Elective versus rescue balloon aortic valvuloplasty for critical aortic stenosis.

BACKGROUND: Balloon aortic valvuloplasty (BAV) may be considered a bridge to further intervention in hemodynamically unstable patients or patients with symptomatic severe aortic stenosis (AS). AIMS: This study aimed to retrospectively compare periprocedural and in­hospital outcomes of AS patients treated with elective BAV (group 1) and rescue BAV (group 2). METHODS: We identified 35 patients in whom BAV was performed between 2010 and 2018. Among them, 16 were treated electively (group 1) and 19 urgently (group 2). RESULTS: Overall, BAV resulted in a significant decrease in the mean transaortic gradient by a median (interquartile range [IQR]) value of 5 (1-10) mm Hg (P <0.01) and the maximal transaortic gradient by a median (IQR) value of 13.5 (2.5-23.2) mm Hg (P <0.01). Postprocedural grade II aortic regurgitation rates increased from 8.6% to 17.1% (P = 0.48). Periprocedural death occurred in 4 patients (11.4%)-all from group 2 (21%) (P = 0.1). In­hospital death occurred in 15 patients (42.8%)-3 patients (18.7%) from group 1 and 12 patients (63.1%) from group 2 (P <0.01). During follow­up, a single patient underwent surgical aortic valve replacement, and transcatheter aortic valve implantation was performed in 4 individuals. A single patient died 22 months after BAV. CONCLUSIONS: Periprocedural and in­hospital mortality in patients with critical AS treated with BAV remains very high, especially in patients treated urgently.

Management strategies and 5-year outcomes in Polish patients with stable coronary artery disease versus other European countries: data from the CLARIFY registry.

INTRODUCTION An international registry of ambulatory patients with stable coronary artery disease (CLARIFY) allows a comparison of management and outcomes in real­life setting. OBJECTIVES We aimed to compare the management strategies and 5­year outcomes in patients from Poland and from other European countries. PATIENTS AND METHODS Stable coronary artery disease was defined as previous myocardial infarction (MI) or revascularization, coronary stenosis greater than 50%, or documented symptomatic myocardial ischemia. Patients were followed on an annual basis for 5 years. RESULTS Among the total of 32 703 patients, 1000 were enrolled in Poland, and 17 326 in other European countries. Polish patients were younger, with a higher proportion of women, smokers, and patients with previous MI, dyslipidemia, and hypertension. Patients in both cohorts received adequate medical treatment, with more Polish patients receiving ß­blockers. Blood pressure and lipid control to target was similar and remained low in both cohorts. Diabetes control and successful smoking cessation rates were lower in Poland than in other European countries. Polish patients more often underwent percutaneous coronary intervention. All­cause (8.5% vs 7.9%; P = 0.81) and cardiovascular death rates (5.3% vs 4.9%; P = 0.82) did not differ between the groups, but fatal or nonfatal MI occurred more often in the Polish cohort (5% vs 3.1%; P = 0.006). Angina control was better in Poland than in other European countries (Canadian Cardiovascular Society class II-IV, 11.5% vs 15.8% of patients; P <0.001). CONCLUSIONS Risk factor control was insufficient both in patients from Poland and in those from other European countries. The more frequent use of revascularization in Polish patients was not linked to improved outcomes, but, together with more extensive prescription of ß­blockers, might have contributed to better angina control.

Anomalous origin of culprit coronary arteries in acute coronary syndromes.

BACKGROUND: The aim of the study was to describe a series of acute coronary syndrome (ACS) patients in whom anomalous origin of culprit coronary artery (AOCCA) was diagnosed. Percutaneous coronary interventions (PCI) in AOCCA are performed very infrequently. METHODS: Electronic databases from three high-volume tertiary cardiac centers were retrospectively searched for the presence of AOCCA in ACS. RESULTS: Different types of AOCCA in ACS were identified in 20 patients. The most frequent AOCCA was left circumflex coronary artery (LCx) originating from right coronary artery (RCA) or directly from the right coronary sinus (RCS), n = 13, followed by high/atypical RCA, n = 3, left coronary artery (LCA) originating from RCS (n = 3) with either RCA-AOCCA (n = 1) or left anterior descending coronary artery (LAD)-AOCCA (n = 1) or RCA originating from left sinus of Valsalva, (n = 1), LAD originating from RCA (n = 1). In 1 ST-segment elevation myocardial infarction (STEMI)-patient RCA-AOCCA cannulation was unsuccessful, in 1 non-STEMI-patient AOCCA was missed, 1 ACS- -patient was treated surgically and 1 ACS-patient was treated conservatively (both patients with non- STEMI). In the remaining patients PCI was successfully performed. CONCLUSIONS: The most frequently encountered AOCCA is LCx branching-off from RCA. AOCCA may either be difficult to cannulate and PCI aborted even in STEMI, or missed, especially when the intermediate branch from LCA is mimicking proper LCx.

PPAR Gamma Expression Levels during Development of Heart Failure in Patients with Coronary Artery Disease after Coronary Artery Bypass-Grafting.

Genetic research has elucidated molecular mechanisms of heart failure (HF). Peroxisome proliferator-activated receptors (PPARs) seem to be important in etiology of HF. The aim of study was to find the correlation between PPARγ expression during development of HF in patients and coronary artery disease (CAD) after coronary artery bypass-grafting (CABG). Methods and Results. We followed up 157 patients (mean age 63) with CAD without clinical, laboratory, or echo parameters of HF who underwent CABG. Clinical and laboratory status were assessed before CABG and at 1, 12, and 24 months. During CABG slices of aorta (Ao) and LV were collected for genetic research. HF was defined as LVEF <40% or NT-proBNP >400 pg/mL or 6MWT <400 m. Patients were divided into 2 groups: with and without HF. PPARγ expression in Ao and LV was not increased in both groups at 2-year follow-up. Sensitivity of PPARγ expression in Ao above 1.1075 in detection of HF was 20.5% (AUC 0.531, 95% CI 0.442-0.619). Positive predictive value (Ppv) was 85.7%. Sensitivity and specificity of PPARγ expression in the LV in detection of HF were 58% and 92.9%, respectively (AUC 0.540, 95% CI 0.452-0.626). Ppv was 73.2%. Conclusion. PPARγ expression in Ao and LV was comparable and should not be used as predictive factor for development of HF in patients with CAD after CABG.

Heart rate and the use of beta-blockers in stable outpatients with coronary artery disease: Polish baseline results of the CLARIFY registry.

BACKGROUND: Heart rate (HR) is an important risk factor in coronary artery disease (CAD). However, there is little contemporary data on HR and the use of HR-lowering medications, particularly beta-blockers, among patients with stable CAD in routine clinical practice. AIM: To describe HR in the Polish population of the CLARIFY registry, overall and in relation to beta-blocker use, and to assess the determinants of HR. METHODS AND RESULTS: CLARIFY is an international, prospective, observational, longitudinal registry of outpatients with stable CAD, defined as either prior myocardial infarction or revascularisation procedure, or evidence of coronary stenosis of at least 50%, or chest pain associated with proven myocardial ischaemia. A total of 33,438 patients from 45 countries in Europe, the Americas, Africa, the Middle East, and Asia/Pacific were enrolled between November 2009 and July 2010. In Poland, 1,004 patients were enrolled between February and June 2010, which was the largest population among countries from Eastern Europe. Most patients were men (72.8%). Mean ± standard deviation age was 62.1 ± 9.1 years. HR determined by pulse was 69.3 ± 9.4 bpm and by electrocardiogram was 68.2 ± 10.6 bpm. Beta-blockers were used in 89.9% of patients. Resting HR ≥ 70 bpm was noted in 49.3% of all patients and in 48.6% of patients on beta-blockers. Resting HR ≥ 70 bpm was significantly more frequent among younger patients, and in those with diabetes, those being treated for arterial hypertension, and who lacked regular physical activity. Patients with HR ≥ 70 bpm at rest had more frequent symptoms of angina and more frequently needed hospitalisation due to heart failure. CONCLUSIONS: Despite a very high rate of beta-blocker use, almost 50% of patients with stable CAD had a resting HR ≥ 70 bpm, which was associated with more frequent angina and ischaemia. Further HR lowering is possible in many patients with CAD. Whether or not this will improve symptoms and outcomes is under investigation.

A severe complication after ST-segment elevation myocardial infarction (Part 2).

We report the case of a 70-year-old woman with ST-segment elevation myocardial infarction of the anterior wall, complicated by ventricular septal rupture (two septal defects--VSDs) with symptoms of cardiogenic shock. After 6 weeks of conservative treatment with inotropes and intra-aortic balloon support, the patient underwent surgical repair of VSDs with good clinical outcome.

A severe complication after ST-segment elevation myocardial infarction (Part 1).

We report the case of a 70-year-old woman with ST-segment elevation myocardial infarction of the anterior wall, complicated by ventricular septal rupture (two septal defects--VSDs) with symptoms of cardiogenic shock. After 6 weeks of conservative treatment with inotropes and intra-aortic balloon support, the patient underwent surgical repair of VSDs with good clinical outcome.