Effect of aortic valve stenosis on haemostasis is independent from vascular atherosclerotic burden.

OBJECTIVE: The aim of study was to assess whether activation of blood coagulation and platelets is enhanced in aortic stenosis (AS) and if so, to determine factors that might modulate these processes. PATIENTS/METHODS: Seventy-five patients with AS (48 males, 27 females, aged 65+/-10 years) were enrolled in the study. A control group comprised 75 age- and sex-matched subjects. We determined markers of thrombin generation (thrombin-antithrombin complex [TAT], prothrombin fragment 1+2 [F1+2]), platelet activation (soluble CD40 ligand [sCD40L], beta-thromboglobulin [beta-TG], P-selectin) in peripheral blood plasma. The extent of atherosclerosis in the carotid and coronary arteries was assessed as a potential confounding factor. RESULTS: Mean concentrations of thrombin and platelet markers were higher approximately two-fold in the AS group than in controls (p<0.005 for all comparisons). Maximal gradient was positively associated with TAT (r=0.61, p<0.001), F1+2 (r=0.60, p<0.001), sCD40L (r=0.52, p<0.01) and beta-TG (r=0.70, p<0.001). Aortic valve area (AVA) negatively associated only with one platelet marker, beta-TG (r=-0.30, p<0.05). The presence of concomitant atherosclerotic plaque in the carotid (in 65% of patients) or coronary arteries (in 43% of patients) did not influence thrombin generation and platelet activation in patients with AS. CONCLUSIONS: AS predisposes to prothrombotic state. Maximal gradient as an index of turbulent flow associated with activation of coagulation and platelets. In contrast, the small aortic valve area was not closely related to these parameters.

Efficacy of intra-operative radiofrequency ablation in patients with permanent atrial fibrillation undergoing concomitant mitral valve replacement.

BACKGROUND: Permanent atrial fibrillation (AF) is present before operation and persists after surgery in 30-40% of patients undergoing mitral valve surgery. Using the maze procedure, 75-82% of patients can be cured of AF, but the procedure is difficult and long lasting. Percutaneous radiofrequency (RF) ablation has emerged as an effective therapy for AF in recent years. AIM: To assess the efficacy of intra-operative RF ablation of AF in patients undergoing mitral valve surgery. METHODS: 100 adults with permanent AF underwent mitral valve replacement. Patients were divided into two groups: the RF group--50 patients qualified for mitral valve replacement and RF ablation; and the control group--50 patients selected for mitral valve replacement without ablation. Odds ratio and 95% confidence interval were examined to assess the influence of several factors on the outcome (free from AF during one-year follow-up based on symptoms and serial Holter ECG recordings). RESULTS: Baseline clinical, demographic and echocardiographic characteristics were similar in both groups. Electrical cardioversion following surgery was required in 76% of patients from the RF group compared with 94% from the control group (p<0.002). In those who underwent cardioversion, sinus rhythm was restored more frequently in RF than control patients (32 vs. 16%, p<0.002). Sinus rhythm at hospital discharge was present in 56% of RF patients compared with 22% of controls (p=0.0001), and after one-year follow-up in 54 vs. 16% (p<0.001), respectively. The use of amiodarone was significantly lower in RF patients compared with controls (32 vs. 70%, p<0.05). NYHA class III (OR 8.5, CI 1.0-394) or IV (OR 36, CI 1.2-1958) and left atrial diameter >6 cm (OR 9.3, CI 0.5-5230) were identified as predictors of AF. CONCLUSIONS: Intra-operative RF ablation performed in the left atrium in patients with chronic AF undergoing mitral valve replacement significantly improves sinus rhythm restoration rate. Advanced heart failure (NYHA class IV) and left atrial diameter >6 cm are negative prognostic factors for sinus rhythm maintenance.

[Factors influencing thrombin generation measured as thrombin-antithrombin complexes levels and using calibrated automated thrombogram in patients with advanced coronary artery disease]. / Czynniki wplywajace na generacje trombiny mierzona jako stezenie kompleksów trombina-antytrombina i metoda automatycznego skalibrowanego trombogramu u chorych z zaawansowana choroba wiencowa.

INTRODUCTION: Haemostatic factors play an important role in atherothrombosis. Thrombin generation is a crucial stage of blood coagulation. OBJECTIVES: Comparison of different thrombin generation markers: thrombin-antithrombin complex (TAT) generation and calibrated automated thrombogram method (CAT). Identification of factors influencing thrombin generation in patients with stable angina (SA) enrolled to the coronary artery bypass grafting (CABG) surgery. Analysis of traditional (age, gender, hypertension and diabetes) and novel (fibrinogen and C-reactive protein [CRP]) risk factors and the antiplatelet therapy (aspirin 75-150 mg/d) in relation to coagulation. PATIENTS AND METHODS: In 135 SA patients with left main coronary artery stenosis (> 50%) or major epicardial artery stenosis (> 70%), plasma TAT levels, maximal thrombin concentration (C(max)) and endogenous thrombin potential (ETP) were determined. A marker of the platelet activation (beta-thromboglobulin) was also measured. RESULTS: No correlations among TAT, C(max), ETP, risk factors and beta-thromboglobulin were observed. Linear regression model showed that independent predictors of TAT levels were age (beta = 0.5; p = < 0.0001), male gender and diabetes (beta = 0.36; p = 0.02). CRP independently predicted TAT and ETP (beta = -0.24 and beta = 0.22; p < 0.05, respectively), while fibrinogen predicted C(max) (beta = 0.21; p < 0.05). Independent predictors of beta-thromboglobulin were a male gender and aspirin use cessation (beta = 0.46; p = 0.01). Aspirin treatment had no effect on thrombin generation. CONCLUSIONS: Age, higher fibrinogen, CRP, diabetes and male gender influence thrombin generation and/or coagulation activation in SA patients. Plasma levels of thrombin-antithrombin complexes do not correlate with the parameters obtained using the calibrated automated thrombogram method (C(max), ETP).

Submassive pulmonary embolism as a mask of acute coronary syndrome.

The paper presents a case of a 77-year-old man, who was admitted to hospital suffering from chest pain. The ECG showed horizontal ST segment depression in the V4-V6 leads. Non-ST segment elevation acute coronary syndrome was diagnosed. However, transthoracic echocardiography revealed signs of pulmonary embolism. The present case indicates the need to consider pulmonary embolism in the differential diagnosis of acute coronary syndromes and underlines the role of echocardiography, which should be performed at the earliest possible stage. (Cardiol J 2007; 14: 402-406).

Brugada syndrome: From diagnosis to treatment.

Brugada syndrome is electrocardiographically characterised by ST segment elevation in right precordial leads and the occurrence of episodes of polymorphic ventricular tachycardia. It is also associated with a high risk of sudden death, which may be the first manifestation of the disease. Various mutations of SCN5A gene encoding for the cardiac sodium channel are among the proven causes of BS. ICD remains the only treatment for BS of proven efficacy. However, many questions about etiology, underlying mechanisms, safety of asymptomatic patients and treatment options for BS remain unanswered. (Cardiol J 2007; 14: 429-435).

[Causes of atrial fibrillation early after coronary artery bypass grafting]. / Analiza przyczyn migotania przedsionków u pacjentów we wczesnym okresie po operacjach pomostowania tetnic wiencowych.

UNLABELLED: The aim of the study was to define the frequency of atrial fibrillation early after coronary artery bypass grafting (CABG) and clinical risk factors for the development of atrial fibrillation in the post-operative course. The study population consisted of 1578 patients (1283 men and 295 women ranging in age from 25 to 85 years, mean age 59.373 +/- 8.686 years) undergoing isolated coronary artery bypass grafting in extracorporeal circulation between 1.01.1998 and 21.12.1999. The patients were divided into two groups: group 1 with atrial fibrillation after CABG (193 patients, mean age 62.399 +/- 7.097 years) and group 2 without atrial fibrillation in the postoperative course (1385 patients, mean age 58.952 +/- 9.009 years). Both groups were compared with respect to pre-, intra- and postoperative parameters. Additionally in group 1 the following aspects were taken into account: timing of atrial fibrillation and its relapses in relation to the surgical procedure, serum potassium level, type and efficacy of antiarrhythmic treatment. RESULTS: Postoperative atrial fibrillation developed in 193 patients i.e. 12.23% of the CABG population. The complication occurred most frequently on the third day after the procedure and it recurred in about 60% of the patients. Analysis of clinical pre, intra- and postoperative factors identified those affecting the occurrence of atrial fibrillation in the postoperative course as follows: age, paroxysmal atrial fibrillation occurring before the operation, previous inferior myocardial infarction, type 2 diabetes mellitus, arterial hypertension, left ventricular ejection fraction, left atrial size, volume of cardioplegia used during the procedure, volume of blood lost during the procedure, postoperative ischaemia, timing of postoperative ischaemia, perioperative withdrawal of beta adrenolytics, prolonged intubation after the procedure, low cardiac output syndrome, prolonged administration of pressor amines after CABG, and Intraaortic balloon counterpulsation, especially during the procedure. CONCLUSIONS: (1) Atrial fibrillation is an important clinical problem early after coronary artery bypass grafting. It is poorly tolerated and shows a tendency to recur. (2) Atrial fibrillation after CABG is most strongly correlated with age over 60 years, arterial hypertension and perioperative withdrawal of beta adrenolytics.

[Patients history following artificial aortic valve and pacemaker implantation]. / Losy chorych po implantacji sztucznej zastawki aortalnej i rozrusznika serca.

UNLABELLED: The follow-up of 22 patients (out of 31 patients after artificial aortic valve and pacemaker implantation between 1982 and 2001) have been evaluated. There were 15 men aged 30-76 (x=55) and 7 women aged 43-69 (x=59). Aortic valve replacement (AVR) was subsequently followed by pacemaker implantation (PI) after approximately 16 days. Indication for permanent stimulation were: atrio-ventricular complete block in 18 patients and atrial fibrillation with slow ventricular response in the remaining 4. There were implanted 15 devices of VVI type and 7 of VDD type. The duration of follow up was 9-196 (x=56) months. All these patients remained in good general state (II degree--19 patients or II/III degree--3 patients acc. to NYHA classification). In 21 out of 22 patients, atrioventricular conduction disturbances and bradyarrhythmia remained for the entire follow-up duration with permanent stimulation (VVI or VAT). In one patient the postoperative complete atrio-ventricular block disappeared during follow up, 24 months after AVR. CONCLUSIONS: 1. The main indication for PI after AVR was complete atrio-ventricular block, persisting 2-3 weeks after surgery, without accompanying atrial fibrillation. 2. In long term follow up after AVR and PI (VVI or VDD) the dominance of 100% capture ventricular pacing have been recorded in almost all cases, which holds the decision of early postoperative PI.

[Atrial fibrillation in a long-term follow-up after mitral valve replacement]. / Migotanie przedsionków w czasie dlugotrwalej obserwacji po implantacji sztucznej zastawki mitralnej.

UNLABELLED: The aim of the study was to analyse cardiac rhythm after mitral valve replacement and to define pre-operative predictive factors for persistence of atrial fibrillation. MATERIAL AND METHODS: The study group consisted of 76 consecutive pts (54 F, 22 M), mean age 54.8 +/- 8.2 (38-71) years in whom mitral valve replacement was performed due to mitral stenosis (15 pts), regurgitation (18 pts) or mixed lesion (43 pts). The prevalence of AF after the procedure was analysed with relation to age, gender and the following preoperative echocardiographic parameters: left atrial size, mitral valve area, mitral regurgitation, tricuspid regurgitation and left ventricular ejection fraction. RESULTS: Chronic AF was present in 51 pts (67.1%) before the procedure and in 34 pts (44.7%) after 17.3 +/- 11.9 months (6-46) follow-up, p<0.005. Patients with AF after operation had larger left atrium size (58.6 +/- 10.9 vs 51.3 +/- 10.1 mm, p<0.005) and lower ejection fraction (53.8 +/- 7.9 vs. 59.9 +/-8.4%, p<0.01) as compared with pts in sinus rhythm. Among 51 pts with preoperative chronic AF, 21 pts recovered to sinus rhythm (subgroup I) and 30 pts remained in AF (subgroup II) after operation. The only significant differences between subgroup I and II were: higher prevalence of mitral regurgitation (85.7 vs 60%, p<0.05), larger mitral valve area (1.4 +/- 0.3 vs 1.1 +/- 0.6 cm2, p<0.025) and higher ejection fraction (58.9 +/- 7.3 vs. 53.4 +/- 8.4%, p<0.025) in subgroup I. CONCLUSIONS: 1. The prevalence of AF diminishes significantly after mitral valve replacement. 2. Patients with pure mitral stenosis are at higher risk of remaining in AF after operation. 3. Preoperative left atrial dimension and LV ejection fraction are the most important predictive parameters for persistence of AF.

[Asymptomatic carotid stenosis: ACS]. / Asymptomatyczna stenoza tetnic szyjnych.

Asymptomatic carotid stenosis (ACS) is the lesion located in the vicinity of the common carotid artery branching, without neurological symptoms caused by insufficient blood flow to the brain. Cerebrovascular diseases represent an important medical as well as social problem, since this is one of the leading causes of mortality and serious invalidity worldwide. Majority of brain insults are caused by stenosing atherosclerotic lesions of the carotid arteries. Thus, early surgical treatment may contribute to lessen this problem. Routine diagnosis of ACS include auscultation and ultra-sonographic examination of carotid arteries. Early detection of the disease enables proper medical prophylaxis and decision for surgical treatment (providing that expected benefit for the patient exceeds possible operative risk, i.e. < 3% of complication rate in experienced surgical wards). That's why of particular importance is to formulate multidisciplinary programs of insult prevention and to conduct multiinstitutional studies in order to establish clear cut indications for surgical treatment, particularly for the group of asymptomatic patients.

[Radiofrequency ablation in patients with persistent atrial fibrillation undergoing mitral valve replacement]. / Ablacja RF u pacjentów z przewleklym migotaniem przedsionków poddanych zabiegom wymiany zastawki mitralnej.

The most frequent arrhythmia is an atrial fibrillation, which involves 10% of population over 70. The mortality in this group is 2 times higher than in general population. Moreover, if the atrial fibrillation co-exists with the rheumatic disease, the risk of the brain embolism is growing up 17 times. In the many European medical centers, intraoperative ablation is the obligatory procedure performed during mitral valve replacement/mitral valvuloplasty or coronary artery bypass grafting. Results of that procedure (in experienced centers) are evaluated on 75%. It reduces significantly the cost of the farther pharmacological treatment and improves the quality of life of the patients. In our Clinic ablation is performed in patients qualified to the mitral valve replacement or mitral valvuloplasty. All procedures are performed in extracorporeal circulation, in general and local hypothermia, with using crystal cardioplegine. Before the clumping of the aorta, on the beating heart ablation in the right atrium is performed. After that, the aorta is being clumped and the heart is being stopped. The left cardiac auricle is being cut off. Then the ablation around the ostia of the pulmonary veins is being done. After that, mitral valve replacement or mitral valvuloplasty procedure is being performed. Changes in the heart wall are transmural through the full wall. From the December 2001 till today 4 ablation procedures were done. Units Cobra (Boston Scientific) and Cardioblate Surgical Ablation System (Medtronic) were used. Both units are based on the unipolar energy with frequency similar to the radio-waves. After this procedure, regular rhythm came back in our 4 patients. Advantages of the intraoperative ablation are: simultaneous procedure with open heart operation, reduction of the price of the treatment, minimal risk of complication.