Effectiveness of a Standardized Combination of Intracameral Mydriatics and Anaesthetic on Mydriasis during Cataract Surgery with Coexisting Diseases.

PURPOSE: To examine the effectiveness of a standardized combination of intracameral mydriatics and anesthetic (SCIMA) on mydriasis in patients with coexisting diseases such as diabetes mellitus (DM) and pseudoexfoliation syndrome (PXF) during phacoemulsification. METHODS: Patients with cataract were included in the study if they achieved pupil dilation diameter ≥ 6.0 mm after the administration of mydriatic eyedrops (ME) during the first visit (V1). During the second visit (V2), pupil size measurements were obtained for phacoemulsification surgery with SCIMA. Effective mydriasis was defined as a pupil diameter ≥ 6.0 mm just prior to capsulorhexis without the use of additional pupil dilating agents. The measurements after ME administration during V1 and after SCIMA use during V2 were compared. RESULTS: 103 patients (103 eyes) were divided into 3 groups: cataract and DM (n = 35), cataract and PXF (n = 32), and cataract without DM or PXF (n = 36). SCIMA administration allowed the achievement of effective mydriasis (≥6.0 mm) in all groups (n = 103; 100%). Mydriasis was significantly larger (p ≤ 0.001) after ME (7.3 mm) than after SCIMA (6.8 mm) administration. CONCLUSIONS: Patients with cataract and such comorbidities as DM or PXF are likely to achieve effective pharmacological mydriasis during cataract phacoemulsification after SCIMA application. Mydriasis after ME is slower and larger, while SCIMA is faster.

Asymptomatic Caseous Calcification of the Mitral Annulus in a 66-Year-Old Woman with 3-Year Imaging Follow-Up.

BACKGROUND Caseous calcification of the mitral annulus (CCMA) is an uncommon form of mitral annular calcification and can be misdiagnosed as heart abscess, neoplasm, or other lesions occupying the atrioventricular groove. Data regarding imaging follow-up of patients with CCMA are limited. This report presents a case of CCMA with a 3-year imaging follow-up. CASE REPORT A 66-year-old asymptomatic woman was referred to our cardiology department for further evaluation of a rapidly expanding intracardiac mass observed using transthoracic echocardiography (TTE) in an outpatient setting. A neoplasm was suspected. Echocardiographic examination was normal 5 years ago, and 2 years later, TTE revealed an echodense structure (10×10 mm) occupying the atrioventricular groove. Three years later, TTE revealed an increase in the size of the lesion (21×18 mm) and a mild acoustic shadow. Cardiac magnetic resonance imaging revealed a pathological mass (20×20×37 mm) in the posterior portion of the mitral annulus that extended into the left ventricle. Using computed tomography, a round mass (20×19×39 mm) with a demarcated area of calcification was revealed in the posterior portion of the mitral annulus. Thus, the intracardiac mass was diagnosed as CCMA. Although there was a considerable increase in lesion size (doubling of lesion size within 3 years), normal intracardiac flow and asymptomatic course of the disease remained. Therefore, this patient underwent conservative management with imaging follow-up. CONCLUSIONS In cases of atypical presentation of CCMA, multimodal imaging may provide an accurate diagnosis and important information regarding the course of the disease.

Choosing a treatment method for post-catheterization pseudoaneurysms guided by the late to early velocity index.

Ultrasound-guided thrombin injection (UGTI) is often the first-line treatment for iatrogenic post-catheterization pseudoaneurysms (psA). There are also first reports of the use of biologically derived tissue glues (TG) instead of sole thrombin especially when UGTI was unsuccessful or in case of psA recurrence. Previously, we have established that a late to early velocity index (LEVI) < 0.2 could be a predictor of an increased risk of psA recurrence after standard UGTI. In this paper, we report our first experiences when the choice of the first-line treatment method was based on LEVI assessment. From May 2017 till January 2020 we included 36 patients with psA. Of them, 10 had LEVI < 0.2 and they underwent ultrasound-guided tissue glue injection (UGTGI) with biological TG and 26 had LEVI > 0.2 and they underwent UGTI. The injection set containing human thrombin and fibrinogen was used for UGTGI. Bovine thrombin was used for UGTI. The success rate was 100% and no psA recurrence was detected during a 2-week follow-up. It was significantly better when compared to the expected recurrence rates based on our previous 14 years of experience (0% vs. 13%, p = 0.01). All complications (10% in the UGTGI group and 15% in the UGTI group) were mild and transient and included clinical symptoms of paresthesia, numbness, tingling, or pain. Their rates were comparable to the rates we previously reported. No significant differences in other characteristics were observed. The approach to choose the first-line treatment method for iatrogenic psA based on LEVI is encouraging. It may increase the success rate and avoid unnecessary repetition of the procedure, without increasing complication rate while keeping costs of the procedure reasonable.

Late to early velocity index as a predictor of iatrogenic femoral artery pseudoaneurysm recurrence in patients treated with ultrasound-guided thrombin injection.

INTRODUCTION: Ultrasound-guided thrombin injection (UGTI) is the preferred treatment of pseudoaneurysms (psA). The potential risk of complications increases with the number of UGTI treatments needed for complete psA obliteration. Identification of risk factors for recurrent psA is needed. MATERIAL AND METHODS: In total, 508 patients with femoral artery psA underwent UGTI, followed by ultrasound examination repeated twice, at 1-week intervals, to assess UGTI effectiveness. In cases of psA recurrence, the procedure was repeated. Clinical and ultrasound data were prospectively collected. RESULTS: The psA recurrence occurred in 76 (15%) patients. UGTI was repeated twice in 49 (64%), three times in 15 (20%) and more than three times in 12 (16%) patients. The median thrombin dose was 150 IU (80-250 IU), and was lower in initial procedures than repeated UGTI (p = 0.025). The median psA volume was 2.26 ml (0.86-5.47 ml). The median length of the communicating channel was 4 mm (0-12 mm). A time interval between vessel catheterization and UGTI greater than 7 days (p < 0.001), a late to early velocity index (LEVI) of < 0.2 identified during the outflow phase (p < 0.001), a psA volume > 5 ml (p = 0.032), and a short communicating channel between the psA and the artery (p = 0.037) predicted psA recurrence. Antiplatelet and anticoagulant agents did not increase the risk. CONCLUSIONS: The LEVI and time interval between artery cannulation and UGTI treatment are strong parameters identifying patients at risk of psA recurrence. The psA volume and communicating channel length are less substantial risks, but still significant. Concomitant antiplatelet and anticoagulant therapy do not affect the success rate of UGTI.

Ultrasound-guided thrombin injection as a preferable method of treatment for iatrogenic pseudoaneurysms after invasive cardiovascular procedures - a single-center experience.

INTRODUCTION: Arterial cannulation is inherently associated with a risk of vascular complications including pseudoaneurysm (psA) that are encountered in both radial and femoral artery access. Among various methods of treatment of pseudoaneurysm the most popular are: watchful waiting for a spontaneous resolution, ultrasound-guided compression, ultrasound-guided thrombin injection (UGTI) and surgical treatment. In many previous reports nonsurgical methods appeared to be effective in most cases. AIM: To evaluate the incidence, characteristics as well as treatment scheme of iatrogenic pseudoaneurysms in a single high-volume cardiovascular intervention center. MATERIAL AND METHODS: The study is a prospective analysis of femoral artery and radial artery pseudoaneurysm cases in a 6-year period (2015-2020) in Swietokrzyskie Cardiology Centre in Kielce, Poland. Analysis of baseline characteristics, treatment and outcomes of all pseudoaneurysm cases was performed. RESULTS: Among a total number of 7268 cardiovascular procedures, with 49.2% being of the radial approach, we diagnosed 113 cases of psA. Global prevalence of femoral artery pseudoaneurysm was 1.29% and that of radial artery pseudoaneurysm was 0.30%. Only 2 patients with femoral puncture were primarily qualified for surgical treatment due to large size of the pseudoaneurysm. The vast majority of patients underwent successful nonsurgical therapy with the major predominance of the UGTI procedure. Effectiveness of the first thrombin injection was as high as 90% in RPA and 85% in FPA, whereas all of the consecutive attempts were successful. CONCLUSIONS: UGTI is nowadays a very effective and safe method of iatrogenic pseudoaneurysm treatment that prevents further necessary surgical procedures.

Clinical presentation and 3-year outcomes of patients with acute coronary syndromes and non-obstructive coronary arteries on angiography.

BACKGROUND: With the emerging interest in patients with myocardial infarction with non-obstructive coronary arteries (MINOCA), there is a need to define an even broader group of patients with the syndrome of myocardial ischemia with non-obstructive coronary arteries (INOCA). There are limited data on the clinical characteristics and prognoses of such patients who present with symptoms of acute coronary syndrome (ACS) and undergo urgent coronary angiography that reveals no significant lesions. The aim of this observational study was to compare patients with ACS INOCA and those with ACS with obstructive coronary artery disease (OCAD) both within unadjusted cohorts and with propensity score matched controls. METHODS AND RESULTS: This observational study was based on the data from the Polish National Registry of Invasive Cardiology Procedures. Of 9744 patients included, 7624 had OCAD and 2120 had ACS INOCA. In unadjusted cohorts, the overall survival and incidence of major adverse cardiovascular events (MACE: death, cardiac arrest, myocardial infarction, stroke, and heart failure hospitalization) until 36 months were higher in patients with ACS OCAD. Following propensity matching, higher win ratios of death (p = 0.02), additional revascularizations by percutaneous coronary intervention or coronary artery bypass graft surgery (p<0.001), and cardiac hospitalization (p<0.001) were observed in these patients. In contrast, the win ratios of myocardial infarction (p = 0.74), heart failure hospitalization (p = 0.86), and MACE (p = 0.07) were not significantly different between the groups. CONCLUSIONS: The prognosis of patients with ACS INOCA was more favorable than that of patients with ACS OCAD; however, the differences diminished after adjustments for the initial clinical profiles. An ACS incident should not be judged as trivial even when cardiac markers remain stable and no significant lesions are found on angiography.

Comparison of the Efficacy and Safety of Two Dosing Protocols for Ultrasound Guided Thrombin Injection in Patients with Iatrogenic Femoral Pseudoaneurysms.

OBJECTIVE: Ultrasound guided thrombin injection (UGTI) is a minimally invasive method of treatment for iatrogenic post-catheterisation femoral pseudoaneurysms (psAs). The optimal dosing protocol for UGTI has not been established. The aim of the study was to compare the success and complication rates between two different dosing protocols (the most commonly used "standard dose protocol" and the "low dose protocol," which is the fractionated administration of smaller thrombin doses of up to 40 IU every 15 s) in patients with a psA with sac volume of ≥1 mL. METHODS: This was a retrospective cohort study, and the analysis was performed using a case matching approach based on propensity score. From June 2004 to August 2018, 384 patients who underwent femoral puncture for transcatheter procedures were diagnosed with femoral psA with a sac volume of ≥1 mL and qualified for UGTI. The patients' mean age was 68 (±10.6) years and there were 217 (56.5%) women. To compare protocols, 124 patients treated according to the low dose protocol were nearest neighbour matched according to their propensity score to 124 patients treated according to the standard dose protocol. RESULTS: The overall success rate (99.2% vs. 98.4%; p = 1) and success rate of the first UGTI attempt (87.1% vs. 86.3%; p = .85) did not differ between the low dose and standard dose groups. Complications were less common in the low dose group (7.3% vs. 16.1%; p = .03) and the median total amount of thrombin used for procedures was smaller in the low dose group (120 IU vs. 195 IU; p = .01). CONCLUSIONS: In patients with femoral psA with sac volume of ≥1 mL, the use of the low dose protocol seemed to be equally effective as the standard dose protocol and was associated with a lower complication rate and reduced thrombin dose.

Long-term clinical outcomes in patients with unstable angina undergoing percutaneous coronary interventions in a contemporary registry data from Poland.

BACKGROUND: Both unstable angina and non-ST-segment elevation myocardial infarction (NSTEMI) are still classified together in non-ST-elevation acute coronary syndromes despite the fact they substantially differ in both clinical profile and prognosis. The aim of the present study was to evaluate contemporary clinical characteristics and outcomes of unstable angina patients after percutaneous coronary intervention (PCI) in comparison with stable angina and NSTEMI in Swietokrzyskie District of Poland in years 2015-2017. METHODS: A total of 7187 patients after PCI from ORPKI Registry (38% with diagnosis of unstable angina) were included into the analysis. Impact of clinical presentation (unstable angina, stable angina, NSTEMI, STEMI) on three-year outcomes were determined. RESULTS: Unstable angina patients were older than stable angina but younger than NSTEMI individuals. In unstable angina group, the percentage of previous myocardial infarction (MI), PCI or coronary artery bypass grafting (CABG) was the highest among all analyzed groups. In three-year observation, the risk of death as well as MI and MACE in unstable angina after PCI was higher than stable angina angina but considerably lower than in the NSTEMI group. Multivariate analysis confirmed that prognosis in NSTEMI was substantially worse in comparison with unstable angina [relative risk (RR) 1.365, 95% confidence interval (CI): 1.126-1.655, P = 0.0015]. On the contrary in unstable angina and stable angina patients, the impact of diagnosis on mortality risk was similar (RR 1.189, 95% CI: 0.932-1.518, P = 0.1620). Parallel results were observed in respect of MI and MACE. Independent predictors of death or MACE were: age, kidney disease, hypertension, diabetes, previous stroke or previous PCI. CONCLUSION: Three-year prognosis in unstable angina was considerable better in comparison with NSTEMI. On the contrary, after adjustment for baseline differences, the outcomes (death, MI, MACE) in unstable angina and stable angina patients were comparable.

Trends in sex differences in clinical characteristics, treatment strategies, and mortality in patients with ST-elevation myocardial infarction in Poland from 2005 to 2011.

INTRODUCTION: During the last decade, there has been an increased awareness of sex differences in the clinical characteristics, management, and mortality in myocardial infarction. Many previous studies have found that women with ST-elevation myocardial infarction (STEMI) have a poorer baseline risk profile, are less intensively treated, and have worse outcomes. OBJECTIVE: To evaluate whether sex disparities in STEMI have changed in recent years. METHODS: This is a retrospective analysis of data on 111 148 STEMI patients enrolled in the Polish Registry of Acute Coronary Syndromes between 2005 and 2011. Temporal trends in the clinical presentation, treatment strategies, and mortality rates between men and women are compared. RESULTS: Throughout the study, women were, on average, older than men, and more frequently presented with hypertension, diabetes, or obesity. These differences showed a tendency for narrowing. The percentage of smokers increased in both sexes. Despite a reduction in prehospital delays, they remained longer in women. Sex differences in prehospital cardiac arrest and cardiogenic shock at admission disappeared. In 2011, women were still less likely to undergo coronary angiography with subsequent revascularization, but it was mainly driven by patients older than 70 years of age who also had a higher in-hospital mortality. Despite the greater relative risk reductions, the crude mortality rates remained significantly higher in women. Female sex was not an independent predictor of mortality. CONCLUSION: Sex differences in STEMI patients were narrowing from 2005 to 2011 in Poland. However, more attention needs to be focused on increasing smoking prevalence, the longer times from symptoms onset to hospital admission in women and the lower frequencies of the use of an invasive treatment strategy in older women, and their worse in-hospital outcomes.

[Transcatheter aortic valve implantation and its place in the contemporary treatment]. / Przezskórna implantacja zastawki aortalnej -- miejsce we wspólczesnej terapii.

Symptomatic stenosis of the aortic valve has recently been an important clinical issue. On one hand the number of patients who need surgical treatment of valve failure is increasing. On the other hand their general state of health and concomitant diseases determine that they are disqualified from surgery. The trasncutaneus technique of replacement of the aortic valve is for these patients a promising alternative. Therefore TAVI procedures have been developed and the number of performed transcatheter aortic valve replacements is still increasing. Although it would appear unlikely that TAVI could replace traditional surgery in the nearest future, it remains a possible treatment option for some of the high risk patients not suitable for surgery.