The Prognostic Significance of Atrial Fibrillation and Left Atrium Size in Patients with Aortic Stenosis.

Aim    Aortic stenosis increases left atrial (LA) pressure and may lead to its remodeling. This can cause supraventricular arrhythmia. The aim of this study was to determine if the size of the LA and the presence of atrial fibrillation are related to the prognosis of patients with aortic stenosis.Material and methods    Clinical evaluation and standard transthoracic echocardiographic studies were performed in 397 patients with moderate to severe aortic stenosis.Results    In all patients, LA dimension above the median (≥43 mm) was associated with a significantly higher risk of death [HR 1.79 (CL 1.06-3.03)] and a LA volume above the median of 80 ml was associated with a significantly higher risk of death [HR 2.44 (CI 1.12-5.33)]. The presence of atrial fibrillation was significantly associated with a higher risk of death (p <0.0001). The presence of atrial fibrillation [HR 1.69 (CI 1.02-2.86)], lower left ventricular ejection fraction [HR 1.23 (CI 1.04-1.45)], higher NYHA heart failure class [HR 4.15 (CI 1.40-13.20)] and renal failure [HR 2.10 (CI 1.31-3.56)] were independent risk factors of death in patients in aortic stenosis.Conclusion    The size and volume of the LA and the occurrence of atrial fibrillation are important risk factors for death in patients with aortic stenosis. The presence of renal dysfunction, low left ventricular ejection fraction, high NYHA functional class and atrial fibrillation are independent risk factors of poor prognosis in patients with aortic stenosis.

18F-fluorodeoxyglucose and 18F-sodium fluoride positron emission tomography imaging in assessing early stages of aortic valve degeneration after transcatheter aortic valve implantation.

INTRODUCTION: Transcatheter aortic valve implantation (TAVI) is a standard treatment for severe aortic stenosis, primarily in elderly patients. With an increasing number of procedures and younger patients, understanding the valve degeneration and its risk factors becomes crucial. OBJECTIVES: We aimed to utilize 18F­sodium fluoride (18F­NaF) and 18F­fluorodeoxyglucose (18F­FDG) positron emission tomography/computed tomography (PET/CT) to evaluate early TAVI valve degeneration. PATIENTS AND METHODS: In this prospective study with a prespecified follow­up protocol, 71 TAVI patients underwent baseline transthoracic and transesophageal echocardiography, and PET/CT with 18F­NaF and 18F­FDG. Of these, 31 patients completed 24­month control examinations, while the others were lost to mortality and the COVID­19 pandemic. We measured PET tracer activity and compared 18F­NaF and 18F­FDG PET/CT uptake at baseline and 24­month follow­up. RESULTS: PET/CT and echocardiography data were analyzed for 31 of the 71 enrolled TAVI patients at a median age of 84 years (interquartile range, 80-86). After TAVI, an improvement in the valve function was observed. During follow­up, the valve function remained stable. PET/CT demonstrated an increase in 18F­FDG maximal uptake in the inner (tissue­to­background ratio, P = 0.009) and outer (P = 0.01) sides of the TAVI valve stent, but no difference in 18F­NaF maximal activity (inner, P = 0.17; outer, P = 0.57). CONCLUSIONS: Twenty­four months post­TAVI, an increase in 18F­FDG uptake, indicative of inflammation, was observed in the valve, while the uptake of the calcification marker (18F­NaF) remained stable. Theseobservations might suggest early stages of TAVI valve degeneration, although further investigation is required to confirm this interpretation.

Hemodynamic parameters of aortic valve prostheses - KRAK-AS registry analysis.

Introduction: The treatment of choice for aortic stenosis is a valve replacement. Some patients have post-procedural increased pressure gradient on the implanted prosthesis because of patient-prosthesis mismatch (PPM), known to adversely influence prognosis. The PPM risk should be initially predicted and effort made to avoid this complication, specifically in large body size patients. Aim: To assess the frequency of PPM taking into account the valvular prosthesis type in a real-life population of consecutive patients included in the Krakow aortic stenosis registry. Material and methods: The KRAK-AS registry was conducted in July-October 2016. Patients were assessed before and after valve surgery and during the 3-year follow-up. Patients who underwent aortic valve intervention were clinically and echocardiographically evaluated within a month after surgery and divided into groups depending on the implanted prosthesis type. Analysis of patients with a smaller (< 23 mm) and larger than median (≥ 23 mm) valve diameter was performed. Results: The valve implantation was performed in 229 patients (42 mechanical, 139 biological, 48 transcatheter). No differences between patient groups compared by PPM occurrence was seen at baseline. Median age was 70 years; 55.5% were men. At least moderate PPM (iEOA ≤ 0.85 cm2/m2) was observed in 40% of mechanical valves, 33% of biological valves, and was significantly less frequent (10%) in patients after transcatheter valve implantation, p = 0.0001. Severe PPM (iEOA < 0.65 cm2/m2) was found in 17.6% of mechanical valve PPM patients, 4.3% of biological ones, and no patients after transcatheter procedure. Conclusions: PPM is a frequent phenomenon in the real-life population of patients undergoing surgical aortic valve replacement, being significantly less frequent in the case of a transcatheter procedure.

Computed tomography and transthoracic echocardiography for assessment of left ventricle geometry in patients with aortic valve stenosis.

Introduction: Standard transthoracic echocardiography (TTE) often is not sufficient to properly visualize the geometry of the left ventricle. One of the clinical imaging modalities that can be used for this purpose is contrast-enhanced, electrocardiologically gated cardiac computed tomography (CT). Aim: To compare cardiac CT and TTE as tools for assessing geometry and function of the left ventricle in patients with severe aortic stenosis. Material and methods: We analyzed 58 consecutive patients (43.1% males, mean age 81.4 ±6.0 years) with severe aortic stenosis, who underwent both cardiac CT and TTE. Results: Left ventricle major axis length is significantly longer in CT than in TTE (81.5 ±11.7 mm vs. 74.6 ±13.5 mm, p = 0.004). No difference was found in end-systolic left ventricle volume between the two imaging methods, while end-diastolic volume of the left ventricle was significantly larger when measured in CT than in both 2D biplane and 3D triplane TTE. The stroke volume was not different between the 2D biplane TTE and CT. No significant difference was found between CT and TTE in the calculation of ejection fraction and LV mass/indexed LV mass (p > 0.05). Conclusions: The use of three-dimensional postprocessing provides a very accurate image of heart structures in CT, which in some aspects may significantly differ from the values estimated by TTE.

Safety and efficacy of repeated balloon aortic valvuloplasty in patients with symptomatic severe aortic stenosis.

BACKGROUND: Long-term outcomes of balloon aortic valvuloplasty (BAV) in patients with severe symptomatic aortic stenosis (AS) are poor, and this procedure needs to be repeated in selected cases. AIMS: We aimed to investigate the safety and efficacy of repeated BAV (reBAV). METHODS: We included consecutive patients who underwent reBAV in three Polish centers between 2010 and 2019. Baseline clinical, echocardiographic, procedural, and outcome data were analyzed. RESULTS: Thirty-five patients (median age 81.5 years, 57.1% women) who underwent reBAV were enrolled. In 42.9% of the patients, index BAV was considered a palliative treatment, and in 54.3% a bridge to definitive treatment. Index BAV decreased peak aortic valve gradient (pAVG) from a median of 78.0 mm Hg to 46.0 mm Hg (P <0.001). After a mean of 255.8 days, reBAV was performed. In most cases (71.4%), the reason for reBAV was the worsening of heart failure symptoms and in 54.3% of patients, reBAV was still considered a palliative option. A decrease in pAVG max from a median of 73.0 mm Hg to 45.0 mm Hg (P <0.001), comparable to index BAV, was observed. The frequency of complications were numerically higher for repeated procedures. During the median (IQR) follow-up of 403.0 (152.0-787.0) days from the index procedure, 80.0% of the patients died. CONCLUSIONS: Acute hemodynamic results of reBAV are comparable to those achieved during index BAV. However, reBAV may carry an increased risk of complications. Moreover, mortality is high due to unfavorable risk profiles or delays in receiving definitive therapy.

Mid-regional pro-adrenomedullin and lactate dehydrogenase as predictors of left ventricular remodeling in patients with myocardial infarction treated with percutaneous coronary intervention.

INTRODUCTION: The main impact of myocardial infarction (MI) is shifting from acute mortality to adverse remodeling, chronic left ventricular (LV) dysfunction, and heart failure. OBJECTIVES: The aim of this study was to assess relationships between levels of circulating biomarkers and the function of LV after MI. PATIENTS AND METHODS: This was a prospective study of 80 patients with MI treated with percutaneous coronary intervention. Novel biomarkers including mid­regional pro­adrenomedullin (MR­proADM), Notch­1, syndecan­4, myeloperoxidase, S­100 protein, soluble ST­2, as well as markers of inflammatory response and tissue injury: galectin­3, C­reactive protein (CRP), lactate dehydrogenase (LDH), and interleukin­6 (IL­6) were assessed in the acute phase of MI. Echocardiography was performed at baseline and 6 month Results: Adverse remodeling, defined as more than 20% increase in LV end­diastolic volume, occurred in 26% of patients. Reverse remodeling (>10% reduction in LV end­systolic volume) was observed in 52% of patients. In the univariable analysis, higher levels of MR­proADM and LDH were predictors of adverse remodeling and higher levels of MR ­proADM, LDH, CRP, and IL ­6 were negative predictors of reverse remodeling. In the multivariable model, LDH remained an independent predictor of adverse remodeling (odds ratio [OR], 3.13; 95% CI, 1.42-8.18; P = 0.003) and a negative predictor of reverse remodeling (OR, 0.37; 95% CI, 0.17-0.8; P = 0.005). CONCLUSIONS: LDH and MR ­proADM seem to be promising biomarkers of adverse remodeling. On the other hand, higher levels of these biomarkers were associated with reduced chance of occurrence of favorable reverse remodeling in MI patients. However, further studies on larger groups of patients are necessary to confirm these data.

Balloon aortic valvuloplasty for severe aortic stenosis may reduce mitral regurgitation in mid-term follow-up.

Introduction: Mitral regurgitation (MR) is a frequent complication in patients with severe aortic stenosis (AS). Material and methods: Echocardiographic assessment of MR was performed at baseline, at 30 days and at 6 months after balloon aortic valvuloplasty (BAV). Results: Data of 271 patients were included in our final analysis, of which 21.2% (n = 85) had at least moderate MR at baseline (in 19 (22.3%) subjects MR was diagnosed as primary). Both groups showed similar severity of AS, but patients in the MR group had a greater left ventricle (LV) size (p = 0.003 for LVESD, p = 0002 for LVEDD) and slightly lower LV ejection fraction (p = 0.04). Mitral regurgitation parameters significantly improved both at 30 days and 6 months after BAV in the MR group (MR jet area: 7.2 (4.5-9.9) vs. 3.6 (2.3-7.2) cm2, and 7.2 (4.5-9.9) vs. 3.2 (2.1-6.7) cm2; %MR/left atrial area 34.5 (23.4-42.7) vs. 17.5 (9.3-29.5) and 34.5 (23.4-42.7) vs. 14.5 (8.3-24.5), p < 0.001 for all). In multivariate logistic regression analysis, the change at 30 days, from baseline, in the LVESD (OR = 1.87; 95% CI: 1.23-2.87; p < 0.001) and LVEF (OR = 0.95; 95% CI: 0.87-1.01; p < 0.001); MR jet area (OR = 2.2, 95% CI: 1.5-4.6; p < 0.001) and the presence of primary MR (OR = 3.2, 95% CI: 1.04-5.98; p < 0.001) were retained as independent predictors of significant persisting MR at 6 months. Conclusions: Balloon aortic valvuloplasty may reduce MR in mid-term follow-up. Predictors of persistent MR at 6 months after BAV included an increase of LVESD and MR jet area and decrease of LVEF at 30 days.

Balloon Aortic Valvuloplasty for Severe Aortic Stenosis as Rescue or Bridge Therapy.

The study aimed to assess procedural complications, patient flow and clinical outcomes after balloon aortic valvuloplasty (BAV) as rescue or bridge therapy, based on data from our registry. A total of 382 BAVs in 374 patients was performed. The main primary indication for BAV was a bridge for TAVI (n = 185, 49.4%). Other indications included a bridge for AVR (n = 26, 6.9%) and rescue procedure in hemodynamically unstable patients (n = 139, 37.2%). The mortality rate at 30 days, 6 and 12 months was 10.4%, 21.6%, 28.3%, respectively. In rescue patients, the death rate raised to 66.9% at 12 months. A significant improvement in symptoms was confirmed after BAV, after 30 days, 6 months, and in survivors after 1 year (p < 0.05 for all). Independent predictors of 12-month mortality were baseline STS score [HR (95% CI) 1.42 (1.34 to 2.88), p < 0.0001], baseline LVEF <20% [HR (95% CI) 1.89 (1.55-2.83), p < 0.0001] and LVEF <30% at 1 month [HR (95% CI) 1.97 (1.62-3.67), p < 0.0001] adjusted for age/gender. In everyday clinical practice in the TAVI era, there are still clinical indications to BAV a standalone procedure as a bridge to surgery, TAVI or for urgent high risk non-cardiac surgical procedures. Patients may improve clinically after BAV with LV function recovery, allowing to perform final therapy, within limited time window, for severe AS which ameliorates long-term outcomes. On the other hand, in patients for whom an isolated BAV becomes a destination therapy, prognosis is extremely poor.

Patent Foramen Ovale Channel Morphometric Characteristics Associated with Cryptogenic Stroke: The MorPFO Score.

BACKGROUND: It is still disputable whether the specific morphologic properties of patent foramen ovale (PFO) may contribute to the occurrence of stroke. The aim of this study was to evaluate the differences in the morphometric and functional features of the PFO channel in patients with cryptogenic stroke and those without stroke. METHODS: PFO channel morphology in 106 consecutive patients with cryptogenic stroke and 93 control patients without stroke with diagnosed PFO (by transesophageal echocardiography) was analyzed using transesophageal echocardiography. A validation cohort was established that consisted of 31 patients with cryptogenic stroke and 30 without stroke. RESULTS: Multivariable regression logistic analyses indicated PFO channel length change (odds ratio [OR], 2.50; 95% confidence interval [CI], 1.75-3.55; P < .001), PFO length/height ratio during the Valsalva maneuver (OR, 0.75; 95% CI, 0.60-0.95; P = .015), septum primum thickness (OR, 0.34; 95% CI, 0.14-0.80; P = .013), septum secundum height (OR, 0.91; 95% CI, 0.84-0.98; P = .013), the presence of an atrial septal aneurysm (OR, 3.38; 95% CI, 1.27-8.97; P = .014), and large shunt (OR, 2.49; 95% CI, 1.13-5.46; P = .022) as PFO-related stroke factors. The Morphologic Stroke Factors of PFO (MorPFO) score was developed, in which six factors were included: PFO channel length reduction (≥21%; 7 points), short septum secundum (<8.6 mm; 5 points), thin septum primum (<1.6 mm; 3 points), large right-to-left shunt (3 points), low PFO channel length/height ratio during the Valsalva maneuver (≤2.1; 2 points), and atrial septal aneurysm presence (1 point). Patients with scores of 0 to 7 points have low-risk PFO channels, those with scores of 8 to 11 points have intermediate-risk PFO channels, and those with scores of 12 to 21 points have high-risk PFO channels. External validation showed good MorPFO score performance (C index = 0.90). CONCLUSIONS: Transesophageal echocardiography can be used to differentiate pathogenic from incidental PFO channels on the basis of their morphologic characteristics. The MorPFO score may help identify high-stroke-risk PFO channels.

Polish Multicenter Registry (Pol-LAS-SE registry). Stress echocardiography in low-gradient aortic stenosis in Poland: numbers, settings, results, complications and clinical practice.

BACKGROUND: The diagnostic workup of low-gradient aortic stenosis (LG AS) is a challenge in clinical practice. AIMS: Our goal was to assess the diagnostic value of stress echocardiography (SE) performed in patients with undefined LG AS with low and preserved ejection fraction (EF) and the impact of its result on therapeutic decisions in Polish third level of reference. METHODS: All the patients with LG AS and with SE performed were recruited in 16 Polish cardiology departments between 2016 and 2019. The main exclusion criteria were as follows: moderate or severe aortic or mitral regurgitation and mitral stenosis. RESULTS: The study group included 163 patients (52% males) with LG AS who underwent SE for adequate diagnostic and therapeutic decision. In 14 patients DSE was non-diagnostic. The mean aortic valve (AV) pressure gradient was 24.1 (7.3) mm Hg, while an AV area was 0.86 (0.2) cm2. Among 149 patients with conclusive DSE, severe AS was found in 59.8%, pseudo-severe in 22%, and moderate AS in 18%. There were no cases of death or vascular events related to DSE. Among 142 patients 63 (44%) patients had an aortic valve intervention in a follow-up (median: 208 days; lower-upper quartile: 73-531 days). Based on the result of the DSE test, severe AS was significantly more often associated with qualification to interventional treatment compared to the moderate and pseudo-severe subgroups (P <0.0001). CONCLUSIONS: The DSE test in severe AS is a valuable diagnostic tool in patients with LG AS in Poland.

Echocardiography during the coronavirus disease 2019 pandemic - the impact of the vaccination program. A 2021 update of the expert opinion of the Working Group on Echocardiography of the Polish Cardiac Society.

The coronavirus disease 2019 (COVID-19) pandemic resulted in an urgent need to reorganize the work of echocardiography laboratories in order to ensure the safety of patients and the protection of physicians, technicians, and other staff members. In the previous Expert Opinion of the Working Group on Echocardiography of Polish Cardiac Society we provided recommendations for the echocardiographic services, in order to ensure maximum possible safety and efficiency of imagers facing epidemic threat. Now, with much better knowledge and larger experience in treating COVID-19 patients and with introduction of vaccination programs, we present updated recommendations for performing transthoracic and transesophageal examinations, including information on the potential impact of personnel and the patient vaccination program, and growing numbers of convalescents on performance of echocardiographic laboratories, with the goal of their ultimate reopening.

The Usefulness of [18F]F-Fluorodeoxyglucose and [18F]F-Sodium Fluoride Positron Emission Tomography Imaging in the Assessment of Early-Stage Aortic Valve Degeneration after Transcatheter Aortic Valve Implantation (TAVI)-Protocol Description and Preliminary Results.

Transcatheter aortic valve implantation (TAVI) is now a well-established treatment for severe aortic stenosis. As the number of procedures and indications increase, the age of patients decreases. However, their durability and factors accelerating the process of degeneration are not well-known. The aim of the study was to verify the possibility of using [18F]F-sodium fluoride ([18F]F-NaF) and [18F]F-fluorodeoxyglucose ([18F]F-FDG) positron emission tomography/computed tomography (PET/CT) in assessing the intensity of TAVI valve degenerative processes. In 73 TAVI patients, transthoracic echocardiography (TTE) at initial (before TAVI), baseline (after TAVI), and during follow-up, as well as transesophageal echocardiography (TEE) and PET/CT, were performed using [18F]F-NaF and [18F]F-FDG at the six-month follow-up (FU) visit as a part of a two-year FU period. The morphology of TAVI valve leaflets were assessed in TEE, transvalvular gradients and effective orifice area (EOA) in TTE. Calcium scores and PET tracer activity were counted. We assessed the relationship between [18F]F-NaF and [18F]F-FDG PET/CT uptake at the 6 = month FU with selected indices e.g.,: transvalvular gradient, valve type, EOA and insufficiency grade at following time points after the TAVI procedure. We present the preliminary PET/CT ([18F]F-NaF, [18F]F-FDG) results at the six-month follow-up period as are part of an ongoing study, which will last two years FU. We enrolled 73 TAVI patients with the mean age of 82.49 ± 7.11 years. A significant decrease in transvalvular gradient and increase of effective orifice area and left ventricle ejection fraction were observed. At six months, FU valve thrombosis was diagnosed in four patients, while 7.6% of patients refused planned controls due to the COVID-19 pandemic. We noticed significant correlations between valve types, EOA and transaortic valve gradients, as well as [18F]F-NaF and [18F]F-FDG uptake in PET/CT. PET/CT imaging with the use of [18F]F-FDG and [18F]F-NaF is intended to be feasible, and it practically allows the standardized uptake value (SUV) to differentiate the area containing the TAVI leaflets from the SUV directly adjacent to the ring calcifications and the calcified native leaflets. This could become the seed for future detection and evaluation capabilities regarding the progression of even early degenerative lesions to the TAVI valve, expressed as local leaflet inflammation and microcalcifications.

Percutaneous closure of atrial septal defect: a consensus document of the joint group of experts from the Association of Cardiovascular Interventions and the Grown-Up Congenital Heart Disease Section of the Polish Cardiac Society.

Atrial septal defect is the most common congenital heart lesion in adults. Although atrial septal defect closure is recommended in those with right heart enlargement or paradoxical embolism, data informing such indications in adults are quite limited. This population has many unique characteristics and needs. In recent years, significant progress has been made with regard to diagnostic modalities that facilitate the diagnostic workup of these patients. However, the decision­making process, especially in selected adult patients population (advanced age, various concomitant diseases, poor LV function [both systolic and diastolic], pulmonary hypertension, concomitant arrhythmias or multiple defects, or deficient rims) is still not easy. Available data are predominantly focused on imaging endpoints and short­term morbidity and mortality rather than long­­term. The evidence base for outcomes with or without defect closure comes from various studies with different observation periods. Moreover, the clinical experience in diagnosing and treating that subgroup of patients is inhomogeneous between individual physicians (cardiologists, imaging specialists, operators) and between small and large experience centers. In the view of the above, the joint group of experts from the Association of Cardiovascular Interventions and the Grown­Up Congenital Heart Disease Section of the Polish Cardiac Society developed the following consensus opinion in order to standardize the principles of diagnosis, indications for treatment, methods of performing procedures, and tenets of postoperative care in Poland.

Early results of the ongoing Polish Registry of Valve Thrombosis after Transcatheter Aortic Valve Implantation (ZAK­POLTAVI).

BACKGROUND: Conflicting data exist regarding the risk factors for transcatheter heart valve thrombosis (THVT). In addition, no optimal pharmacological strategy to treat THVT has been established so far Aims: The aim of this study was to assess the incidence, risk factors, diagnostic workup, and treatment of THVT in Poland. METHODS: Data were collected retrospectively in themulticenter registry of patients with THVT (ZAK­POLTAVI) between November 2008 and November 2018. Transcatheter heart valve thrombosis was defined as an increased mean transvalvular gradient accompanied by a decreased effective orifice area or severe aortic regurgitation, reversible after treatment. Baseline characteristics and procedural data were compared between patients with THVT and those without THVT (matched by age, sex, and diabetic status). RESULTS: In a group of 2307 patients undergoing transcatheter aortic valve implantation (TAVI), 26 patients with THVT were identified (incidence, 1.14%). In half of the patients, THVT was diagnosed within 6 months after TAVI. As compared with the control group, patients with THVT more frequently had chronic obstructive pulmonary disease (P = 0.035), a smaller aortic valve area (P = 0.007), a higher mean postprocedural transvalvular gradient (P = 0.037), and a lower platelet count (P = 0.029) at the time of the diagnosis. A total of 24 patients (84.6%) received anticoagulation therapy for THVT, and complete resolution of THVT was noted in 12 individuals (46.1%). We observed thromboembolic complications in 2 patients (7.7%). CONCLUSIONS: Transcatheter heart valve thrombosis is a rare complication of TAVI. However, a higher risk of THVT may be expected in patients with chronic obstructive pulmonary disease, a smaller aortic valve area, a higher mean postprocedural transvalvular gradient, and a lower platelet count. Anticoagulation alone or combined with antiplatelet therapy seems to be the optimal pharmacological treatment in this population.