Acute and long-term outcomes of percutaneous balloon aortic valvuloplasty for the treatment of severe aortic stenosis.

OBJECTIVES: This study aimed to evaluate the indications, short- and long-term outcomes of balloon aortic valvuloplasty (BAV) in patients with severe aortic stenosis (AS). METHODS: A cohort of 112 patients with AS underwent 114 BAV procedures between October 2012 and July 2015 in two Polish interventional cardiology centers. Clinical and echocardiographic data were prospectively collected within 1, 6, and 12 months follow-up. RESULTS: BAV was performed as a bridge to TAVI (51.8%), surgical aortic valve replacement (AVR, 5.4%), before urgent noncardiac surgery (8.0%), for symptom relief (33.0%) and cardiogenic shock (1.8%). Periprocedural, in-hospital, 1-, 6-, 12-month mortality were 2.7%; 8.9%; 8.9%; 16.9%; 22.3%, respectively. Serious periprocedural adverse events occurred in 18.8% of patients. After the procedure, mean aortic valve area (AVA) increased from 0.59 ± 0.18 to 0.82 ± 0.24 cm2 , mean peak aortic valve gradient (pAVG) decreased from 94.0 ± 27.6 to 65.4 ± 20.0 mm Hg, mean aortic gradient decreased from 58.0 ± 17.8 to 40.5 ± 14.6 mm Hg, P < 0.05 for all. Left ventricular ejection fraction (LVEF) increased from median (interquartile range) of 53.5 (30 - 64) to 60 (45 - 65)% after 1 month (P < 0.05). In patients with impaired left ventricle function (LVEF <40%), LVEF significantly improved (median increase of 16%) after 1 and 6 months (P < 0.05). At 12 months patients had higher AVA, pAVG, and LVEF as compared to baseline (P < 0.05). CONCLUSIONS: BAV is a useful procedure in high-risk AS patients, where achieved effects can be sufficient in bridging patients for TAVI/AVR. © 2016 Wiley Periodicals, Inc.

Ticagrelor effectively inhibits platelet aggregation in comatose survivors of cardiac arrest undergoing primary percutaneous coronary intervention treated with mild therapeutic hypothermia.

BACKGROUND: Mild therapeutic hypothermia (MTH) is believed to reduce the effectiveness of antiplatelet drugs. Effective dual-antiplatelet therapy after percutaneous coronary intervention (PCI) is mandatory to avoid acute stent thrombosis. The effectiveness of ticagrelor in MTH-treated out-of-hospital cardiac arrest (OHCA) survivors is still a matter of debate. The aim of the study was to evaluate the impact of MTH on the platelet-inhibitory effect of ticagrelor in comatose survivors of OHCA treated with primary PCI. METHODS: Eighteen comatose survivors of OHCA with acute coronary syndrome undergoing immediate PCI treated with MTH were compared with 14 patients with uncomplicated primary myocardial infarction after PCI, matched for gender and age, in a prospective, single-center, observational study. Platelet aggregation was evaluated using VerifyNow P2Y12 point-of-care testing at 3 time points: admission (T0), during MTH (T1), and 48-72 h after rewarming (T2). RESULTS: Ticagrelor effectively inhibits platelet aggregation in OHCA patients subjected to MTH and in all patients in the control group. The effectiveness of ticagrelor did not differ between the MTH group and the control group (p = 0.581). In 2 cases in the MTH population, the platelet response to ticagrelor was inadequate, and in one of them it remained insufficient during the re-warming phase. There was no stent thrombosis in these patients. CONCLUSIONS: The present study confirmed the effectiveness of ticagrelor to inhibit platelets in myocardial infarction patients after OHCA treated with primary PCI undergoing hypothermia. The use of cooling was not associated with an increased risk of stent thrombosis.

One-Year Outcome of Glycoprotein IIb/IIIa Inhibitor Therapy in Patients with Myocardial Infarction-Related Cardiogenic Shock.

BACKGROUND: We aimed to evaluate the effect of intravenous glycoprotein IIb/IIIa receptor inhibitors (GPIs) on in-hospital survival and mortality during and at the 1-year follow-up in patients undergoing percutaneous coronary intervention (PCI) for myocardial infarction (MI) complicated by cardiogenic shock (CS), who were included in the Polish Registry of Acute Coronary Syndromes (PL-ACS). METHODS: From 2003 to 2019, 466,566 MI patients were included in the PL-ACS registry. A total of 10,193 patients with CS received PCI on admission. Among them, GPIs were used in 3934 patients. RESULTS: The patients treated with GPIs were younger, had lower systolic blood pressure on admission, required inotropes and intra-aortic balloon pump (IABP) support more frequently, and showed a lower efficacy of coronary angioplasty. In both groups, the same rates of in-hospital adverse events were observed. A lower mortality rate was reported in the group treated with GPIs 12 months after admission (54.9% vs. 57.9%, p = 0.002). Therapy with GPI was an independent factor reducing the risk of mortality in the 12-month follow-up. CONCLUSIONS: The addition of GPIs to the standard pharmacotherapy combined with PCI in patients with MI and CS on admission reduced the risk of death in the 12-month follow-up period without increasing in-hospital adverse event rates.

Increased risk profile in the treatment of patients with symptomatic degenerative aortic valve stenosis over the last 10 years.

INTRODUCTION: Currently, Cardiology Centres are overfilled with patients with degenerative aortic valve stenosis (DAS), usually eldery, with severe concommittant comorbidities, who are referred for further decisions and possible intervention. AIM: To evaluate changes in the risk profile of patients with severe DAS admitted to the cardiology department a decade ago compared with patients currently being admitted. MATERIAL AND METHODS: We retrospectively evaluated all patients admitted with confirmed severe DAS, hospitalized during 2005-2006 (group I: 140 patients) and in 2016 (group II: 152 patients), admitted for aortic valve intervention. A standard transthoracic echocardiogram, cardiovascular symptom and risk factor distribution, perioperative risk with the logistic EuroSCORE II and STS mortality scores were obtained. RESULTS: Patients in group II were significantly older (p < 0.001), had more cardiovascular risk factors, and more often presented with atrial fibrillation (27% vs. 11.4%, p = 0.001), renal impairment (34.9% vs. 22.8%; p = 0.024), severe lung disease (17.1% vs. 2.1%, p < 0.001), and extracardiac arteriopathy (40.1% vs. 17.8%, p < 0.001). The aortic valve area (AVA) (p = 0.356), mean-transvalvular pressure gradient (p = 0.215), and left ventricular ejection fraction (p = 0.768) were similar in both groups. However, the prevalence of pulmonary hypertension, severe mitral regurgitation, and low-flow, low-gradient DAS were 3.1-, 8.4- and 1.84-fold more frequent in group II than group I. The percentages of subjects with EuroSCORE II and STS scores ≥ 4% in 2005-2006 were 7.1% and 6.4%, as compared to 27% and 26.3% in 2016 (both p < 0.001). 22% of patients in 2016, as compared to 31% in 2005/2006, were considered ineligible for DAS intervention. CONCLUSIONS: In just a decade, the risk profile of patients admitted with DAS has increased hugely, mainly due to older age, accumulation of comorbidities and more advanced disease at presentation. Although transcatheter aortic valve intervention has expanded the indications for intervention in high-risk patients, the number of patients disqualified from interventional treatment remains high.

Sex-Related Differences in Outcomes After Percutaneous Balloon Aortic Valvuloplasty.

OBJECTIVES: We aimed to evaluate sex-related differences in short-term and long-term outcomes of patients undergoing balloon aortic valvuloplasty (BAV) for severe aortic stenosis (AS). METHODS: A total of 112 patients with severe AS underwent 114 BAV procedures as palliative procedure, bridge to definitive treatment, or before urgent non-cardiac surgery. Patients were followed for 24 months. RESULTS: Of the 112 patients, 70 (62.5%) were women. Women were older, and had a higher STS score and higher prevalence of chronic kidney disease and arterial hypertension. Indications for BAV did not differ by gender. Women had a higher risk of vascular complications than men (15.7% vs 0.0%; P=.01), but with a similar rate of major periprocedural complications (17.1% vs 9.5%; P=.40). Transcatheter aortic valve implantation (TAVI) was performed in 22.8% of women and 26.2% of men (P=.61) and surgical aortic valve replacement in 10% of women and 11.9% of men (P=.70). Women and men treated finally with TAVI/aortic valve replacement had lower mortality as compared with conservative treatment (P<.01). No difference in in-hospital and 24-month mortality between women and men was observed (11.4% vs 4.9% [P=.26]; 63.3% vs 39.0% [P=.22], respectively). In a multivariable Cox model, STS score above 9.8% (hazard ratio, 2.29; 95% confidence interval, 1.09-4.83; P=.03) was an independent predictor of all-cause death only in women. CONCLUSION: Despite the presence of sex-related differences in baseline and procedural characteristics as well as in the risk of vascular complications, no difference in major procedural complications and long-term mortality was confirmed for patients with severe AS undergoing BAV.

Angiographic result of index PCI determines the presence of right ventricular infarction in patients with acute inferior myocardial infarction.

It is still a matter of debate which patients with acute inferior myocardial infarction are at increased risk of developing right ventricular (RV) myocardial infarction (RVMI). Cardiac magnetic resonance imaging (CMRI) with late enchancement (LE) is regarded as the gold standard for RVMI assessment. We aimed to determine the impact of initial angiographic status and salutary effect of primary percutaneous coronary intervention (PCI) on the presence of RVMI. In 114 patients undergoing emergency angiography and primary PCI of right coronary artery, 3-5 days after index PCI, LE CMRI was performed for assessing the RVMI. Forty-eight patients (42%) demonstrated RVMI. Multivariate regression analysis identified TIMI flow <2 in at least one RV branch after PCI as an independent angiographic predictor of RVMI [odds ratio (OR) 143.00, 95% confidence interval (CI) 18.10-1130.05, p < 0.001]. ST-segment elevation ≥ 1 mm in V4R was present in 83 (73%). TIMI flow <3 in at least one RV branch before PCI (OR 4.07, 95% CI 1.24-13.33, p = 0.02) was independent angiographic predictor of ST-segment elevation ≥ 1 mm in V4R. The only predictor of RVMI was TIMI flow <2 in at least one RV branch after PCI. ST-segment elevation ≥ 1 mm in V4R is caused by TIMI <3 flow in at least one RV branch before index PCI.