The association of body composition assessment with hospital length of stay in off-pump coronary artery bypass patients.

Introduction: Bioelectrical impedance analysis is a widely available, non-invasive method for body composition assessment. Aim: To elucidate the perioperative body composition alterations and their prognostic utility for hospital length of stay (LOS) in low risk, off-pump coronary artery bypass (OPCAB) patients. Material and methods: Fifty patients undergoing elective OPCAB were included in the study. Body composition assessments were performed 1 day before the scheduled surgery and on the 6th postoperative day. Patients were grouped into < 9 days (n = 29, 58%) and ≥ 9 days (n = 21, 42%). Multivariate logistic regression analysis was performed to create a body composition-based screening panel for prolonged hospital stay. Results: No significant differences in anthropometric measurements, clinical characteristics or occurrence of postoperative complications were detected between the study groups. Patients with longer hospitalization had significantly higher content of fat mass (FM%) and fat mass index (FMI), and significantly lower content of fat free mass (FFM%) baseline parameters (p = 0.011, p = 0.04 and p = 0.012, respectively). High FM% values had 15-fold, low FFM% values had 13-fold and high FMI values had 7-fold higher risk of experiencing longer stay in the hospital (p = 0.001, p = 0.001 and p = 0.005, respectively). The combined panel of three variables (higher FM%, lower FFM% and higher FMI) had 16-fold higher risk of longer hospitalization (adjusted OR = 16.40; 95% CI: 3.52-76.34; p = 0.0004). Conclusions: Preoperative high FM and low FFM content are independent predictors of prolonged hospital length of stay in normal- and increased-BMI patients after OPCAB.

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.

Effects of ischaemic postconditioning in aortic valve replacement: a multicenter randomized controlled trial.

OBJECTIVES: The effect of ischaemic postconditioning (IPost) on postcardioplegic cardiac function is not known. We hypothesized that IPost was cardioprotective in adult patients undergoing elective aortic valve replacement. METHODS: In a multicentre, prospective, randomized trial, patients (n = 209) were randomized to either a standard operation (controls) or postconditioning. Immediately before the cross-clamp was released, patients in the postconditioning group underwent 3 cycles of flow/non-flow (2 min each) of normothermic blood via the antegrade cardioplegia line. The primary end point was cardiac index. Secondary end points included additional haemodynamic measurements, biomarkers of cardiomyocyte injury, renal function parameters, intra- and postoperative arrhythmias and use of inotropic agents. RESULTS: There was no significant difference between the groups regarding cardiac index [mean between-group difference, 95% confidence interval (CI), 0.11 (-0.1 to 0.3), P = 0.27]. Postconditioning had no effect on other haemodynamic parametres. There was no between-group difference regarding troponin T or creatine kinase MB. Postconditioning reduced the relative risk for arrhythmias by 45% (P = 0.03) when postoperative atrial fibrillation and intraoperative ventricular fibrillation were combined. There were no differences in patients with/without diabetes, patients above/below 70 years of age or between the centres. However, after postconditioning, the cardiac index [95% CI, 0.46 (0.2-0.7), P = 0.001], cardiac output (P < 0.001), mean arterial pressure (P < 0.001) and left ventricular stroke work index (P < 0.001) were higher in males compared to females. CONCLUSIONS: IPost had no overall cardioprotective effects in patients undergoing aortic valve replacement but improved postoperative cardiac performance in men compared to women.

Transcatheter aortic valve­in­valve implantation for failed surgical bioprostheses: results from the Polish Transcatheter Aortic Valve-in-Valve Implantation (ViV­TAVI) Registry

INTRODUCTION: Transcatheter aortic valve­in ­valve implantation (ViV­TAVI) has emerged as an alternative to redo surgery in patients with failed surgical aortic bioprosthesis. OBJECTIVES: We evaluated the safety and efficacy of ViV­TAVI in Polish patients after surgical aortic valve replacement. PATIENTS AND METHODS: This was a nationwide multicenter registry of ViV­TAVI procedures. Data were collected using an online form, and the clinical follow ­up lasted 1 year. RESULTS: From 2008 to 2020, 130 ViV­TAVI procedures were performed (1.9% of all transcatheter aortic valve implantation [TAVI] cases). A considerable increase in ViV­TAVI procedures since 2018 has been observed (n = 59, 45% of ViV­TAVI cases). Hancock II, Freestyle, and homograft were the most frequently treated bioprostheses. The self ­expanding supra ­annular Corevalve / Evolut valve was used in 76% of cases. In 21% of cases, the mean postprocedural pressure gradient (PG) exceeded 20 mm Hg. All­cause mortal­ity at 1 year was 10.8%. Aortic valve stenosis was associated with a higher mean PG than aortic valve regurgitation or mixed disease (P = 0.004). Supra ­annular transcatheter aortic valves were associated with lower mean PGs than intra ­annular valves (P = 0.004). Second ­generation devices were associated with shorter procedure time (120 min vs 135 min, P = 0.04), less frequent need for additional TAVI (2% vs 10%, P = 0.04), and lower 1­year cardiovascular mortality (95% vs 82.8%, P = 0.03) than first­generation valves. CONCLUSIONS: Transcatheter treatment of failed bioprostheses is increasingly common, with the best hemodynamic effect shown for supra ­annular valves. The introduction of second­generation valves has improved procedural and clinical outcomes.

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.

Pleiotropic Effects of Acetylsalicylic Acid after Coronary Artery Bypass Grafting-Beyond Platelet Inhibition.

Acetylsalicylic acid (ASA) is one of the most frequently used medications worldwide. Yet, the main indications for ASA are the atherosclerosis-based cardiovascular diseases, including coronary artery disease (CAD). Despite the increasing number of percutaneous procedures to treat CAD, coronary artery bypass grafting (CABG) remains the treatment of choice in patients with multivessel CAD and intermediate or high anatomical lesion complexity. Taking into account that CABG is a potent activator of inflammation, ASA is an important part in the postoperative therapy, not only due to ASA antiplatelet action, but also as an anti-inflammatory agent. Additional benefits of ASA after CABG include anticancerogenic, hypotensive, antiproliferative, anti-osteoporotic, and neuroprotective effects, which are especially important in patients after CABG, prone to hypertension, graft occlusion, atherosclerosis progression, and cognitive impairment. Here, we discuss the pleiotropic effects of ASA after CABG and provide insights into the mechanisms underlying the benefits of treatment with ASA, beyond platelet inhibition. Since some of ASA pleiotropic effects seem to increase the risk of bleeding, it could be considered a starting point to investigate whether the increase of the intensity of the treatment with ASA after CABG is beneficial for the CABG group of patients.

Transcatheter aortic valve-in-valve implantation in failed stentless bioprostheses.

OBJECTIVE: To compare the safety and efficacy of transcathether aortic valve-in-valve implantation (ViV-TAVI) in degenerated stentless bioprostheses with failed stented valves and degenerated native aortic valves. INTRODUCTION: Little is known about ViV-TAVI in degenerated stentless valves. METHODS: Out of 45 ViV-TAVI procedures reported in the POL-TAVI registry, 20 failed stentless valves were compared with 25 stented prostheses and propensity-matched with 45 native TAVI cases. The mean follow-up was 633 (95% confidence interval [CI], 471-795) days and Valve Academic Research Consortium-2 (VARC-2) definitions were applied. RESULTS: Patients with degenerated stentless valves were younger (65.6, CI 58-73.1 years vs 75.6, CI 72.2-78 [stented] vs 80.1, CI 78.7-81.6 y. [native], P < 0.001). Implantation was required later after surgery (11.5, CI 8-14.9 years) in the stentless cohort as compared with the stented one (6.2, CI 4.7-7.6 years, P = 0.006). ViV-TAVI in the stentless group was also associated with larger amount of contrast (211, CI 157-266 mL vs 135, CI 104-167 mL [stented] vs 132 (119-145) mL [native], P = 0.022). Using VARC-2 composite endpoints, ViV-TAVI in stentless prostheses was characterized by a lower device success (50% vs 76% in stented vs 88.9% in native TAVI, P < 0.001), but comparable early safety up to 30 days (73.7% vs 84% vs 81.8%, respectively, log-rank P = 0.667) and long-term clinical efficacy beyond 30 days (72.2% vs 72% vs 73.8%, respectively, log-rank P = 0.963). CONCLUSIONS: Despite technical challenges and a lower device success, ViV-TAVI in stentless aortic bioprostheses achieves similar safety, efficacy, and functional improvement as in stented or degenerated native valves.

Common carotid artery access for transcatheter aortic valve implantation.

Transcatheter aortic valve implantation (TAVI) is an alternative method of treatment for severe symptomatic aortic stenosis in patients who are at high risk of surgical aortic valve replacement (AVR). In randomised clinical trials TAVI was shown to be superior to standard medical therapy in a cohort of inoperable patients and non-inferior to AVR in high-risk operable patients. Additionally, in a recent trial with self-expandable prosthesis use, TAVI was associated with lower mortality compared with surgery. Usually, femoral arteries are the most common vascular access to deliver the bioprosthesis; however, in some cases (up to 20%) this route may not be applied because of significant peripheral artery disease or tortuosity. In this article, we present the first two TAVI procedures in Poland performed via the left common carotid artery.

Minimally invasive off-pump video-assisted endoscopic surgical pulmonary vein isolation using bipolar radiofrequency ablation - preliminary report.

BACKGROUND: Atrial fibrillation (AF) is the most common arrhythmia, having a strong impact on long-term stroke and heart failure prevalence and mortality. Nowadays, rapid development in the field of minimising the invasiveness of surgical ablation of AF can be observed. AIM: To report on the feasibility and early results of the first Polish experience with a novel technique of minimally invasive video-assisted beating heart bilateral surgical ablation for lone paroxysmal AF using irrigated bipolar radiofrequency technique. METHODS: Between February and December 2006, 6 patients with highly symptomatic paroxysmal AF, resistant to pharmacological treatment, underwent video-assisted beating heart bilateral pulmonary vein isolation using irrigated bipolar radiofrequency combined with vein of Marshall dissection and left atrial appendage closure. In 2 patients at least 2 unsuccessful percutaenous ablations had previously been performed. RESULTS: There were no complications. Ablation time was on average 88+/-12.1 seconds. At least one recurrence of AF was observed in 4 patients in the early postoperative period; in 3 of them an electrical cardioversion was performed. All patients were discharged home in stable sinus rhythm. Three patients have exceeded 3 months' observation; one has reached 6 months of observation. All are in stable sinus rhythm and the follow-up course is uneventful. CONCLUSIONS: Minimally invasive video-assisted beating heart bilateral surgical ablation for lone paroxysmal AF using irrigated bipolar radiofrequency is effective and safe. These promising results have to be confirmed by larger studies.

One step removal of dumb-bell tumors by postero-lateral thoracotomy and extended foraminectomy.

OBJECTIVE: Thoracic dumb-bell tumors are rare, usually benign tumors in the posterior mediastinum, consisting of intrathoracic and intraspinal parts. Surgical removal is the treatment of choice, performed by two teams - neurosurgeons and thoracic surgeons operating in a prescribed order. METHODS: Between 1994 and 1997 five patients had dumb-bell tumors removed in a one-step operation involving postero-lateral thoracotomy and extended foraminectomy. This operating method, rarely described in the medical literature, consists of intrathoracic and intraspinal parts being performed by a thoracic team independently or with the assistance of a neurosurgeon. Initially the intrathoracic part is resected, followed by an extensive widening of the intervertebral foramen to an appropriate extension and the removal of the remaining intraspinal part of the tumor. RESULTS: Four postero-lateral thoracotomies and one incision over a huge tumor in the thoraco-lumbal region, without entering the pleural cavity, were performed. In one patient postoperative, transient leakage of the cerebral fluid was observed. No form of late complications or neurologic sequelae have been reported within a 5-year follow-up. CONCLUSIONS: One-step removal of a dumb-bell tumor by postero-lateral thoracotomy and extended foraminectomy is a safe surgical procedure that can be performed by the thoracic team alone. Early and late surgical results confirm the appropriateness and usefulness of the method.

The influence of blood transfusion on survival in operated non-small cell lung cancer patients.

BACKGROUND: It has been postulated that allogeneic transfusions have immunosuppressive effects that can promote tumor growth and metastasis formation. Despite the variety of publications on this controversial topic, the influence of blood transfusion on survival is not yet clearly identified. The impact of autologous blood transfusion on survival has only occasionally been analyzed in cancer patients. OBJECTIVE: To determine the effect of perioperative allogeneic and autologous blood transfusions on survival in non-small cell lung cancer patients treated with curative pulmonary resection. METHODS: Of 493 consecutive patients, 185 (37.5%) received allogeneic blood products and 145 (29.4%) received autologous blood products, whereas 163 patients (33.1%) received no blood products. Survival analysis included univariate log-rank test and multivariate Cox regression model. RESULTS: Three-year survival probabilities in allogeneic, autologous, and nontransfused groups were 40%, 48%, and 61%, respectively, and the estimated 5-year survival probabilities were 34%, 38%, and 48%, respectively. In the univariate analysis there was a reduced survival in allogeneic versus nontransfused group (P <.01). In the multivariate analysis stage (P <.01), initial hemoglobin level (P =.01) and sedimentation rate (P =.03) remained significant factors, whereas the type of blood transfusion (allogeneic versus autologous) was no longer significant. There was no significant impact of transfusion in the multivariate analysis when patients in stage III or patients who underwent pneumonectomy were excluded. CONCLUSION: Neither allogeneic nor autologous blood transfusion has independent, adverse survival impact in non-small cell lung cancer patients treated with radical pulmonary resection.