Vascular Remodeling of Clinically Used Patches and Decellularized Pericardial Matrices Recellularized with Autologous or Allogeneic Cells in a Porcine Carotid Artery Model.

Background: Cardiovascular surgery is confronted by a lack of suitable materials for patch repair. Acellular animal tissues serve as an abundant source of promising biomaterials. The aim of our study was to explore the bio-integration of decellularized or recellularized pericardial matrices in vivo. Methods: Porcine (allograft) and ovine (heterograft, xenograft) pericardia were decellularized using 1% sodium dodecyl sulfate ((1) Allo-decel and (2) Xeno-decel). We used two cell types for pressure-stimulated recellularization in a bioreactor: autologous adipose tissue-derived stromal cells (ASCs) isolated from subcutaneous fat of pigs ((3) Allo-ASC and (4) Xeno-ASC) and allogeneic Wharton's jelly mesenchymal stem cells (WJCs) ((5) Allo-WJC and (6) Xeno-WJC). These six experimental patches were implanted in porcine carotid arteries for one month. For comparison, we also implanted six types of control patches, namely, arterial or venous autografts, expanded polytetrafluoroethylene (ePTFE Propaten® Gore®), polyethylene terephthalate (PET Vascutek®), chemically stabilized bovine pericardium (XenoSure®), and detoxified porcine pericardium (BioIntegral® NoReact®). The grafts were evaluated through the use of flowmetry, angiography, and histological examination. Results: All grafts were well-integrated and patent with no signs of thrombosis, stenosis, or aneurysm. A histological analysis revealed that the arterial autograft resembled a native artery. All other control and experimental patches developed neo-adventitial inflammation (NAI) and neo-intimal hyperplasia (NIH), and the endothelial lining was present. NAI and NIH were most prominent on XenoSure® and Xeno-decel and least prominent on NoReact®. In xenografts, the degree of NIH developed in the following order: Xeno-decel > Xeno-ASC > Xeno-WJC. NAI and patch resorption increased in Allo-ASC and Xeno-ASC and decreased in Allo-WJC and Xeno-WJC. Conclusions: In our setting, pre-implant seeding with ASC or WJC had a modest impact on vascular patch remodeling. However, ASC increased the neo-adventitial inflammatory reaction and patch resorption, suggesting accelerated remodeling. WJC mitigated this response, as well as neo-intimal hyperplasia on xenografts, suggesting immunomodulatory properties.

Serum albumin in patients undergoing transcatheter aortic valve replacement: A meta-analysis.

Transcatheter aortic valve replacement is becoming a more common therapeutic option for the treatment of aortic stenosis in patients at high risk for invasive surgery, but detecting which patients will benefit clinically can be challenging. Hypoalbuminemia is a useful prognostic marker for chronic inflammation in this population. We carried out a systematic review and meta-analysis of studies evaluating the prognostic value of serum albumin level in patients undergoing transcatheter aortic valve replacement. A literature search of PubMed, Embase, ScienceDirect, Web of Science, SciELO, BIOSIS, Wanfang, and CNKI databases was conducted. Articles published between January 2000 and December 2017 reporting on the prognostic value of low levels of serum albumin in patients undergoing transcatheter aortic valve replacement were analyzed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. 11 studies including 6456 patients met inclusion criteria for meta-analysis. A lower serum albumin level was associated with a lower survival rate at follow-up in patients who underwent transcatheter aortic valve replacement. A sub-group analysis of eight studies reporting adjusted hazard ratios indicated that low serum albumin was independently correlated with increased post-operative mortality. The hazard ratio of mortality risk associated with each 1 g/dL increment in serum albumin level was 0.46, suggesting a potential dose-response relationship between increased serum albumin level and increased survival rate in patients undergoing transcatheter aortic valve replacement. This meta-analysis provides strong evidence for the utility of serum albumin as a prognostic marker in aortic stenosis patients undergoing transcatheter aortic valve replacement, with low serum albumin levels (2.5-3.5 g/dL) suggesting poor prognosis.

Vasa vasorum of the failed aorto-coronary venous grafts.

PURPOSE: This study was designed to investigate the distribution of vasa vasorum in walls of failed aorto-coronary venous grafts. METHODS: Fifty-one diseased venous grafts harvested from 39 patients underwent qualitative histological evaluation. The morphology of the grade of the pathological changes and the extent of the vascularisation were examined, and related to the length of the interval between the primary surgery and the explantation. The obtained results were placed into five groups, substantially differing one from the other in morphology and vascularisation. RESULTS: The intervals between grafts implantation and explantation ranged from 1 day to 35 years. The onset of arterialization of the graft media was observed on average at 1 month after bypass implantation. During this same time period massive intimal hyperplasia and atherosclerosis occurred. Vasa vasorum proliferation from the adventitia to the outer layers of the media was first apparent between 7 and 24 months after implantation. Proliferation of the vasa vasorum throughout the entire atherosclerotic media and hyperplastic intima continued for a much longer time interval. CONCLUSION: No correlation between neoangiogenesis and age, sex or type of bypassed coronary branch was proven. Regarding the given findings, the authors believe that changes in hemodynamic conditions and endothelial trauma are primarily responsible for the development of graft disease and that vasa vasorum proliferation is only a secondary reaction to the structural changes of the graft wall. To what extent the frequently present pre-existing intimal hyperplasia of venous bypass grafts play in the development of graft disease remains questionable.

Procalcitonin Dynamics After Long-Term Ventricular Assist Device Implantation.

BACKGROUND: Infectious complications (IC) are one of the main causes of worsening prognosis after long-term ventricular assist device (LVAD) implantation. Procalcitonin (PCT) is widely used for diagnosis of a bacterial infection. The objective of this study was to assess PCT dynamics after LVAD surgery and their relationship to the infectious complications. METHODS: A total of 25 consecutive patients indicated for LVAD implantation as a bridge to heart transplant were included. Procalcitonin levels were prospectively assessed before surgery and during the postoperative period (day 1, 2, 14 and 30). Values were compared according to the presence of IC. RESULTS: Procalcitonin levels were low before surgery, raised significantly within 1st and 2nd day after operation and decreased in the 14th and 30th days back to the baseline. There was no significant difference in PCT values between patients with or without IC as well as with or without right ventricle assist device (RVAD). Acute renal failure (ARF) increased PCT significantly only 14 days after LVAD implantation. In patients with ARF and/or RVAD we observed significantly higher PCT values in the 2nd, 14th and 30th day after operation. In subjects with IC and/or ARF and/or RVAD we also observed significantly elevated PCT concentrations 2 and 14 days after surgery. CONCLUSIONS: Our data show that the ability of PCT to detect IC in patients after LVAD implantation is limited and its concentrations more likely correlate with postoperative complications in general.

Native T1 Relaxation Time and Extracellular Volume Fraction as Accurate Markers of Diffuse Myocardial Fibrosis in Heart Valve Disease　- Comparison With Targeted Left Ventricular Myocardial Biopsy.

BACKGROUND: The aim of our study was to investigate the relationship between the cardiac magnetic resonance (CMR)-derived native T1 relaxation time and myocardial extracellular volume (ECV) fraction and the extent of diffuse myocardial fibrosis (DMF) on targeted myocardial left ventricular (LV) biopsy. METHODS AND RESULTS: The study population consisted of 40 patients (age 63±8 years, 65% male) undergoing valve and/or ascending aorta surgery for severe aortic stenosis (77.5%), root dilatation (7.5%) or valve regurgitation (15%). The T1 relaxation time was assessed in the basal interventricular septum pre- and 10-min post-contrast administration using the modified Look-Locker Inversion recovery sequence prior to surgery. LV myocardial biopsy specimen was obtained during surgery from the basal interventricular septal segment matched with the T1 mapping assessment. The percentage of myocardial collagen was quantified using picrosirius red staining. The average percentage of myocardial collagen was 22.0±14.8%. Both native T1 relaxation time with cutoff value ≥1,010 ms (sensitivity=90%, specificity=73%, area under the curve=0.82) and ECV with cutoff value ≥0.32 (sensitivity=80%, specificity=90%, area under the curve=0.85) showed high accuracy to identify severe (>30%) DMF. The native T1 relaxation time showed significant correlation with LV mass (P<0.01). CONCLUSIONS: Native T1 relaxation time and ECV at 10 min after contrast administration are accurate markers of DMF. (Circ J 2016; 80: 1202-1209).

Novel insights into pretransplant allosensitization in heart transplant recipients in the contemporary era of immunosuppression and rejection surveillance.

Solid-phase assays (SPA) have facilitated detection and definition of antibodies to human leukocyte antigens (HLA) and major histocompatibility complex class I chain-related antigen A (MICA). However, clinical consequences of pretransplant SPA results in heart transplantation have been studied insufficiently in the current era of immunosuppression and rejection surveillance. Pretransplant sera, panel-reactive antibodies (PRA), pretransplant crossmatch, and clinical data were retrospectively analyzed in 264 adult heart transplant recipients. The specificity of HLA and MICA antibodies and C1q-binding activity of donor-specific antibodies (DSA) were defined using SPA. Pretransplant HLA antibodies were detected in 57 (22%) individuals, in 28 individuals (11%); these antibodies were DSA after transplant. Preformed DSA and elevated peak PRA were independent predictors of pathologic AMR, which occurred in 19 individuals (7%). The increasing number of DSA and the cumulative mean fluorescence intensity of DSA were associated with AMR. C1q-binding assay was a suboptimal predictor of AMR in our cohort. Pretransplant allosensitization and MICA antibodies were related neither to impaired graft survival nor to other adverse clinical events during a median follow-up of 39 months. Identification of preformed DSA by SPA, in addition to PRA monitoring, may predict AMR in the contemporary era of heart transplantation.

Tricuspid valve surgery in patients with idiopathic hypereosinophilic syndrome.

A 53-year-old female with idiopathic hypereosinophilic syndrome underwent recurrent tricuspid valve replacement for Löffler's endocarditis. We review the literature on tricuspid valve surgery in patients with this uncommon disorder.

Physical Activity and Exercise as a Basic Preventive Measure (Primary Prevention, Prevention after Renal Transplantation).

Movement is an inseparable part of one's life, and has been a basic everyday activity through the history of mankind. However, a lack of physical activity and availability of food have resulted in a variety of serious health impairments. The 20th century has witnessed a steep rise of mortality from cardiovascular disease, increase in the prevalence of type-2 diabetes mellitus, malignant diseases, and dramatic increase in body weight initially in industrialized nations followed, in the last two decades of the last century, by the populations of third-world countries with all inherent consequences of this phenomenon. Preventive programmes involving physical activity have also been on the list of top priorities of various materials issued by the World Health Organization. Physical activity is one of the simplest non-pharmacological tools in the prevention of a plethora of diseases. The simplest physical activity, even for therapeutic purposes, is walking. We can walk any time, virtually anywhere, so walking is also the least expensive therapeutic option.

[The current state and future of care of patients with congenital heart defects]. / Soucasný stav a budoucnost péce o nemocné s vrozeným srdecními vadami.

Care of patients with congenital heart diseases in Czech Republic does not have only important history, falling to the prewar period, but especially systematic and long-term work with excellent results in pediatric patients. With improvements in the care of these patients also improves their survival with the need for continuous care in adulthood including reoperation, catheter ablations incisional tachycardias and other specialized procedures in difficult heart morphology. The article is a reflection and an appeal to all responsible professionals, organizers and payers of health care, how to proceed and provide specialized training, continuity of care for these patients, including proposed organizational changes and outlines the need for further development in this important medical field.

High-density epicardial activation mapping to optimize the site for video-thoracoscopic left ventricular lead implant.

BACKGROUND: The left ventricular (LV) lead local electrogram (EGM) delay from the beginning of the QRS complex (QLV) is considered a strong predictor of response to cardiac resynchronization therapy. We have developed a method for fast epicardial QLV mapping during video-thoracoscopic surgery to guide LV lead placement. METHODS: A three-port, video-thoracoscopic approach was used for LV free wall epicardial mapping and lead implantation. A decapolar electrophysiological catheter was introduced through one port and systematically attached to multiple accessible LV sites. The pacing lead was targeted to the site with maximum QLV. The LV free wall activation pattern was analyzed in 16 pre-specified anatomical segments. RESULTS: We implanted LV leads in 13 patients with LBBB or IVCD. The procedural and mapping times were 142 ± 39 minutes and 20 ± 9 minutes, respectively. A total of 15.0 ± 2.2 LV segments were mappable with variable spatial distribution of QLV-optimum. The QLV ratio (QLV/QRSd) at the optimum segment was significantly higher (by 0.17 ± 0.08, p < 0.00001) as compared to an empirical midventricular lateral segment. The LV lead was implanted at the optimum segment in 11 patients (at an adjacent segment in 2 patients) achieving a QLV ratio of 0.82 ± 0.09 (range 0.63-0.93) and 99.5 ± 0.6% match with intraprocedural mapping. CONCLUSION: Video-thoracoscopic LV lead implantation can be effectively and safely guided by epicardial QLV mapping. This strategy was highly successful in targeting the selected LV segment and resulted in significantly higher QLV ratios compared to an empirical midventricular lateral segment.

Fungal infections associated with long-term mechanical circulatory support-diagnosis and management.

Left ventricular assist devices (LVADs) are increasingly used as a treatment option for advanced heart failure. Fungal infections present a serious concern given the high association with major adverse events including death in this group of patients. The objective of this review is to summarize the incidence, risk factors, method for diagnosis, complication rate, and outcomes in patients with VADs who develop fungal infections.

Intracardiac ectopic thyroid (struma cordis).

A 67-year-old male with a history of gastrointestinal malignancy was found to have a tumor in the right ventricular outflow tract. The tumor was surgically removed, and the histological diagnosis was thyroid struma. We review the literature on this rare cardiac tumor.

[30 years heart transplantation program in Institute for Clinical and Experimental Medicine in Prague]. / 30 let programu transplantace srdce v Institutu klinické a experimentální medicíny v Praze.

Heart transplantation has become in recent decades an established method for the treatment of advanced heart failure. Precisely, it was in January 2014 when 30 years have passed since the start of clinical heart transplantation program at the Institute for Clinical and Experimental Medicine. 936 heart transplants were performed by the end of 2013. The transplant program has reached considerable development since its beginnings. The knowledge of whole issue has deepened, indication criteria have been extended, new immunosuppressives are available and many of them are still in research. Life expectancy of patients has been prolonged and quality of life has improved. Nevertheless, the care of transplant patient is very complicated task for medical professionals and brings a lot of problems to solve.

Interposition of right internal iliac artery free-graft for left coronary artery reimplantation in adults with anomalous left coronary artery originating from the pulmonary artery: case series and long-term results.

Anomalous left coronary artery originating from the pulmonary artery (ALCAPA) is an infrequent congenital anomaly. Presentation of this syndrome is rare in adults. Nevertheless, adult patients are at risk of ischaemia, arrhythmias or sudden cardiac death and always require surgical intervention. At our institution, a specific technique of interposition of the right internal iliac artery as a free-graft for left coronary artery reimplantation was used in adult ALCAPA patients. The aim of this report is to determine long-term results and experiences with this surgical technique.

External Support of Autologous Internal Jugular Vein Grafts with FRAME Mesh in a Porcine Carotid Artery Model.

BACKGROUND: Autologous vein grafts are widely used for bypass procedures in cardiovascular surgery. However, these grafts are susceptible to failure due to vein graft disease. Our study aimed to evaluate the impact of the latest-generation FRAME external support on vein graft remodeling in a preclinical model. METHODS: We performed autologous internal jugular vein interposition grafting in porcine carotid arteries for one month. Four grafts were supported with a FRAME mesh, while seven unsupported grafts served as controls. The conduits were examined through flowmetry, angiography, macroscopy, and microscopy. RESULTS: The one-month patency rate of FRAME-supported grafts was 100% (4/4), whereas that of unsupported controls was 43% (3/7, Log-rank p = 0.071). On explant angiography, FRAME grafts exhibited significantly more areas with no or mild stenosis (9/12) compared to control grafts (3/21, p = 0.0009). Blood flow at explantation was higher in the FRAME grafts (145 ± 51 mL/min) than in the controls (46 ± 85 mL/min, p = 0.066). Area and thickness of neo-intimal hyperplasia (NIH) at proximal anastomoses were similar for the FRAME and the control groups: 5.79 ± 1.38 versus 6.94 ± 1.10 mm2, respectively (p = 0.558) and 480 ± 95 vs. 587 ± 52 µm2/µm, respectively (p = 0.401). However, in the midgraft portions, the NIH area and thickness were significantly lower in the FRAME group than in the control group: 3.73 ± 0.64 vs. 6.27 ± 0.64 mm2, respectively (p = 0.022) and 258 ± 49 vs. 518 ± 36 µm2/µm, respectively (p = 0.0002). CONCLUSIONS: In our porcine model, the external mesh FRAME improved the patency of vein-to-carotid artery grafts and protected them from stenosis, particularly in the mid regions. The midgraft neo-intimal hyperplasia was two-fold thinner in the meshed grafts than in the controls.

Mitral valve repair versus replacement in simultaneous aortic and mitral valve surgery.

BACKGROUND: Double valve replacement for concomitant aortic and mitral valve disease is associated with substantial morbidity and mortality. Excellent results with valve repair in isolated mitral valve lesions have been reported; therefore, whether its potential benefits would translate into better outcomes in patients with combined mitral-aortic disease was investigated. METHODS: A retrospective observational study was performed involving 341 patients who underwent aortic valve replacement with either mitral valve repair (n=42) or double valve replacement (n=299). Data were analyzed for early mortality, late valve-related complications and survival. RESULTS: The early mortality rate was 11.9% for valve repair and 11.0% for replacement (P=0.797). Survival (± SD) was 67±11% in mitral valve repair with aortic valve replacement and 81±3% in double valve replacement at five years of follow-up (P=0.187). The percentage of patients who did not experience major adverse valve-related events at five years of follow-up was 83±9% in those who underwent mitral valve repair with aortic valve replacement and 89±2% in patients who underwent double valve replacement (P=0.412). Age >70 years (HR 2.4 [95% CI 1.1 to 4.9]; P=0.023) and renal dysfunction (HR 1.9 [95% CI 1.2 to 3.7]; P=0.01) were independent predictors of decreased survival. CONCLUSIONS: In patients with double valve disease, both mitral valve repair and replacement provided comparable early outcomes. There were no significant differences in valve-related reoperations, anticoagulation-related complications or prosthetic valve endocarditis. Patient-related factors appear to be the major determinant of late survival, irrespective of the type of operation.

[False aneurysm of the wall of a venous graft in a patient with an implanted MGuard type of coronary stent: case report and description of the microscopic changes]. / Nepravá výdut steny zilního stepu u pacienta s implantovaným MGuard typem koronárního stentu: kazuistické sdelení a popis mikroskopických zmen.

The present case report demonstrates a development of a false aneurysm in a venous coronary bypass graft wall, which developed at the previous MGuard stent implantation area in a 67-year-old patient. Subsequent histological examination revealed a false aneurysm image, without detection of vascular wall layers in its wall. Microscopically mild neointimal proliferation within the stent was also detected, with a strong granulomatous inflammatory reaction, mostly focused on the PET fibre mesh present on the surface of the stent. This article demonstrates the need for a multidisciplinary approach in dealing with pathological changes in stented blood vessels; the authors would also like to remind the public of the possibility of histological examination of stented vessels in the Czech Republic.

A pilot study of systolic dyssynchrony index by real time three-dimensional echocardiography and Doppler tissue imaging parameters predicting the hemodynamic response to biventricular pacing in the early postoperative period after cardiac surgery.

OBJECTIVE: To evaluate systolic dyssynchrony index (SDI) measured by real time three-dimensional echocardiography (RT3DE) and Doppler tissue imaging (DTI) dyssynchrony parameters in predicting the hemodynamic response to biventricular (BIV) pacing in the early postoperative period after cardiac surgery. To compare right ventricular (RV) and BIV pacing using invasively measured hemodynamic values. METHODS: A prospective randomized clinical study enrolling 11 patients with ischemic heart disease, concomitant valvular heart disease, and left ventricular ejection fraction (LVEF) ≤ 35% comparing preoperative SDI by RT3DE and DTI LV dyssynchrony parameters to hemodynamic values obtained during RV or BIV sequential (DDD) epicardial pacing in the first 72 hours after cardiac surgery. RESULTS: BIV pacing produced a statistically significant higher cardiac output (CO) (6.27 ± 1.55 L/min) and cardiac index (CI) (3.44 ± 0.93 L/min per m(2) ) than RV pacing (CO 5.44 ± 0.97 L/min, CI 3.03 ± 0.83 L/min per m(2) , P < 0.05). We found a statistically moderate correlation between preoperative SDI by RT3DE and CO (r = 0.596, P < 0.05) and a nonsignificant correlation to CI (r = 0.535, P < 0.10) during BIV pacing. No correlation was observed between DTI dyssynchrony parameters and measured hemodynamic values. BIV pacing reduced the ICU stay and inotropic support requirements of patients after heart surgery. CONCLUSIONS: SDI measured preoperatively using RT3DE can predict CO during BIV pacing in the early postoperative period after cardiac surgery. BIV pacing is more hemodynamically effective than RV pacing in patients with LV dysfunction after coronary artery bypass grafting with or without a valve procedure.

Aortic dissections following heart transplantations.

BACKGROUND: Aortic dissection in a cardiac allograft is an uncommon complication of heart transplantation with only few cases reported in the literature. METHOD: We report a case of 46-year-old female who underwent orthotopic heart transplantation for dilated cardiomyopathy 22 years earlier. During surveillance echocardiographic examination she was diagnosed with type A aortic dissection limited to the donor aorta. The aortic root was successfully replaced using a valve-sparing David procedure. The pathogenesis and surgical management of these dissections is reviewed. CONCLUSION: Appropriate surgical repair performed in a timely fashion leads to excellent results improving the prognosis of these patients.

The hemodynamic effect of right ventricle (RV), RT3DE targeted left ventricle (LV) and biventricular (BIV) pacing in the early postoperative period after cardiac surgery.

BACKGROUND: Congestive heart failure negatively impacts the prognosis in patients after cardiac surgery. The aim of our study was to assess the value of targeted cardiac resynchronization therapy (CRT) within 72 hours after cardiac surgery in patients with mechanical dyssynchrony, who had an ejection fraction ≤ 35%, QRS ≥150 ms or between 120 and 150 ms. METHODS: A prospective randomized trial based on three-dimensional echocardiography (RT3DE) and optimized sequential dual-chamber (DDD ) pacing in patients after cardiac surgery. DDD epicardial pacing (Medtronic coaxial epicardial leads 6495) was provided by a modified Medtronic INSYNC III Pacemaker (Medtronic Inc., Minneapolis, MN, USA). SUMMARY OF RESULTS: The study included 21 patients with ischemic heart disease (HD) or valvular HD (16 men, 5 women, average age 69 years) with left ventricle (LV) dysfunction after cardiac surgery . Patients with biventricular (BIV) (CO 6.7 ± 1.7 L/min, CI 3.5 ± 0.8 L/min/m(2) ) and LV (CO 6.2 ± 1.5 L/min, CI 3.2 ± 0.7 L/min/m(2) ) pacing had statistically significantly higher CO and CI than patients with right ventricular (RV) (CO 5.4 ± 1.4 L/min, CI 2.8 ± 0.6 L/min/m(2) ) pacing (BIV vs RV P ≤ 0.001; LV vs RV P ≤ 0.05; BIV vs LV P ≤ 0.05). CONCLUSIONS: RT3DE targeted and optimized CRT in the early postperative period after cardiac surgery provided better hemodynamic results than RV pacing.