Optimal Management of Patients with Severe Coronary Artery Disease following Multidisciplinary Heart Team Approach-Insights from Tertiary Cardiovascular Care Center.

Background: The purpose of this retrospective study was to investigate outcomes of patients with severe coronary artery disease (CAD) after implementing various treatment strategies following multidisciplinary Heart Team (MHT) discussion. Methods Primary and secondary endpoints and quality of life during a mean (SD) follow-up of 37 (14) months of patients with severe CAD (three-vessel [3-VD] or/and left main [LM] disease) qualified after MHT discussion to optimal medical treatment (OMT) alone, OMT and coronary artery bypass grafting (CABG), or OMT and percutaneous coronary intervention (PCI) were evaluated. As the primary endpoint, major adverse cardiac or cerebrovascular events (MACCE) (i.e., death from any cause, stroke, myocardial infarction, or repeat/need for revascularization) were considered. Result: From 2016 to 2019, 176 MHT meetings were held, and a total of 1286 participants with severe CAD and completely implemented MHT decisions (OMT, CABG, or PCI for 251, 356, and 679 patients, respectively) were included. The occurrence of the primary endpoint was significantly increased in OMT-group (154 (61.4%) vs. CABG and PCI groups­110 (30.9%) and 302 (44.5%) patients, respectively (p < 0.05). For interventional strategies only­CABG was associated with reduced rates of MACCE and repeat revascularization, while the superiority of PCI for stroke and disabling stroke was observed (p < 0.05). The general health status assessed at the end of the follow-up was significantly better for patients who underwent CABG or PCI than in the OMT group (p < 0.05). Conclusions: In this real-life study, we presented a single-center experience of providing optimal medical care for patients with severe CAD following MHT discussion.

Long-term outcomes and quality of life following implementation of dedicated mitral valve Heart Team decisions for patients with severe mitral valve regurgitation in tertiary cardiovascular care center.

BACKGROUND: This study was purposed to investigate which treatment strategy was associated with the most favourable prognosis for patients with severe mitral regurgitation (MR) following Heart Team (HT)-decisions implementation. METHODS: In this retrospective study, long-term outcomes of patients with severe MR qualified after HT discussion to: optimal medical treatment (OMT) alone, OMT and MitraClip (MC) procedure or OMT and mitral valve replacement (MVR) were evaluated. The primary endpoint was defined as cardiovascular (CV) death and the secondary endpoints included all-cause mortality, myocardial infarctions (MI), strokes, hospitalizations for heart failure exacerbation and CV events during a mean (standard deviation [SD]) follow-up of 29 (15) months. RESULTS: From 2016 to 2019, 176 HT meetings were held and a total of 157 participants (mean age [SD] = 71.0 [9.2], 63.7% male) with severe MR and completely implemented HT decisions (OMT, MC or MVR for 53, 58 and 46 patients, respectively) were included into final analysis. Comparing OMT, MC and MVR groups statistically significant differences between the implemented procedures and occurrence of primary and secondary endpoints with the most frequent in OMT-group were observed (p < 0.05). However, for interventional strategy MC was non-inferior to MVR for all endpoints (p > 0.05). General health status assessed at the end of follow-up were significantly the lowest for MVR, then for MC and the highest for OMT-group (p < 0.01). CONCLUSIONS: In the present study it was demonstrated that after careful HT evaluation of patients with severe MR at high risk of surgery, percutaneous strategy (MC) can be considered as equivalent to surgical treatment (MVR) with non-inferior outcomes.

Heart Team for Optimal Management of Patients with Severe Aortic Stenosis-Long-Term Outcomes and Quality of Life from Tertiary Cardiovascular Care Center.

BACKGROUND: This retrospective study was proposed to investigate outcomes of patients with severe aortic stenosis (AS) after implementation of various treatment strategies following dedicated Heart Team (HT) decisions. METHODS: Primary and secondary endpoints and quality of life during a median follow-up of 866 days of patients with severe AS qualified after HT discussion to: optimal medical treatment (OMT) alone, OMT and transcather aortic valve replacement (TAVR) or OMT and surgical aortic valve replacement (SAVR) were evaluated. As the primary endpoint composite of all-cause mortality, non-fatal disabling strokes and non-fatal rehospitalizations for AS were considered, while other clinical outcomes were determined as secondary endpoints. RESULTS: From 2016 to 2019, 176 HT meetings were held, and a total of 482 participants with severe AS and completely implemented HT decisions (OMT, TAVR and SAVR for 79, 318 and 85, respectively) were included in the final analysis. SAVR and TAVR were found to be superior to OMT for primary and all secondary endpoints (p < 0.05). Comparing interventional strategies only, TAVR was associated with reduced risk of acute kidney injury, new onset of atrial fibrillation and major bleeding, while the superiority of SAVR for major vascular complications and need for permanent pacemaker implantation was observed (p < 0.05). The quality of life assessed at the end of follow-up was significantly better for patients who underwent TAVR or SAVR than in OMT-group (p < 0.05). CONCLUSIONS: We demonstrated that after careful implementation of HT decisions interventional strategies compared to OMT only provide superior outcomes and quality of life for patients with AS.

Temporal trends of transcatheter aortic valve implantation in a high-volume academic center over 10 years.

BACKGROUND: Indications for transcatheter aortic valve implantation (TAVI) have gradually expanded since its introduction. AIMS: The aim was to analyze temporal trends in TAVI characteristics based on the experience of a high-volume academic center over the period of 10 years. METHODS: Five hundred and six consecutive (n = 506) patients with 1-year follow-up were divided into early (G1, years 2010-2013, n = 130), intermediate (G2, 2014-2016, n = 164) and recent (G3, 2017-2019, n = 212) experience groups. RESULTS: Patient's age remained constant over time (mean [SD]; G1 = 79.1 [7.1] years vs G2 = 79.1 [7.1] years vs G3 = 79.7 [6.6] years, P = 0.73) but surgical risk in G3 was lower (log Euroscore, median [IQR]: G1 = 14.0 [8.4-20.2] vs G2 = 12.0 [7.0-22.2] vs G3 = 5.1 [3.5-8.5]; P <0.001). Major/life-threatening bleeding (G1 = 26.9% vs G2 = 12.8% vs G3 = 9.4%; P <0.001), major vascular complications (G1 = 15.4% vs G2 = 8.5% vs G3 = 5.7%; P = 0.02) and moderate/severe paravalvular leak (G1 = 16.2% vs G2 = 11% vs G3 = 7.5%; P = 0.046) were decreasing with time. There was a significant drop in all-cause 1-year mortality in G3 (G1 = 20% vs G2 = 17.7% vs G3 = 9.1%; log rank = 0.01). CONCLUSIONS: The age of TAVI recipients remained unchanged over the last decade. Decreasing surgical risk coupled with improvements in procedural technique and care resulted in fewer periprocedural complications and better 1-year survival.

Platelet to red cell distribution width ratio for predicting clopidogrel efficacy in patients undergoing percutaneous coronary interventions: insights from the ONSIDE-TEST study.

INTRODUCTION Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel remains a cornerstone of pharmacotherapy after percutaneous coronary intervention (PCI). It has been demonstrated that even up to 30% of patients receiving DAPT have inadequate response to clopidogrel, namely, high on­treatment platelet reactivity (HPR). The platelet to red cell distribution width (P­RDW) ratio represents an indicator of cardiovascular risk and may be related to HPR. OBJECTIVES The aim of the present study was to establish whether the P­RDW ratio predicts HPR in clopidogrel­treated patients undergoing elective PCI. PATIENTS AND METHODS This was a subanalysis of the prospective randomized­controlled ONSIDE TEST study. A total of 70 patients were included in the analysis, of whom 12 were identified with HPR. The HPR was defined as the values above the threshold of 208 platelet reactivity units (PRU >208) by the VerifyNowP2Y12 assay. RESULTS The P­RDW ratio was lower in patients with HPR than in those without HPR (mean [SD], 14.37 [4.13] vs 17.734 [4.96]; P = 0.03). A logistic regression analysis showed that the P­RDW ratio was associated with HPR (P = 0.03). Using a cut­off level of 15.23, the P­RDW ratio predicted HPR with a sensitivity of 69% and specificity of 75% (odds ratio, 6.67; 95% CI, 0.561-0.890; P = 0.02; are under the receiver operating characteristic curve, 0.723). CONCLUSIONS The P­RDW ratio may serve as a supplementary tool for identification of patients at risk of HPR. Further studies are warranted to assess its role in planning DAPT among patients undergoing PCI.

Age is the main determinant of glycated hemoglobin levels in a general Polish population without diabetes: The NATPOL 2011 Study.

BACKGROUND: Measurements of glycated hemoglobin (HbA1c) in non-diabetics can identify subjects who are at increased risk for future cardiovascular (CV) events. There is no consensus agreement whether the addition of HbA1c improves the CV risk prediction. OBJECTIVES: The objective of this study was to assess mean values of HbA1c levels in a representative sample of general, diabetes mellitus (DM)-free Polish population, and its subgroups, and to identify important covariants. MATERIAL AND METHODS: HbA1c was measured in blood samples collected from 1,868 participants (males/ females (M/F) 901/967, age: range 18-74, mean 44.03 years) of NATPOLL 2011 study without previously and newly diagnosed DM. Univariate and multivariate analyses of HbA1c level in relationship to age, body mass index (BMI), waist circumference (WC), systolic blood pressure (SBP), diastolic blood pressure (DBP), fasting plasma glucose (FPG), lipids, creatinine, C-reactive protein (CRP), gender, and smoking status were performed. RESULTS: Mean HbA1c level was 5.46 ±0.31% in the entire population and significantly higher levels were found in subjects with male gender, hypertension, fasting hyperglycemia, abdominal obesity, and higher BMI values but not in smokers. Univariate analysis revealed numerous significant correlations of HbA1c with the highest values correlation coefficient values for age (r = 0.55), FPG (r = 0.43), WC (r = 0.36), and BMI (r = 0.36). The best, final multivariate model explained 40% of HbA1c variance and the most important covariant was the age, explaining approx. 50% of R2, followed by FPG and BMI. CONCLUSIONS: HbA1c in non-diabetic level is associated with certain CV risk factors, mainly with age. Since known risk factors explain less than a half of HbA1c variance, the inclusion of HbA1c into the assessment may increase the performance of algorithms predicting CV risk.

Functional polymorphism of the renalase gene is associated with cardiac hypertrophy in female patients with aortic stenosis.

Renalase decreases circulating catecholamines concentration and is important in maintaining primary cellular metabolism. Renalase acts through the plasma membrane calcium ATPase 4b in the heart, which affects pressure overload but not exercise induced heart hypertrophy. The aim of this study was to test the association between a functional polymorphism Glu37Asp (rs2296545) of the renalase gene and left ventricular hypertrophy in a large cohort of patients with aortic stenosis. The study group consisted of 657 patients with aortic stenosis referred for aortic valve replacement. Preoperative echocardiographic assessment was performed to obtain cardiac phenotypes. Generalized-linear models were implemented to analyze data using crude or full model adjusted for selected clinical factors. In females, the Asp37 variant of the Glu37Asp polymorphism was associated with higher left ventricular mass (p = 0.0021 and p = 0.055 crude and full model respectively), intraventricular septal thickness (p = 0.0003 and p = 0.0143) and posterior wall thickness (p = 0.0005 and p = 0.0219) all indexed to body surface area, as well as relative wall thickness (p = 0.001 and p = 0.0097). No significant associations were found among the male patients. In conclusion, we have found the association of the renalase Glu37Asp polymorphism with left ventricle hypertrophy in large group of females with aortic stenosis. The Glu37Asp polymorphism causes not only amino-acid substitution in FAD binding domain but may also change binding affinity of the hypoxia- and hypertrophy-related transcription factors and influence renalase gene expression. Our data suggest that renalase might play a role in hypertrophic response to pressure overload, but the exact mechanism requires further investigation.

Association of the common genetic polymorphisms and haplotypes of the chymase gene with left ventricular mass in male patients with symptomatic aortic stenosis.

We investigated the association between polymorphisms and haplotypes of the chymase 1 gene (CMA1) and the left ventricular mass index (LVM/BSA) in a large cohort of patients with aortic stenosis (AS). Additionally, the gender differences in cardiac remodeling and hypertrophy were analyzed. The genetic background may affect the myocardial response to pressure overload. In human cardiac tissue, CMA1 is involved in angiotensin II production and TGF-ß activation, which are two major players in the pathogenesis of hypertrophy and fibrosis. Preoperative echocardiographic data from 648 patients with significant symptomatic AS were used. The LVM/BSA was significantly lower (p<0.0001), but relative wall thickness (RWT) was significantly higher (p = 0.0009) in the women compared with the men. The haplotypes were reconstructed using six genotyped polymorphisms: rs5248, rs4519248, rs1956932, rs17184822, rs1956923, and rs1800875. The haplotype h1.ACAGGA was associated with higher LVM/BSA (p = 9.84 × 10(-5)), and the haplotype h2.ATAGAG was associated with lower LVM/BSA (p = 0.0061) in men, and no significant differences were found in women. Two polymorphisms within the promoter region of the CMA1 gene, namely rs1800875 (p = 0.0067) and rs1956923 (p = 0.0015), influenced the value of the LVM/BSA in males. The polymorphisms and haplotypes of the CMA1 locus are associated with cardiac hypertrophy in male patients with symptomatic AS. Appropriate methods for the indexation of heart dimensions revealed substantial sex-related differences in the myocardial response to pressure overload.

[Improvement of left ventricular function during combined carvedilol, ramipril and spironolactone therapy after myocarditis in patient treated earlier by chemotherapy due to Hodgkin's lymphoma - 3-years follow-up]. / Poprawa funkcji lewej komory podczas terapii skojarzonej karwedilolem, ramiprilem i spironolaktonem po zapaleniu miesnia sercowego u chorej leczonej wczesniej chemioterapia z powodu chloniaka Hodgkina - obserwacja 3-letnia.

The case of woman with dysfunction of left ventricle (LV) possible due to Hodgkin's lymphoma treatment and following myocarditis is presented. Triple therapy with carvedilol, ramipril and spironolactone was continued to prevent further LV remodeling. During 3-years follow-up repeated echocardiographic examinations revealed gradual improvement of LV function and clinical condition of the patient. Results of current studies suggest benefits of early implementation of aldosterone antagonist therapy in addition to ACE-inhibitors/angiotensin receptors blockers and beta-blockers in patients with chronic heart failure.