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.

Valve-in-valve transcatheter transfemoral mitral valve implantation (ViV-TMVI): Characteristics and early results from nationwide registry.

BACKGROUND: Valve-in-valve transcatheter transfemoral mitral valve implantation (ViV-TMVI) is an emerging treatment alternative to reoperation in high surgical risk patients with a failed mitral bioprostheses. AIM: To describe characteristics and evaluate 30-day outcomes of ViV-TMVI in the Polish population. METHODS: Nationwide registry was initiated to collect data of all patients with failed mitral bioprosthesis undergoing ViV-TMVI in Poland. This study presents 30-days clinical and echocardiographic follow-up. RESULTS: Overall, 27 ViV-TMVI were performed in 8 centers until May 2022 (85% since 2020). Mean (standard deviation [SD]) age was 73 (11.6) years with the median (interquartile range [IQR]) STS score of 5.3% (4.3%-14.3%). Mean (SD) time between surgical implantation and ViV-TMVI was 8.2 (3.2) years. Failed Hancock II (29%) and Perimount Magna (22%) were most frequently treated. Mechanisms of failure were equally often pure mitral regurgitation or stenosis (both 37%) with mixed etiology in 26%. Balloon-expandable Sapien 3/Ultra were used in all but 1 patient. Technical success was 96.3% (1 patient required additional prosthesis). Mean (SD) transvalvular mitral gradient reached 6.7 (2.2) mm Hg and mitral valve area was 1.8 (0.4) cm². None of the patients had moderate or severe mitral regurgitation with only 14.8% graded as mild. In 92.6% device success (2 patients had mean gradient ≥10 mm Hg) and in 85.6% procedural success was present. There were no deaths, cerebrovascular events or need for mitral valve surgery during 30-day follow-up. CONCLUSIONS: In short-term observation ViV-TMVI is safe and effective alternative for patients with failed mitral bioprosthesis at high surgical risk of re-operation. Longer observations on larger sample are warranted.

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.

The causes of thrombocytopenia after transcatheter aortic valve implantation.

INTRODUCTION: Even though thrombocytopenia following transcatheter aortic valve implantation (TAVI) has been described, further investigation of this phenomenon is needed. AIMS: To determine which factors may explain the fall in platelet count that occurs after implantation of a TAVI device, including markers of platelet and blood coagulation activation. MATERIAL AND METHODS: 32 patients without previous indications for dual antiplatelet therapy (mean age 78.5±7.9 years, 62% females) with severe aortic valve stenosis (mean gradient 54.6±16.9mmHg) who qualified for TAVI procedure (Edwards Sapien XT) were prospectively analyzed. Platelet counts were analyzed before the surgery, on the day of the procedure and for the three following postoperative days (POD 1 to 3). To assess platelet activation P-selectin (PS, serum) and platelet factor 4 (PF-4, CTAD plasma) were measured, whereas for the evaluation of coagulation activation prothrombin fragments 1+2 (F1+2, plasma) were assessed before the procedure, on POD-1 and POD-3 (ELISA). RESULTS: During the postoperative period a significant platelet count drop, the most evident on POD-2, was observed followed by a platelet count raise. The platelet count drop correlated directly with the amount of iodinated contrast agent (r=0.42, p=0.016) and inversely with baseline mean platelet volume (r=-0.37, p=0.046). Neither clinical nor perioperative parameters, except contrast medium, influenced platelet count decrease. No significant differences regarding the concentration of the evaluated markers in patients with and without thrombocytopenia were found. PF-4 and F1+2 significantly changed during the study (p<0.05). Greater acute PF-4 decrease correlated with greater acute platelet count drop (r=0.48, p=0.043), and during the study slower PF-4 increase correlated with higher platelet count increase on POD-3 (r=-0.505, p=0.032). Lower baseline PS correlated with lower baseline platelet count and higher platelet count increase on POD-3 (r=0.45, p=0.04 and =-0.55, p=0.02, respectively). No significant correlations between F1+2 concentrations and platelet count changes have been found. CONCLUSIONS: Platelet reduction shortly after TAVI procedure is related to the amount of contrast agent applied during the procedure. Platelet activation and blood coagulation along with impaired baseline platelet renewal might be the mechanisms of thrombocytopenia following TAVI procedure.

Single-centre experience in surgery of acute aortic type A dissection and true aortic arch aneurysm.

BACKGROUND: Surgery of the aortic arch is challenging. AIM: To assess the results of aortic arch surgery. METHODS: Analysis of 172 patients operated on arch dissection (emergency group: 97 patients) or aneurysm (elective group: 75 patients) between 2007 and 2014. Arch surgery was defined as a procedure requiring circumferential anastomosis at the level of the aortic arch or the descending aorta with the use of techniques of brain protection (deep hypothermic circulatory arrest [DHCA] or selective antegrade cerebral perfusion [SACP]) and/or debranching of at least one supra-aortic vessel. RESULTS: Men predominated in both groups (> 70%). Men were younger in the emergency group (55 vs. 66 years; p < 0.008). The operative risk was higher in the emergency group (19.2% vs. 12.5%; p < 0.001). Forty-nine per cent of the patients from the emergency group and 5% from the elective group were operated with antiplatelet therapy (p < 0.001). Extended hemiarch procedure was performed in 79% (n = 77) in the emergency and 76% (n = 57) in the elective group. Total arch replacement was performed in 19 (21%) patients from the emergency and 18 (24%) patients from the elective group. In these patients debranching was performed in 68% of the emergency patients group and in 67% of the elective group. Elephant trunk procedure (classic/frozen) was performed in 53% (n = 10) from the emergency and in 78% (n = 14) of patients from the elective group. Aortic valve sparing surgery was performed in 20% of patients from the emergency and 9% from the elective group (p = 0.063). DHCA was performed in 58% (n = 43) of patients from the elective group and 39% (n = 37) from the emergency group. SACP was performed in 61% (n = 58) of patients from the emergency and 42% (n = 31) from the elective group. Thirty-day mortality in the emergency group reached 33% (n = 32), and in the elective group 15% (n = 11; p = 0.007). In multivariate analysis, predictors of death in the emergency group were: Logistic EuroSCORE above 19.5%, extracorporeal circulation time above 228 min, and postoperative acute renal failure (ARF); and in the elective group: DHCA time above 26 min, rethoracotomy due to bleeding, and ARF. Follow-up was completed in 100% of patients in terms of vital status. The mean follow-up time of the patients from the emergency group was 24.3 ± 27.10 (min 0, max 92) months, and from the elective group 30.3 ± 24.5 (min 0, max 99) months. During the follow-up period all-cause mortality in the emergency group was 43% (n = 42/97), and in the elective group it was 36% (n = 27/75). CONCLUSIONS: Early mortality in the emergency group was higher, while long-term mortality did not differ among the groups. Postoperative ARF is a critical predictor of mortality in both groups.

Effect of leukocyte-depleted blood cardioplegia on the early outcome in patients with preserved left ventricular function undergoing surgical revascularisation.

BACKGROUND: It has been shown that leukocytes play one of the key roles in the myocardial reperfusion injury. AIM: To examine the effects of cardiac protection with leukocyte-depleted blood cardioplegia on the early outcome of patients with preserved left ventricular function who undergo surgical revascularisation. METHODS: The study group consisted of 58 patients with coronary artery disease (CAD) undergoing coronary artery bypass grafting (CABG) who were randomised to receive leukocyte-depleted blood cardioplegia (leukocyte filter Pall BC1B) (group A, n=29) or to receive standard blood cardioplegia (group B, n=29). Peri-operative mortality and morbidity as well as haemodynamical and biochemical parameters were compared between these two groups. RESULTS: No early death occurred. There were no statistical differences in clinical data between the groups. Only cardiac index measured 24 hours after declamping of aorta was significantly higher in group A than in group B (3.6+/-0.6 l/min/m(2) vs 2.95+/-0.45 l/min/m(2), p<0.05). Group B showed significant higher release of creatine kinase (CK) 6 and 12 hours, and CK-MB 6, 12, and 24 hours after unclumping the aorta whereas troponin I level was similar in both groups. CONCLUSIONS: The use of leukocyte-depleted blood cardioplegia during elective CABG did not improve the early outcome.

[Neuropsychiatric complication after surgical procedures--literature review]. / Neuropsychiatryczne powiklania u chorych po operacjach serca z uzyciem krazenia pozaustrojowego--przeglad pismiennictwa.

2-3% of patients after cardiac procedures with the use of cardiopulmonary by-pass develop neurological complications with focal symptoms. Also to there may be mental, emotional and intellectual disturbances. This kind of complications occurs in 33-83% of patients. The post-cardiopulmonary by-pass delirium is a syndrome with diverse symptoms. Confusion, hallucinations, paranoid illusions, psycho-motoric excitation, fear may also occur. A high level of serotonin and overstimulation of 5-HT2 receptors in the central nervous system are the reason of delirium. The relief of symptoms may be achieved by intravenous administration of Ondansetron, an antagonist of 5-HT2 receptors.

[Acute normovolemic hemodilution together with aprotinin applied as a scheme of blood saving in cardiac surgery]. / Ostra normowolemiczna hemodylucja w polaczeniu z podawaniem aprotyniny jako schemat oszczedzania krwi w kardiochirurgii.

The risk of blood loss in open heart surgery procedures is related to a high level of homologous blood transfusion. Due to numerous possible complications connected with transfusion, as well as the increase in prices of blood preparations, methods of blood saving are of great interest. The aim of the study was to assess acute normovolemic hemo-dilution (ANH) efficacy and aprotinin administration in homologous blood usage limitations. The study was conducted in the group of 265 patients operated on during the period of 12 months. The control group consisted of patients operated on during the period 6 months. The scheme of ANH with the administration of aprotinin was applied in the second half-year period. A statistically significant reduction in the percentage of patients who required blood transfusions was observed (77.2%/53%). The scheme applied enabled to reduce procedure costs in regard to blood preparation purchase. The results have shown that ANH together with antifibrinolytic drug administration is not only an efficient but also profitable strategy of blood saving.

Emergence of OXA-48 carbapenemase-producing Enterobacter cloacae ST89 infection in Poland.

BACKGROUND: The utility of carbapenems, which are considered 'last-line' agents, is being diminished by the growing incidence of various resistance mechanisms in bacteria. We aimed to investigate the molecular mechanism of carbapenem resistance in Enterobacter cloacae recovered from a 76-year-old patient who had undergone coronary artery bypass grafting and repair of the mitral and tricuspid valves. Interestingly, the patient had no prior history of hospital admission abroad. METHODS: The Carba-NP test II and synergy testing were performed to confirm carbapenemase activity. PCR was used to detect carbapenemase-encoding genes. Nucleotide and amino acid sequence analysis was performed to identify OXA-48 variants. Moreover, we performed multilocus sequence typing (MLST) of multidrug-resistant (MDR) E. cloacae. RESULTS: We detected no significant increase in zone diameter around disks with inhibitors. However, the Carba-NP test II revealed carbapenemase activity in all isolates. All isolates showed the presence of the exact OXA-48 carbapenemase variant. Furthermore, MLST analysis revealed that the MDR E. cloacae isolates belonged to ST89. CONCLUSIONS: We report a case of infection caused by a unique carbapenem-resistant E. cloacae ST89 producing OXA-48 carbapenemase. Interestingly, these pathogens developed resistance to other 'last-resort' agents, namely colistin and tigecycline. There is a crucial need for surveillance programs aimed at screening for carbapenemase-producing Gram-negative bacteria, especially in patients transferred from high-incidence areas.

Intraoperative echocardiographic assessment of the severe isolated ostial stenosis of left main coronary artery before and after surgical patch angioplasty.

Isolated critical ostial stenosis of left main coronary artery is currently treated by conventional bypass surgery. Surgical patch angioplasty in an alternative surgical approach. Transesophageal echocardiography enables visualization of proximal branches of left and right coronary artery. The report describes intraoperative echocardiographic assessment of surgical left main coronary artery angioplasty.