Analysis of complications in transfemoral transcatheter aortic valve implantation: a single-center study.

INTRODUCTION: Transfemoral access is a prevailing approach for transcatheter aortic valve implantation (TAVI) in contemporary practice, with a shift from surgical arteriotomy to a percutaneous arterial approach. OBJECTIVES: This study assessed long- and short­term mortality, along with Valve Academic Research Consortium-2-defined complications in percutaneous transfemoral approach (PTA) TAVI. Furthermore, it explored the impact of a learning curve on procedural outcomes. PATIENTS AND METHODS: The study included 600 patients undergoing PTA TAVI at the National Institute of Cardiology, Warsaw, Poland, from January 2009 to September 2020. Retrospective data comparison involved 2 groups: early experience (first 200 patients) and late experience (next 400 patients). RESULTS: The primary end point (composite of life­threatening bleeding, major vascular complication, or death at 30 days) occurred less often in the late experience group (28% vs 17.5%; P = 0.003). The late experience group also showed fewer cases of vascular complications (19% vs 10.7%; P = 0.005) and major bleeding (17.5% vs 8.5%; P = 0.001). Propensity matching yielded similar trends, including reduced frequency of pacemaker implantation (22.8% vs 10.9%; P = 0.03) and shorter median (interquartile range) hospitalization (11 [8-18] vs 7 [6-12] days; P <0.001) in the late experience group. CONCLUSIONS: The late experience group rated with PTA TAVI exhibited significantly reduced periprocedural complications, indicating a positive impact of accumulated expertise.

Hyaluronic Acid-Alginate Homogeneous Structures with Polylactide Coating Applied in Controlled Antibiotic Release.

The use of a controlled-release drug carrier is an innovative solution for the treatment of local infections, in particular in dentistry, skin diseases, and in open wounds. The biocompatibility, biodegradability, the possibility of a large amount of drug adsorbed (especially those with hydrophilic properties), and the ability to create structures of any shape and size are the reasons for hydrogels to be frequently studied. The main disadvantage of hydrogel carriers is the rapid rate of drug release; hence, in this study, an attempt was made to additionally chemically cross-link 1-ethyl-3-(3-dimethyl aminopropyl)-1-carbodiimide hydrochloride (EDC) with the hyaluronic acid-alginate (HA-SAL) structure. The answer to significantly reduce the mass flux typical for hydrogel structure was to surround it with a polymer layer using a dry cover. By coating the carriers with polylactide, the release time was increased by around forty times. As the carriers were designed to reduce local bacterial infections, among others in dentistry, the released antibiotics were amoxycillin, metronidazole, and doxycycline.

Patterns of changes in functional and neurocognitive status in elderly patients after transcatheter vs. surgical aortic valve replacements.

BACKGROUND: Replacement of severely stenotic aortic valve may influence cognitive and physical functioning. The aim of this study was to compare cognitive and functional status after surgical (SAVR) vs. transcatheter aortic valve replacements (TAVR) in the elderly with severe aortic stenosis (AS). METHODS: It was a prospective observational study with over 6 months of follow-up. Eighty ≥70-year-old patients with AS underwent TAVR (N.=40) or SAVR (N.=40). Mini Mental State Exam (MMSE), activities daily living (ADL) score and instrumental activities daily living (IADL) score were used to assess the cognitive status, fundamental functioning and complex independent living skills, respectively. The tests were conducted at baseline and 6 months after the procedure. Additionally, MMSE was carried out at discharge. RESULTS: Baseline MMSE score was lower in the TAVR vs. SAVR group (P=0.001). In the SAVR group, there was a transient in-hospital decline in mean MMSE score (P=0.020), absent in the TAVR group. Baseline ADL and IADL scores were lower in TAVR patients. Both groups experienced mild improvement. The average increase among those with improved IADL score was larger after TAVR (2.37 vs. 1.37 after SAVR; P=0.029). A systolic blood pressure (SBP) decrease <60 mmHg as well as larger periprocedural shift in SBP (expressed by a difference between maximum and minimum SBP) during TAVR were associated with the decline in the ADL (P=0.001) and IADL scores (P=0.043). CONCLUSIONS: Cognitive patterns differed between the TAVR and SAVR patients. A transient MMSE decline did not alter the 6-month status. TAVR might improve functionality. Periprocedural SBP decrease and larger changes in SBP are risk factors for functionality deterioration after TAVR.

Serum beta-2 microglobulin levels for predicting acute kidney injury complicating aortic valve replacement.

OBJECTIVES: Acute kidney injury complicating both transcatheter and surgical aortic valve replacement is associated with high rates of morbidity and mortality. The aim of this study was to investigate the role of serum beta 2 (ß2) microglobulin, cystatin C and neutrophil gelatinase-associated lipocalin levels in detecting periprocedural acute kidney injury. METHODS: Eighty consecutive patients who were 70 years of age or older and who were having surgical (n = 40) or transcatheter (n = 40) aortic valve replacement were recruited in a prospective study. The biomarkers were tested before the procedure, 6 times afterwards, at discharge and at a 6-month follow-up visit. RESULTS: The baseline ß2-microglobulin level was the strongest predictor of acute kidney injury as a complication of transcatheter aortic valve replacement [odds ratio (OR) 5.277, P = 0.009]. Its level 24 h after the procedure reached the largest area under the curve (AUC) of 0.880 (P < 0.001) for detecting acute kidney injury. In multivariate logistic regression analysis, the levels of ß2-microglobulin and cystatin C 24 h after the procedure were significantly associated with acute kidney injury after transcatheter valve replacement (OR 38.15, P = 0.044; OR 1782, P = 0.019, respectively). In the surgical aortic valve replacement group, the highest AUCs belonged to ß2-microglobulin and cystatin C at 24 h (AUC = 0.808, P = 0.003 and AUC = 0.854, P = 0.001, respectively). Their higher values were also associated with acute kidney injury (OR 17.2, P = 0.018; OR 965.6, P = 0.02, respectively). A persistent increase in the postoperative levels of ß2-microglobulin following acute kidney injury was associated with the progression of chronic kidney disease for 6 months after both transcatheter (OR 6.56, P = 0.030) and surgical (OR 7.67, P = 0.03) aortic valve replacements. CONCLUSIONS: Serum ß2-microglobulin had the potential to predict acute kidney injury complicating transcatheter valve replacement and to diagnose it as early as 24 h after both the transcatheter and the surgical procedures. Furthermore, the serum level of ß2-microglobulin was indicative of the progression of chronic kidney disease.

Role of ß2-microglobulin in postoperative cognitive decline.

AIM: ß2-microglobulin (ß2M) was proved to affect hippocampal functions in mice. MATERIALS & METHODS: Seventy-one patients undergoing aortic valve replacement were analyzed in prospective observational study. Kidney biomarkers and Mini Mental State Examinations (MMSEs) were performed before procedure, at discharge and after 6 months. RESULTS: Patients with ß2M increase over the median change (>0.42 mg/l) experienced a significant in-hospital drop in MMSE (p = 0.005). Patients with ß2M increase over the median change also failed to improve a delayed-word-recall domain of the test (p = 0.826) while patients with a lower increase improved results in the domain (p = 0.004). After 6 months, MMSE improvement was associated with a significant decrease in ß2M (p = 0.042). CONCLUSION: These are the first in man data demonstrating relation between changes in cognition and ß2M. The phenomenon was reversible which indicates its therapeutic potential.

Effects of an immunosuppressive treatment on the rat prostate.

The aim of this study was to determine the influence of different combinations of immunosuppressive drugs on the morphology, ultrastructure, and expression of proliferating cell nuclear antigen and cytoskeleton proteins in the rat dorsolateral prostate. The studies were conducted on 48 male Wistar rats. The animals were divided into eight groups: a control group and seven experimental groups. For 6 months, the animals in the experimental groups were administered a combination of drugs including rapamycin (Rapa), cyclosporin A, tacrolimus (Tac), mycophenolate mofetil, and prednisone (Pred), according to the standard three-drug regimens for immunosuppressive therapy used in clinical practice. An evaluation of the morphology and ultrastructure was conducted, and a quantitative evaluation of the expression of proliferating cell nuclear antigen and desmin- and cytokeratin-positive cells with weak, moderate, and strong expression was performed. The combination of Rapa, Tac, and Pred caused the smallest morphological and ultrastructural changes in the rat prostate cells. In the case of rats whose treatment was switched to Rapa monotherapy, a decreased percentage of proliferating cells of both the glandular epithelium and the stroma was found. Decreases in body weight and changes in the expression of cytokeratin and desmin were observed in all the experimental rats. The combination of Rapa, Tac, and Pred would seem to be the most beneficial for patients who do not suffer from prostate diseases. Our results justify the use of inhibitors of the mammalian target of Rapa in the treatment of patients with prostate cancer. The changes in the expression of cytoskeleton proteins may be the result of direct adverse effects of the immunosuppressive drugs, which are studied in this article, on the structure and organization of intermediate filament proteins.

[Central nervous system embolism in the course of infective endocarditis]. / Zatorowosc osrodkowego ukladu nerwowego jako powiklanie infekcyjnego zapalenia wsierdzia.

Despite the progress made in diagnosis and treatment of heart valve diseases, the incidence of infective endocarditis (IE) remains constant. It is still associated with high mortality and high rate of embolic complications, including most dangerous one, i.e. stroke. It has a significant impact on further treatment and qualifications for cardiac surgery. In this paper, the authors discuss the epidemiology, mechanisms of stroke and its impact on the qualifications for cardiac surgery. The authors discuss the problem of clinically silent central nervous system embolism in the course of IE and the usefulness of neuroimaging and markers of central nervous system damage in diagnosis of cerebral embolism.

Factors affecting long-term survival after aortic valve replacement.

BACKGROUND AND AIM: To evaluate long-term outcomes of surgical aortic valve replacement (AVR) due to significant aortic stenosis (AS) and assess changes in factors affecting survival during a 10-year period in patients referred for surgery from a single centre. METHODS: We evaluated 1143 patients (478 women, 665 men; mean age 61 ± 5 years) treated in the Department of Valvular Heart Disease at the Institute of Cardiology in Warsaw who were referred for AVR due to significant AS in 1998-2008 and survived the surgery and the initial 30-day postoperative period. We assessed long-term survival in relation to preoperative parameters including demographic data (age, gender), clinical variables (New York Heart Association [NYHA] class, presence of a significant coronary artery stenosis, arterial hypertension, reduced left ventricular ejection fraction [LVEF]), and operative parameters (prosthetic valve type: biological vs. mechanical, and the type of the surgery: isolated AVR vs. AVR combined with coronary artery bypass grafting). RESULTS: Ten-year survival was worse in men compared to women (p = 0.001), with the effect of gender gradually decreasing after 3 years of follow-up. Factors affecting long-term survival included age (p = 0.0001) and NYHA class (p = 0.005) in women, and age (p = 0.0001), NYHA class (p = 0.0001), arterial hypertension (p = 0.01), reduced LVEF (p = 0.03), and the presence of significant coronary artery stenoses (p = 0.0001) in men. Evaluation of factors affecting 1-, 3-, 5-, and 7-year survival showed their variability mostly in men. CONCLUSIONS: Long-term surgical outcomes in patients with significant AS are very good, with better survival in women compared to men, although these differences attenuated after 3 years. Factors affecting 10-year survival are different in women and men: a significant effect in women was noted only for age and preoperative NYHA class, while in men for age, NYHA class, hypertension, reduced LVEF, and the presence of significant coronary artery stenoses. During 10-year follow-up, longitudinal changes can be noted in factors affecting survival after AVR.

Percutaneous closure of prosthetic paravalvular leaks.

Paravalvular leaks (PVLs) are relatively common after valve replacement. These leaks are usually small and disappear during the follow-up. Symptomatic PVLs occur in 1% to 2% of patients undergoing valve replacement. PVLs causing clinical consequences require surgical intervention. Surgery is considered the gold standard of dehiscence repair. In recent years, the use of percutaneous closure devices for closing PVLs has been proposed as an alternative to surgery. Such techniques are less invasive and can be used in most high-risk patients instead of performing repeat surgery. This article describes how to assess the leak as well as the technical aspects of the procedure.

Rare complication after mitral valve replacement due to infective endocarditis.

A 27-year-old woman who had undergone mitral valve replacement for infective endocarditis developed a significant paravalvular leak. Percutaneous transcatheter obliteration of the defect using an Amplatzer Vascular Plug III was undertaken, with an excellent clinical outcome.

Rare complication after mitral valve replacement due to infective endocarditis (Part 2).

A 27-year-old woman who had undergone mitral valve replacement for infective endocarditis developed a significant paravalvular leak. Percutaneous transcatheter obliteration of the defect using an Amplatzer Vascular Plug III was undertaken, with an excellent clinical outcome.

Clinically overt and silent cerebral embolism in the course of infective endocarditis.

The data on cerebral embolism prevalence in the course of infective endocarditis (IE) are most probably underestimated. Part of the cerebral embolism episodes are clinically silent. The objective of this study was to assess the prevalence of clinically silent cerebral embolism in the course of IE and to correlate hematological, inflammatory, and echocardiography parameters with the presence of clinically overt or silent cerebral embolisms. For this purpose, we examined 65 patients with IE by blood test, cultures, echocardiography, and MRI/CT imaging. Clinically overt cerebral embolism was found in 13 patients; 52 patients had no clinically overt cerebral embolism. MRI/CT examinations revealed that among patients with no clinically overt cerebral embolism, 24 had clinically silent cerebral embolism. Thus, 37 patients in all were diagnosed with a cerebral embolism episode (overt + clinically silent). Clinically silent cerebral embolism was diagnosed in 36.9% of all patients, being as high as 64.8% of cerebral embolism cases. Silent or overt embolism development did not depend on the localization of the inflammatory process in either native or artificial valves. The type of cerebral embolism was not found to be influenced by leukocytosis, platelet count, ESR, or hsCRP levels. Neither was the type of embolism found to be influenced by the etiologic factor. Nine patients died. In three patients, the cause of death was hemorrhage from a cerebral apoplectic focus. These results suggest that clinically silent central nervous system embolism is a common complication of infective endocarditis and each patient should undergo a neuroimaging examination.

[Infective endocarditis caused by Erysipelothrix rhusiopathiae--case report]. / Infekcyjne zapalenie wsierdzia wywolane paleczka rózycy.

Infective endocarditis (IE) is an infectious disease, which leads to death when is untreated. In most cases IE is caused by typical bacteria. IE caused by atypical bacteria is rare. In this paper, we describe a female patient with IE caused by Erysipelothrix rhusiopathiae (ER). Due to inflammation and leaflets' damage she underwent double-valve implantation (aortic and mitral ones). A long-term antibiotic therapy was given with good outcome. We also describe the organism, types of human diseases caused by ER and treatment options.

[Favorable reverse remodelling of the left ventricle in elderly patients following aortic valve replacement]. / Odwrotny remodeling lewej komory po chirurgicznej korekcji zwezenia zastawki aortalnej u osób w starszym wieku.

UNLABELLED: Progress of surgical technique and anaesthesia enabled aortic valve replacement in the very elderly patients. However both valvular heart disease and ageing are associated with myocardial fibrosis. It is not known whether reverse remodelling and regression of hypertrophy, observed in the young patients after aortic valve surgery is possible also in the elderly. The aim of the study was to evaluate the changes of left ventricular structure and function in the elderly patients subjected to aortic valve replacement for aortic stenosis. Echocardiographic examinations were performed prior to surgery, approximately 4 weeks after the procedure and after an average of 32 months of follow-up. Left ventricular end-systolic (LVESV) and end-diastolic volumes (LVEDV) and ejection fraction (LVEF) were measured, as well as interventricular septum (IVSD) and posterior wall thickness (PWD). 43 patients over 74 years old (range 74-83), with aortic stenosis and transvalvular aortic gradient of 60-150 mmHg (mean 104 mm Hg), were included in the analysis. 17 patients received biological and 26 mechanical prosthesis. During the long term follow up LVEDV decreased from 143 ml to 114 ml, LVESV from 59 ml to 36 ml and EF increased from 59% to 68% (all p<0.05). Significant regression of left ventricular wall hypertrophy was observed (IVSD from 1.53 cm to 1.32 cm and PWD from 1.4 cm to 1.28 cm, all p<0.05). IN CONCLUSION: the improvement of physical efficiency were observed. Favorable reverse remodelling of the left ventricle is observed also in elderly patients following valve replacement.

[Treatment outcome of prosthetic valve endocarditis]. / Wyniki leczenia infekcyjnego zapalenia wsierdzia na sztucznych zastawkach serca.

BACKGROUND AND AIMS OF THE STUDY: Prosthetic valve endocarditis (PVE) occurred from 1 to 9% of patient after heart valve replacement. The aim of the present study was to assess the long term outcome of the treatment of PVE and to analyze the recurrence of infective endocarditis (IE). MATERIAL: Hospital mortality, recurrence and late survival were analyzed in 59 patients hospitalized in the Institute of Cardiology for PVE between 1988-95. There were 26 females and 33 males with age ranging from 17 to 71 years (mean 48). The onset of PVE was within 60 days from valve replacement in 17 patients and therefore it was considered as early PVE, in 42 patients PVE occurred beyond 60 days from valve replacement was considered as late. METHODS: The criteria of Durack et al. were applied to diagnose PVE. Each patient was classified as having definite PVE, possible PVE, or rejected PVE. The late examinations were performed out-patient in Ist Department of Valvular Heart Disease of Institute of Cardiology. RESULTS: Prosthetic valve replacement in addition to medical treatment was preferred for 34 (58%) of the 59 cases (8 death), whereas 25 (42%) cases were only managed medically (5 death). The overall hospital mortality rate was 22% (13 patients). There were 8 (17%) episodes of recurrence with mean interval of 6 months between both episodes. 6 patients were cured, 2 died. Staphylococcal epidermidis infection was present in 63%. Recurrence of IE due to the same microorganism was in 88% of episodes. During follow up (mean 4 years) 5 late deaths occurred. Actual 4 years survival was 69%. CONCLUSIONS: 1. Mean survival after 4 years was 69%, 2. Total mortality was 31%, 22% hospital, 9% in late observation (decreased from 8% in first 2 years to 1% mean 4 years after cure, 3. Recurrence of IE was observed in 17% of episodes, most cases (88%) were caused by the same bacteria as in the primary infection.

[Is there any difference in quality of life after 12 months surgical treatment of acquired heart valve disease in comparison to results after three months?]. / Czy istnieje róznica w jakosci zycia po 12 miesiacach od operacji nabytych wad zastawkowych w porównaniu z wynikami uzyskanymi po 3 miesiacach?

The quality of life in eighty patients three and twelve months after surgical treatment of acquired heart valve disease was assessed. The significant extension of distance in 6 minute walk test and clinical improvement measured in change of NYHA functional classes after three and twelve months was noticed. However twelve months after valve replacement in comparison to results after three months no further improvement of quality of life in the matter of physical, psychical and social factors was seen.