Nationwide experience with transcarotid transcatheter aortic valve implantation: Insights from the POL-CAROTID registry.

BACKGROUND: The carotid artery is an alternative access route for transcatheter aortic valve implantation (TAVI), especially useful in patients unsuitable for traditional access routes including transfemoral (TF), subclavian, transapical, and aortic. AIMS: To investigate the feasibility and safety of transcarotid (TC) access for TAVI in comparison to the TF approach in a multicenter setting. METHODS: A total of 41 patients, treated between December 2014 and December 2018, were retrospectively reported to the Polish Registry of Common Carotid Artery Access for TAVI (POL-CAROTID). The median follow-up time was 619 (365-944) days, and Valve Academic Research Consortium-2 (VARC-2) definitions were applied. Clinical outcomes were compared with 41 propensity-matched TF-TAVI patients. RESULTS: The mean (standard deviation [SD]) patients' age was 78.0 (7.2) years, and 29 patients (70.7%) were men. Prohibitive iliofemoral anatomy and/or obesity (46.3%) and/or the presence of a stent graft in the abdominal aorta (31.7%) were the most common indications for TC-TAVI. Device success for TC-TAVI was comparable with the matched TF-TAVI group (90.2% vs. 95.3%, respectively, P = 0.396), and no periprocedural mortality was observed. Moreover, early safety was similar between the two groups (92.7% vs. 95.3%, respectively, log-rank P = 0.658) with only 1 case of non-disabling stroke during the first month after TC-TAVI. Consequently, no cerebrovascular events were observed in the mid-term, and the clinical efficacy of TC-TAVI corresponded well with TF-TAVI (90.2% vs. 92.7%, respectively, log-rank P = 0.716). A total of 4 (9.8%) deaths were noted in the TC-TAVI cohort in comparison to 3 (7.3%) in the TF-TAVI group. CONCLUSIONS: The results of the study indicated that the first cohort of Polish patients with implantations of second-generation transcarotid transcatheter heart valves had a similar prognosis to TF-TAVI with regard to safety and feasibility. TC access may be considered an optimal alternative for patients in whom the TF approach is precluded.

Simultaneous surgical treatment of hepatocellular carcinoma with tumor thrombus in the inferior vena cava and ischemic heart disease own research and literature review.

<b> Introduction:</b> Hepatocellular carcinoma (HCC) is the third leading cause of cancer-related death worldwide. Tumor penetration into the inferior vena cava/right atrium is rare, as it occurs only in 34% of HCC patients. There are no clear guidelines for the management of this stage of disease. </br></br> <b>Aim:</b> This is a case report of a patient with HCC and tumor thrombus in the inferior vena cava and with advanced coronary artery disease. </br></br> <b> Materials and methods:</b> The patient was qualified for a simultaneous cardiac surgery and liver resection with removal of the tumor thrombus from the inferior vena cava due to a high risk of sudden cardiac death. The first stage involved aortocoronary bypass followed by a right-sided hemihepatectomy with removal of the tumor thrombus from the inferior vena cava (this part of the operation was performed by extracorporeal circulation). The postoperative period was uneventful. Surgical treatment is one of the therapeutic options that offers a chance to radically remove the tumor and extend the patient's life. From a standpoint, these operations are extremely difficult and carry a high risk of perioperative complications (up to 40%). At the same time, the patient is at risk of complications due to cancer, such as pulmonary embolism, tricuspid stenosis, and congestive heart failure, which should be considered when choosing a treatment method. A significant number of patients also suffer from chronic conditions that worsen the prognosis. Cardiac diseases combined with tumor thrombus in the inferior vena cava may cause sudden cardiac death. </br></br> <b>Conclusions:</b> Surgical treatment should be considered in patients with HCC and tumor thrombus in the inferior vena cava, especially in patients with cardiovascular disease burden, as it is not only a chance to prolong life, but also to protect them against life-threatening cardiac complications.

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.

Echocardiographic photorealistic imaging of leiomyomatosis intravascularis.

We present a case of patient with leiomyomatosis intravascularis. To diagnose, we used 3D photorealistic imaging which allowed us better visualisation of pathological structures as well as planning the surgical procedure in greater detail. The main advantage of this technique is the possibility to move the virtual light source and thus visualize the specific part of the heart.

Atherosclerosis Pathways are Activated in Pericoronary Adipose Tissue of Patients with Coronary Artery Disease.

PURPOSE: Perivascular release of inflammatory mediators may accelerate coronary lesion formation and contribute to plaque instability. Accordingly, we compared gene expression in pericoronary adipose tissue (PCAT) in patients with advanced coronary artery disease (CAD) and non-CAD controls. PATIENTS AND METHODS: PCAT samples were collected during coronary bypass grafting from CAD patients (n = 21) and controls undergoing valve replacement surgery, with CAD excluded by coronary angiography (n = 19). Gene expression was measured by GeneChip™ Human Transcriptome Array 2.0. Obtained list of 1348 transcripts (2.0%) that passed the filter criteria was further analyzed by Ingenuity Pathway Analysis software, identifying 735 unique differentially expressed genes (DEGs). RESULTS: Among the CAD patients, 416 (30.9%) transcripts were upregulated, and 932 (69.1%) were downregulated, compared to controls. The top upregulated genes were involved in inflammation and atherosclerosis (chemokines, interleukin-6, selectin E and low-density lipoprotein cholesterol (LDL-C) receptor), whereas the downregulated genes were involved in cardiac ischaemia and remodelling, platelet function and mitochondrial function (miR-3671, miR-4524a, multimerin, biglycan, tissue factor pathway inhibitor (TFPI), glucuronidases, miR-548, collagen type I, III, IV). Among the top upstream regulators, we identified molecules that have proinflammatory and atherosclerotic features (High Mobility Group Box 2 (HMGB2), platelet-derived growth platelet (PDGF) and evolutionarily conserved signaling intermediate in Toll pathways (ESCIT)). The activated pathway related to DEGs consisted of molecules with well-established role in the pathogenesis of atherosclerosis (TFPI, plasminogen activator, plasminogen activator, urokinase receptor (PLAUR), thrombomodulin). Moreover, we showed that 22 of the altered genes form a pro-atherogenic network. CONCLUSION: Altered gene expression in PCAT of CAD patients, with genes upregulation and activation of pathway involved in inflammation and atherosclerosis, may be involved in CAD development and progression.

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.

Cardiovascular Drug Use and Risk of Actinic Keratosis: A Case-Control Study.

INTRODUCTION: Actinic keratosis (AK) is a precancerous skin lesion. Currently, many experts treat actinic keratosis as squamous cell carcinoma in situ. It is well established that exposure of the skin to ultraviolet radiation is a major risk factor for the development of actinic keratosis. Some studies suggest an association between keratinocyte cancers and photosensitizing cardiovascular drugs. The aim of this study was to establish an association between cardiovascular drug use and the presence of AK. METHODS: A total of 400 patients were enrolled into the study (200 with AK; 200 healthy persons in the control group). The group of patients with AK consisted of 106 women and 94 men (mean age 71 years). The control group included 102 women and 98 men (mean age 69 years). An analysis of the risk factors for developing actinic keratosis was performed in all patients with AK on the basis of a detailed, standardized interview. RESULTS: The statistical analysis showed that features independently associated with increased risk of AK included: age > 80 years (OR 4.14; 95% CI 2.4-7.3), positive cancer history (OR 1.94; 95% CI 1.0-3.6), positive history of sunburns when < 18 years old (OR 2.18; 95% CI 1.3-3.7) and taking angiotensin-converting enzyme inhibitors (OR 2.28; 95% CI 1.2-4.3), angiotensin receptor AT1 blockers (OR 2.90; 95% CI 1.1-7.9) and calcium channel blockers (OR 2.4; 95% CI 1.0-5.3). CONCLUSION: In conclusion, our study presented an association between cardiovascular drug use and the risk of developing AK.

[Aortic aneurysym dissection in 80-year-old woman]. / Tetniak rozwarstwiajacy aorty wstepujacej u 80-letniej kobiety.

We present a case of 80-year-old woman with a history of paroxysmal atrial fibrillation admitted to the cardiology department due to syncope and chest pain with suspicion of pulmonary embolism. In course of further diagnostics the initial diagnosis was excluded and anticoagulant treatment was stopped. The real cause of the above signs and symptoms was aortic dissection. It was diagnosed by echocardiography and confirmed by CT scan. Patient was immediately transferred to the cardiosurgery department and successfully operated. The patient was discharged after 33 days in good condition.

Changing trends in aortic valve procedures over the past ten years-from mechanical prosthesis via stented bioprosthesis to TAVI procedures-analysis of 50,846 aortic valve cases based on a Polish National Cardiac Surgery Database.

BACKGROUND: Aortic valve replacement (AVR) is one of the most common surgeries performed in cardiac surgery operating rooms. We present actual, real life trends from the last 10 years for AVR interventions based on a multicentre National Registry of Cardiac Surgery Database. METHODS: The study population consisted of all 50,846 consecutive adult patients who underwent AVR between January 2006 and August 2016 in all cardiac surgery units in Poland. The main outcome measures were changes in the number of valves, characteristics of valves, operative details, and in-hospital mortality. Analysis consisted of all aortic valve (AV) procedures, including isolated AV surgery, combination procedures and patients who had a prior valve operation. RESULTS: In last 10 years, the number of procedures increased by 46%. Isolated surgical AVR was performed in 61.2%, AVR + coronary artery bypass grafting (CABG) in 23.9%, AVR + mitral valve replacement (MVR) in 7%, and transcatheter aortic valve implantation (TAVI) in 2.3% of patients. The mean patient age increased significantly from 61.4 years in 2006 to 66.1 years in 2016. Aortic stenosis was diagnosed in 73.4%, severe aortic insufficiency in 15.8% of cases. The most common valve pathology was calcification. Congenital valve dysfunction was diagnosed in 3.7% of cases. There was a 33.7% increase of bioprosthesis, and the most common implanted bioprosthesis was the Hancock II. The most common implanted mechanical prosthesis was the St. Jude Medical Mechanical Valve. In-hospital mortality decreased significantly over the 10-year period in all AV procedures from 10.9% in 2006 to 8.3% in 2016. Mean in-hospital mortality was: 4.0% in isolated surgical AVR, 5.4% in TAVI, 6.8% in AVR + CABG, 9.8% in AVR + MVR, 17.2% in AVR + MVR + CABG. CONCLUSIONS: In the last ten years, the number of AV procedure has doubled. Mortality was significantly lower with all types of AV procedure despite very rapid aging of AVR patients. TAVI procedure rapidly grew in popularity. There is significant increase in the use of bioprosthesis.

Perioperative risk assessment with Euroscore and Euroscore II in patients with coronary artery or valvular disease.

Nowadays, both the European System for Cardiac Operative Risk Evaluation (EuroSCORE) logistic (ESL) and EuroSCORE II (ESII) models are used worldwide in predicting in-hospital mortality after cardiac operation. However, these scales are based on different populations and represent different medical approaches. The aim of the study was to assess the effectiveness of the ESL and the ESII risk scores in predicting in-hospital death and prolonged hospitalization in intensive care unit (ICU) after coronary artery bypass grafting (CABG), aortic valve replacement (AVR), and mitral valve replacement (MVR) by comparison of an estimated risk and a real-life observation at a reference cardiac surgery unit.This retrospective study was based on medical records of patients who underwent a CABG, AVR, or MVR at a reference cardiac surgery unit in a 2-year period. Primary endpoint was defined as in-hospital death. Secondary endpoint was a prolonged hospitalization at the ICU, defined as longer than 3 days.The study encompassed 586 patients [114 (23.1%) female, mean age 65.8 ±â€Š10.5 years], including 493 patients undergoing CABG, 66 patients undergoing AVR, and 27 patients undergoing MVR. The ESL and ESII risk scores were higher in MVR subgroup (31.7% ±â€Š30.5% and 15.3% ±â€Š19.4%) and AVR subgroup (9.7% ±â€Š11.6% and 3.2% ±â€Š4.2%) than in CABG subgroup (6.9% ±â€Š10.4% and 2.5% ±â€Š4.1%; P < .001). Subgroups of patients were significantly different in terms of clinical, biochemical, and echocardiography factors. Primary endpoint occurred in 36 (6.1%) patients: 21 (4.3%), 7 (10.6%), and 8 (29.7%) in CABG, AVR, and MVR subgroups, respectively. The ESII underestimated the risk of mortality. Secondary endpoint occurred in 210 (35.8%) patients: 172 (34.9%), 22 (33.4%), and 16 (59.3%) in CABG, AVR, and MVR subgroups, respectively.In the study, the perioperative risk estimated with the ESL and the ESII risk scores was compared with a real-life outcome among over 500 patients. Regardless of the type of surgery, result in the ESL was better correlated with the risk of in-hospital death.

Dual antiplatelet therapy is safe and efficient after left atrial appendage closure.

BACKGROUND: Despite results of the PROTECT AF trial, many patients undergoing left atrial appendage closure (LAAC) have unconditional contraindications to warfarin. AIM: We sought to investigate whether double antiplatelet therapy (DAPT) is safe in patients after LAAC. METHODS: Forty-four consecutive patients (22 males, mean age 74 ± 7.8 years) with non-valvular atrial fibrillation (NVAF) underwent LAAC procedure using a Watchman device followed by DAPT (75 mg/d aspirin and 75 mg/d clopidogrel). After the procedure and during 98 days' follow-up including transoesophageal echocardiography, peri-procedural complications and clinical outcomes were investigated. RESULTS: Mean CHA2DS2-VASc score was 4.9 ± 1.5 and mean HAS-BLED score was 3.6 ± 0.8. The main LAAC indication was contraindication to anticoagulation reflected by HAS-BLED score ≥ 3 observed in 95.5% cases (among them history of bleeding in 38 patients, 90.5%). 36.4% of patients have history of stroke or transient ischaemic attack. The procedure was successful in 97.7%. Peri-procedural complications were tamponade (2.3%) and one death (2.3%) unrelated to the procedure with no bleeding or vascular complications. During follow-up neither stroke nor bleeding were observed, whereas two device related thrombi and two unrelated deaths occurred. CONCLUSIONS: LAAC followed by DAPT seems to be a safe and efficient alternative for stroke prevention in patients with NVAF who have contraindications to anticoagulation therapy. This strategy may provide a significant reduction of events such as stroke and bleeding versus the score-predicted rate.

[Off-pump coronary artery bypass]. / Pomostowanie aortalno-wiencowe bez uzycia krazenia pozaustrojowego.

Development of beating heart coronary artery bypass surgery was possible since introduction of heart stabilizing instruments in mid-90's. THE AIM OF THIS REVIEW: To summarize available evidence of benefits of beating heart coronary artery bypass surgery in comparison with use of cardiopulmonary bypass during surgery. Methods of heart stabilization during operation without cardiopulmonary bypass allow to performing complete revascularization with lower degree of myocardial damage. The main advantage of beating heart coronary bypass surgery is excluding systemic inflammatory response following cardiopulmonary bypass use. And therefore less incident of renal failure, clotting disturbances, respiratory complications. There is lower incidence of microthrombotic formation and central nervous system complications. Early mortality is significantly lower and it is safer to operate on high risk patients (over 75 years old, female, with acute coronary syndrome, ascending aorta arteriosclerosis). CONCLUSION: The technique of beating heart coronary artery bypass surgery reduces risk of central nervous system complications, renal failure, respiratory problems and coagulation disturbances. The complete revascularisation is possible. This technique is available to enlarging group of patients, especially the high perioperative risk patients.

[Severe cardiovascular complications due to the pituitary adenoma with acromegaly. An interdisciplinary approach to the treatment. A case report]. / Ciezkie powiklania sercowo-naczyniowe w przebiegu guza przysadki powodujacego akromegalie. Propozycja równoczesnego wielospecjalistycznego leczenia. Opis przypadku.

Acromegaly reduces life expectancy and leads to 3-5-fold increase in mortality. The main causes are cardiovascular, pulmonary and enhanced prevalence of deaths from malignancy. Successful therapy ought to normalize GH, IGF-I secretion, remove the adenoma mass and its local pressure effects and preserve pituitary functions intact to improve systemic morbidity and normalize mortality. The primary therapy for most patients with acromegaly is still transsphenoidal adenomectomy. The authors present a 64-year-old woman with diagnosed GH-secreting pituitary macroadenoma suffering from severe coronary heart disease and diabetes mellitus. Somatostatin analogue therapy was ineffective in our patient. She was unfit for transsphenoidal adenomectomy. The patient was qualified for coronary artery bypass grafting after cardiological investigation. We have decided to carry out the bypass grafting and transsphenoidal adenomectomy during one anaesthesia. Both surgical procedures and postoperative time were uncomplicated. Our patient feels well and she is in outpatient follow-up.

[Off-pump coronary artery bypass grafting and left ventricular aneurysm resection--a case report]. / Skojarzona operacja pomostowania tetnic wiencowych oraz resekcja tetniaka lewej komory bez uzycia krazenia pozaustrojowego--opis przypadku.

We present the case of a 55-year-old patient with coronary heart disease of class III of the Canadian Cardiovascular Society (CCS), after cardiac antero-lateral wall infarction at unknown time. Coronarography revealed 90% occlusion of three branches of left coronary artery. Ventriculography showed dyskinetic aneurysm of apex and anterior wall without presence of thrombus. On the basis of the performed examination the patient was qualified to off-pump coronary artery bypass (OPCAB) and left ventricular aneurysm resection (LVAn). On the beating heart with the use of Octopus II stabilizer distal (side to side) anastomosis was performed to marginal branch and (end to side) to circumflex as a jump graft. Subsequently left internal thoracic artery to left anterior descending branch anastomosis was performed. And then, on the beating heart on the two Teflon pads entry of aneurysm was closed by the mattress sutures. Next the aneurysm was resected and closed with additional continuous suture. There were non operative and post-operative complications.

Pulmonary artery aneurysm in an adult patient with idiopathic dilatation of the pulmonary artery.

Idiopathic dilatation of the pulmonary artery (IDPA) is a rare congenital heart disease. It has been described for almost one hundred years, and numerous definitions have been proposed. The IDPA diagnostic criteria have not been updated for years. Secondary to primary disease, pulmonary artery aneurism was recognised as a lethal defect; however, long-term follow-up of patients with IDPA has not been well researched. Thus, indications to medical or surgical treatment are not evidence based. Here, we present a rare case of a 54-year-old patient with IDPA, who remained under observation for 36 years without surgical intervention.

Intraoperative assessment of mitral valve and peri-operative results of surgical treatment of mitral valve disease in patients who previously underwent closed surgical and percutaneous transluminal mitral commissurotomy.

BACKGROUND: Surgical open or closed mitral commisurotomy and percutaneous transluminal mitral commissurotomy (PTMC) are the well-established therapies in patients with mitral valve stenosis. However, due to various factors the long-term effects may not be optimal in some patients, so they should undergo surgical mitral valve replacement. AIM: The intra-operative assessment of the morphology of mitral valve and the evaluation of the peri-operative results of surgical treatment in patients with mitral valve disease who previously underwent closed surgical commissurotomy followed by PTMC. METHODS: Twenty one patients (20 males, mean age 49 years) who underwent surgery due to mitral valve disease after closed mitral commissurotomy and PTMC, are presented. The time from closed mitral commissurotomy to PTMC was 3-42 years, and the time from PTMC to mitral valve replacement - 9 days to almost 9 years. RESULTS: One patient died on the second day after the operation because of left ventricular failure. The outcome of the remaining patients was good. Advanced changes of the mitral valve and subvalvular apparatus were present in the majority of patients. CONCLUSIONS: The results of the implantation of mitral valve prosthesis in patients who previously underwent closed surgical mitral commissurotomy and PTMC are good. In some patients with a history of closed surgical mitral commissurotomy, PTMC delays surgical replacement of the mitral valve. Advanced changes in the mitral valve leaflets and subvalvular apparatus are the causes of PTMC failure.

Changes in cardiac adrenergic nervous system after transmyocardial laser revascularisation assessed by I-123-MIBG SPECT. A preliminary report.

BACKGROUND: Metaiodobenzylguanidine (MIBG), a noradrenaline analogue which may be labelled with I-123, has been used in the assessment of pre-synaptic activity of the cardiac adrenergic nervous system (Syst(adren)) in several diseases. The effects of transmyocardial laser revascularisation (TMLR) on Syst(adren) have not yet been established. AIM: To examine whether TMLR-induced changes in Syst(adren) may be one of the mechanisms responsible for clinical improvement in patients undergoing this method of revascularisation. METHODS: The study group consisted of 19 patients (mean age 63+/-9 years) who underwent TMLR, by using high-power CO(2) laser; as a single method of cardiac revascularisation. Syst(adren) was assessed before TMLR (STUDY-0), soon after the procedure (mean 13+/-5 days, STUDY-I), and in 12 patients six months after TMLR (STUDY-II). In total, 50 studies using I-123-MIBG SPECT were performed. The regional distribution of tracer was assessed qualitatively, using a 17-segment model of the left ventricle. RESULTS: In 16% of examinations the assessment of the I-123-MIBG uptake was not possible due to the poor quality of images. Thus, 41 SPECT studies (16 - STUDY-0, 16 - STUDY-I, and 9 - STUDY-II) were analysed and compared. In STUDY-0, an impaired uptake of I-123-MIBG was found in 193 of 272 analysed segments. In STUDY-I, the I-123-MIBG uptake increased in 5% of defects (CI(0,95)=3-9%) and deteriorated in 55% (CI(0,95)=48-62%). When STUDY-II was compared with baseline, the uptake was increased in 25% of defects (CI(0,95)=17-34%) and decreased in further 25% of defects. When STUDY-II was compared with STUDY-I, the uptake increased in 67% (CI(0,95)=58-75%) of defects and did not deteriorate in any. The global MIBG uptake in STUDY-I decreased in 15 patients (94%, CI(0,95)=70-100%) when compared with baseline, and increased in all 9 patients with long-term follow-up data available, when STUDY-II to STUDY-I was compared. CONCLUSIONS: TMLR significantly deteriorates Syst(adren) activity which, however, improves 6 months after the procedure to the values similar to those assessed pre-operatively. TMLR-induced impairment of Syst(adren) may contribute to the clinical improvement observed shortly (<6 months) after the procedure.