Left atrium volume and function changes during stress in patients with primary mitral regurgitation and preserved left ventricular ejection fraction.

INTRODUCTION: Patients with primary mitral regurgitation (MR) usually remain asymptomatic for a long time due to compensatory mechanisms and an adequate treatment could be delayed. Stress echocardiography and speckle-tracking analysis could help to evaluate impaired left atrium (LA) function before the manifestation of clinically significant myocardial changes in asymptomatic patients with primary MR and preserved left ventricular (LV) ejection fraction (EF). METHODS: This study prospectively enrolled 91 patients with preserved LV EF (≥60%) at rest, of which 60 patients had moderate-to-severe MR and 31 were healthy controls. Rest and stress (bicycle ergometry) echocardiography and speckle-tracking offline analysis were performed. RESULTS: In MR group LA volume indices were higher at rest and during stress, while LA reservoir, conduit, and contractile fractions were decreased (p < .005). LA deformation parameters at rest were similar in both groups. During maximum stress LA conduit, contractile fractions and reservoir strain were lower (p < .05) in patients with MR. Indices of LA volume were related to SPAP at rest and during stress. Higher NT-proBNP concentrations was associated with higher LA volume indices, decreased contractile and reservoir functions during peak stress (p < .05). LA volume indices, LA EF, and filling index at rest could predict exercise-induced pulmonary hypertension (EIPH) (p < .05). CONCLUSIONS: In patients with primary MR and preserved LV EF, LA parameters are related to SPAP and NT-pro-BNP concentration. LA volume indices, LA EF and LA filling index are predictors of EIPH.

Surgical coronary angioplasty of both coronary ostia after chest radiotherapy. Is it good alternative to conventional coronary bypass surgery?

INTRODUCTION: Isolated coronary ostial stenosis of both ostia is a rare, potentially life-threatening condition, occurring in 0.1%-0.2% of patients undergoing coronary angiography. CASE REPORT: We present a case of a 69-year-old woman with a past medical history of breast cancer, who had been treated with radiotherapy, which most likely caused significant stenosis of both coronary ostia and likely accelerated aortic stenosis. Surgical angioplasty with autopericardium patch reconstruction of the left main coronary artery and right coronary arteries due to proximal stenotic disease was performed instead of venous or arterial bypasses with concomitant aortic valve replacement. The postoperative course was uneventful. There were no cardiovascular events 5 years after operation, and the patient remained free of any symptoms. CONCLUSIONS: Surgical coronary angioplasty offers an alternative to conventional coronary artery bypass grafting in isolated coronary ostial lesions and is advantageous in restoring more physiological myocardial perfusion, especially in those cases when conduits are suspected to be fibrotic, scarred or stenosed after radiation therapy or if there is the need to preserve conduits for future myocardial revascularisation in young patients.

Surgical dilemma - spare or replace regurgitant aortic valve: Late comparative outcomes of two strategies.

BACKGROUND: To evaluate different aortic root surgery techniques and their contemporary clinical outcomes in patients with regurgitant aortic valve and aortic root aneurysm. METHODS: The study consisted of 141 adult patients who underwent aortic valve reimplantation (David group = 73) or aortic valve replacement surgery (Bentall group = 68) for aortic valve regurgitation (AR) and dilatation of the aortic root at our institution within the same period (April 2004-October 2016). Kaplan-Meier method was used to estimate survival and other clinically relevant outcomes between the groups. RESULTS: The completeness of clinical follow-up was 100%, with a mean time of 8.0 ± 3.8 years. Thirty-day (in-hospital) mortality rates were equivalent between groups (1.3 and 1.5%, p = 1.0). The overall survival rates at 10 years were significantly better for the David group patients comparing to Bentall group patients (95.3 ± 2.6% vs 79.7 ± 6.8%; p = 0.04) with similar freedom from AV related reoperation (94.4 ± 2.7% vs 98.5 ± 1.5%; p = 0.2). Freedom from bleeding events at 10 years was 90.7 ± 3.6% for Bentall group patients and none were observed among David group patients (p = 0.01). CONCLUSIONS: Aortic valve and root surgery can be performed with equivalent safety and efficacy using either valve-sparing (David procedure) or valve-replacing (Bentall procedure) techniques in selected patients. Furthermore, patients after the David procedure demonstrated significantly improved survival and low risk of bleeding in comparison to the Bentall procedure with an acceptable risk of reoperation at 10 years follow-up.

Detection of TRPM6 and TRPM7 Proteins in Normal and Diseased Cardiac Atrial Tissue and Isolated Cardiomyocytes.

Magnesium-sensitive transient receptor potential melastatin (TRPM) ion channels, TRPM6 and TRPM7, are present in several organs, but their roles in the heart remain unclear. Therefore, here, we studied the expression patterns of TRPM6 and TRPM7 in normal and diseased myocardium. Cardiac atrial tissue and cardiomyocytes were obtained from healthy pigs and undiseased human hearts as well as from hearts of patients with ischemic heart disease (IHD) or atrial fibrillation (AF). Immunofluorescence and ELISA were used to detect TRP proteins. TRPM6 and TRPM7 immunofluorescence signals, localized at/near the cell surface or intracellularly, were detected in pig and human atrial tissues. The TRP channel modulators carvacrol (CAR, 100 µM) or 2-aminoethoxydiphenyl borate (2-APB, 500 µM) decreased the TRPM7 signal, but enhanced that of TRPM6. At a higher concentration (2 mM), 2-APB enhanced the signals of both proteins. TRPM6 and TRPM7 immunofluorescence signals and protein concentrations were increased in atrial cells and tissues from IHD or AF patients. TRPM6 and TRPM7 proteins were both detected in cardiac atrial tissue, with relatively similar subcellular localization, but distinctive drug sensitivity profiles. Their upregulated expression in IHD and AF suggests a possible role of the channels in cardiac atrial disease.

Evidence for the expression of TRPM6 and TRPM7 in cardiomyocytes from all four chamber walls of the human heart.

The expression of the channels-enzymes TRPM6 and TRPM7 in the human heart remains poorly defined, and TRPM6 is generally considered not to be expressed in cardiomyocytes. We examined their expression at protein and mRNA levels using right atrial samples resected from patients (n = 72) with or without ischemic heart disease (IHD) and samples from all chamber walls of explanted human hearts (n = 9). TRPM6 and TRPM7 proteins were detected using immunofluorescence on isolated cardiomyocytes, ELISA on tissue homogenates, and immunostaining of cardiac tissue, whereas their mRNAs were detected by RT-qPCR. Both TRPM6 and TRPM7 were present in all chamber walls, with TRPM7 being more abundant. TRPM6 was co-expressed with TRPM7. The expression levels were dependent on cell incubation conditions (presence or absence of divalent cations, pH of the extracellular milieu, presence of TRP channel inhibitors 2-aminoethoxydiphenyl-borate and carvacrol). These drugs reduced TRPM7 immunofluorescence but increased that of TRPM6. TRPM6 and TRPM7 expression was increased in tissues from IHD patients. This is the first demonstration of the presence and co-expression of TRPM6 and TRPM7 in cardiomyocytes from all chamber walls of the human heart. The increased TRPM6 and TRPM7 expression in IHD suggests that the chanzymes are involved in the pathophysiology of the disease.

Optical mapping of the pig heart in situ under artificial blood circulation.

The emergence of optical imaging has revolutionized the investigation of cardiac electrical activity and associated disorders in various cardiac pathologies. The electrical signals of the heart and the propagation pathways are crucial for elucidating the mechanisms of various cardiac pathological conditions, including arrhythmia. The synthesis of near-infrared voltage-sensitive dyes and the voltage sensitivity of the FDA-approved dye Cardiogreen have increased the importance of optical mapping (OM) as a prospective tool in clinical practice. We aimed to develop a method for the high-spatiotemporal-resolution OM of the large animal hearts in situ using di-4-ANBDQBS and Cardiogreen under patho/physiological conditions. OM was adapted to monitor cardiac electrical behaviour in an open-chest pig heart model with physiological or artificial blood circulation. We detail the methods and display the OM data obtained using di-4-ANBDQBS and Cardiogreen. Activation time, action potential duration, repolarization time and conduction velocity maps were constructed. The technique was applied to track cardiac electrical activity during regional ischaemia and arrhythmia. Our study is the first to apply high-spatiotemporal-resolution OM in the pig heart in situ to record cardiac electrical activity qualitatively under artificial blood perfusion. The use of an FDA-approved voltage-sensitive dye and artificial blood perfusion in a swine model, which is generally accepted as a valuable pre-clinical model, demonstrates the promise of OM for clinical application.

Predictors of early mortality after surgical treatment of infective endocarditis: a single-center experience.

OBJECTIVE: Surgical management of infective endocarditis continues to be challenging and is associated with significant morbidity and mortality. The objective of our study was to determine the risk factors and conditions associated with poor early infective endocarditis surgical treatment outcomes-30-day postoperative mortality. METHODS: A total of 124 patients who underwent surgery for infective endocarditis at the Hospital of Lithuanian University of Health Sciences Kaunas Clinics from January 2010 to December 2017 were retrospectively included in this study. The primary endpoints were 30-day postoperative mortality and identification of risk factors associated with it. Secondary endpoints were early postoperative outcomes and complication rates. RESULTS: During the study period, 124 patients with infective endocarditis underwent cardiac surgery, presenting an overall 30-day postoperative mortality rate of 10.48%. Mean age was 58 ± 14.4 years with 95 (76.61%) males. Independent predictive factors of early mortality were age >63 years (odds ratio = 6.4, 95% confidence interval = 1.66-24.66, p = 0.003), body mass index >30 kg/m² (odds ratio = 7.74, 95% confidence interval = 2.20-27.27, p = 0.003), and ischemic heart disease (odds ratio, 6.6, 95% confidence interval = 1.62-26.90, p = 0.003), as well as intraoperative parameters-prolonged aortic cross-clamp >84.5 minutes (odds ratio = 3.79, 95% confidence interval = 1.10-13.08, p = 0.03) and cardiopulmonary bypass time >107.5 minutes (odds ratio = 10.0, 95% confidence interval = 1.26-79.58, p = 0.023). Staphylococcus aureus infection (odds ratio = 5.04, 95% confidence interval = 1.29-19.64, p = 0.012), infective endocarditis-related intracardiac complication such as paravalvular abscess detected by transesophageal echocardiography (odds ratio = 4.32, 95% confidence interval = 1.31-14.25, p = 0.01), and infective endocarditis complicated by septic or cardiogenic shock (odds ratio, 18.43, 95% confidence interval = 4.59-73.98, p = 0.001) were statistically significant factors for increased risk of 30-day postoperative mortality. CONCLUSION: Surgical treatment of infective endocarditis showed good results in our center. The independent predictors of 30-day postoperative mortality for patients who underwent cardiac surgery for infective endocarditis were age, body mass index, ischemic heart disease, prolonged aortic cross-clamp and cardiopulmonary bypass time, Staphylococcus aureus infection, paravalvular abscess, and septic or cardiogenic shock.

Long-term outcomes and predictors of recurrent aortic regurgitation after aortic valve-sparing and reconstructive cusp surgery: a single centre experience.

BACKGROUND: Aortic valve sparing surgery (AVS), in combination with aortic cusp repair (ACR), still raises many questions about the increased surgical complexity and applicability for patients with pure aortic valve regurgitation (AR). The aim of this study was to investigate our long-term outcomes and predictors of recurrent AR (> 2+) after AVS and reconstructive cusp surgery. METHODS: We reviewed data of 81 patients who underwent AVS (a reimplantation technique) with concomitant ACR for AR and or dilatation of the aortic root at our institution during the period from April 2004 to October 2016. On preoperative echocardiography, the majority of the patients, 70 (86.4%) presented with severe AR grade (> 3+) and 28 (34.5%) of the patients had the bicuspid phenotype. Time to event analysis (long-term survival, freedom from reoperation, and recurrence of AR > 2+) was performed with the Kaplan-Meier method. Multivariate Cox regression risk analysis was performed to identify independent predictors of recurrent AR (> 2+). The mean follow-up was 5.3 ± 3.3 years and 100% complete. RESULTS: The in-hospital (30-day) mortality rate after elective surgery was 1.2%. The overall actuarial survival rates were 92.9 ± 3.1% and 90.4 ± 3.9% at five and 10 years, respectively. Actuarial freedom from recurrent AR (> 2+) was 83.7 ± 4.5% within the cohort at five and 10 years. The cumulative freedom from all causes of cardiac reoperation was 94.2 ± 2.8% within the cohort at 10 years. Neither bleeding nor thromboembolic or permanent neurologic events were reported during follow-up. By multivariate analysis, independent predictors of reccurent AR (> 2+) were an effective height lower than 9 mm (p= 0.02) and intraoperative residual mild AR (p= 0.0001). CONCLUSIONS: AVS with ACR, combined in a systematic fashion, is a safe and reproducible option with low risk of long-term valve related events and normal life expectancy for patients with pure aortic regurgitation. The competent aortic valve and effective height, not lower than 9 mm intraoperatively, are mandatory to achieve long-lasting AV competency.

Early and long-term results of aortic valve sparing aortic root reimplantation surgery for bicuspid and tricuspid aortic valves.

INTRODUCTION: To evaluate early and long-term clinical outcomes following aortic valve sparing aortic root reimplantation surgery in patients with leaking bicuspid and tricuspid aortic valves. METHODS: The study consisted of 92 consecutive adult patients (tricuspid aortic valve group = 63 and bicuspid aortic valve group = 29) who underwent aortic valve sparing aortic root reimplantation surgery with or without aortic cusp repair for dilatation of the aortic root and/or aortic valve regurgitation at our institution from April 2004 to October 2016. Clinical outcomes were investigated using Kaplan-Meier and log-rank tests between groups. RESULTS: The follow-up was 100% complete with a mean time of 5.3 ± 3.3 years. The 30-day in-hospital mortality was 3.1% in tricuspid aortic valve group and 3.4% in bicuspid aortic valve group patients. The overall survival rates at 10 years did not differ between bicuspid aortic valve and tricuspid aortic valve patient groups (96.6 ± 3.3% vs. 90.3 ± 4.2%, p = 0.3). Freedom from recurrent aortic valve regurgitation (>2+) at 10 years was 90.5 ± 4.1% in tricuspid aortic valve group and 75.7 ± 8.7% in bicuspid aortic valve group (p = 0.06). Freedom from aortic valve reoperation at 10 years was 100% in tricuspid aortic valve group and 83.9 ± 7.4% in bicuspid aortic valve group (p = 0.002). CONCLUSION: Aortic valve sparing aortic root reimplantation surgery is a safe and efficient technique, providing acceptable long-term survival with low rates of valve-related complications in both tricuspid aortic valve and bicuspid aortic valve patient groups. However, aortic valve reoperation rates at 10 years follow-up were higher in bicuspid aortic valve group patients compared to tricuspid aortic valve group patients.

Changes in right ventricular longitudinal function: primary mitral and concomitant tricuspid valve repair.

OBJECTIVES: To evaluate the impact of concomitant tricuspid valve (TV) repair on the right ventricular (RV) function postoperatively and within the 6 months following degenerative mitral valve (MV) repair. METHODS: The prospective study included 37 patients (mean age 57.32 ± 2.13 years) with severe MV regurgitation due to primary MV prolapse. Nineteen underwent successful MV repair (TV(-) group). Additional TV repair due to moderate-to-severe TV regurgitation was performed in 18 (TV(+) group). Two-dimensional (2D) speckle-tracking and tissue Doppler echocardiography was performed for all patients before surgery and 7 days and 6 months after surgery. RESULTS: Preoperative dimensions and indices of RV longitudinal function did not differ between the groups (right ventricle end-diastolic diameter (RVEDD) was 33.53 ± 0.94 mm vs. 34.67 ± 1.72 mm, tricuspid annular systolic motion (S') was 15.06 ± 0.85 cm/s vs. 16.0 ± 1.27 cm/s, tricuspid annular plane systolic excursion (TAPSE) was 24.02 ± 1.06 mm vs. 22.4 ± 1.36 mm, respectively; p>0.05). RVEDD decreased significantly and did not change within the follow-up in the TV(-) group. In the TV(+) group, RVEDD decreased early after surgery and more markedly six months later in comparison to the TV(-) group. Indices of RV systolic longitudinal function decreased early after surgery and had a tendency to increase after six months in both groups. Regional longitudinal strains of the lateral RV wall decreased early after surgery and improved within the six months in the TV(-) group and did not change significantly in the TV(+) group. CONCLUSIONS: Additional TV repair in degenerative MV repair more markedly reduces RV dimensions and does not have a negative impact on RV systolic function in comparison to an isolated MV repair although these conclusions are of limited value due to the lack of a control group.

Voltage-Sensitive Fluorescence of Indocyanine Green in the Heart.

So far, the optical mapping of cardiac electrical signals using voltage-sensitive fluorescent dyes has only been performed in experimental studies because these dyes are not yet approved for clinical use. It was recently reported that the well-known and widely used fluorescent dye indocyanine green (ICG), which has FDA approval, exhibits voltage sensitivity in various tissues, thus raising hopes that electrical activity could be optically mapped in the clinic. The aim of this study was to explore the possibility of using ICG to monitor cardiac electrical activity. Optical mapping experiments were performed on Langendorff rabbit hearts stained with ICG and perfused with electromechanical uncouplers. The residual contraction force and electrical action potentials were recorded simultaneously. Our research confirms that ICG is a voltage-sensitive dye with a dual-component (fast and slow) response to membrane potential changes. The fast component of the optical signal (OS) can have opposite polarities in different parts of the fluorescence spectrum. In contrast, the polarity of the slow component remains the same throughout the entire spectrum. Separating the OS into these components revealed two different voltage-sensitivity mechanisms for ICG. The fast component of the OS appears to be electrochromic in nature, whereas the slow component may arise from the redistribution of the dye molecules within or around the membrane. Both components quite accurately track the time of electrical signal propagation, but only the fast component is suitable for estimating the shape and duration of action potentials. Because ICG has voltage-sensitive properties in the entire heart, we suggest that it can be used to monitor cardiac electrical behavior in the clinic.

[Aortic root surgery: early postoperative results of different surgical techniques]. / Aortos saknies operacijos: skirtingu operaciniu metodiku ankstyvieji rezultatai.

UNLABELLED: The aim of the study was to evaluate early postoperative results of different surgical techniques of aortic root surgery. MATERIAL AND METHODS: Between January 2004 and November 2007, a cohort of 83 patients underwent aortic root surgery in the Heart Center, Hospital of Kaunas University of Medicine. Patients were divided into three groups: Group 1 (18 patients) - reimplantation of the aortic valve within a vascular graft (David operation), Group 2 (48 patients) - replacement of the ascending aorta and aortic valve using a valved conduit (Bentall de Bono operation), and Group 3 (17 patients) - biological aortic root replacement. Study protocol included clinical data, operative data, and postoperative major adverse effects: reoperations for bleeding, stroke and lethal outcomes. RESULTS: Patients undergoing biological aortic root replacement were older as compared with other groups. The mean age in the Group 1 was 50.3+/-3.5 years vs. 57+/-2.0 years in the Group 2 and 67.8+/-3.3 years in the Group 3 (P<0.05). The main indication for the aortic root surgery was the aneurysm of the aortic root and ascending aorta in the Group 1 and 2 patients (64.7% and 72%), while in the Group 3, the main indication was fibrocalcinosis of aortic valve, aortic annulus, and ascending aorta (61.1%). The 30-day hospital mortality rates were as follows: 5.8% (n=1), in the Group 1; 10.4% (n=5), in the Group 2; 5.5% (n=1), in the Group 3. In the early postoperative period, 11 reoperations were performed due to bleeding events: in the Group 1, after planned/emergency surgery (n=2/2), and in the Group 2 (n=1/6), respectively. The function of aortic valve improved significantly in all groups of patients early after surgery. In the Group 1, the degree of aortic regurgitation decreased from 2.5+/-0.8 to 1.1+/-0.6 (P<0.05); in the Groups 2 and 3, the mean gradient through the aortic valve decreased from 39.9+/-7.5 to 17.1+/-5.3 mm Hg and from 48.8+/-18.0 to 20.1+/-11.0 mm Hg, respectively (P<0.05). No reoperation for aortic valve failure before the discharge was required in all groups of patients, and neither thromboembolic complications nor stroke events were noted in any group. CONCLUSIONS: Different aortic root surgery techniques showed similar postoperative results. New aortic root surgery methods such as aortic root-preserving/sparing procedures and concurrent aortic valve leaflet repair or aortic root replacement with the bioprosthesis can be selected for a diverse class of aortic root pathology with low perioperative mortality rates and good early postoperative results.