial clip and ganglionated plexi ablation) followed by diagnostic catheterization and RF ablation 3 months later. In this session, electrical mapping of the left atrium was performed and any incomplete isolation lines were completed. Mitral and cavotricuspid isthmus ablation lines were performed during this session as well. RESULTS: The preoperative mean duration time of AF was 33 ± 27 months with 17% patients with persistent and 83% patients with long-standing persistent AF. The mean size of the left atrium was 48 ± 5 mm. The complete surgical ablation protocol was achieved in 97% of patients, with no death, and no early stroke or pacemaker implantation in the early postoperative period. In 63% of patients, the left atrial appendage was excluded with an epicardial clip. An endocardial touch-up for achievement of bidirectional block of pulmonary veins was necessary in 10 patients (33%) and on the box, (roof and floor) lesions in 20 patients (67%). Freedom from atrial fibrillation was 77% after surgical ablation and 93% after the completed hybrid procedure. CONCLUSIONS: The sequential, two-staged hybrid strategy (surgical thoracoscopic followed by catheter ablation) is feasible and safe with a high post-procedural success and seems to represent the optimal treatment with low risk load and potentially long-term benefit for patients with a persistent and long-standing persistent form atrial fibrillation.

Catheter ablation for paroxysmal atrial fibrillation: a randomized comparison between multielectrode catheter and point-by-point ablation.

INTRODUCTION: Catheter ablation for paroxysmal atrial fibrillation is widely used for patients with drug-refractory paroxysms of arrhythmia. Recently, novel technologies have been introduced to the market that aim to simplify and shorten the procedure. AIM: To compare the clinical outcome of pulmonary vein (PV) isolation using a multipolar circular ablation catheter (PVAC group), with point-by-point PV isolation using an irrigated-tip ablation catheter and the CARTO mapping system (CARTO group; CARTO, Biosense Webster, Diamond Bar, CA, USA). METHODS: Patients with documented PAF were randomized to undergo PV isolation using PVAC or CARTO. Atrial fibrillation (AF) recurrences were documented by serial 7-day Holter monitoring. RESULTS: One hundred and two patients (mean age 58 ± 11 years, 68 men) were included in the study. The patients had comparable baseline clinical characteristics, including left atrial dimensions and left ventricular ejection fraction, in both study arms (PVAC: n = 51 and CARTO: n = 51). Total procedural and fluoroscopic times were significantly shorter in the PVAC group (107 ± 31 minutes vs 208 ± 46 minutes, P < 0.0001 and 16 ± 5 minutes vs 28 ± 8 minutes, P < 0.0001, respectively). The AF recurrence was documented in 23% and 29% of patients in the PVAC and CARTO groups, respectively (P = 0.8), during the mean follow-up of 200 ± 13 days. No serious complications were noted in both study groups. CONCLUSIONS: Clinical success rates of PV isolation are similar when using multipolar circular PV ablation catheter and point-by-point ablation with a three-dimensional (3D) navigation system in patients with PAF, and results in shorter procedural and fluoroscopic times with a comparable safety profile.

Prevalence of stress-induced myocardial stunning (Tako-Tsubo cardiomyopathy) among patients undergoing emergency coronary angiography for suspected acute myocardial infarction.

Stress-induced myocardial stunning is defined as a syndrome of acute chest pain, ST-T changes on the ECG and transient left ventricular apical wall motion abnormalities mimicking acute myocardial infarction but with surprisingly normal coronary angiography findings. The aim of this retrospective study is to assess the prevalence of stress-induced myocardial stunning among patients undergoing urgent coronary angiography for suspected acute myocardial infarction. During a four-year period (2002-2005), a total of 5876 patients underwent urgent coronary angiography for suspected acute myocardial infarction at three tertiary centers. Four patients fulfilled the diagnostic criteria for stress-induced myocardial stunning. Thus, the cath-lab prevalence of stress-induced myocardial stunning (i.e. among patients undergoing urgent coronary angiography for suspected acute myocardial infarction) was estimated as 1 per 1469 ST-elevation coronary angiograms (i.e. 0.07%) The estimated annual population incidence of this rare disorder was calculated as 0.00006%. Stress-induced myocardial stunning is an extremely rare syndrome among patients undergoing emergency coronary angiography for suspected acute myocardial infarction.

The second-generation aortic connector: six months' angiographic follow-up.

PURPOSE: Recently, new mechanical anastomotic devices have been developed. Initial results appear to be equivalent to those obtained with suture. The aim of the study was to evaluate the 6-month angiographic patency and clinical results with the St. Jude Medical second-generation aortic connector for proximal aortosaphenous graft anastomosis. DESCRIPTION: From September 2002 to June 2003, 45 connectors were implanted in 39 patients. Thirty-three patients with 36 connectors underwent 6-month angiographic and clinical follow-up. EVALUATION: One connector had an early occlusion and 2 connectors and 1 vein graft were occluded at 6-month angiography, for a patency rate of 88.9% (32 of 36). No device-related complications were detected at 6-month follow-up. CONCLUSIONS: The second-generation aortic connector is safe and easy to use. Preliminary results show no device-related complications and a satisfactory 6-month angiographic patency.