Electromechanical factors associated with favourable outcome in cardiac resynchronization therapy.

AIMS: Electromechanical coupling in patients receiving cardiac resynchronization therapy (CRT) is not fully understood. Our aim was to determine the best combination of electrical and mechanical substrates associated with effective CRT. METHODS AND RESULTS: Sixty-two patients were prospectively enrolled from two centres. Patients underwent 12-lead electrocardiogram (ECG), cardiovascular magnetic resonance (CMR), echocardiography, and anatomo-electromechanical mapping (AEMM). Remodelling was measured as the end-systolic volume (ΔESV) decrease at 6 months. CRT was defined effective with ΔESV ≤ -15%. QRS duration (QRSd) was measured from ECG. Area strain was obtained from AEMM and used to derive systolic stretch index (SSI) and total left-ventricular mechanical time. Total left-ventricular activation time (TLVAT) and transeptal time (TST) were derived from AEMM and ECG. Scar was measured from CMR. Significant correlations were observed between ΔESV and TST [rho = 0.42; responder: 50 (20-58) vs. non-responder: 33 (8-44) ms], TLVAT [-0.68; 81 (73-97) vs. 112 (96-127) ms], scar [-0.27; 0.0 (0.0-1.2) vs. 8.7 (0.0-19.1)%], and SSI [0.41; 10.7 (7.1-16.8) vs. 4.2 (2.9-5.5)], but not QRSd [-0.13; 155 (140-176) vs. 167 (155-177) ms]. TLVAT and SSI were highly accurate in identifying CRT response [area under the curve (AUC) > 0.80], followed by scar (AUC > 0.70). Total left-ventricular activation time (odds ratio = 0.91), scar (0.94), and SSI (1.29) were independent factors associated with effective CRT. Subjects with SSI >7.9% and TLVAT <91 ms all responded to CRT with a median ΔESV ≈ -50%, while low SSI and prolonged TLVAT were more common in non-responders (ΔESV ≈ -5%). CONCLUSION: Electromechanical measurements are better associated with CRT response than conventional ECG variables. The absence of scar combined with high SSI and low TLVAT ensures effectiveness of CRT.

The influence of scar on the spatio-temporal relationship between electrical and mechanical activation in heart failure patients.

AIMS: The aim of this study was to determine the relationship between electrical and mechanical activation in heart failure (HF) patients and whether electromechanical coupling is affected by scar. METHODS AND RESULTS: Seventy HF patients referred for cardiac resynchronization therapy or biological therapy underwent endocardial anatomo-electromechanical mapping (AEMM) and delayed-enhancement magnetic resonance (CMR) scans. Area strain and activation times were derived from AEMM data, allowing to correlate mechanical and electrical activation in time and space with unprecedented accuracy. Special attention was paid to the effect of presence of CMR-evidenced scar. Patients were divided into a scar (n = 43) and a non-scar group (n-27). Correlation between time of electrical and mechanical activation was stronger in the non-scar compared to the scar group [R = 0.84 (0.72-0.89) vs. 0.74 (0.52-0.88), respectively; P = 0.01]. The overlap between latest electrical and mechanical activation areas was larger in the absence than in presence of scar [72% (54-81) vs. 56% (36-73), respectively; P = 0.02], with smaller distance between the centroids of the two regions [10.7 (4.9-17.4) vs. 20.3 (6.9-29.4) % of left ventricular radius, P = 0.02]. CONCLUSION: Scar decreases the association between electrical and mechanical activation, even when scar is remote from late activated regions.

Sex Difference in Patients With Ischemic Heart Failure Undergoing Surgical Revascularization: Results From the STICH Trial (Surgical Treatment for Ischemic Heart Failure).

BACKGROUND: Female sex is conventionally considered a risk factor for coronary artery bypass grafting (CABG) and has been included as a poor prognostic factor in multiple cardiac operative risk evaluation scores. We aimed to investigate the association of sex and the long-term benefit of CABG in patients with ischemic left ventricular dysfunction enrolled in the prospective STICH trial (Surgical Treatment for Ischemic Heart Failure Study). METHODS: The STICH trial randomized 1212 patients (148 [12%] women and 1064 [88%] men) with coronary artery disease and left ventricular ejection fraction ≤35% to CABG+medical therapy (MED) versus MED alone. Long-term (10-year) outcomes with each treatment were compared according to sex. RESULTS: At baseline, women were older (63.4 versus 59.3 years; P=0.016) with higher body mass index (27.9 versus 26.7 kg/m2; P=0.001). Women had more coronary artery disease risk factors (diabetes mellitus, 55.4% versus 37.2%; hypertension, 70.9% versus 58.6%; hyperlipidemia, 70.3% versus 58.9%) except for smoking (13.5% versus 21.8%) and had lower rates of prior CABG (0% versus 3.4%; all P<0.05) than men. Moreover, women had higher New York Heart Association class (class III/IV, 66.2% versus 57.0%), lower 6-minute walk capacity (300 versus 350 m), and lower Kansas City Cardiomyopathy Questionnaire overall summary scores (51 versus 63; all P<0.05). Over 10 years of follow-up, all-cause mortality (49.0% versus 65.8%; adjusted hazard ratio, 0.67; 95% confidence interval, 0.52-0.86; P=0.002) and cardiovascular mortality (34.3% versus 52.3%; adjusted hazard ratio, 0.65; 95% confidence interval, 0.48-0.89; P=0.006) were significantly lower in women compared with men. With randomization to CABG+MED versus MED treatment, there was no significant interaction between sex and treatment group in all-cause mortality, cardiovascular mortality, or the composite of all-cause mortality or cardiovascular hospitalization (all P>0.05). In addition, surgical deaths were not statistically different (1.5% versus 5.1%; P=0.187) between sexes among patients randomized to CABG per protocol as initial treatment. CONCLUSIONS: Sex is not associated with the effect of CABG+MED versus MED on all-cause mortality, cardiovascular mortality, the composite of death or cardiovascular hospitalization, or surgical deaths in patients with ischemic left ventricular dysfunction. Thus, sex should not influence treatment decisions about CABG in these patients. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT00023595.

Ischemic conditioning of human heart muscle depends on opioid-receptor system.

BACKGROUND: Despite progress in the invasive treatment of ischemic heart disease, the ability to limit ischemia-reperfusion (I/R) injury remains largely unrealized. Ischemic pre-conditioning (IPC) and post-conditioning (POC) induce the protective mechanisms of resistance against I/R injury. Stimulation of opioid receptors mimic the protective effect of IPC or POC in an animal models. We tested the hypothesis, that IPC and POC provide cardioprotection in opioid-dependent mechanism in human myocardium. METHODS: Human atrial trabeculae were subjected to I/R injury. To achieve IPC, single hypoxia period preceded the applied lethal hypoxia, to achieve POC triple hypoxia periods followed lethal hypoxia. Naloxone was used at the onset of lethal hypoxia in IPC protocol, and at the time of re-oxygenation in POC protocol. Contractive function of the myocardium was assessed as maximal force of contraction (Amax), rate of rise of force of contraction (+dV/dT) and diastolic parameter - rate of decay of force of contraction (-dV/dT). RESULTS: Co-application of naloxone with IPC or POC resulted in decrease of Amax, +dV/dT and -dV/dT during re-oxygenation period as compared to IPC or POC only. CONCLUSIONS: Naloxone abrogates beneficial effect of IPC and POC. IPC and POC in humans provide cardioprotection in opioid receptor system dependent mechanism.

Frailty Syndrome in Heart Failure Patients who are Receiving Cardiac Resynchronization.

BACKGROUND: We hypothesized that patients with de novo cardiac resynchronization therapy (CRT) implantation had a more intense frailty syndrome when compared to the patients who qualified for a system upgrade. METHODS: One hundred and six patients aged ≥65 years were included. They were divided into two groups: de novo CRT implantation--74 patients and upgrade from standard right heart pacing--32 patients. A CRT was finally implanted in all of the patients. Frailty was evaluated using the Canadian Study of Health and Aging Clinical Frailty Scale (CSHA-CFS). RESULTS: The average results in CSHA-CFS were statistically higher (5.3 ± 0.8) in the de novo patients when compared to the patients who qualified for a system upgrade (4.9 ± 0.8); P = 0.027. Frailty syndrome was recognized in 81.1% of the patients in the de novo group and in 68.7% of the patients in the upgrade group; P = 0.164. Only one patient of the 106 had no attributes of frailty (or exposed ones) syndrome. CONCLUSIONS: Frailty syndrome is a common phenomenon in patients with heart failure and over 65 years of age. The syndrome is most often recognized in patients who are de novo qualified for cardiac resynchronization.

Transvenous lead extraction safety and efficacy in infected and noninfected patients using mechanical-only tools: Prospective registry from a high-volume center.

BACKGROUND: Transvenous lead extraction (TLE) is a well-established treatment option for patients with cardiac implantable electronic devices (CIED) complications. OBJECTIVE: The purpose of this study was to evaluate the safety and efficacy of TLE in CIED infection and non-CIED infection patients. METHODS: Consecutive patients who underwent TLE between 2016 and 2022 entered the EXTRACT Registry. Models of prediction were constructed for periprocedural clinical and procedural success and the incidence of major complications, including death in 30 days. RESULTS: The registry enrolled 504 patients (mean age 66.6 ± 12.8 years; 65.7% male). Complete procedural success was achieved in 474 patients (94.0%) and clinical success in 492 patients (97.6%). The total number of major and minor complications was 16 (3.2%) and 51 (10%), respectively. Three patients (0.6%) died during the procedure. New York Heart Association functional class IV and C-reactive protein levels defined before the procedure were independent predictors of any major complication, including death in 30 days in CIED infection patients. The time since the last preceding procedure and platelet count before the procedure were independent predictors of any major complication, including death in 30 days in non-CIED infection patients. CONCLUSIONS: TLE is safe and successfully performed in most patients, with a low major complication rate. CIED infection patients demonstrate better periprocedural clinical success and complete procedural success. However, CIED infection predicts higher 30-day mortality compared with non-CIED infection patients. Predictors of any major complication, including death in 30 days, differ between CIED infection and non-CIED infection patients.

Severe sleep apnea as a predictor of failure to respond to cardiac resynchronization therapy.

BACKGROUND: The response to cardiac resynchronization therapy (CRT) is suboptimal in one-third of patients. OBJECTIVES: The study aimed to evaluate the impact of sleep-disordered breathing (SDB) on the CRT-induced left ventricular (LV) reverse remodeling and response for CRT in patients with ischemic congestive heart failure (CHF). METHODS: A total of 37 patients aged 65.43 years (SD 6.05), seven of whom were females, were treated with CRT according to class I European Society of Cardiology recommendations. Clinical evaluation, polysomnography, and contrast echocardiography were performed twice during the six-month follow-up (6M-FU) to assess the effect of CRT. RESULTS: In 33 patients (89.1%), sleep-disordered breathing (SDB), predominantly central sleep apnea (70.3%) was observed. This include nine patients (24.3%) with an apnea-hypopnea index (AHI) of >30 events/hour. During the 6M-FU, 16 patients (47.1%) responded to CRT by reducing LV end-systolic volume index (LVESVi) by ≥15%. We stated a directly proportional linear relationship between AHI value and LV volume: LVESVi p = 0.004, and LV end-diastolic volume index p = 0.006. CONCLUSIONS: Pre-existing severe SDB can impair the LV volumetric response to CRT even in an optimally selected group with class I indications for resynchronization, which may have an impact on long-term prognosis.

Remifentanil but not sufentanil induces cardioprotection in human ischemic heart muscle in vitro.

BACKGROUND: Previous studies on animal models have suggested that δ-opioid receptor (OR) signaling is the primary pathway responsible for opioids' cardioprotective effect. We hypothesize that the µ-OR's activation protects the human heart muscle. METHODS: We performed the experiments on muscular trabeculae obtained from the right atrial appendages of 104 consecutive patients subjected to coronary artery bypass surgery. Two trabeculae from each patient were studied simultaneously and exposed to 60 min of hypoxia with subsequent 60 min of reoxygenation. Remifentanil (5 µM or 50 µM) or sufentanil (40 µM or 400 µM) was used from the time of reoxygenation. Trabeculae contractility was assessed as the maximal amplitude of the contraction at baseline, after 60 min of hypoxia, during reoxygenation, and after norepinephrine application. RESULTS: During reperfusion, the application of remifentanil improved cardiomyocytes' function as compared to the control group (time from reperfusion: 15 min: 39.8% vs. 21.7%, p = 0.01; 30 min: 41.4% vs. 21.8%, p = 0.01; 60 min: 42.7% vs. 26.9%, p = 0.04; after norepinephrine: 64.7% vs. 43.2%, p = 0.03). The application of sufentanil did not influence cardiomyocyte function as can be seen when comparing the results of the experimental and control group. CONCLUSIONS: Remifentanil, but not sufentanil, induces a cardioprotective effect on human right atria muscle in in vitro conditions, manifested as the increased amplitude of their contraction during reperfusion after 60 min of ischemia.

Relationships between Heart Chamber Morphology or Function and Respiratory Parameters in Patients with HFrEF and Various Types of Sleep-Disordered Breathing.

Sleep-disordered breathing (SDB), i.e., central sleep apnea (CSA) and obstructive sleep apnea (OSA), affects the prognosis of patients with heart failure with reduced ejection fraction (HFrEF). The study assessed the relationships between heart chamber size or function and respiratory parameters in patients with HFrEF and various types of SDB. The 84 participants were patients aged 68.3 ± 8.4 years (80% men) with an average left ventricular ejection fraction (LVEF) of 25.5 ± 6.85% who qualified for cardioverter-defibrillator implantation with or without cardiac resynchronization therapy. SDB, defined by an apnea-hypopnea index (AHI) ≥ five events/hour, was diagnosed in 76 patients (90.5%); SDB was severe in 31 (36.9%), moderate in 26 (31.0%), and mild in 19 (22.6%). CSA was the most common type of SDB (64 patients, 76.2%). A direct proportional relationship existed only in the CSA group between LVEF or stroke volume (SV) and AHI (p = 0.02 and p = 0.07), and between LVEF or SV and the percentage of total sleep time spent with hemoglobin oxygen saturation < 90% (p = 0.06 and p = 0.07). In contrast, the OSA group was the only group in which right ventricle size showed a positive relationship with AHI (for basal linear dimension [RVD1] p = 0.06), mean duration of the respiratory event (for RVD1 p = 0.03, for proximal outflow diameter [RVOT proximal] p = 0.009), and maximum duration of respiratory event (for RVD1 p = 0.049, for RVOT proximal p = 0.006). We concluded that in HFrEF patients, SDB severity is related to LV systolic function and SV only in CSA, whereas RV size correlates primarily with apnea/hypopnea episode duration in OSA.

Statistical agreement of left ventricle measurements using cardiac magnetic resonance and 2D echocardiography in ischemic heart failure.

BACKGROUND: The aim of this study was to compare cardiac magnetic resonance imaging (CMR) with 2-dimensional echocardiography (2D echo) in the assessment of left ventricle (LV) function parameters and mass in patients with ischemic heart disease and severely depressed LV function. Although 2D echo is commonly used to assess LV indices, CMR is the state-of-the-art technique. Agreement between these 2 methods in these patients has not been well established. MATERIAL/METHODS: LV indexed end systolic and diastolic volumes (EDVi and ESVi), indexed mass (LVMi) and ejection fraction (EF) were assessed in 67 patients (12 women), using 2D echo and CMR. RESULTS: According to statistical analysis (Bland-Altman), 2D echo underestimated LV EDV and ESV and overestimated EF and LVMi compared to CMR. The highest correlation between 2D echo and CMR was found for EDVi (R2=0.73, p<0.0001) and ESVi (R2=0.69, p<0.0001) and the lowest for EF (R2=0.21, p=0.001) and LVMi (R2=0.20, p=0.002). The maximal differences between 2D echo and CMR were found for highest mesurements of LV volumes and mass, and for lowest EF values. CONCLUSIONS: There is moderate to strong correlation between CMR and 2D echo in the assessment of LV function parameters and mass in patients with ischemic heart failure. Between-method agreement depends on the degree of LV dysfunction. The results of assessment of the severely damaged LV obtained by the use of 2D echo should be interpreted with caution.

The Effects of His Bundle Pacing Compared to Classic Resynchronization Therapy in Patients with Pacing-Induced Cardiomyopathy.

Pacing-induced cardiomyopathy (PICM) is among the most common right ventricular pacing complications. Upgrading to cardiac resynchronization therapy (CRT) is the recommended treatment option. Conduction system pacing with His bundle pacing (HBP) has the potential to restore synchronous ventricular activation and can be an alternative to biventricular pacing (BVP). Patients with PICM scheduled for a system upgrade to CRT were included in the prospective cohort study. Either HBP or BVP was used for CRT. Electrocardiographic, clinical, and echocardiographic measurements were recorded at baseline and six-month follow-up. HBP was successful in 44 of 53 patients (83%). Thirty-nine patients with HBP and 22 with BVP completed a 6-month follow-up. HBP led to a higher reduction in QRS duration than BVP, 118.3 ± 14.20 ms vs. 150.5 ± 18.64 ms, p < 0.0001. The improvement in New York Heart Association (NYHA) class by one or two was more common in patients with HBP than those with BiV (p = 0.04). Left ventricular ejection fraction (LVEF) improved in BVP patients from 32.9 ± 7.93% to 43.9 ± 8.07%, p < 0.0001, and in HBP patients from 34.9 ± 6.45% to 48.6 ± 7.73%, p < 0.0001. The improvement in LVEF was more considerable in HBP patients than in BVP patients, p = 0.019. The improvement in clinical outcomes and left ventricle reverse remodeling was more significant with HBP than BVP. HBP can be a valid alternative to BVP for upgrade procedures in PICM patients.

The usefulness of His bundle pacing in a heterogeneous population of patients with impaired left ventricular systolic function.

BACKGROUND: His bundle pacing (HBP) maintains a physiological activation pattern of ventricular activation, and in patients with intraventricular conduction delay (IVCD) it can normalize wide QRS duration. METHODS: A total of 181 patients from the HBP registry were enrolled into a the study, which was conducted at the Department of Electrocardiology in Katowice, Poland. The patients had left ventricular ejection fraction (LVEF) < 50% and were implanted between November 2015 and April 2019. The HBP indications were as follows: 1) bradycardia and atrioventricular conduction disturbances with expected high pacing burden, 2) IVCD, LVEF ≤ 35%, with an indication for resynchronization therapy, 3) the need to upgrade to resynchronization therapy due to pacing-induced cardiomyopathy. Pacing parameters and echocardiographic and clinical data were assessed for up to 2 years of follow-up (FU). RESULTS: His bundle pacing was successful in 154 (85.1%) patients. Eighty-two patients completed a 6-month FU. The mean age was 70.6 ± 9.23 years, and 79% were males. At 6 months FU LVEF improved from 35.3 ± 8.22% to 43.1 ± 10.14% (p < 0.0001), and indexed left ventricular end-systolic volume (LVESVi) decreased from 63.1 ± 25.21 mL/m² to 51.9 ± 22.79 mL/m² (p < 0.0001). In 53.1%, the LVESVi reduction was greater than 15%. The improvement in LVEF and LVESVi was also observed after 24 months of FU. CONCLUSIONS: His bundle pacing in permanently paced patients when LVEF is reduced below 50% is associated with improvement in LVEF and reverse left ventricle remodeling.

Local electromechanical alterations determine the left ventricle rotational dynamics in CRT-eligible heart failure patients.

Left ventricle, LV wringing wall motion relies on physiological muscle fiber orientation, fibrotic status, and electromechanics (EM). The loss of proper EM activation can lead to rigid-body-type (RBT) LV rotation, which is associated with advanced heart failure (HF) and challenges in resynchronization. To describe the EM coupling and scar tissue burden with respect to rotational patterns observed on the LV in patients with ischemic heart failure with reduced ejection fraction (HFrEF) left bundle branch block (LBBB). Thirty patients with HFrEF/LBBB underwent EM analysis of the left ventricle using an invasive electro-mechanical catheter mapping system (NOGA XP, Biosense Webster). The following parameters were evaluated: rotation angle; rotation velocity; unipolar/bipolar voltage; local activation time, LAT; local electro-mechanical delay, LEMD; total electro-mechanical delay, TEMD. Patients underwent late-gadolinium enhancement cMRI when possible. The different LV rotation pattern served as sole parameter for patients' grouping into two categories: wringing rotation (Group A, n = 6) and RBT rotation (Group B, n = 24). All parameters were aggregated into a nine segment, three sector and whole LV models, and compared at multiple scales. Segmental statistical analysis in Group B revealed significant inhomogeneities, across the LV, regarding voltage level, scar burdening, and LEMD changes: correlation analysis showed correspondently a loss of synchronization between electrical (LAT) and mechanical activation (TEMD). On contrary, Group A (relatively low number of patients) did not present significant differences in LEMD across LV segments, therefore electrical (LAT) and mechanical (TEMD) activation were well synchronized. Fibrosis burden was in general associated with areas of low voltage. The rotational behavior of LV in HF/LBBB patients is determined by the local alteration of EM coupling. These findings serve as a strong basic groundwork for a hypothesis that EM analysis may predict CRT response.Clinical trial registration: SUM No. KNW/0022/KB1/17/15.

Perivascular tissue of internal thoracic artery releases potent nitric oxide and prostacyclin-independent anticontractile factor.

OBJECTIVE: It has been recently suggested that perivascular tissue (PVT) releases hypothetic adipocyte- or adventitia-derived relaxing factor. The aim of the study was to assess anticontractile properties of perivascular tissue of human internal thoracic artery (ITA) and to check if this activity is nitric oxide (NO)- or prostacyclin-dependent. We also analyzed the influence of pleural adipose tissue on ITA reactivity. METHODS: Human ITA rings were studied in vitro. First, skeletonized and pedicled ITA reactivity to serotonin and angiotensin II was compared. In subsequent experiments fragments of ITA were skeletonized and divided into two preparations. One was incubated alone, the other together with PVT or pleural adipose tissue floating freely in the bath. First, concentration-response curves to either serotonin or angiotensin II were constructed. Tissue was then transferred from one bath to the other and concentration-response curves were reconstructed. The same protocol was applied with the inhibition of NO synthase with L-NMMA (10(-4)M) and cyclooxygenase with indomethacin (10(-5)M). RESULTS: Skeletonization augmented contractile response to serotonin (E(max) 16.6+/-1.85 mN vs 43.8+/-3.87 mN; pedicled vs skeletonized ITA, respectively; p<0.001) and angiotensin II (E(max) 10.9+/-1.07 mN vs 26.6+/-1.45 mN, respectively; p<0.001). PVT presence in the bath caused decrease of E(max) from 40.8+/-5.01 to 20.1+/-2.69 mN for serotonin; p<0.001 and from 31.4+/-3.75 to 13.0+/-1.60 mN for angiotensin II, p<0.001 (PVT(-) vs PVT(+), respectively). PVT did not change ITA sensitivity (EC(50)) to serotonin or angiotensin II. Pleural adipose tissue did not change the contractile response of ITA to serotonin (E(max) 37.2+/-4.95 mN vs 36.3+/-4.83 mN, pleural fat+and pleural fat-, respectively; p=0.9). NO and prostacyclin inhibition failed to abolish anticontractile properties of perivascular tissue. PVT with cyclooxygenase and NO synthase inhibition decreased E(max) of serotonin from 46.6+/-3.03 to 28.2+/-4.02 mN, p<0.001 and E(max) of angiotensin II from 27.2+/-2.00 to 16.4+/-2.10 mN, p<0.001. CONCLUSIONS: Perivascular tissue of ITA releases potent, soluble, nitric oxide and prostacyclin-independent anticontractile factor. The pleural adipose tissue does not influence ITA reactivity to vasoconstrictors. Preservation of perivascular tissue may protect against vasospasm of ITA graft in clinical settings.

[Clinical significance of transesophageal and epiaortal echocardiography of ascending aorta in risk estimation of neurological complications in coronary artery by-pass patients]. / Znaczenie badania echokardiograficznego przezprzelykowego i epiaortalnego aorty wstepujacej w prognozowaniu ryzyka powiklan neurologicznych u chorych poddanych zabiegowi pomostowania tetnic wiencowych.

UNLABELLED: Advanced atherosclerotic changes in aortal wall are an important factor in taking decision to use minimal-invasive method of coronary artery by-pass grafting. There are some methods for diagnosing atherosclerotic changes in ascending aorta, i.e.: roentgenogram, computer tomography, magnetic resonance imaging, transthoracic echocardiography and especially transesophageal echocardiography and epiaortal echocardiography. THE AIM OF THE STUDY: To define usefulness of transesophageal and epiaortal echocardiography as a method of prognosing neurological complications in patients during coronary artery by-pass grafting. MATERIAL AND METHODS: Study group consisted of 32 consecutive patients who had coronary surgery in II Chair and Department of Cardiosurgery, Silesian Medical University in Katowice due to ischemic heart disease in whom before the surgery ascending aorta wall was evaluated with transesophageal and epiaortal echocardiography and then monitoring of microembolism was performed. Transesophageal examination was performed with Philips Sonos 7500 device with 5 MHz transducer in anesthetized patient. Ascending aorta from level of aortic valve to the aortic arch in long and short axis was evaluated. Epiaortal echocardiography was performer with 7.5 MHz vesseltransducer and Hewlett-Packard Sonos 100 CF H-P device immediately after chest opening. Transesophageal echocardiography of ascending aorta evaluated: intima-media complex thickness and presence of atherosclerotic plaques and calcifications. Microembolism monitoring was performed in 18 patients before and during surgery. Using 2 MHz transducer placed in left and right temporal region number of microembolic incidents were evaluated. RESULTS: Analysis of relationship between aortic wall thickness and microembolic signals during cardiopulmonary by-pass was performed. During cardiopulmonary by-pass microembolic signals (from 7 to 698 signals) were detected in 7 patients. During analysis number of microembolic signals was normalized to cardiopulmonary by-pass duration time. CONCLUSIONS: There was found correlation between number of microembolic signals during cardiopulmonary by-pass and thickness of aortic posterior wall in all of it's levels, using epiaortal method in short axis. This same was found using lateral wall measurements. There was no correlation between aortic wall thickness evaluated with transesophageal echocardiography and numbers of microembolic signals.

Opioidergic conditioning of the human heart muscle in nitric oxide-dependent mechanism.

BACKGROUND: Opioidergic conditioning is well documented to trigger cardioprotection against ischemia/ reperfusion (I/R) injury. Previous studies on animal models have suggested that nitric oxide (NO) mediates the beneficial effect of opioids, but the role of NO in humans seems to be controversial. OBJECTIVES: The aim of the study was to assess the influence of NO modulators on opioid-induced cardioprotection in the human myocardium. MATERIAL AND METHODS: Trabeculae of the human right atria were electrically driven in an organ bath and subjected to simulated I/R injury. The non-selective inhibitor of nitric oxide synthase (NOS) - N-methyl-l-arginine (LNMMA), the donor of NO - S-Nitroso-N-acetylpenicillamine (SNAP) or morphine (in the amount of 10-4 M) were used at the time of re-oxygenation. The additional trabecula was subjected to the hypoxia protocol only (control). The contractility of the myocardium was assessed as the maximal force of a contraction (Amax), the rate of rise of the force of a contraction (Slope L) and the cardiac muscle relaxation - as the rate of decay of the force of a contraction (Slope T). RESULTS: The application of 100 µM LNMMA resulted in the decrease of Amax, Slope L and Slope T during the re-oxygenation period as compared to control. The application of 10-4 M morphine and/or 100 µM SNAP resulted in a partial reversal of the detrimental influence of LNMMA. CONCLUSIONS: At the re-oxygenation period, the blockade of NO synthesis has a deleterious effect on the systolic and diastolic function of the human myocardium as well as attenuates the beneficial effect of morphine conditioning.

[Mitral annuloplasty ring dehiscence after blunt chest trauma]. / Oderwanie sztucznego pierscienia mitralnego w wyniku tepego urazu klatki piersiowej.

A case of recurrent severe mitral regurgitation following blunt chest trauma with deceleration injury in a 61-year-old woman is presented. The patient had undergone previous CABG and mitral annuloplasty with the use of a flexible (Duran) ring. At reoperation, partial dehiscence of the annuloplasty ring, which had become rigid, was found. This was successfully repaired.

'Opioidergic postconditioning' of heart muscle during ischemia/reperfusion injury.

BACKGROUND: Ischemic preconditioning and postconditioning are the novel strategies of attaining cardioprotection against ischemia/reperfusion (I/R) injury. Previous studies suggested the role of opioid pathway, however the class of opioid receptors responsible for this effect in humans remains unknown. The aim of the study was to assess the influence of opioids on simulated I/R injury outcomes in the hu-man myocardium. METHODS: Trabeculae of the human right atrium were electrically driven in organ bath and subjected to simulated I/R injury. Morphine (10-4M, 10-5M, 10-6M) or d-opioid receptor agonist DADLE (10-8M, 10-7M, 10-6M) was used at the time of re-oxygenation. Additional trabecula was subjected to hypoxia protocol only (Control). Contractive force of the myocardium was assessed as the maximal force of a contraction (Amax), the rate of rise of the force of a contraction (Slope L) and relaxation as the rate of decay of the force of a contraction (Slope T). RESULTS: Application of morphine 10-4M resulted in increase of Amax, Slope L and Slope T during re-oxygenation period as compared to Control (77.99 ± 1.5% vs. 68.8 ± 2.2%, p < 0.05; 45.72 ± 2.9% vs. 34.12 ± 5.1%, p < 0.05; 40.95 ± 2.5% vs. 32.37 ± 4.3%, p < 0.05). Parameters were not significantly different in the lower morphine concentrations. Application of DADLE 10-6M resulted in decrease of Amax and Slope L as compared to Control (68.13 ± 5.5% vs. 76.62 ± 6.6%, p < 0.05; 28.29 ± 2.2 vs. 34.80 ± 3.9%, p < 0.05). CONCLUSIONS: At re-oxygenation, morphine improves systolic and diastolic function of the human myo-cardium in the dose-dependent manner. Delta-opioid receptor stimulation attenuates systolic function of human heart muscle which remains in contrast to previous reports with animal models of I/R injury. (Cardiol J 2017; 24, 4: 419-425).

Left internal mammary artery improves 5-year survival in patients under 40 subjected to surgical revascularization.

BACKGROUND: The population of young patients under 40 requiring coronary bypass surgery is characterized by an extremely and unusually rapid progression of coronary heart disease. The aim of the present study was to assess the clinical status and quality of life in these patients after surgery in relation to the type of conduit used to revascularize the left anterior descending artery (LAD). METHODS: One hundred seventeen patients under 40 (range, 30-40 years) underwent coronary artery bypass grafting (CABG) at our institution between 1991 and 1999. Ninety-one patients received LIMA to LAD graft (group A), and in 26 patients the saphenous vein was used to graft this vessel (group B). Seventy-eight patients (63 in group A and 15 in group B) were assessed after a mean time of 71 +/- 26 months. They were asked to fill out a questionnaire aimed at their subjective assessment of their quality of life as compared with their preoperative status. RESULTS: Five-year actuarial survival was higher in patients with LIMA to LAD graft (log rank test: P < .004). The functional status of patients in group B was significantly worse in comparison to group A: respectively, CCS 2.2 +/- 1.1 versus 1.5 +/- 0.7; (P = .02), NYHA 2.2 +/- 1.1 versus 1.3 +/- 0.5; (P = .002). Patients in group B more frequently required reinstitution of nitroglycerine treatment (93% versus 56%; P = .025). We failed to show differences between the 2 groups as far as subjective quality of life is concerned. In summary, 63% of patients perceived it to be worse, 29% to be better, and 8% felt it had not changed. CONCLUSION: The use of LIMA is crucial in patients undergoing CABG under the age of 40 in order to achieve the best possible surgical results. Quicker recurrence of coronary disease symptoms is observed when a vein is used to graft the LAD. It may reflect an earlier progress of atherosclerosis in venous grafts.