Islets of heterogeneous myocardium within the scar in cardiac magnetic resonance predict ventricular tachycardia after myocardial infarction.

INTRODUCTION: We assessed findings in cardiac magnetic resonance (CMR) as predictors of ventricular tachycardia (VT) after myocardial infarction (MI), which could allow for more precise identification of patients at risk of sudden cardiac death. METHODS: Forty-eight patients after prior MI were enrolled and divided into two groups: with (n = 24) and without (n = 24) VT. VT was confirmed by electrophysiological study and exit site was estimated based on 12-lead electrocardiogram. All patients underwent CMR with late gadolinium enhancement. RESULTS: The examined groups did not differ significantly in clinical and demographical parameters (including LV ejection fraction). There was a significant difference in the infarct age between the VT and non-VT group (15.8 ± 8.4 vs 7.1 ± 6.7 years, respectively; P = .002), with the cut-off point at the level of 12 years. In the scar core, islets of heterogeneous myocardium were revealed. They were defined as areas of potentially viable myocardium within or adjacent to the core scar. The number of islets was the strongest independent predictor of VT (odds ratio [OR], 1.42; confidence interval [CI], 1.17-1.73), but total islet size and the largest islet area were also significantly higher in the VT group (OR, 1.04; CI, 1.02-1.07 and OR, 1.16; CI, 1.01-1.27, respectively). Myocardial segments with fibrosis forming 25%-75% of the ventricular wall were associated with a higher incidence of VT (7.5 ± 2.1 vs 5.7 ± 2.6; P = .014). Three-dimension CMR reconstruction confirmed good correlation of the location of the islets/channels with VT exit site during electroanatomical mapping in five cases. CONCLUSIONS: The identification and quantification of islets of heterogeneous myocardium within the scar might be useful for predicting VT in patients after MI.

Fibrinolysis or primary PCI in ST-segment elevation myocardial infarction.

BACKGROUND: It is not known whether prehospital fibrinolysis, coupled with timely coronary angiography, provides a clinical outcome similar to that with primary percutaneous coronary intervention (PCI) early after acute ST-segment elevation myocardial infarction (STEMI). METHODS: Among 1892 patients with STEMI who presented within 3 hours after symptom onset and who were unable to undergo primary PCI within 1 hour, patients were randomly assigned to undergo either primary PCI or fibrinolytic therapy with bolus tenecteplase (amended to half dose in patients ≥75 years of age), clopidogrel, and enoxaparin before transport to a PCI-capable hospital. Emergency coronary angiography was performed if fibrinolysis failed; otherwise, angiography was performed 6 to 24 hours after randomization. The primary end point was a composite of death, shock, congestive heart failure, or reinfarction up to 30 days. RESULTS: The primary end point occurred in 116 of 939 patients (12.4%) in the fibrinolysis group and in 135 of 943 patients (14.3%) in the primary PCI group (relative risk in the fibrinolysis group, 0.86; 95% confidence interval, 0.68 to 1.09; P=0.21). Emergency angiography was required in 36.3% of patients in the fibrinolysis group, whereas the remainder of patients underwent angiography at a median of 17 hours after randomization. More intracranial hemorrhages occurred in the fibrinolysis group than in the primary PCI group (1.0% vs. 0.2%, P=0.04; after protocol amendment, 0.5% vs. 0.3%, P=0.45). The rates of nonintracranial bleeding were similar in the two groups. CONCLUSIONS: Prehospital fibrinolysis with timely coronary angiography resulted in effective reperfusion in patients with early STEMI who could not undergo primary PCI within 1 hour after the first medical contact. However, fibrinolysis was associated with a slightly increased risk of intracranial bleeding. (Funded by Boehringer Ingelheim; ClinicalTrials.gov number, NCT00623623.).

Long Coronary Lesions Treated With Thin Strut Bioresorbable Polymer Drug Eluting Stent: Experience From Multicentre Randomized CENTURY II Study.

OBJECTIVES: To assess performance of new, bioresorbable polymer sirolimus-eluting stent (BP-SES), in patients with long coronary lesions (LL) and to compare it to permanent polymer everolimus-eluting stent (PP-EES). BACKGROUND: LL have been associated with worse clinical outcomes in percutaneous coronary interventions (PCI). The impact of lesion length on the outcomes of drug eluting stent (DES) implantations is not as clear. METHODS: In the frame of a randomized, multicentre CENTURY II study, out of 1119 patients enrolled, 182 patients had LL (defined as ≥25 mm), and were assigned randomly to treatment with BP-SES (101) or PP-EES (81). Primary endpoint was target lesion failure (TLF, composite of cardiac death, target vessel related myocardial infarction [MI], and target lesion revascularization [TLR]) at 9 months. All data were 100% monitored and adverse events were adjudicated by an independent clinical event committee. RESULTS: The baseline patient and lesion characteristics were similar in the 2 study arms. At 9-months, the rates of cardiac death (2.0% vs 1.2%; P = 0.70), MI (3.0% vs 4.9%; P = 0.49) and clinically driven TLR (2.0% vs 3.7%; P = 0.48) and TLF (6.9% vs 8.6%; P = 0.67) were similar for BP-SES and PP-EES, respectively. There was no stent thrombosis (ST) in BP-SES group up to 9 months, while 1 case (1.2%) of ST was recorded in PP-EES group (P = 0.44). CONCLUSIONS: Patients with LL showed similar clinical outcomes when treated with Ultimaster BP-SES and Xience PP-EES.

Endomyocardial biopsy via the femoral access - still safe and valuable diagnostic tool.

BACKGROUND: The endomyocardial biopsy has proven to be an integral diagnostic tool for surveillance of cardiac allograft rejection and identification of myocardial diseases. Nevertheless, this invasive procedure is not risk-free. This study focuses on the risk of complications and diagnostic performance of right ventricular endomyocardial biopsy (EMB). METHODS: In this single-center retrospective study, we analyzed 315 EMB procedures performed between July 2008 and May 2015 in 73 patients. All EMBs were made via the right femoral vein approach under fluoroscopic control to evaluate suspected myocarditis, unclear heart failure, unexplained cardiomyopathy, assumed infiltrative and storage disease or as a part of routine allograft rejection monitoring and clinically suspected rejection diagnosis after heart transplantation (HTx). Obtained specimens were diagnosed histopathologically by one experienced pathologist. All patients underwent a 12-lead electrocardiogram (ECG), ECG monitoring, transthoracic echocardiography before and after EMB to obtain a detailed assessment of the incidence of heart rhythm disorders, pericardial effusions or worsening valve insufficiency. Complications resulting from the procedure were classified as major or minor according to the risk of death. RESULTS: Among all the 315 biopsies, 86.67% were performed in 32 patients after HTx, 3.81% in patients with myocarditis, 2.54% in patients with dilated cardiomyopathy and 1.9% in patients with amyloidosis. The overall complications rate was 1.9% (6 of 315 procedures). Major complications included perforation with pericardial tamponade requiring surgical intervention (0.64%, 2 of 315 procedures). Minor complications included: pericardial effusion (0.32%, 1 of 315 procedures), local hematoma (0.64%, 2 of 315 procedures) and right coronary artery-right ventricle fistula in HTx recipient (0.32%, 1 of 315 procedures). CONCLUSIONS: EMB is a safe procedure with low risk of serious complications and high effectiveness for the evaluation of unexplained left ventricle dysfunction and monitoring allograft rejection after HTx.

The effect of trimetazidine added to pharmacological treatment on all-cause mortality in patients with systolic heart failure.

UNLABELLED: The anti-ischemic agent trimetazidine (TMZ) added to pharmacological treatment appears to have positive effects on cardiac parameters of patients with heart failure (HF) as a result of specific antioxidant properties. OBJECTIVES: We aimed to verify whether the marked improvement provided by TMZ in echocardiographic and clinical parameters was likely to translate into reduced all-cause mortality in systolic HF patients. METHODS: Meta-analysis of available published prospective randomized controlled trial (RCT) data (1967-2014) retrieved from PubMed, Web of Science and Cochrane Collaboration. RESULTS: A total of 326 patients from 3 RCTs were analyzed: 164 who received TMZ on top of pharmacological HF therapy and 162 controls. Study durations ranged from 12 to 48 months. The analysis had no publication bias and the studies were homogeneous (p = 0.442, I(2) = 0). The results show a significant effect of TMZ on the reduction of all-cause mortality (RR = 0.283, p < 0.0001). The rate of events attributable to the drug was lower with TMZ than it was among control patients. CONCLUSION: This meta-analysis suggests that in patients with HF, TMZ given as an add-on therapy is likely to provide a protective effect, reduce all-cause mortality and increase event-free survival, and could be an effective and useful adjunct to our armamentarium for the treatment of HF patients.

Impact of intracoronary bone marrow cell therapy on left ventricular function in the setting of ST-segment elevation myocardial infarction: a collaborative meta-analysis.

AIMS: The objective of the present analysis was to systematically examine the effect of intracoronary bone marrow cell (BMC) therapy on left ventricular (LV) function after ST-segment elevation myocardial infarction in various subgroups of patients by performing a collaborative meta-analysis of randomized controlled trials. METHODS AND RESULTS: We identified all randomized controlled trials comparing intracoronary BMC infusion as treatment for ST-segment elevation myocardial infarction. We contacted the principal investigator for each participating trial to provide summary data with regard to different pre-specified subgroups [age, diabetes mellitus, time from symptoms to percutaneous coronary intervention, infarct-related artery, LV end-diastolic volume index (EDVI), LV ejection fraction (EF), infarct size, presence of microvascular obstruction, timing of cell infusion, and injected cell number] and three different endpoints [change in LVEF, LVEDVI, and LV end-systolic volume index (ESVI)]. Data from 16 studies were combined including 1641 patients (984 cell therapy, 657 controls). The absolute improvement in LVEF was greater among BMC-treated patients compared with controls: [2.55% increase, 95% confidence interval (CI) 1.83-3.26, P < 0.001]. Cell therapy significantly reduced LVEDVI and LVESVI (-3.17 mL/m², 95% CI: -4.86 to -1.47, P < 0.001; -2.60 mL/m², 95% CI -3.84 to -1.35, P < 0.001, respectively). Treatment benefit in terms of LVEF improvement was more pronounced in younger patients (age <55, 3.38%, 95% CI: 2.36-4.39) compared with older patients (age ≥ 55 years, 1.77%, 95% CI: 0.80-2.74, P = 0.03). This heterogeneity in treatment effect was also observed with respect to the reduction in LVEDVI and LVESVI. Moreover, patients with baseline LVEF <40% derived more benefit from intracoronary BMC therapy. LVEF improvement was 5.30%, 95% CI: 4.27-6.33 in patients with LVEF <40% compared with 1.45%, 95% CI: 0.60 to 2.31 in LVEF ≥ 40%, P < 0.001. No clear interaction was observed between other subgroups and outcomes. CONCLUSION: Intracoronary BMC infusion is associated with improvement of LV function and remodelling in patients after ST-segment elevation myocardial infarction. Younger patients and patients with a more severely depressed LVEF at baseline derived most benefit from this adjunctive therapy.

Postconditioning reduces enzymatic infarct size and improves microvascular reperfusion in patients with ST-segment elevation myocardial infarction.

OBJECTIVES: Postconditioning has been reported to reduce infarct size in ST-segment myocardial infarction (STEMI). However, recently, few other studies did not show any effect of postconditioning and suggested that it may be even harmful. We sought to assess whether postconditioning could reduce infarct size and improve myocardial reperfusion in early presenters with STEMI. METHODS: 72 STEMI patients treated with primary percutaneous coronary intervention (PCI) were randomly assigned to either the postconditioning (n = 35) or the standard PCI group (control group; n = 37). Blood samples were obtained for creatine kinase (CK) and its MB isoform (CK-MB) within 36 h. The angiographic (myocardial blush grade, MBG) and electrocardiographic (ST-segment resolution, STR) data were evaluated and compared between groups. RESULTS: The areas under the curve of CK and CK-MB release were significantly reduced in the postconditioning group compared with the control group (38,612.91 ± 25,028.42 vs. 60,547.30 ± 25,264.63 for CK and 5,498.23 ± 3,787.91 vs. 7,443.12 ± 3,561.13 for CK-MB, p < 0.0001). MBG was significantly better in the postconditioning group than in the control group (MBG 3: 82.3 vs. 47.1%, p = 0.0023). In the postconditioning group, STR >70% was more often observed (97.1 vs. 64.1%, p = 0.0007). CONCLUSIONS: In patients with STEMI, postconditioning could significantly reduce enzymatic infarct size and improve myocardial reperfusion.

Age-related limitations of interleukin-6 in predicting early mortality in acute ST-elevation myocardial infarction.

Interleukin-6 (IL-6) is an inflammatory cytokine whose levels increase significantly during myocardial infarction (MI). It has been hypothesised that the concentrations of IL-6 at admission may be useful in prognosticating long-term outcomes. It is unclear, however, whether IL-6 could improve the prognosis of early mortality in MI. We have compared serum IL-6 levels and analysed the disease course in 158 patients with ST-elevation MI (STEMI) who either survived (n = 148) or died (n = 10) within 30 days following the admission. Patients were treated in a single university centre with primary percutaneous coronary intervention (PCI). The non-survivors (6.3%) displayed most of typical risk factors for poor outcome. In addition they had significantly higher concentrations of IL-6 at hospital admission (median values 8.5 vs. 2.0 pg/ml; p = 0.038). However, they were also significantly older than the survivors (median values 72 vs. 57 years; p = 0.0001). IL-6 levels are known to increase with age and we could confirm a significant correlation between patients' calendar age and circulating IL-6 (p = 0.009). Regression analysis revealed that IL-6 concentrations were significantly affected by patients' age but they did not independently relate to patients' outcome. Such results indicate that circulating IL-6 at admission may be of limited value in predicting early mortality in STEMI. It is important to recognize that, because of the small group of patients who died (N = 10), the results must be interpreted with caution. Therefore, we stress that these results should be viewed as preliminary and further validated in a larger set of patients.

Cardiovascular safety of antihistamines.

Histamine is a mediator, which increases the permeability of capillaries during the early phase of allergic reaction, causes smooth muscle contraction of bronchi and stimulates mucous glands in the nasal cavity. Antihistamines are the basis of symptomatic treatment in the majority of allergic diseases, especially allergic rhinitis, allergic conjunctivitis, urticaria and anaphylaxis. The cardiotoxic effects of the two withdrawn drugs, terfenadine and astemizole, were manifested by prolonged QT intervals and triggering torsades de pointes (TdP) caused by blockade of the 'rapid' I Kr potassium channels. These phenomena, however, are not a class effect. This review deals with a new generation of antihistamine drugs in the context of QT interval prolongation risk.

Comparison of diffusion-weighted with T2-weighted imaging for detection of edema in acute myocardial infarction.

BACKGROUND: Recent studies, performed with the use of a commercially available diffusion weighted imaging (DWI) sequence, showed that they are sensitive to the increase of water content in the myocardium and may be used as an alternative to the standard T2-weighted sequences. The aim of this study was to compare two methods of myocardial edema imaging: DWI and T2-TIRM. METHODS: The study included 91 acute and post STEMI patients. We applied a qualitative and quantitative image analysis. The qualitative analysis consisted of evaluation of the quality of blood suppression, presence of artifacts and occurrence of high signal (edema) areas. On the basis of edema detection in AMI and control (post STEMI) group, the sensitivity and specificity of TIRM and DWI were determined. Two contrast to noise ratios (CNR) were calculated: CNR1--the contrast between edema and healthy myocardium and CNR2--the contrast between edema and intraventricular blood pool. The area of edema was measured for both TIRM and DWI sequences and compared with the infarct size in LGE images. RESULTS: Edema occurred more frequently in the DWI sequence. A major difference was observed in the inferior wall, where an edema-high signal was observed in 46% in T2-TIRM, whereas in the DWI sequence in 85%. An analysis of the image quality parameters showed that the use of DWI sequence allows complete blood signal suppression in the left ventricular cavity and reduces the occurrence of motion artifacts. However, it is connected with a higher incidence of magnetic susceptibility artifacts and image distortion. An analysis of the CNRs showed that CNR1 in T2-TIRM sequence depends on the infarct location and has the lowest value for the inferior wall. The area of edema measured on DWI images was significantly larger than in T2-TIRM. CONCLUSIONS: DWI is a new technique for edema detection in patients with acute myocardial infarction which may be recommended for the diagnosis of acute injuries, especially in patients with slow-flow artifacts in TIRM images.

Effect of new method of intracoronary adenosine injection during primary percutaneous coronary intervention on microvascular reperfusion injury - clinical outcome and 1-year follow-up.

OBJECTIVES: The aim of this single-center, randomized placebo-controlled trial in 70 consecutive patients (64 ± 14 years) with acute myocardial infarction was to examine the role of a new protocol of adenosine administration during primary angioplasty on immediate electrocardiographic and angiographic results, clinical outcome and 1-year follow-up. METHODS: Group A (n = 35) twice received intracoronary adenosine through the guiding catheter: immediately after crossing the lesion of the infarct-related artery with guidewire and then after first balloon inflation. Group B (n = 35) received placebo. RESULTS: Resolution of ST segment elevation was more frequently observed in the adenosine than in the placebo group (p < 0.01). Percutaneous coronary intervention (PCI) resulted in borderline better TIMI 3 flow after the procedure in the adenosine group than in the placebo group. Myocardial blush grade 3 at the end of the procedure was significantly improved in the adenosine compared to the placebo group (p < 0.05). At 1-year the composite end-point of death, recurrent myocardial infarction, heart failure and clinically driven target vessel revascularization was present in 8 patients in the adenosine group and 16 patients in placebo group (p < 0.05). CONCLUSIONS: Intracoronary adenosine improved electrocardiographic and angiographic results in patients undergoing primary PCI and seemed to be associated with more favorable clinical course.

Microvolt T wave alternans in adults with congenital heart diseases characterized by right ventricle pathology or single ventricle physiology: a case control study.

BACKGROUND: Among adults with congenital heart diseases (CHD) evaluation of sudden cardiac death (SCD) risk remains a great challenge. Although microvolt T-wave alternans has been incorporated into SCD risk stratification algorithm, its role in adults with CHD still requires investigation. We sought to determine the incidence of MTWA in this specific group and its coincidence with ventricular arrhythmia (VA) and other clinical findings presumably associated with SCD. METHODS: A case-control study was performed in which 102 patients with CHD characterized by right ventricle pathology or single ventricle physiology (TGA, UVH, Ebstein's anomaly, ccTGA, Eisenmenger syndrome, DORV, CAT, unoperated ToF) were compared to 45 age- and sex-matched controls. All subjects underwent spectral MTWA test, ambulatory ecg monitoring, cardiopulmonary test, BNP assessment. After excluding technically inadequate traces, the remaining MTWA results were classified as positive(+), negative(-) and indeterminate(ind). Due to similar prognostic significance MTWA(+) and (ind) were combined into a common group labeled 'abnormal'. RESULTS: Abnormal MTWA was present more often in the study group, compared to controls (39.2% vs 2.3%, p = 0.00001). Sustained ventricular tachycardia (sVT) was observed more often among subjects with abnormal MTWA compared to MTWA(-): 19.4% vs 3.6%, p = 0.026. The patients with abnormal MTWA had a lower blood saturation (p = 0.047), more often were males (p = 0.031), had higher NYHA class (p = 0.04), worse cardiopulmonary parameters: %PeakVO2 (p = 0.034), %HRmax (p = 0.003). Factors proven to increase probability of abnormal MTWA on multivariate linear regression analysis were: sVT (OR = 20.7, p = 0.037) and male gender (OR = 15.9, p = 0.001); on univariate analysis: male gender (OR = 2.7, p = 0.021), presence of VA (OR = 2.6, p = 0.049), NYHA > I (OR = 2.06, p = 0.033), %HRmax (OR = 0.94, p = 0.005), %PeakVO2 (OR = 0.97, p = 0.042), VE/VCO2slope (OR = 1.05, p = 0.037). CONCLUSIONS: Abnormal MTWA occurs significantly more often in adults with the chosen forms of CHD than among healthy subjects. The probability of abnormal MTWA increases in patients with malignant VA, in males and among subjects with heart failure and cyanosis. MTWA might be of potential role in risk stratification for SCD in adults with CHD.

Clinical factors affecting survival in patients with D-transposition of the great arteries after atrial switch repair: A meta-analysis.

BACKGROUND: Atrial switch repair (AtrSR) was the initial operation method in patients with D-transposition of the great arteries (D-TGA) constituting the right ventricle as a systemic one. Currently, it has been replaced with arterial switch operation (ASO), but the cohort of adults after AtrSR is still large and requires strict cardiological management of late complications. For this reason, we aimed to evaluate potential long-term mortality risk factors in patients with D-TGA after AtrSR (either Mustard or Senning procedures) Methods: We searched the MEDLINE database for suitable trials. We included 22 retrospective and prospective cohort studies of patients with D-TGA with at least 5 years mean/median follow-up time after Mustard or Senning procedures, with an endpoint of non-sudden cardiac death (n-SCD) and sudden cardiac death (SCD) after at least 30 days following surgery. RESULTS: A total of 2912 patients were enrolled, of whom 351 met the combined endpoint of n-SCD/SCD. The long-term mortality risk factors were New York Heart Association (NYHA) class ≥III/heart failure hospitalization (odds ratio [OR], 7.25; 95% confidence interval [CI], 2.67-19.7), tricuspid valve regurgitation (OR, 4.64; 95% CI, 1.95-11.05), Mustard procedure (OR, 2.15; 95% CI, 1.37-3.35), complex D-TGA (OR, 2.41; 95% CI, 1.31-4.43), and right ventricular dysfunction (OR, 1.94; 95% CI, 0.99-3.79). Supraventricular arrhythmia (SVT; OR, 2.07; 95% CI, 0.88-4.85) and pacemaker implantation (OR, 2.37; 95% CI, 0.48-11.69) did not affect long-term survival in this group of patients. In an additional analysis, SVT showed a statistically significant impact on SCD (OR, 2.74; 95% CI, 1.36-5.53) but not on n-SCD (OR, 1.5; 95% CI, 0.37-6.0). CONCLUSIONS: This meta-analysis demonstrated that at least moderate tricuspid valve regurgitation, NYHA class ≥III/heart failure hospitalization, right ventricular dysfunction, complex D-TGA, and Mustard procedure are risk factors for long-term mortality in patients after AtrSR.

The impact of left circumflex coronary artery ostium stenosis on outcomes for patients after percutaneous coronary intervention for unprotected left main disease.

BACKGROUND: The impact of left circumflex coronary artery (LCX) ostium atherosclerosis in left main coronary artery (LM) bifurcation disease is not well-known. AIM: The study aimed to assess whether the involvement of LCX ostium carries prognostic implications in patients undergoing unprotected LM percutaneous coronary intervention (PCI). METHODS: Consecutive 564 patients with unprotected LM (ULMCA) disease who underwent LM PCI between January 2015 and February 2021, with at least 1 year of available follow-up were included in the study. The first group was composed of 145 patients with ULMCA disease with LCX ostium stenosis, and the second group consisted of 419 patients with ULMCA disease without LCX ostium stenosis. RESULTS: Patients in the group with ULMCA disease with LCX ostium stenosis were significantly older and had more comorbidities. The two-stent technique was used more often in the group with LCX ostium stenosis (62.8% vs. 14.6%; P <0.001). During 7-year follow-up, all-cause mortality did not differ significantly between groups with and without LCX ostium stenosis (P = 0.50). The use of one-stent or two-stent technique also did not impact mortality in patients with LCX ostial lesions (P = 0.75). Long-term mortality subanalysis for three groups of patients: (1) patients with LM plus LCX ostium stenosis; (2) LM plus left anterior descending artery (LAD) ostium stenosis; (3) LM plus LCX ostium plus LAD ostium stenosis also did not differ significantly (P = 0.63). CONCLUSIONS: LCX ostium involvement in LM disease PCI is not associated with adverse long-term outcomes, which is highly beneficial for the Heart Team's decision-making process.

Dentigenous infectious foci - a risk factor of infective endocarditis.

BACKGROUND: Dentigenous, infectious foci are frequently associated with the development of various diseases. The role of such foci in the evolution of endocarditis still remains unclear. This article presents the concluding results of an interdisciplinary study verifying the influence of dentigenous, infectious foci on the development of infective endocarditis. MATERIAL/METHODS: The study subjects were 60 adult patients with history of infective endocarditis and coexistent acquired heart disease, along with the presence at least 2 odontogenic infectious foci (ie, 2 or more teeth with gangrenous pulp and periodontitis). The group had earlier been qualified for the procedure of heart valve replacement. Swabs of removed heart valve tissue with inflammatory lesions and blood were then examined microbiologically. Swabs of root canals and their periapical areas, of periodontal pockets, and of heart valves were also collected. RESULTS: Microbial flora, cultured from intradental foci, blood and heart valves, fully corresponded in 14 patients. This was accompanied in almost all cases by more advanced periodontitis (2nd degree, Scandinavian classification), irrespective of the bacterial co-occurrence mentioned. In the remaining patients, such consistency was not found. CONCLUSIONS: Among various dentigenous, infectious foci, the intradental foci appear to constitute a risk factor for infective endocarditis.

Do non-vitamin K antagonist oral anticoagulants increase the risk of myocardial infarction?

Non-vitamin K antagonist oral anticoagulants (NOACs), compared with warfarin, have a favorable risk-benefit profile. However, in the RE-LY study in patients with atrial fibrillation (AF), the number of patients with MI was higher in the dabigatran group as compared to the warfarin group. Many meta-analyses showed that dabigatran treatment led to an increased risk of myocardial infarction (MI). Large real-world data (RWD) did not confirm an increase in the risk of MI during dabigatran treatment. In our meta-analysis we excluded RWD, and each of the four drugs was evaluated in two key-phase III randomized controlled trials: in patients with AF and patients with AF and chronic coronary syndrome or acute coronary syndrome treated with percutaneous coronary interventions. In each study, warfarin was the comparator for NOACs. In this homogeneous group of patients, dabigatran, in direct comparison with warfarin, significantly increased the risk of MI by about 30%. Moreover, the risk of MI was also significantly higher than the opposite effect of activated factor (F) X inhibitors (FXa inhibitors) vs. warfarin. In our network meta-analysis, considering individual NOACs in recommended doses, we found an increased risk of MI compared to warfarin only in patients treated with dabigatran 150 mg twice a day and, in particular, 110 mg twice a day. In this review we present evidence supporting our opinion that in patients with AF and coronary stenting, the choice of NOACs (direct FXa vs. thrombin inhibitors) is equally as important as choosing the optimal antiplatelet therapy (single or dual antiplatelet therapy).

Peri-Procedural Troponin Elevation after Percutaneous Coronary Intervention for Left Main Coronary Artery Disease.

Left main (LM) percutaneous coronary interventions (PCI) are challenging and highly invasive procedures. Periprocedural myocardial injury (Troponin (Tn) elevation > 99th percentile) is frequently detected after LM PCI, being identified even in up to 67% of patients. However, the prognostic implications of periprocedural Tn elevation after LM PCI remain controversial. We aim to assess the impact and prognostic significance of the periprocedural troponin elevation on long-term outcomes in patients undergoing LM PCI in a real-world setting. Consecutive 673 patients who underwent LM PCI in our department between January 2015 to February 2021 were included in a prospective registry. The first group consisted of 323 patients with major cardiac Troponin I elevation defined as an elevation of Tn values > 5× the 99th percentile in patients with normal baseline values or post-procedure Tn rise by >20% in patients with elevated pre-procedure Tn in whom the Tn level was stable or falling (based on the fourth universal definition of myocardial infarction). The second group consisted of patients without major cardiac Troponin I elevation. Seven-year long-term all-cause mortality was not higher in the group with major Tn elevation (36.9% vs. 40.6%; p = 0.818). Naturally, periprocedural myocardial infarction was diagnosed only in patients from groups with major Tn elevation (4.9% of all patients). In-hospital death and other periprocedural complications did not differ significantly between the two study groups. The adjusted HRs for mortality post-PCI in patients with a periprocedural myocardial infarction were not significant. Long-term mortality subanalysis for the group with criteria for cardiac procedural myocardial injury showed no significant differences (39.5% vs. 38.8%; p = 0.997). The occurrence of Tn elevation (>1×; >5×; >35× and >70× URL) after LM PCI was not associated with adverse long-term outcomes. The results of the study suggest that the isolated periprocedural troponin elevation is not clinically significant.

Short- and Long-Term Outcomes of Left Main Coronary Artery Stenting in Patients Disqualified from Coronary Artery Bypass Graft Surgery.

The study aims to evaluate the short- and long-term outcomes of left main percutaneous coronary interventions (LM PCI) in patients disqualified from coronary artery bypass graft surgery (CABG). We included 459 patients (mean age: 68.4 ± 9.4 years, 24.4% females), with at least 1-year follow-up; 396 patients in whom PCI was offered as an alternative to CABG (Group 1); and 63 patients who were disqualified from CABG by the Heart Team (Group 2). The SYNTAX score (29.1 ± 9.5 vs. 23.2 ± 9.7; p < 0.001) and Euroscore II value (2.72 ± 2.01 vs. 2.15 ± 2.16; p = 0.007) were significantly higher and ejection fraction was significantly lower (46% vs. 51.4%; p < 0.001) in Group 2. Patients in Group 2 more often required complex stenting techniques (33.3% vs. 16.2%; p = 0.001). The procedure success rates were very high and did not differ between groups (100% vs. 99.2%; p = 0.882). We observed no difference in periprocedural complication rates (12.7% vs. 7.8%; p = 0.198), but the long-term all-cause mortality rate was higher in Group 2 (26% vs. 21%; p = 0.031). LM PCI in patients disqualified from CABG is an effective and safe procedure with a low in-hospital complication rate. Long-term results are satisfactory.

Very long-term follow-up of patients with coronary bifurcation lesions treated with bioresorbable scaffolds.

BACKGROUNDS: The data concerning the use of bioresorbable vascular scaffolds (BVS) in coronary bifurcation lesions are limited. AIMS: The objective of the study was to evaluate the early and very long-term clinical outcomes of bifurcation stenting with ABSORB BVS. METHODS: One hundred consecutive patients with coronary bifurcation lesions treated with BVS were included. A total of 124 BVS were implanted. Provisional side branch stenting was performed in 66 patients, distal main stenting in 14 patients, systematic T stenting in 2, and T with minimal protrusion (TAP) in 5 patients. Side branch ostial stenting was performed in additional 12 patients. RESULTS: The procedural success was achieved in 98% of patients. In long-term follow-up, the rate of cardiac death was 4.0%, target vessel myocardial infarction was 5.0%, and target vessel revascularization (TVR) was 11%. The cumulative incidence of definite/probable scaffold thrombosis (ST) was 2% at long-term follow-up. Comparison with the historical drug-eluting stents (DES) group revealed higher mortality and major adverse cardiac events rate in the ABSORB group. CONCLUSIONS: Stenting of coronary bifurcation lesions of low-to-moderate complexity with BVS was feasible with good acute performance and acceptable results. However, the risk of death and major adverse cardiovascular events was higher as compared with DES.

Interpretation of elevated serum VEGF concentrations in patients with myocardial infarction.

Serum has been considered an unsuitable medium for measurements of circulating vascular endothelial growth factor (VEGF) since platelets release significant quantities of VEGF during clotting. Nevertheless, the assessment of platelet-derived VEGF may be important in patients with acute coronary syndromes characterized by intraluminal thrombosis. The present study aimed at identifying the factors that impact on the interpretation of serum VEGF concentrations in patients with ST-elevation myocardial infarction (STEMI). VEGF was measured in 106 patients with STEMI and correlated with clinical and angiographic parameters. Serum VEGF levels were significantly higher in patients with STEMI than in healthy controls. Although the average number of platelets did not differ between the groups, the patients with STEMI, but not the controls, exhibited a significant correlation between serum VEGF levels and platelet counts. Stratification of patients according to different criteria revealed that VEGF concentrations were particularly elevated shortly (<3h) after the onset of chest pain in those patients who had occluding thrombi graded as large (3-4) on a TIMI scale. These data demonstrate that high levels of serum VEGF detected early in the course of STEMI may derive from activated platelets and may characterize patients with extensive intracoronary thrombosis.