Description and prevalence of ventricular mitral annular disjunction: variation of normality or pathological variant?

INTRODUCTION AND OBJECTIVES: The aim of this study was to investigate a new variation of the atrial wall-mitral annulus-ventricular wall junction along the mural mitral leaflet and commissures: the ventricular mitral annular disjunction (v-MAD). This new variant is characterized by spatial displacement of the mitral leaflet hinge line by more than 2mm toward the left ventricle. METHODS: We examined a cohort of autopsied human hearts (n=224, 21.9% females, 47.9±17.6 years) from patients without known cardiovascular disease to identify the presence of v-MAD. RESULTS: More than half (57.1%) of the hearts showed no signs of MAD in the mural mitral leaflet or mitral commissures. However, v-MAD was found in 23.6% of cases, located within 20.1% of mural leaflets, 2.2% in superolateral commissures, and 1.3% in inferoseptal commissures. V-MAD was not uniformly distributed along the mitral annulus circumference, with the most frequent site being the P2 scallop (19.6% of hearts). The v-MAD height was significantly greater in mural leaflets than in commissures (4.4 mm±1.2 mm vs 2.1 mm±0.1 mm; P<.001). No specific variations in mitral valve morphology or anthropometrical features of donors were associated with the presence or distribution of v-MADs. Microscopic examinations revealed the overlap of the thin layer of atrial myocardium over ventricular myocardium in areas of v-MAD. CONCLUSIONS: Our study is the first to present a detailed definition and morphometric description of v-MAD. Further studies should focus on the clinical significance of v-MAD to elucidate whether it represents a benign anatomical variant or a significant clinical anomaly.

Morphology of the mural and commissural atrioventricular junction of the mitral valve.

OBJECTIVE: This study investigates mitral annular disjunctions (MAD) in the atrial wall-mitral annulus-ventricular wall junction along the mural mitral leaflet and commissures. METHODS: We examined 224 adult human hearts (21.9% females, 47.9±17.6 years) devoid of cardiovascular diseases (especially mitral valve disease). These hearts were obtained during forensic medical autopsies conducted between January 2018 and June 2021. MAD was defined as a spatial displacement (≥2 mm) of the leaflet hinge line towards the left atrium. We provided a detailed morphometric analysis (disjunction height) and histological examination of MADs. RESULTS: MADs were observed in 19.6% of all studied hearts. They appeared in 12.1% of mural leaflets. The P1 scallop was the primary site for disjunctions (8.9%), followed by the P2 scallop (5.4%) and P3 scallop (4.5%). MADs were found in 9.8% of all superolateral and 5.8% of all inferoseptal commissures. The average height for leaflet MADs was 3.0±0.6 mm, whereas that for commissural MADs was 2.1±0.5 mm (p<0.0001). The microscopical arrangement of MADs in both the mural leaflet and commissures revealed a disjunction shifted towards left atrial aspect, filled with connective tissue and covered by elongated valve annulus. The size of the MAD remained remarkably uniform and showed no correlation with other anthropometric factors (all p>0.05). CONCLUSIONS: In the cohort of the patients with healthy hearts, MAD is present in about 20% of all studied hearts. The MADs identified tend to be localised, confined to a single scallop. Moreover, MADs in the commissures are notably smaller than those in the mural leaflet.

Do two operators improve outcomes in left main percutaneous coronary intervention? Insights from the ORPKI Registry.

BACKGROUND: Significant left main coronary artery (LMCA) disease is prevalent in 7% of patients undergoing angiography. Limited data exists on the impact of double scrubbing in LMCA PCI. We sought to assess periprocedural outcomes in two-operator LMCA percutaneous coronary intervention (PCI). METHODS: Using data from the Polish National Registry of PCI (ORPKI), we collected data on 28,745 patients undergoing LMCA PCI from 154 centers. Patients were divided into two groups based on the number of operators performing PCI (one vs. two operators). RESULTS: LMCA PCI was performed by a single operator in 86% of the cases and by two operators in 14% of cases. Patients treated by two operators had a greater comorbidity burden including diabetes mellitus, arterial hypertension, previous myocardial infarction, and previous revascularization. In addition, these were more likely to be treated in high-volume centers, by operators with higher volume of LMCA PCIs. The risk of periprocedural death (2.37% vs. 2.44%; P=0.78), as well as cardiac arrest, coronary artery perforation, no-reflow, and puncture site bleeding was comparable between the two groups. On multivariable analysis, we found that a two-operator strategy was an independent predictor of periprocedural death, with this effect being much more profound in an elective setting (OR=5.13 [1.37-19.26]; P=0.015), compared to an urgent (ACS) setting (OR=1.32 [1.00-1.73]; P=0.047). CONCLUSIONS: Our study suggests that a two-operator approach is not necessarily routinely recommended for LMCA interventions, although it can be considered for more complex cases.

The Impact of Age on the Physiological Assessment of Borderline Coronary Stenoses.

Background and Objectives: Coronary angiography is the gold standard for diagnosing coronary artery disease (CAD). In the case of borderline changes, patients require further diagnosis through ischemia assessment via one of the recommended methods of invasive evaluation. This study aimed to assess whether clinical factors influence the risk of a positive result in invasive myocardial ischemia assessment and if these potential factors change with the patient's age and the consistency of ischemia assessment. Materials and Methods: Data were collected retrospectively on all consecutive patients hospitalized in the University Hospital in Krakow between 2020 and 2021, on whom physiological assessments of coronary circulation were performed. Patients were divided into two groups: patients aged 60 or younger and patients older than 60. Results: Despite the older patients having more risk factors for CAD, their physiological assessment results of borderline lesions were similar to those of the younger patients. Positive fractional flow reserve (FFR) assessments were obtained from almost 50% of vessels. In the younger patients, cigarette use and type 2 diabetes mellitus increased the risk of a positive FFR result by 3.5 and 2.5 times, respectively. In the older patients, male gender and peripheral vascular disease significantly increased the risk of a positive FFR by 2.5 and 2 times, respectively. Conclusions: Clinical characteristics of patients undergoing physiological assessment of borderline coronary stenosis varied significantly by age. Refining the definition of borderline lesions to include age, gender, and other factors may improve the identification of patients who would benefit from physiological assessment and coronary revascularization.

Influence of sex on the functional assessment of myocardial ischemia.

BACKGROUND: Fractional flow reserve (FFR) and non-hyperemic resting pressure ratios, such as instantaneous wave-free ratio (iFR) and resting full-cycle ratio (RFR), are recommended for evaluating the significance of angiographically intermediate coronary stenoses. Despite their usefulness, approximately 20% of assessed lesions exhibit discordance between FFR and iFR/RFR. AIMS: The role of sex in this discrepancy remains uncertain; thus, we aimed to investigate its impact on the discordance between FFR and iFR/RFR. METHODS: We reviewed 417 consecutive intermediate stenotic lesions from 381 patients, stratified by sex and assessed with both FFR and iFR/RFR. FFR ≤0.80 and iFR/RFR ≤0.89 were considered positive for ischemia. RESULTS: Of the 381 patients, 92 (24.1%) were women. Women were older, had a lower estimated glomerular filtration rate (eGFR), higher ejection fraction, and were more likely to have peripheral artery disease than men. Median FFR and iFR/RFR values were lower in men than in women (FFR 0.86 vs. 0.80; P <0.001; iFR 0.92 vs. 0.90; P = 0.049). However, overall discordance prevalence was similar for both sexes (20.6% vs. 15.1%; P = 0.22). In men, eGFR, insulin-treated diabetes mellitus, and arterial hypertension were predictors of positive FFR | negative iFR/RFR discordance, while eGFR, insulin-treated diabetes mellitus, atrial fibrillation, and chronic obstructive pulmonary disease were predictors of negative FFR | positive iFR/RFR discordance. No factors associated with either discordance were identified in women. CONCLUSIONS: FFR and iFR/RFR results indicating significant ischemia were more common in men than women when assessing intermediate coronary stenoses. Nevertheless, sex did not predict discordant results.

Operator-patient sex discordance and periprocedural outcomes of percutaneous coronary intervention (from the ORPKI Polish National Registry).

Introduction: A recent study suggested that sex discordance between surgeons and patients negatively affects the outcomes of patients undergoing common surgical procedures. Aim: We sought to assess whether such an impact exists for periprocedural outcomes of percutaneous coronary intervention (PCI). Material and methods: From 2014 to 2020, data on 581,744 patients undergoing single-stage coronary angiography and PCI from 154 centers were collected. Patients were divided into four groups based on the patient and operator sex. Operator-patient sex discordance was defined as the procedure done by a male operator on a female patient or by a female operator on a male patient. Results: Of 581,744 patients treated by 34 female and 782 male operators, 194,691 patients were sex discordant with their operator (female operator with male patient 12,479; male operator with female patient 182,212) while 387,053 were sex concordant (female operator with female patient 6,068; male operator with male patient 380,985). Among female patients, no difference in the risk of periprocedural complications, including death (0.65% vs. 0.82%; p = 0.10), between patients discordant versus concordant with operators was observed. Among male patients the risk of death (0.55% vs. 0.43%; p = 0.037) and bleeding at the puncture site (0.13% vs. 0.08%; p = 0.046) was higher in patients discordant with operators. However, the differences were no longer significant after adjustment for covariates. Conclusions: No detrimental effect of operator-patient sex discordance on periprocedural outcomes was confirmed in all-comer patients undergoing PCI. Some of the observed differences in outcomes were primarily related to the differences in baseline risk profile.

Influence of diabetes mellitus on the invasive assessment of myocardial ischemia in patients with coronary artery disease.

INTRODUCTION: Current guidelines recommend physiological evaluation of borderline coronary artery stenoses using hyperemic (fractional flow reserve [FFR]) and nonhyperemic (instantaneous wave­free ratio [iFR] and resting full­cycle ratio [RFR]) methods. However, comorbidities, such as diabetes mellitus (DM), may influence the results of the assessment. OBJECTIVES: We sought to investigate the impact of DM and insulin treatment on the discordance between FFR and iFR/RFR. PATIENTS AND METHODS: A total of 417 intermediate stenoses in 381 patients underwent FFR and iFR/RFR assessment. FFR lower than or equal to 0.8 and iFR/RFR lower than or equal to 0.89 indicated significant ischemia. The patients were categorized based on DM diagnosis and insulin treatment status. RESULTS: Of the 381 patients, 154 (40.4%) had DM. Among these, 58 patients (37.7%) received insulin treatment. Diabetic patients had higher body mass index and glycated hemoglobin levels, and lower ejection fraction. FFR and iFR/RFR analyses were conducted in 417 vessels with available measurements for both tests. A good correlation between FFR and iFR/RFR was confirmed in both diabetic (R = 0.77) and nondiabetic (R = 0.74) patients. Discordance between FFR and iFR/RFR occurred in approximately 20% of cases, and the frequency of discordance was not affected by the diabetic status. However, insulin­treated DM was independently associated with a higher risk of negative FFR and positive iFR/RFR discordance (odds ratio, 4.61; 95% CI, 1.38-15.4; P = 0.01). Also, the optimal cutoff value for FFR identifying significant ischemia in DM patients treated with insulin was higher (0.84) than the generally recommended value. CONCLUSIONS: The rate of FFR and iFR/FFR discordance was similar regardless of the diabetes status, and insulin­treated DM was associated with an increased risk of negative FFR and positive iFR/RFR discordance.

Thrombus containing lesions strategies during primary percutaneous coronary interventions in ST-segment elevation myocardial infarction: insights from ORPKI National Registry.

In the era of potent P2Y12 inhibitors, according to current guidelines, treatment with glycoprotein IIb/IIIa inhibitors (GPIs) should be limited to bail-out and/or highly thrombotic situations. Similarly, the recommendation for aspiration thrombectomy (AT) is downgraded to very selective use. We examine the prevalence, and predictors of GPI and AT use in STEMI patients referred to primary percutaneous coronary intervention (PCI). Data on 116,873 consecutive STEMI patients referred to primary PCI in Poland between 2015 and 2020 were analyzed. GPIs were administered in 29.3%, AT was used in 11.6%, and combined treatment with both in 6.1%. There was a mild trend toward a decrease in GPI and AT usage during the analyzed years. On the contrary, there was a rapid growth of the ticagrelor/prasugrel usage rate from 6.5 to 48.1%. Occluded infarct-related artery at baseline and no-reflow during PCI were the strongest predictors of GPI administration (OR 2.3; 95% CI 2.22-2.38 and OR 3.47; 95% CI 3.13-3.84, respectively) and combined usage of GPI and AT (OR 4.4; 95% CI 4.08-4.8 and OR 3.49; 95% CI 3.08-3.95 respectively) in a multivariate logistic regression model. Similarly, the administration of ticagrelor/prasugrel was an independent predictor of both adjunctive treatment strategies. In STEMI patients in Poland, GPIs are selectively used in one in four patients during primary PCI, and the combined usage of GPI and AT is marginal. Despite the rapid growth in potent P2Y12 inhibitors usage in recent years, GPIs are selectively used at a stable rate during PCI in highly thrombotic lesions.

Comparison of Fractional Flow Reserve with Resting Non-Hyperemic Indices in Patients with Coronary Artery Disease.

Guidelines recommend using hyperemic (FFR) and non-hyperemic (iFR/RFR) methods of evaluating coronary artery stenoses in patients with coronary artery disease. However, in some cases, achieved results indicating significant ischemia may differ between those methods. Thus, we sought to identify predictors of such a discrepancy. Data were collected on all consecutive patients with chronic coronary syndrome hospitalized between 2020 and 2021. For 279 patients (417 vessels), results for both FFR and iFR/RFR were available. Values of ≤0.80 for FFR and ≤0.89 for iFR/RFR were considered positive for ischemia. Discordant measurements of FFR and iFR/RFR were observed in 80 (19.2%) patients. Atrial fibrillation was the only predictor of the overall FFR and iFR/RFR discordance - OR (95%CI) 1.90 (1.02-3.51); p = 0.040. The chance of positive FFR and negative iFR/RFR decreased independently with age - OR (95%CI) 0.96 (0.93-0.99); p = 0.024. On the contrary, insulin-treated diabetes mellitus was the predictor of negative FFR and positive iFR/RFR discrepancy - OR (95%CI) 4.61 (1.38-15.40); p = 0.013. In everyday clinical practice, iFR/FFR correlates well with FFR. However, discordance between these methods is quite common. Physicians should be aware of the risk of such discordance in patients with atrial fibrillation, advanced age, and insulin-treated diabetes mellitus.

Diabetes Mellitus Is Still a Strong Predictor of Periprocedural Outcomes of Primary Percutaneous Coronary Interventions in Patients Presenting with ST-Segment Elevation Myocardial Infarction (from the ORPKI Polish National Registry).

The impact of diabetes mellitus (DM) on outcomes of patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) was confirmed by several studies. However, it is unclear whether this effect is still present in large groups of unselected patients undergoing up-to-date treatment. Thus, we sought to assess the impact of DM on periprocedural outcomes of primary PCI in STEMI using data from the Polish National Registry of PCI. Data on 150,782 STEMI patients undergoing primary PCI were collected. Of them, 26,360 (17.5%) patients had DM. Patients with DM were higher-risk individuals who experienced longer reperfusion delays and were less likely to have closed infarct-related artery at baseline (TIMI 0 + 1 flow: 73.2% vs. 72.0%; p < 0.0001) and achieve optimal reperfusion after PCI (TIMI 3 flow: 91.8% vs. 88.5%; p < 0.0001). The periprocedural mortality (1.1% vs. 1.9%; p < 0.0001) was higher in patients with DM and DM was identified as an independent predictor of periprocedural death. In conclusion, despite continuous progress in STEMI treatment, DM remains a strong predictor of periprocedural mortality. However, this detrimental effect of DM may be partially explained by the overall higher risk profile of diabetic patients.

Increased prevalence of celiac disease and its clinical picture among patients with diabetes mellitus type 1 - observations from a single pediatric center in Central Europe.

INTRODUCTION: The aim of our study was to analyze the incidence and the clinical characteristic of celiac disease (CD) in pediatric population with type 1 diabetes mellitus (T1DM). MATERIAL AND METHODS: The data of 880 patients with T1DM, 429 girls, mean age 12.14 ±4.0 years was retrospectively retrieved from medical records. Patients with T1DM and CD were selected and a detailed analysis of CD prevalence and its clinical characteristic at the time of CD diagnosis was performed. The data were compared with the previous data from our center published a decade ago. RESULTS: CD was suspected in 85/880 patients (9.65%) on the base of results of serological tests, but finally CD was diagnosed in 73/880 patients with T1DM (8.3%), in 53/429 girls (12.3%) and in 20/451 boys (4.4%). Most patients (71%) had CD diagnosed after T1DM onset. The majority of CD patients (72%) was asymptomatic. The CD diagnosis was not associated with inappropriate metabolic control of diabetes. The onset age of diabetes in children with CD was significantly lower than in those without CD (5.8 ±3.6 years vs. 7.56 ±4.0 years, p = 0.04). The prevalence of CD is significantly higher than a decade ago in our center (8.3% vs. 5.7%, p = 0.001). CONCLUSIONS: In light of increasing prevalence of mainly asymptomatic CD in patients with T1DM, CD screening is necessary. However positive serological tests, which are currently used in screening, and are the first step of diagnostics, in some patients allow only to suspect the CD and further diagnostic steps should be performed.

Metformin and changes in serum lipid profile in lean patients with polycystic ovary syndrome.

Introduction: The aim of our study was to assess the values of total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C) and triglycerides before and after treatment with metformin in lean patients with polycystic ovary syndrome (PCOS). Material and Methods: 32 patients received metformin 1500 mg per day in three divided doses. Lipids measurements were performed twice: before and after 6 months of treatment with metformin. Results: In lean patients with PCOS after treatment with metformin we observed: statistically significant lower LDL-C levels (4.16±0.79 mmol/l vs 3.4±0.86 mmol/l, p<0.05) and triglycerides levels (1.8±0.53 mmol/l vs 1.12±0.64 mmol/l, p<0.05). We observed an increase in HDL values and a decrease in total cholesterol values, but these changes were not statistically significant (1.5±0.71 mmol/l vs 1.71±0.69 mmol/l, p=0.09; 5.87±0.92 mmol/l vs 5.69±0.97 mmol/l, p=0.11). Conclusion: Our study showed that treatment of 1500 mg metformin for about six months among PCOS women results in an improvement in serum lipid profiles. We observed a significant decrease in LDL-C and triglycerides values after metformin therapy.