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.

NT-proBNP increase during stress echocardiography predicts significant changes in ischemic mitral regurgitation severity in patients qualified for surgical revascularization.

BACKGROUND: In many patients, significant changes in ischemic mitral regurgitation (IMR) severity during exercise can be observed independent of the degree of IMR at rest. This study aimed to investigate the correlations between N-terminal fragment B-type natriuretic peptide (NT-proBNP) and echocardiography measurements at rest and at peak exercise in patients with moderate IMR who qualified for surgical revascularization. METHODS: A total of 100 patients eligible for coronary artery bypass grafting, were included in this prospective study. All patients underwent exercise echocardiography. Additionally, the levels of NT-proBNP were measured at rest and after peak exercise. RESULTS: A positive correlation of absolute NT-proBNP levels with effective regurgitant orifice area (EROA) were observed and with tricuspid regurgitant peak gradient (TRPG) at peak exercise. Absolute ΔNT-proBNP during exercise and the tenting area at rest were independent predictors of severe IMR at peak exercise. The level of absolute ΔNT-proBNP during exercise and coaptation height at rest were the most important predictors of significant increases in TRPG. The best cutoff value for ΔNT-proBNP as a predictor for increases in EROA at peak exercise was 68.9 pg/mL and to predict an increase in TRPG ≥ 50 mmHg at peak exercise was 68 pg/mL. CONCLUSIONS: The level of ΔNT-proBNP during exercise was the most important parameter in predicting significant changes in IMR severity and pulmonary pressure. Based on the present data, it can be speculated that integration of the assessment of NT-proBNP at rest and at exercise might improve patient selection for valve surgery.

The quality of life in patients with at least moderate ischemic mitral regurgitation qualified to cardiosurgery treatment.

B a c k g r o u n d: To assess and compare mid-term outcomes and the quality of life (QoL) in patients with multivessel coronary artery disease (MVD) and moderate ischemic mitral regurgitation (IMR), treated with either coronary artery bypass grafting (CABG; group I) or CABG + mitral annuloplasty (CABG+MA; group II) in 12-months follow-up after surgery. M e t h o d s: We prospectively analyzed 74 patients (50.7% female, 66 [67-72] years) with at least moderate IMR, 3-24 weeks after myocardial infarction (MI). The effective regurgitation orifice (ERO) was used for a quantitative IMR assessment. To evaluate QoL we used a Short Form-36 (SF-36) questionnaire. R e s u l t s: Patients in group II spent more time in the hospital, expired more infection complications and received more often in-hospital complications requiring use amines and intra-aortic balloon pump as compared to those in group I. Analysis of SF-36 showed that all patients treated surgically notable improved their QoL during 12 months of follow-up. C o n c l u s i o n s: We observed a significant improvement in QoL among patients with MVD in 12 months follow-up after surgery irrespective of treatment type.

Stress Echocardiography Protocol for Deciding Type of Surgery in Ischemic Mitral Regurgitation: Predictors of Mitral Regurgitation Recurrence following CABG Alone.

PURPOSE: Although coronary artery bypass grafting alone (CABGa), or, with mitral annuloplasty (CABGmp), is considered the best therapeutic strategy for patients with ischemic mitral regurgitation (IMR), some recurrences are still reported. The aim of this study was to evaluate the use of the mitral deformation indices (MDI) as a predictor of recurrence of mitral regurgitation in a 12-month follow-up after CABG alone. METHODS: A total of 145 patients after myocardial infarction with significant IMR, eligible for CABG, were prospectively enrolled in the study. Mitral valve morphology, left ventricle function, IMR degree as assessed by effective regurgitation orifice area (ERO), myocardial viability, and MDI were assessed prior to surgery. Patients were referred for CABGa (gr.1; n = 90) or CABGmp (gr.2; n = 55) based on clinical assessment, and the results of rest and stress echocardiography (exercise echocardiography and low dose dobutamine echocardiography-DBX). One year after surgery, each patient underwent the evaluation of cardiovascular events. Univariable logistic regression analysis was used to identify the factors of recurrence of IMR in 1 year follow-up. Serial echo examinations were performed in all patients at discharge, and at 1 and 12 months after surgery. RESULTS: Logistic regression analysis revealed that in CABGa, group preoperative changes of tenting area (TA) and coaptation high (CH) during DBX remained the predictors of the recurrence of IMR in 12 months follow-up. TAdbx > 1 cm2 provided a sensitivity of 90% and specificity of 29%, (AUC 0.6436). The best cut-off value for CHdbx was 0.4 cm (sensitivity 90%, specificity 34%; AUC 0.6432). In both groups (CABGa vs. CABGmp) no significant differences were observed in 12-month mortality (1.2% vs. 0%; p = 1.0), hospitalizations due to the heart failure (HF) exacerbation (5.9% vs. 8.5%; p = 0.72), and in the incidence of the composite endpoint (deaths/CV hosp/stroke) (7% vs. 8.5%; p = 0.742). CONCLUSIONS: The preoperative assessment of MDI changes during dbx can be used to identify patients with IMR qualified to CABG alone at increased risk of recurrence of IMR in 1 year follow-up. Mitral deformation analysis should be used for a better qualification of patients with IMR to the exact surgical approach.

Sex-dependent differences in clinical characteristics and in-hospital outcomes in patients with takotsubo syndrome.

INTRODUCTION: Takotsubo syndrome (TTS) is an acute reversible left ventricular dysfunction, which occurs mainly in postmenopausal women. OBJECTIVES: The goal of this study was to compare the course of the disease and prognoses in men and women with TTS in 2 large Polish university hospitals. PATIENTS AND METHODS: The analysis included 232 patients (211 women and 21 men) hospitalized at the 1st Chair and Department of Cardiology at the Medical University of Warsaw and at the 1st Department of Cardiology at the Medical University of Gdansk. RESULTS: Men who developed TTS were more likely to live alone than women. Physical stress triggered TTS more often in men than in women. There were no differences in the prevalence of risk factors and comorbidities, except for a higher prevalence of smoking in men. With regard to the cardiac biomarkers, both admission and peak levels of N­terminal prohormone of brain natriuretic peptide were higher in women. ST­segment depression was found more frequently in men than in women (25% vs 6.2%). Despite the same length of hospitalization, ejection fraction at discharge was lower in men than in women (50% vs 60%). In­hospital outcomes (arrhythmias, mechanical complications, cardiogenic shock, mortality rate) were similar in both groups. ß-Adrenolytics and statins were more often prescribed to women than to men (74.5% vs 52.4% and 68.3% vs 38.1%). Moreover, there was a tendency toward more frequent use of P2Y12 inhibitors in men than in women (23.8% vs 10.4%). CONCLUSIONS: Differences occurred in the clinical course of TTS between men and women. However, in­hospital outcomes were similar in both groups.

Comparison of Complications and In-Hospital Mortality in Female Patients with Takotsubo Syndrome and ST-Segment Elevation Myocardial Infarction.

BACKGROUND: Takotsubo syndrome (TTS) is a clinical condition that mimics acute myocardial infarction (MI). More than 90% patients are women, mainly postmenopausal. Research suggests that up to 5% of women evaluated for a MI actually have TTS and that diagnose may be underestimated. Patients with TTS are generally able to fully recover within a period of days to weeks. However, serious, potentially fatal, complications may occur. METHODS: In 117 consecutive female patients hospitalized with TTS and 117 consecutive female patients with ST-segment elevation MI, we collected data regarding cardiovascular risk factors, comorbidities, and complications. We compared all in-hospital complications in both groups and analyzed factors influencing the composite endpoint which was cardiogenic shock and death from any cause. RESULTS: In our study patients with TTS had a lower incidence of serious complications compared to the ST-segment elevation MI group. Moreover, in-hospital mortality was also lower in the TTS group. The factors which influenced cardiogenic shock and death from any cause were: heart rate at admission, diastolic blood pressure at admission, C-reactive protein (CRP) concentration at admission, chest pain at admission, ST-segment depression in the electrocardiography at admission, and ejection fraction at admission. Moreover, patients with exacerbation of chronic disease as the cause of TTS also reached the composite endpoint more often. CONCLUSIONS: Female patients with TTS had more favorable in-hospital prognoses than patients with ST-segment elevation MI. However, serious complications occurred. The factors which influenced the composite endpoint came from readily available data-within the first hour after admission to the hospital.

Radiofrequency ablation without the use of fluoroscopy - in what kind of patients is it feasible?

INTRODUCTION: The aim of the study was to describe the experience in performing ablation without fluoroscopy. MATERIAL AND METHODS: From 575 ablation procedures with CARTO performed in the period 2003-2008, 108 (42 M; age 40 ±16 years) were done without fluoroscopy. One patient had ablation using the Localisa system. There was one man with thrombocytopenia and two pregnant women. RESULTS: Right ventricular (RV) outflow tract arrhythmias and other RV arrhythmias were noted in 38 patients (35%) and 17 patients (15%), respectively. There were 5 (4.6%) left ventricular (LV) outflow tract arrhythmias and 19 (17.5%) other LV tachycardias; right accessory pathways in 17 patients (20%), in the middle cardiac vein in 1, Mahaim fibres in 1, and 3 cases of permanent junctional reciprocating tachycardias. One patient with CRT had AV node ablation (Localisa). In 3 patients there were also other arrhythmias treated: slow AV nodal pathway, typical flutter isthmus and right atrial tachycardia. In 2004, 1/96 CARTO procedures was done without fluoroscopy, in 2006 2/97, in 2007 19 (2 in LV) of 93, in 2008 87 (22 in LV) of 204. The percentage of ablations without fluoroscopy in every hundred CARTO procedures was: 1%, 1%, 8%, 23%, 46%, 28% (mean 18%). There were no procedure-related complications. CONCLUSIONS: It is feasible to perform ablations within both right and left sides of the heart without fluoroscopy. The number and type of non-fluoroscopic procedures depends on the operator's experience. Pregnant patients, with malignant history or with hematologic diseases should be ablated without fluoroscopy in centres that specialise in these kinds of procedures.

Utility of stress echocardiography in selecting the optimal mitral valve procedure in patients with severe ischemic mitral regurgitation undergoing coronary artery bypass grafting.

INTRODUCTION: Severe functional ischemic mitral regurgitation (FIMR) considerably worsens the prognosis of patients after myocardial infarction. The complex pathomechanism of FIMR and its dynamic nature make it difficult to develop effective therapeutic methods. OBJECTIVES: The aim of the study was to prospectively assess a diagnostic strategy based on stress echocardiography in referring patients with severe FIMR for appropriate surgical procedure: coronary artery bypass grafting alone (CABGa) or CABG with mitral annuloplasty (CABGma) or replacement (CABGmr). PATIENTS AND METHODS: A prospective analysis included 42 patients (23 women, 19 men) aged 67 ±12 years with severe FIMR after myocardial infarction, scheduled for CABG. In each patient, mitral valve morphology, left ventricular function, FIMR degree as assessed by the effective regurgitation orifice area (severe ≥ 20 mm²), myocardial viability, and mitral deformation indexes were assessed prior to surgery. Based on clinical assessment and rest and stress echocardiography parameters, patients were referred for CABGa (group 1; n = 6), CABGma (group 2; n = 27), or CABGmr (group 3; n = 9). RESULTS: In all study groups, no differences in clinical and echocardiographic results were observed during a 12-month follow-up. A significant improvement was reported in the majority of patients regardless of the surgical procedure. Early (30-day) mortality in the whole study population was 11.9% (n = 5). Survival at 12 months was 100%, 81.5%, and 77.8% for groups 1, 2, and 3, respectively (P = 0.3). In all study groups, a statistically significant FIMR reduction was observed in a 12-month follow-up: small, moderate, and severe FIMR was observed in 29 (83%), 5 (14%), and 1 (3%) surviving patient, respectively. Reverse left ventricular remodeling was observed in 83% of the patients in group 1, 63.7% in group 2, and 100% in group 3 (statistically nonsignificant difference). CONCLUSIONS: The presented diagnostic strategy, based on stress echocardiography, may facilitate the process of choosing a suitable cardiac surgical procedure for patients with severe FIMR.

Clinical presentation, treatment, and long-term outcomes in patients with takotsubo cardiomyopathy. Experience of a single cardiology center.

INTRODUCTION: Takotsubo cardiomyopathy (TTC) is a rare transient cardiomyopathy mimicking acute coronary syndrome (ACS). OBJECTIVES: The aim of the study was to retrospectively analyze the clinical course, treatment strategies, and follow-up of patients with TTC. PATIENTS AND METHODS: Among all patients hospitalized in the department between January 2005 and January 2010, we identified a group of patients who were fulfilling the modified Mayo Clinic criteria for the diagnosis of TTC. Clinical presentation, hospital course, and clinical outcomes were analyzed. RESULTS: A total of 31 patients with TTC were included into the study; women comprised 93.5% of the study population. The most common symptoms included chest pain and dyspnea caused by emotional or physical stress. Cardiogenic shock was present in 2 subjects and life-threatening ventricular arrhythmias in 3 other patients. Twenty-four patients had ST-segment elevation on the electrocardiogram. A mean left ventricular ejection fraction was 42 +/-8.6% during contractility abnormalities, and it increased to 58 +/-7.9% during recovery. Troponin I was positive in 30 cases with a mean peak level of 2.7 +/-5.1 ng/ml. Follow-up data were available in 23 patients and a mean follow-up was 955 +/-502.8 days. We did not observe a recurrence of TTC. CONCLUSIONS: TTC is observed mainly in postmenopausal women. Clinical presentation of TTC is almost indistinguishable from ACS, but its course is milder and the outcomes are better.

Prognostic significance of platelet function in the early phase of ST-elevation myocardial infarction treated with primary angioplasty.

BACKGROUND: There are limited data concerning global platelet function response to antiplatelet therapy in ST-segment elevation myocardial infarction (STEMI). The aim was to determine the frequency and clinical significance of inadequate inhibition of two major platelet activation pathways: the thromboxane A2 (TXA2)- and ADP-dependent, in the early phase of STEMI. MATERIAL/METHODS: Platelet function was measured with a Platelet Function Analyzer-100 in 125 consecutive survivors of STEMI on days 3 (48+/-2 h) and 30 after stenting. Inadequate inhibition of the TXA2-dependent activation pathway was defined as a collagen-epinephrine closure time <193 and of the ADP-dependent as a collagen-adenosine closure time <130 seconds. RESULTS: The study population was divided into groups I (n=67/53%; both pathways inhibited, complete inhibition), II (n=21/17%; one pathway inhibited, partial inhibition), and III (n=37/30%; neither pathway inhibited, no inhibition). LV remodeling occurred more frequently in groups II and III than in group I (40% and 62% vs. 14%, P=0.038 and <0.0001, respectively). At six months the combined rate of death, nonfatal reinfarction, stroke, and rehospitalization for heart failure was 3% in group I, 23.8% in II, and 54.1% in III (log rank=39.2, P for trend <0.0001). By multivariate regression analysis, no or partial inhibition were independent predictors of LV remodeling and combined clinical outcome. CONCLUSIONS: Inadequate platelet function inhibition in acute phase STEMI despite standard antiplatelet therapy is associated with increased risk of poor LV performance and combined clinical events. This may suggest the need for intensified antiplatelet therapy in the early phase of STEMI.

Baseline platelet reactivity in acute myocardial infarction treated with primary angioplasty--influence on myocardial reperfusion, left ventricular performance, and clinical events.

BACKGROUND: Platelet reactivity is believed to play a key role in the pathophysiology of ST-segment elevation myocardial infarction (STEMI). We sought to determine whether platelet reactivity predicts impaired myocardial reperfusion, left ventricular (LV) dysfunction, and clinical events in an unselected group of patients with STEMI. METHODS: Platelet reactivity was measured before primary angioplasty in 125 consecutive patients with the use of Platelet Function Analyzer-100. Six-month follow-up was performed. RESULTS: Patients were stratified into 4 quartiles according to the collagen adenosine diphosphate closure time (CADP-CT), with the fourth quartile (CADP-CT < or = 55 seconds; n = 32) defined as high reactivity. There was an increasing rate of diabetes across quartiles: 6% in the first and 38% in fourth (P < .0001). Myocardial Blush Grade 0 or 1 and the absence of ST-segment resolution (< or = 50%) were observed more often in the fourth quartile than in quartiles 1 through 3 (84% vs 22%, 27%, 35% and 81% vs 16%, 17%, 26%, respectively; P < .0001 for all). In logistic regression, high reactivity was an independent predictor of Myocardial Blush Grade 0 or 1 (odds ratio [OR], 22.7; 95% confidence interval [CI], 6.5-78.8; P < .0001), ST-segment resolution < or = 50% (OR, 28.6; 95% CI, 8.6-95.2; P < .0001), LV remodeling (OR, 10.4; 95% CI, 3.3-32.7; P < .0001), lack of early (OR, 7.9; 95% CI, 2.8-22.3; P < .0001) and late LV functional recovery (OR, 7.3; 95% CI, 2.9-18.8; P < .0001), and clinical events (OR, 7.8; 95% CI, 2.5-24.9; P = .0005). CONCLUSIONS: Platelet reactivity is an independent predictor of myocardial reperfusion. Moreover, CADP-CT being a marker of myocardial reflow may also provide early prognostic information concerning LV performance and adverse clinical events after STEMI.

Value of transesophageal dobutamine stress echocardiography for selection of the type of cardiac surgery in significant ischaemic mitral insufficiency.

BACKGROUND: Ischaemic mitral regurgitation (IMR) may be surgically treated by isolated myocardial revascularisation or in combination with valve repair. Dobutamine stress echocardiography (DSE) may be helpful in selecting an optimal surgical strategy. AIM: To develop the optimal surgical approach to patients (pts) with significant (ERO lO2 cm(2)) IMR on the basis of TEE-DSE. An attempt was undertaken to select patients in whom coronary revascularisation should be performed alone or in combination with reconstruction of mitral apparatus. METHODS: The study group comprised 212 pts (M/F--134/78; mean age 65+/-10 years) with a history of Q-wave myocardial infarction qualified to elective surgical revascularisation on the basis of coronary angiography. In 25 pts with significant IMR (ejection fraction <40%, wall motion score index 1.8+/-0.3) TEE-DSE was performed. Based on TEE-DSE results pts were divided into the following groups: Group I--7 pts with significant reduction of MR and improvement of left ventricular contractility following dobutamine infusion and qualified to CABG; and Group II (n=18) without significant changes of IMR (9 pts) or with significant reduction of IMR without significant influence on WMSI (9 pts) who were qualified to CABG with mitral valve surgery. RESULTS: In 4 pts from Group II valve replacement was performed and the remaining 14 pts had mitral annuloplasty. Echocardiographic assessments performed 2-7 days, 6 months and 12 months following the surgical procedure revealed IMR intensity as follows (number of patients is given): Group I--small 5/4/4, moderate 2/2/2, severe 0/0/0, Group II--small 15/14/13, moderate 2/3/3, severe 0/0/0. CONCLUSIONS: TEE-DSE seems to be a useful tool for optimal selection of surgical treatment in patients with significant IMR and qualification for CABG.

[Patient with stable ischaemic heart disease and essential thrombocythemia in Invasive Cardiology Laboratory -- role of the automated systems for estimation of platelet aggregation]. / Chory ze stabilna choroba wiencowa i wspólistniejaca nadplytkowoscia samoistna w pracowni kardiologii inwazyjnej. Rola zautomatyzowanych systemów oceny stopnia agregacji plytek.

Patient with stable ischaemic heart disease and essential thrombocythemia in Invasive Cardiology Laboratory -- role of the automated systems for estimation of platelet aggregation. A case of a 63-year-old male patient with essential thrombocythemia and coronary artery disease is presented. The patient underwent elective coronary angiography and subsequent angioplasty of the intermediate branch. The procedure was complicated by a massive thrombosis of the right coronary artery. Tirofiban and subsequent stenting relieved anginal symptoms. Next, platelet activity was monitored using the platelet function analyser PFA-100 which enabled optimisation of the antiplatelet agent dosages. The usefulness of this device in the catheterisation laboratory is discussed.