Monocyte-to-lymphocyte ratio correlates with parathyroid hormone concentration in patients with severe symptomatic aortic stenosis.

PURPOSE: The normal healthy valve is devoid of inflammatory cells, however background of aortic stenosis (AS) may include inflammatory processes. Moreover, the link between hyperparathyroidism and heart failure is postulated. Simple whole blood analysis with indices is a beneficial tool in cardiovascular diseases' assessment. The purpose of the study was to evaluate correlation between parathyroid hormone (PTH) and simple blood parameters in severe AS. MATERIAL AND METHODS: The study included 62 patients with severe AS. Patients with inflammatory or autoimmune co-morbidities were excluded. Blood samples were collected, and clinical and demographic data were analyzed. RESULTS: The final study group comprised 55 patients (31 females, 56.4%; mean age 77.13 (SD 6.76)). In 23 patients (41.8%), PTH concentration was markedly increased. The study group was divided into two subgroups according to the PTH concentration. Patients from both groups did not differ significantly in terms of age and co-morbidities. PTH concentration correlated positively with monocyte-lymphocyte ratio (MLR) (p â€‹= â€‹0.008, Spearman rho 0.356) and platelet-lymphocyte ratio (PLR) (p â€‹= â€‹0.047, Spearman rho 0.269), creatinine level (p â€‹= â€‹0.001, Spearman rho 0.425) and glomerular filtration rate (GFR-MDRD) (p â€‹= â€‹0.009, Spearman rho -0.349). The multivariable logistic regression with backward analysis revealed MLR (p â€‹= â€‹0.029) and GFR (p â€‹= â€‹0.028) as independent significant predictors of abnormal PTH values. The receiver operator characteristics (ROC) curve was performed for the model of MLR and GFR-MDRD (AUC â€‹= â€‹0.777), yielding the sensitivity of 60.9% and specificity of 90.6%. CONCLUSIONS: PTH concentration correlates with monocyte-to-lymphocyte and platelet-to-lymphocyte ratios in calcified AS.

Open-Heart Cardio-Thoracic Biological Valve Replacement Following Complicated Transcatheter Aortic Valve Implantation.

Transcatheter aortic valve implantation (TAVI) is currently becoming the method of choice in high-risk patients with severe aortic valve stenosis. Post-TAVI complications are more common owing to the increasing use of the method. The majority of TAVI complications derive from concomitant aortic stenosis with moderate/severe aortic insufficiency, paravalvular leak, and atrioventricular block. The contemporary TAVI qualification process includes a thorough echocardiography and angio-CT of the aorta, which is crucial in assessing valve measurements, determining the position of the coronary arteries branching from the aorta, and choosing the optimal valve size. We present the case report of an 81-year-old patient admitted to our hospital because of exacerbation of the clinical condition and development of pulmonary edema a few days after TAVI. Despite the reduction of the initial leak, an echocardiographic examination revealed the remaining severe paravalvular aortic leakage. We performed open-heart cardio-thoracic surgery, explanted the TAVI valve, and implanted the biological prosthesis (Edwards Perimount Magna size 25). Introduction of new interventional treatment approaches and the availability of imaging tools have substantially reduced the incidence of significant paravalvular leak and offered a better prognosis for patients undergoing TAVI.

Pre-operative systemic inflammatory response index influences long-term survival rate in off-pump surgical revascularization.

Coronary artery bypass revascularization is still the optimal treatment for complex coronary artery disease with good long-term results. The relation between inflammatory activation in the post-operative period and the long-term prognosis was already postulated. The possible predictive role of preoperative inflammatory indexes after the off-pump coronary artery bypass grafting technique on long term survival was the aim of the study. Study population included 171 patients with a median age of 64 years (59-64) operated on using off-pump technique between January and December 2014. Patients enrolled in the current study were followed-up for 8 years. We conducted a multivariable analysis of pre-operative and post-operative inflammatory markers based on analysis of the whole blood count. The overall survival rate was 80% for the total follow-up period, while 34 deaths were reported (30-days mortality rate of 1%). In the multivariable analysis, a pre-operative value of systemic inflammatory response index (SIRI) >1.27 (HR = 6.16, 95% CI 2.17-17.48, p = 0.012) revealed a prognostic value for long-term mortality assessment after off-pump surgery. Preoperative inflammatory activation evaluated by systemic inflammatory reaction index (SIRI) possess a prognostic value for patients with complex coronary artery disease. The SIRI value above 1.27 indicates a worse late prognosis after off-pump coronary artery bypass (AUC = 0.682, p<0.001).

Pulmonary artery systolic pressure at 1-month predicts 1-year survival after transcatheter aortic valve implantation.

BACKGROUND: Pulmonary hypertension related to left ventricle heart disease is a common finding in patients with severe aortic stenosis treated with transcatheter aortic valve implantation (TAVI) and is associated with a higher mortality rate. AIMS: The study aimed to analyze the influence of pulmonary artery systolic pressure (PASP) changes after TAVI on long-term survival. METHODS: TAVI was performed in 362 patients between January 2013 and December 2018. The study group comprised 210 patients who underwent a detailed 1-month follow-up. RESULTS: At 1-month, 142 had a stable or decreased PASP value (Group 1), while in 68 patients an increase was observed (Group 2). During 1-year follow-up, 20 patients died (9.5%), 9 in Group 1 and 11 in Group 2 (P = 0.02). The receiver operating characteristic (ROC) curve analysis (area under the curve [AUC], 0.750) revealed a significant value of 1-month measurement for 1-year mortality prediction. The cutoff for the PASP value predictive of mortality was ≤41 mm Hg. A Kaplan-Meier analysis showed significantly higher mortality in patients without a 1-month PASP decrease. In the multivariable analysis, PASP measured at 1-month after TAVI (hazard ratio, 1.040; 95% confidence interval, 1.019-1.062; P < 0.001) was an independent predictor of 1-year mortality. Each 1 mm Hg increase in PASP predicts a 4% increase in the risk of death. CONCLUSION: Decreased or stable value of PASP at 1-month follow-up may predict better 1-year survival after TAVI, while each 1 mm Hg increase in PASP confers a 4% greater risk of 1-year mortality.

Neutrophil-to-lymphocyte ratio as a predictor of inflammatory response in patients with acute kidney injury after transcatheter aortic valve implantation.

BACKGROUND: Persistent inflammatory response after transcatheter aortic valve implantation (TAVI) is one of the possible causes of early and mid-term postprocedural adverse events. OBJECTIVES: To establish the predictive role of whole blood parameters on inflammatory response characteristics within a 1-year follow-up. MATERIAL AND METHODS: The study group comprised 163 consecutive patients (52.1% females), mean age 78.6 (±6.6) years (± standard deviation (SD)) who underwent TAVI and completed 1-year follow-up on-site examinations. Patients were retrospectively divided into acute kidney injury (AKI) and non-AKI subgroups. Clinical and laboratory data were collected. In-hospital and follow-up outcomes were assessed. RESULTS: The clinical and procedural details did not show significant differences between AKI and non-AKI groups. Neutrophil-to-lymphocyte ratio (NLR) decreased from baseline to measurement after 1 year with a statistically significant decline in the whole study population and non-AKI subgroup (both p = 0.005). The baseline NLR cutoff value of 4.2 for the non-AKI group ((area under the curve (AUC) = 0.718, p < 0.0001; sensitivity 46.27%, specificity 92.31%) and of 3.8 for the AKI group (AUC = 0.673, p = 0.0174; sensitivity 59.25%, specificity 84%) had prognostic properties for persistent NLR elevation. CONCLUSIONS: The NLR decreases after TAVI, and this phenomenon is more evident in patients without AKI. Furthermore, baseline NLR cutoff values may be considered predictors of persistence of inflammatory response.

Safety and performance of a novel cerebral embolic protection device for transcatheter aortic valve implantation: the PROTEMBO C Trial.

BACKGROUND: Stroke remains a feared complication associated with transcatheter aortic valve implantation (TAVI). Embolic cerebral injury occurs in the majority of TAVI cases and can lead to cognitive dysfunction. AIMS: The PROTEMBO C Trial evaluated the safety and performance of the ProtEmbo Cerebral Protection System in TAVI patients. METHODS: Forty-one patients were enrolled in this single-arm study conducted at 8 European centres. The primary safety endpoint was the rate of VARC 2-defined major adverse cardiac and cerebrovascular events (MACCE) at 30 days; the primary performance endpoint was the composite rate of technical success versus performance goals (PG). Secondary endpoints included brain diffusion-weighted magnetic resonance imaging (DW-MRI), new lesion volume, and the rate of death or all strokes compared to historical data. RESULTS: Thirty-seven of 41 enrolled patients underwent TAVI with the ProtEmbo device (intention-to-treat [ITT] population). Both primary endpoints were met. MACCE at 30 days was 8.1% (upper limit of the 95% confidence interval [CI]: 21.3% vs PG 25%; p=0.009), and technical success was 94.6% (lower limit of the 95% CI: 82.3% vs PG 75%; p=0.003). New DW-MRI lesion volumes with ProtEmbo were smaller than in historical data, and 87% of patients completing MRI follow-up had no single lesion >150 mm3. There was 1 stroke in a patient in whom the device was removed prematurely before TAVI completion. CONCLUSIONS: The PROTEMBO C Trial met its primary safety and performance endpoints compared to prespecified historical PGs. Patients had smaller brain lesion volumes on DW-MRI compared to prior series and no larger single lesions. These results warrant further evaluation of the ProtEmbo in a larger randomised controlled trial (RCT).

Increased neutrophil-to-lymphocyte ratio is associated with higher incidence of acute kidney injury and worse survival after transcatheter aortic valve implantation.

BACKGROUND: Although considered a minimally invasive procedure, transcatheter aortic valve implantation (TAVI) generates an inflammatory response which is related to post-procedural complications including acute kidney injury (AKI). The aim of the present study was to analyse the association between simple, easily available post-operative morphological parameters of inflammatory status such as neutrophil-to-lymphocyte ratio (NLR) and AKI as well as post-discharge survival. METHODS: The study group was comprised of 203 consecutive patients (102 females and 101 males, mean age 78 ± 6.9 years) who underwent TAVI between January 2013 and March 2017. Demographic and clinical data were collected. Baseline and subsequent post-procedural blood samples (8, 24, 48, 72 at discharge) were taken. Blood morphology (including NLR) and creatinine concentration were assessed. Long-term survival was also analyzed. RESULTS: Seventy-four (36.5%) patients developed AKI. Baseline morphological parameters did not differ between subject with and without AKI. Those reflecting post-procedural inflammatory response, including leucocytes, neutrophils and NLR increased significantly following TAVI in both subgroups and the rise was more pronounced in AKI patients (p < 0.001). A comparison of Kaplan-Meier curves for patients with the lowest (NLR 1; below 25th percentile) and highest NLR (NLR 3; above 75th) revealed a significant difference in the log-rank test (p = 0.049). Estimated probability of 1-, 2- and 5-year survival were 100% vs. 79%, 94% vs. 77% and 75% vs. 46%, respectively in subgroup NLR 1 and NLR 3. CONCLUSIONS: Inflammatory response after TAVI, estimated by means of NLR, is more pronounced in patients with AKI. A higher value of NLR is associated with a lower probability of long-term survival after TAVI.

Association between time-related changes in routine blood morphological parameters and renal function after transcatheter aortic valve implantation - a preliminary study.

INTRODUCTION: Transcatheter aortic valve implantation (TAVI) although minimally invasive is still accompanied by changes in blood morphological parameters, some of them linked to unfavorable outcomes. AIM: To find any association between changes in blood morphology reflecting an inflammatory response and acute kidney injury (AKI). MATERIAL AND METHODS: This study involved 176 consecutive transfemoral TAVI patients with a mean age of 78.4 ±7.0 years. Serum creatinine concentration (CREA) and blood morphology were analyzed in the blood samples taken before the procedure, then approximately 1, 24, 48 and 72 hours after the procedure, and lastly at the time of discharge. Post-procedural maximal or minimal values (max/min) and max/min-to-bs ratio of the laboratory parameters were also calculated. RESULTS: Leucocyte (WBC) and neutrophil (NEUT) counts increased significantly after the procedure whereas lymphocyte (LYMPH) counts declined markedly, reaching the highest or lowest values 24 hours after the procedure. A significant increase in neutrophil-to-lymphocyte ratio (NLR) was observed. Platelet count (PLT) dropped to a minimum at 72 hours after TAVI but at discharge did not return to the admission level. TAVI was associated with a marked increase in CREA with a peak at 48 hours after the procedure (135.7 ±75.9 µM/l). Patients with AKI (n = 65; 36.9%) presented more pronounced variations in relative changes in counts of all blood morphological parameters. A positive moderate (r = 0.412) correlation between maximal NLR and relative CREA changes was noted. CONCLUSIONS: TAVI is associated with significant changes in blood morphological parameters that reflect an inflammatory response. They are more pronounced among subjects with post-procedural AKI.

Platelet function in patients undergoing surgical and transcatheter aortic valve replacement: a comparative study.

BACKGROUND: Intervention-induced platelet hypercoagulability may pose a risk of serious adverse events for patients. AIMS: This study aimed to assess whether surgical and transcatheter aortic valve replacement (SAVR and TAVR) differ in periprocedural platelet activity. METHODS: The total number of 24 patients with a mean age (SD) of 71 (13) years who underwent SAVR (n = 12) or TAVR (n = 12) were recruited for the study. The following parameters were evaluated at 4 time-points: (i) platelet indices: total platelet count (PLT), platelet distribution width (PDW) and mean platelet volume (MPV), (ii) MPV/PLT ratio, (iii) platelet level of lipid peroxidation: malondialdehyde (MDA) content and MDA/PLT ratio. Eventually, percentage variations of PLT, PDW, and MPV in relation to the baseline values were determined. RESULTS: MPV/PLT ratio increased significantly after procedures in both groups (P = 0.01 in TAVI and P = 0.01 in SAVR). MDA concentrations were significantly higher when assessed directly post-procedure (P = 0.04) as well as 24 hours later (P = 0.01) in the SAVR and TAVI groups. The indirect parameter of platelet activity indexed for platelet counts (MDA/PLT) was comparable between both groups before and 48 hours after procedures, but was significantly higher in SAVR patients, particularly after 24 hours after interventions (P = 0.04; medians TAVR vs SAVR, respectively). CONCLUSIONS: Standard surgical aortic valve replacement is associated with a more pronounced platelet reaction to intervention-induced injury, as compared to the transcatheter-based procedure. The importance of these laboratory findings requires further investigation focused on early and late clinical outcomes.

How the COVID-19 pandemic changed treatment of severe aortic stenosis: a single cardiac center experience.

BACKGROUND: Currently, two effective therapeutic options for severe aortic stenosis (AS) are available, one catheter-based [transcatheter aortic valve implantation (TAVI)], the other open surgical approach [surgical aortic valve replacement (SAVR)]. The COVID-19 pandemic has limited the availability of medical procedures. The purpose of this cross-sectional study was to assess if this pandemic had any impact on the treatment strategy of severe AS in a single cardiac center. METHODS: This study involved AS patients treated in 3-month periods (February through April) over 3 consecutive years 2018, 2019 [defined as COV(-) group] and 2020 [COV(+)]. We assessed if there were any differences regarding patients' clinical profile, applied therapeutic method, procedure complexity and early clinical outcomes. RESULTS: In the years 2018 through 2019, approximately 50% of AS patients were treated classically (SAVR) while in 2020 this rate dropped to 34%. The preoperative clinical characteristic of TAVI subjects was comparable irrespective of the year. Regarding SAVR, more patients in COV(+) underwent urgent and more complex procedures. More of them were found in NYHA class III or IV, and had lower left ventricular ejection fraction (LVEF) (51.9%±14.4% vs. 58.3%±8.1%; P=0.021) than in COV(-) individuals. During the pandemic, a change in applied therapeutic methods and differences in patients' clinical profile did not have an unfavorable impact on in-hospital mortality (2.0% before vs. 3.6% during pandemic) and morbidity. Of note, intubation time and in-hospital stay were significantly shorter (P<0.05) in 2020 (4.2 hours and 7.5 days) than in the previous years (7.5 hours and 9.0 days, respectively). CONCLUSIONS: The coronavirus pandemic has changed substantially the management of severe AS. The shift into less invasive treatment method of AS patients resulted in shortening of in-hospital stay without compromise of short-term outcomes.

Long-term biventricular circulatory support with POLVAD-MEV paracorporeal pulsatile pumps. Single-centre experience.

INTRODUCTION: Severe heart failure decompensation requires circulatory mechanical support in emergency situations. Polish paracorporeal pulsatile pumps, POLVAD-MEV, are designed for biventricular end-stage heart dysfunction. AIM: To evaluate long-term POLVAD-MEV therapy by multiple pump exchange in patients on a transplant list. MATERIAL AND METHODS: There were 3 patients in INTERMACS level 1 referred for emergency POLVAD-MED implantation due to acute heart failure deterioration. The paracorporeal pulsatile mechanical support was applied due to severe biventricular dysfunction. RESULTS: They were supported by paracorporeal biventricular POLVAD-MEV pumps for 438, 473 and 394 days until heart transplantation. During the hospitalisation the pumps required multiple pumps exchanges within 29 ±10 (4-49) day intervals. CONCLUSIONS: POLVAD-MEV paracorporeal pulsatile pumps present a safe option for long-term circulatory support in a selected group of patients. Therapy requires pump exchange but enables survival while awaiting a heart transplant.

Transcatheter Aortic Valve Replacement Is Associated with Less Oxidative Stress and Faster Recovery of Antioxidant Capacity than Surgical Aortic Valve Replacement.

The objective of this study was to compare oxidative stress indices in 24 patients (mean ± SD age 71 ± 13 years) undergoing surgical aortic valve replacement (SAVR) versus transcatheter aortic valve replacement (TAVR). Serum total antioxidant capacity (TAC), copper/zinc ratio (Cu/Zn), activity of lactate dehydrogenase (LDH), and thiobarbituric acid reactive substances (TBARS) were assessed at four different time-points: pre-procedure, immediately post-procedure, and one day and two days after the procedure. All oxidative stress parameters were comparable in both groups pre-procedure. TAC decreased significantly when assessed immediately after procedures in both groups (p < 0.001); however, the magnitude of the reduction was more pronounced after SAVR (88% decrease from baseline: 1.8 ± 0.1 vs. 0.2 ± 0.03 mM) compared to TAVR procedures (53% decrease from baseline: 1.9 ± 0.1 vs. 1.0 ± 0.1 mM; p < 0.001). TAC returned to baseline two days after TAVR in all patients, but was still reduced by 55% two days after SAVR. In concordance, TBARS levels and Cu/Zn ratio increased significantly with maximum levels immediately after procedures in both groups (p < 0.001), but the magnitude of the increase was significantly higher in SAVR compared to TAVR (TBARS: 3.93 ± 0.61 µM vs. 1.25 ± 0.30 µM, p = 0.015; Cu/Zn ratio: 2.33 ± 0.11 vs. 1.80 ± 0.12; p < 0.001). Two days after the procedure, TBARS levels and the Cu/Zn ratio returned to baseline after TAVR, with no full recovery after SAVR. TAVR is associated with a lesser redox imbalance and faster recovery of antioxidant capacity compared to SAVR.

Endovascular treatment of complex diseases of the thoracic aorta-10 years single centre experience.

BACKGROUND: Introduction of invasive endovascular techniques constituted a real a breakthrough in the treatment of aortic aneurysm dissection and rupture. We assessed the effectiveness and safety of thoracic endovascular aortic repair (TEVAR) in patients with thoracic aortic pathologies. METHODS: Between 2007 and 2017, 118 patients with thoracic aortic pathology underwent TEVAR. Among them, 20 (16.9%) patients required hybrid procedures. Stent grafts indication were thoracic aortic aneurysm in 46 (39.0%) patients, type B dissection in 68 (57.6%) patients and other indications in 4 (3.3%). Procedural success rate, in-hospital and late mortality and morbidity were evaluated. RESULTS: The patients were followed-up for a mean of 55 months (range, 6-118 months). The technical success rate was 96%. Five patients died during the first 30 days after procedure (mortality 4.2%), four due to ischemic stroke followed by multi-organ failure and another one hemodynamically significant type I endoleak. Most of them were noted in the first years of our study. Five others died during post-discharged period. Four patients developed neurological complications, including stroke (n=2; 1.7%) and paraparesis (n=2; 1.7%). There were 6 (5.1%) primary (5 type I and 1 type II) and 3 (2.5%) secondary endoleaks (1 type I and 2 type III). Secondary interventions were required in 8 subjects. There was one case of stent collapse and two retrograde aortic dissection. CONCLUSIONS: Treatment of descending aortic diseases by using stent graft implantation has become the method of choice, decreasing the risk of open surgery, especially in patients with severe clinical state and comorbidities. However, effectiveness and safety may be achieved by experience team.

Off pump hybrid extra-anatomic techniques for aortic arch repair-own experience.

BACKGROUND: Treatment of the aortic arch pathologies is technically challenging. In this study we assess early and late outcomes of hybrid aortic arch repairs that comprise extra-anatomic surgical procedures completed by thoracic endovascular interventions [thoracic endovascular aortic repair (TEVAR)]. METHODS: Since 2007, 21 patients (8 women and 13 men) with a median age of 48 years have undergone hybrid procedures for aortic arch pathologies. All of them were treated without cardio-pulmonary bypass. All survivors were followed up regularly and imaging examination were performed. A technical success, procedural complications as well as the early and late mortality and morbidity rates were evaluated. RESULTS: All patients survived surgery and TEVAR was technically successful in all of them. However, 2 individuals died (in-hospital mortality rate 9.5%) during in-hospital stay, both due to multi-organ failure (MOF). Additionally, one patient developed symptoms of cerebral stroke, another one of spinal cord ischemia. During the follow-up that ranged from 6 to 118 months and was completed by 100% of the survivors, one patient died 3 years after procedure because of sepsis (aorto-oesophageal fistula prior to intervention) and late vascular graft occlusions were noted in three cases. CONCLUSIONS: Hybrid procedures on the aortic arch that comprise surgical and endovascular interventions has become an attractive and safe therapeutic option with acceptable mortality and morbidity rate. They may be considered as a method of choice in treatment of the elderly and high-risk patients.