Atrial septum anatomy as a predictor of ischemic neurological episodes in patients with a patent foramen ovale.

BACKGROUND: The correlation between atrial septum anatomy and the risk of ischemic neurological events remains underexplored. AIMS: This study aimed to examine both the functional and anatomical attributes of the atrial septum and identify predictors of stroke and/or transient ischemic attack (TIA) in patients diagnosed with patent foramen ovale (PFO). METHODS: A total of 155 patients diagnosed with PFO, with a cardiological cause of neurological events, were enrolled. Transesophageal echocardiography was utilized to assess the anatomy of the PFO canal, size of the right-to-left shunt, thickness of the primary and secondary atrial septum, presence of atrial septum aneurysm, and anatomical structures of the right atrium. RESULTS: Regression analysis showed that factors such as female sex, hypercholesterolemia, PFO canal width, and a large right-to-left shunt were significantly associated with stroke and/or TIA. Receiver operating characteristic analysis indicated that the width of the PFO canal holds a relatively weak, although significant predictive, value for ischemic neurological episodes (area under the curve = 0.7; P = 0.002). A PFO canal width of 4 mm was associated with 70% sensitivity and 55% specificity for predicting stroke and/or TIA. CONCLUSIONS: The atrial septum's anatomy, especially the dimensions of the PFO canal and the magnitude of the right-to-left shunt, combined with specific demographic and clinical factors, are linked to ischemic neurological incidents in PFO patients.

Experience in patent foramen ovale closure with the CERA Lifetech occluder in patients with cryptogenic stroke.

Introduction: Nowadays, percutaneous closure of patent foramen ovale (PFO) in patients after cryptogenic stroke is becoming a dominating strategy. The most commonly used and investigated device is the Amplatzer occluder. However, several other devices have been designed for transcatheter closure of PFO, which are not so well examined. Aim: To assess the effectiveness and safety of PFO closure with the Lifetech CERA occluder. Material and methods: A prospective, single-arm registry of patients with PFO treated with CERA occluder (Lifetech Scientific, Shenzhen, China) implantation was conducted. We assessed peri-procedural and 12-month follow-up. Patients were screened for the residual shunt in transcranial Doppler/transesophageal echocardiography. Results: Ninety-six patients entered the registry. Most patients were women (76%) and the analyzed group was relatively young (mean age of 42.3 ±13.6 years). Before closure, most patients had a large shunt through the PFO. Procedures of PFO closure were performed under TEE guidance. All procedures were made under local anesthesia and all patients had the PFO successfully closed. No device-related complications were reported in the peri-procedural period or during follow-up. No recurrent neurological ischemic events were reported at 12 months. During follow-up we observed a 9% rate of residual shunts, which were mostly small. Conclusions: The study confirmed excellent immediate and 12-month results of CERA occluder implantation in patients with PFO.

Recurrent cerebrovascular events in patients with a history of cryptogenic stroke or transient ischemic attack and patent foramen ovale in a long­term follow­up.

INTRODUCTION: Cryptogenic stroke may be associated with a patent foramen ovale (PFO). Both cardiovascular risk factors and transcatheter closure of PFO may have an impact on the risk of recurrent cerebrovascular events. OBJECTIVES: The aim of the study was to assess the occurrence and risk factors of recurrent cerebrovascular events (rCVE) in patients with a history of cryptogenic stroke or transient ischemic attack (TIA) and PFO. PATIENTS AND METHODS: Overall, 392 patients (median [interquartile range, IQR] age 39.5 [30-49] years, 64.3% women, 35.7% men) with a history of cryptogenic stroke / TIA and confirmed PFO underwent a long­term follow­up with a median (IQR) of 51.5 (35-65) months. The primary end point was defined as rCVE including stroke and TIA. RESULTS: During the follow­up, 17 patients with a history of cryptogenic stroke / TIA and confirmed PFO (4.3%, 11 women, 6 men) developed rCVE. In a multivariable analysis, the Risk of Paradoxical Embolism (RoPE) score was associated with a lower risk of rCVE (odds ratio [OR], 0.61 per 1 point; 95% CI, 0.45-0.84; P = 0.002). The transcatheter closure of PFO did not have a significant impact on rCVE in the study population (P = 0.19). CONCLUSIONS: The occurrence of rCVE in the patients with cryptogenic stroke / TIA and PFO reached 4.3% regardless of a high percentage of patients who underwent the PFO closure. RoPE score was associated with a lower risk of rCVE in the study population.

Early stage of atherosclerosis in aortocoronary saphenous vein grafts: intravascular ultrasound study

Abstract Introduction: Angiographically visible plaques in patent vein grafts are usually detected years after surgery. Our aim was to examine early plaque formation in vein grafts. Methods: Bypass angiography and intravascular ultrasonography (IVUS) examination were performed on 77 aortocoronary saphenous vein grafts (SVGs) implanted in 36 patients during the first 2 years after CABG. In each graft, a good quality 25 mm ultrasound image was analyzed. We measured: plaque area, lumen area, external elastic membrane (EEM) area, graft area and wall area. For the comparative assessment of SVGs, the index plaque area/EEM area was calculated. Data were analyzed for the following 4 time periods: I - 0-4 months (22 grafts), II - 5-8 months (23 grafts), III - 9-12 months (19 grafts) and IV - 13-16 months (13 grafts) after CABG. Student's t and Fisher-Snedecor tests were used for the purpose of statistical analysis in this retrospective study. Results: In period I, plaque formation (neointimal) was observed in 10 grafts (45%), with a mean plaque area of 1.59 mm., in 6 grafts (26%) in period II, with a mean plaque area of 1.03 mm. and in 15 grafts (71%) in period III, with a mean plaque area of 1.41 mm., and in all (100%) grafts in period IV, with mean plaque area of 2,3 mm.. Average index plaque area/EEM area in periods I, II, III and IV were 0.12, 0.08, 0.13 and 0.22. We have showed a significant plaque increase between periods II and IV(P=0.038). Conclusion: IVUS showed plaque in about 40% of venous grafts during the first year after CABG. Between 13-16 months plaque was visible in all studied grafts.

Early Stage of Atherosclerosis in Aortocoronary Saphenous Vein Grafts: Intravascular Ultrasound Study.

INTRODUCTION: Angiographically visible plaques in patent vein grafts are usually detected years after surgery. Our aim was to examine early plaque formation in vein grafts. METHODS: Bypass angiography and intravascular ultrasonography (IVUS) examination were performed on 77 aortocoronary saphenous vein grafts (SVGs) implanted in 36 patients during the first 2 years after CABG. In each graft, a good quality 25 mm ultrasound image was analyzed. We measured: plaque area, lumen area, external elastic membrane (EEM) area, graft area and wall area. For the comparative assessment of SVGs, the index plaque area/EEM area was calculated. Data were analyzed for the following 4 time periods: I - 0-4 months (22 grafts), II - 5-8 months (23 grafts), III - 9-12 months (19 grafts) and IV - 13-16 months (13 grafts) after CABG. Student's t and Fisher-Snedecor tests were used for the purpose of statistical analysis in this retrospective study. RESULTS: In period I, plaque formation (neointimal) was observed in 10 grafts (45%), with a mean plaque area of 1.59 mm., in 6 grafts (26%) in period II, with a mean plaque area of 1.03 mm. and in 15 grafts (71%) in period III, with a mean plaque area of 1.41 mm., and in all (100%) grafts in period IV, with mean plaque area of 2,3 mm.. Average index plaque area/EEM area in periods I, II, III and IV were 0.12, 0.08, 0.13 and 0.22. We have showed a significant plaque increase between periods II and IV(P=0.038). CONCLUSION: IVUS showed plaque in about 40% of venous grafts during the first year after CABG. Between 13-16 months plaque was visible in all studied grafts.

Temporal healing patterns and coverage dynamics after new Polish transcatheter PFO occluder implantation in a swine.

BACKGROUND: Although currently used devices for interventional closure of patent foramen ovale (PFO) are widely used due to the minimally invasive nature of this technique and high success rate, there is still a need to look for new materials and designs in order to improve the treatment outcomes. AIM: To evaluate the safety, biocompatibility, temporal healing patterns, and coverage dynamics of the new Polish PFO occluder (Balton, Warsaw, Poland) in a swine model - an observation that may assist the decision with regard to its first-in-human use and duration of anticoagulation therapy. METHODS: In total, 12 pigs were scheduled for 28-day (n = 6) and 90-day follow-up (n = 6). In each animal, using a standard femoral venous approach, one PFO occluder was implanted and subsequently, in order to verify device position stability, the Minnesota manoeuvre was performed. At follow-up, all devices underwent a comprehensive evaluation with the use of high-resolution radiography (Faxitron MX-20 system), scanning electron microscopy (SEM), and standard histopathological techniques. RESULTS: All PFO occluders were implanted successfully with no complications. The Faxitron revealed that all nitinol portions of the frame appeared intact and breaks were not detected at both studied time points. Overall, the device appeared to be well deployed in the atrial septum. At 28 days the average neointimal coverage of the right side of the PFO occluder by SEM was 92%; while in contrast the left side had less coverage, at 63%. At 90 days, the coverage of the right side of the occluder was 96.8%, while the left side of the PFO occluder improved and had similar coverage of 93.3%. By histology the endothelialisation process was virtually complete at 90 days. At the early time-point the overall inflammatory infiltrate was moderate and subsequently it diminished and was only mild or occasionally moderate at 90-day follow-up. At both time points the inflammatory reaction was limited to the neointimal tissue surrounding the device. CONCLUSIONS: Our study confirmed safety and good overall biocompatibility of the new Polish PFO occluder, which is comparable to other devices available on the market - an observation that supports the decision with regard to its first-in-human application. Neoendothelialisation was virtually completed at 90 days, suggesting that similarly to other widely used devices a minimum of three to six months of anticoagulation therapy should be recommended.

Neointima development in externally stented saphenous vein grafts.

INTRODUCTION: The main limitation of coronary artery bypass grafting (CABG) is rapid neointimal hyperplasia leading to graft failure. AIM: To assess plaque formation in saphenous vein grafts (SVG) covered by an external Dacron stent in comparison with the classical technique. MATERIAL AND METHODS: In the study group vein grafts covered by external stent mesh made of Dacron were implanted. An intravascular ultrasonography (IVUS) study was performed in 35 aorto-coronary SVG covered by an external Dacron stent and in 64 normal SVG during the first year after CABG. In each SVG 25 mm of good quality IVUS image, volumes of lumen, plaque (neointima), outer border of the vein graft (external SVG) and adventitia were calculated in three time periods: 0-130 days, 130-260 days and 260-390 days. RESULTS: Between the first and second time period, lumen volume (mm3) was reduced from 10.33 ±4.4, to 6.80 ±2.23 in the second period and 5.69 ±1.26 in the third one. This effect was much less marked in normal grafts. The corresponding lumen volume (mm3) was: 10.90 ±3.9, 9.15 ±2.94 and 8.92 ±2.93 in consecutive time periods. Plaque volume (mm3) did not change in control grafts during the course of the study, but it increased very significantly in stented grafts from 0.86 ±1.24 in the first period to 2.70 ±1.58 in the second and 3.29 ±2.66 in the third one. CONCLUSIONS: The experimental technique of implanting SVG covered with an external elastic Dacron stent seems to be inferior to traditional ones. This is probably due to the more complicated process of vein implantation and higher micro-injury occurrence during the surgery.

Transcatheter closure of patent foramen ovale using the internal jugular venous approach.

Transcatheter closure of patent foramen ovale is routinely performed using the transfemoral approach, which is safe and technically easy. Our case represents the rare situation where the procedure needs to be performed using the right internal jugular venous approach. According to our best knowledge this is the first report of a patent foramen ovale closure procedure with access through the internal jugular with necessity to advance the guide wire and transseptal sheath into the left ventricle. Developing alternative techniques of transcatheter patent foramen ovale closure seems to be especially important in rare cases where transfemoral access is unavailable.

[Periprocedural and late complications after percutaneous closure of patent foramen ovale: a single centre experience].

BACKGROUND: Patent foramen ovale (PFO) is a potential risk factor for ischaemic stroke in young individuals. An interventional method of secondary stroke prevention in PFO patients is its percutaneous closure. AIM: To assess safety and effectiveness (i.e. lack of residual shunt) of percutaneous PFO closure in patients with history of cryptogenic cerebrovascular event. METHODS: 149 patients (56 men/93 women), aged 39 ± 12 years, underwent percutaneous PFO closure. The implantation was performed under local anaesthesia, guided by trans-oesophageal echocardiography (TEE) and fluoroscopy. Follow-up trans-thoracic echocardiography (TTE) was performed at 1 month and follow-up TEE at 6-months. In cases of residual shunt, additional TEE was performed after ensuing 6 months. RESULTS: Effective PFO closure (no residual shunt) was achieved in 91.3% patients at 6 months and 95.3% patients at 12 months. In 2 patients transient atrial fibrillation was observed during the procedure. In 2 patients, a puncture site haematoma developed and in 1 patient superficial thrombophlebitis was noted. In 1 patient a small pericardial effusion was observed, which resolved at day 3 post-procedurally, after administration of non-steroidal anti-inflammatory drugs. CONCLUSIONS: Percutaneous PFO closure seems to be a safe procedure when performed in a centre with adequate expertise with regard to these procedures.

Percutaneous closure of the left atrial appendage to prevent ischaemic stroke in patients with atrial fibrillation who require but have contraindications to oral anticoagulation.

Atrial fibrillation (AF) is associated with a five-fold increased risk for stroke due to cardioembolic events. Most strokes in patients with AF arise from thrombus formation in the left atrial appendage (LAA). Oral anticoagulation is a standard treatment of AF patients with high risk of stroke. However, the main drawbacks of oral anticoagulation are high risk of major bleeding and imperfect effectiveness dependent on a very narrow therapeutic range. In this article, based on two case reports, we describe a method of percutaneous closure of the LAA. We discuss indications, describe the procedure and mention possible complications. LAA closure seems to be a promising tool to prevent AF-related strokes in a selected group of patients.

Risk factors of asymptomatic restenosis in patients with first anterior ST elevation myocardial infarction treated by primary percutaneous coronary intervention.

BACKGROUND: The issue of predicting coronary artery restenosis, especially silent, in patients following primary percutaneous coronary intervention (PCI) has been extensively studied, however, risk factors have not been fully defined. AIM: To asses the frequency of silent restenosis and its predictors in patients with anterior ST elevation myocardial infarction (STEMI) treated with primary PCI and implantation of bare metal stents (BMS). METHODS: We recruited a cohort of 114 patients with first anterior STEMI treated with primary PCI within 12 hours of the onset of symptoms, and with the left anterior descending coronary artery occlusion (TIMI 0) and successful flow restoration (TIMI 3). A 12-lead ECG was performed before and 60 minutes after PCI. Troponin I and CK-MB were measured on admission and after six, 12 and 24 hours. Transthoracic echocardiography (TTE) was performed at discharge. Resting TTE and coronary angiography were performed after a six month follow-up in asymptomatic patients. RESULTS: The frequency of silent restenosis in our study group was 23.9%. The best multivariate models in logistic regression of restenosis prediction were: lower end-systolic volume of the left ventricle assessed two days after infarction longer lesion and smaller reference diameter of the stented vessel. CONCLUSIONS: Silent restenosis in patients with first anterior STEMI treated by primary PCI with the use of BMS is still frequent. The best ways to identify patients with silent restenosis at six month follow-up, apart from the lower end systolic volume in the echocardiographic study, are longer narrowing in the infarct-related artery and lower reference diameter of the treated vessel.

Predictive value of ischemic mitral regurgitation during the acute phase of ST elevation myocardial infarction treated with primary coronary intervention for left ventricular remodeling in long-term follow-up.

UNLABELLED: Reperfusion therapy, mainly primary percutaneous coronary intervention (PCI), has improved survival and lowered complication rate in patients with ST elevation myocardial infarction (STEMI). Nevertheless, some patients develop left ventricular remodeling (LVR) during long-term follow-up. AIMS: To assess the incidence of ischemic mitral regurgitation (MR) in the acute phase of STEMI treated with primary PCI. To assess prognostic value of MR during acute STEMI for prediction of LVR during long-term follow-up. METHODS: This is a prospective, single-center study in 83 patients with the first STEMI. Inclusion criteria were as follows: time from symptom onset to PCI less than 12 h and successful restoration of blood flow (thrombolysis in myocardial infarction 3) in the infarct-related coronary artery. Transthoracic echocardiography was performed at discharge and 6 months after the MI. RESULTS: At hospital discharge, ischemic MR was found in 35 (42%) patients. At 6 months follow-up, LVR was present in 21 (25%) patients. Univariate analysis revealed that remodeling could be predicted by age, weight, treatment with abciximab, left ventricular ejection fraction (LVEF), leaflets coaptation, coaptation height, tenting area, presence of MR, degree of MR. The best multivariate logistic regression model for remodeling prediction at 6 months was combination of ischemic MR degree (odds ratio (OR)=14.5; 95% confidence interval (CI): 3.89-54.0, P<0.00005), abciximab therapy (OR=0.09; 95% CI: 0.01-0.84, P<0.03) and LVEF (OR=0.89; 95% CI: 0.81-0.99, P<0.03). CONCLUSION: Ischemic MR in STEMI is frequent, even despite effective primary PCI. The regurgitation grade and lower LVEF assessed at hospital discharge and lack of abciximab administration could predict development of LVR at 6 months.

Altered fibrin clot structure/function in patients with cryptogenic ischemic stroke.

BACKGROUND AND PURPOSE: We tested the hypothesis that fibrin structure/function is unfavorably altered in patients with cryptogenic ischemic stroke. METHODS: Ex vivo plasma fibrin clot permeability, turbidimetry, and efficiency of fibrinolysis were determined in 89 patients with patent foramen ovale (PFO) and a history of first-ever stroke, 58 patients with first-ever stroke and no PFO, and 120 healthy controls. RESULTS: Stroke patients, evaluated 3 to 19 months after the event, and controls did not differ with regard to age, sex, smoking, and fibrinogen. Stroke patients with or without PFO had lower clot permeability (P<0.0001), faster fibrin polymerization (P<0.0001), prolonged clot lysis time (P<0.0001), higher maximum D-dimer levels released from clots (P<0.0001), and maximum rate of D-dimer release (P=0.02) than controls. Time from stroke occurrence showed no association with any clot variables. Scanning electron microscopy of fibrin clots showed increased fiber diameter and density in stroke patients. Clots from stroke patients with PFO were more permeable and showed shorter lysis time compared to those without PFO, and this was related to lower proportion of smokers in the former group. CONCLUSIONS: Altered fibrin clot structure and resistance to fibrinolysis are associated with cryptogenic stroke.

[Results of treating myocardial infarction patients with ST segment elevation in Górnoslaskim Osrodku Kardiologii in Katowice]. / Wyniki leczenia chorych z zawalem serca z uniesieniem odcinka ST w Górnoslaskim Osrodku Kardiologii w Katowicach.

BACKGROUND: Reperfusion therapy reduces mortality rate in patients with acute myocardial infarction with ST-segment elevation (STEMI). AIM: The aim of the study was to access the early outcome of patiens (pts) with STEMI admitted to Upper Silesian Cardiology Centre in 2002. METHODS: 957 pts with AMI were enrolled into the study. The influence of several factors on in-hospital mortality was analised. RESULTS: Out of 957 pts 51 died during hospitalization (5,3%). Coronary angiography was performed in 98,0% of pts. Primary PTCA was performed in 94,5% of pts. Stents were implanted in 85,9% of patients who underwent PTCA. The following factors significantly contributed to increased mortality among pts with acute myocardial infarction: female sex (p<0,02), multivessel disease (p<0,05), age above 65 yrs (p<0,001), time from the onset of chest pain above 6 hours (p<0,01) and 12 hours (p<0,001). The use of GP IIB/IIIA inhibitors significantly reduced the mortality rate (p<0,05). Cardiogenic shock was the only independent factor of the increased risk of mortality in multivariate regression analysis (p<0,0001) with relative risk of death (RR 33,5). The mortality rate in pts with shock was 40,2%: 70,8% in case of conservative treatment, 70% in the group of failed PTCA and only 17,2% in the group of successful PTCA. Among pts who underwent primary PTCA the failure to restore coronary blood flow of the infarct related artery contributed to increased relative risk of death (RR 14,5) (p<0,001). Stents improved the survival rate (p<0,01). In PTCA group cardiogenic shock and failed PTCA were independent risk factors in multivariate regression analysis. CONCLUSIONS: The results of our study show low rate of in-hospital mortality in pts without cardiogenic shock (1,2%). PTCA is highly successful method of treatment of pts with shock with mortality rate 17,2% in pts who underwent successful procedure.