Stent-Save a Life international survey on the practice of primary percutaneous coronary intervention during the COVID-19 pandemic.

Aim: To assess the impact of the COVID-19 pandemic on admissions of patients with acute coronary syndromes (ACS) and primary percutaneous coronary intervention (PPCI) in countries participating in the Stent-Save a Life (SSL) global initiative. Methods and Results: We conducted a multicenter observational survey to collect data on patient admissions for ACS, ST-elevation myocardial infarction (STEMI) and PPCI in participating SSL member countries through a period during the COVID-19 outbreak (March and April 2020) compared with the equivalent period in 2019. Of the 32 member countries of the SSL global initiative, 17 agreed to participate in the survey (three in Africa, five in Asia, six in Europe and three in Latin America). Overall reductions of 27.5% and 20.0% were observed in admissions for ACS and STEMI, respectively. The decrease in PPCI was 26.7%. This trend was observed in all except two countries. In these two, the pandemic peaked later than in the other countries. Conclusions: This survey shows that the COVID-19 outbreak was associated with a significant reduction in hospital admissions for ACS and STEMI as well as a reduction in PPCI, which can be explained by both patient- and system-related factors.

Objetivos: Avaliar o impacto da pandemia COVID-19 nas admissões de doentes com síndromes coronárias agudas (SCA) e angioplastia coronária primária (PPCI) em países que participam da iniciativa global Stent-Save a Life (SSL). Métodos e resultados: Realizámos estudo observacional multicêntrico para coletar dados sobre admissões de doentes por ACS, STEMI e PPCI nos países participantes no SSL durante um período do surto COVID-19 (março e abril de 2020) em comparação com o período homólogo de 2019. Dos 32 países membros da iniciativa global SSL, 17 aceitaram participar no estudo (3 de África, 5 da Ásia, 6 da Europa e 3 da América Latina (LATAM)). Observámos uma redução global de 27,5% e 20,0% nos internamentos com SCA e STEMI, respetivamente. A diminuição do PPCI foi de 26,7%. Essa tendência foi observada em todos os países, exceto dois. Nestes dois países, a pandemia atingiu o pico mais tarde do que nos restantes. Conclusões: Este estudo mostra que o surto de COVID-19 foi associado a uma redução significativa de admissões hospitalares por SCA e STEMI, bem como uma redução de PPCI, o que pode ser explicado por fatores relacionados com o doente e com o sistema.

Echocardiographic Assessment of Ischaemic Mitral Regurgitation, Mechanism, Severity, Impact on Treatment Strategy and Long Term Outcome.

INTRODUCTION: The commonest mitral regurgitation etiologies are degenerative (60%), rheumatic post-inflammatory, 12%) and functional (25%). Due to the large number of patients with acute MI, the incidence of ischaemic MR is also high. Ischaemic mitral regurgitation is a complex multifactorial disease that involves left ventricular geometry, the mitral annulus, and the valvular/subvalvular apparatus. Ischaemic mitral regurgitation is an important consequence of LV remodeling after myocardial infarction. RESEARCH OBJECTIVES: The objective of this study is to determine the role of echocardiography in detecting and assessment of mitral regurgitation mechanism, severity, impact on treatment strategy and long term outcome in patients with myocardial infarction during the follow up period of 5 years. Also one of objectives to determine if the absence or presence of ischaemic MR is associated with increased morbidity and mortality in patients with myocardial infarction. PATIENTS AND METHODS: The study covered 138 adult patients. All patients were subjected to echocardiography evaluation after acute myocardial infarction during the period of follow up for 5 years. The patients were examined on an ultrasound machine Philips iE 33 xMatrix, Philips HD 11 XE, and GE Vivid 7 equipped with all cardiologic probes for adults and multi-plan TEE probes. We evaluated mechanisms and severity of mitral regurgitation which includes the regurgitant volume (RV), effective regurgitant orifice area (EROA), the regurgitant fraction (RF), Jet/LA area, also we measured the of vena contracta width (VC width cm) for assessment of IMR severity, papillary muscles anatomy and displacement, LV systolic function ± dilation, LV regional wall motion abnormality WMA, LV WMI, Left ventricle LV remodeling, impact on treatment strategy and long term mortality. RESULTS: We analyzed and follow up 138 patients with previous (>16 days) Q-wave myocardial infarction by ECG who underwent TTE and TEE echocardiography for detection and assessment of ischaemic mitral regurgitation (IMR) with baseline age (62 ± 9), ejection fraction (EF 41±12%), the regurgitant volume (RV) were 42±21 mL/beat, and effective regurgitant orifice area (EROA) 20±16 mm(2), the regurgitant fraction (RF) were 48±10%, Jet/LA area 47±12%. Also we measured the of vena contracta width (VC width cm) 0,4±0,6 for assessment of IMR severity. During 5 years follow up, total mortality for patients with moderate/severe IMR-grade II-IV (54.2±1.8%) were higher than for those with mild IMR-grade I (30.4±2.9%) (P<0.05), the total mortality for patients with EROA ≥20 mm(2)(54±1.9%) were higher than for those with EROA <20 mm(2)(27.2±2.7%) (P<0.05), and the total mortality for patients with RVol ≥30 mL (56.8±1.7%) were higher than for those with RVol<30ml (29.4±2.9%) (P<0.05). After assessment of IMR and during follow up period 64 patients (46%) underwent CABG alone or combined CABG with mitral valve repair or replacement. In this study, the procedure of concomitant down-sized ring annuloplasty at the time if CABG surgery has a failure rate around 24% in terms of high late recurrence rate of IMR during the follow period especially after 18-42 months. CONCLUSION: The presence of ischaemic MR is associated with increased morbidity and mortality. Chronic IMR, an independent predictor of mortality with a reported survival of 40-60% at 5 years. Ischaemic mitral regurgitation has important prognosis implications in patients with coronary heart disease. Recognizing the mechanism of valve incompetence is an essential point for the surgical planning and for a good result of the mitral repair. It is important that echocardiographers understand the complex nature of the condition. Despite remarkable progress in reparative surgery, further investigation is still necessary to find the best approach to treat ischaemic mitral regurgitation.

Current uses of ISACS-TC registry in Mostar.

Cardiovascular disease (CVD) contributes greatly to inequalities in health in Europe. The acute myocardial infarction (MI) in hospital death rate in Bosnia and Herzegovina is three fold higher than in European Union countries before the enlargement in 2004. There is also a striking difference in mortality between Bosnia and Herzegovina and Central and East European countries that joined the EU in 2004. Rapid development of high technology treatment procedures, which followed the economic recovery of the European Union countries, still have only limited influence on the overall control of MI death rate. Large potential to control MI death rate lies in developing PCI capable network with target to rapid reperfusion therapy in MI patients. The hypothesis that social factors may contribute to explain high MI death rate is attractive, but still is an assumption. However, if confirmed, transforming such knowledge into a practical health policy would be a great challenge. A resource-saving balanced assessment approach to health technology development is warrant in Bosnia and Herzegovina. An international help is needed.

Reperfusion therapy for ST elevation acute myocardial infarction 2010/2011: current status in 37 ESC countries.

AIMS: Primary percutaneous coronary intervention (PPCI) is the preferred reperfusion therapy in ST-elevation myocardial infarction (STEMI). We conducted this study to evaluate the contemporary status on the use and type of reperfusion therapy in patients admitted with STEMI in the European Society of Cardiology (ESC) member countries. METHODS AND RESULTS: A cross-sectional descriptive study based on aggregated country-level data on the use of reperfusion therapy in patients admitted with STEMI during 2010 or 2011. Thirty-seven ESC countries were able to provide data from existing national or regional registries. In countries where no such registries exist, data were based on best expert estimates. Data were collected on the use of STEMI reperfusion treatment and mortality, the numbers of cardiologists, and the availability of PPCI facilities in each country. Our survey provides a brief data summary of the degree of variation in reperfusion therapy across Europe. The number of PPCI procedures varied between countries, ranging from 23 to 884 per million inhabitants. Primary percutaneous coronary intervention and thrombolysis were the dominant reperfusion strategy in 33 and 4 countries, respectively. The mean population served by a single PPCI centre with a 24-h service 7 days a week ranged from 31 300 inhabitants per centre to 6 533 000 inhabitants per centre. Twenty-seven of the total 37 countries participated in a former survey from 2007, and major increases in PPCI utilization were observed in 13 of these countries. CONCLUSION: Large variations in reperfusion treatment are still present across Europe. Countries in Eastern and Southern Europe reported that a substantial number of STEMI patients are not receiving any reperfusion therapy. Implementation of the best reperfusion therapy as recommended in the guidelines should be encouraged.

The role of echocardiography in diagnosis and follow up of patients with takotsubo cardiomyopathy or acute ballooning syndrome.

BACKGROUND: The transient left ventricular apical ballooning syndrome, also known as takotsubo cardiomyopathy was first described in Japan approximately 20 years ago (Satoh and coworkers, 1991). It was later described elsewhere as well and is being increasingly recognized. Takotsubo Cardiomyopathy characterized by transient apical and midventricular LV dysfunction in the absence of significant coronary artery disease that is triggered by emotional or physical stress. Its name refers to a contraption used for catching octopuses and suggests the aspect assumed by the ventricle during the systole due to the typical regional wall motion abnormalities that occur after onset. Takotsubo cardiomiopathy occurring mainly in post-menopausal women, echocardiography in the Takotsubo cardiomyopathy reveals during its acute phase a ballooning resembling the octopus trap configuration--the apex and lateral ventricular segments are hypokinetic while the base is hyperkinetic--along with reduced ejection fraction. Ventricular function will usually recover within a few days/weeks. OBJECTIVE AND PURPOSE: The objective of this study is to determine the role of echocardiography in detecting and establishing the diagnosis of Takotsubo cardiomiopathy in patients with suspect acute coronary syndrome and during the follow up period. PATIENTS AND METHODS: The study covered 12 adult patients the majority are women (92%) who were subjected to echocardiography evaluation as part of the clinical cardiological examination due to suspect acute coronary syndrome or Takotsubo Stress Cardiomyopathy. The patients were examined on an ultrasound machine Philips iE 33 x Matrix, ATL HDI and GE Vived 7 equipped with all cardiologic probes for adults and multi-plan TEE probes. We evaluated clinical characteristics, LV systolic function, biomarkers, and prognosis in all patients. RESULTS: Among all the patients referred for Echocardiographic evaluation for left ventricle motion abnormalities with suspect acute coronary syndrome, the echo exam revealed 12 patients with acute apical ballooning which involving the left ventricular apex and med-ventricle. The triggering factors were physical stress in 4 patients (33%) and emotional stress in 8 patients (67%). The initial symptom was chest pain (n = 8, 67%) rather than dyspnea (n = 4, 33%). An initial electrocardiogram (EKG) presented ST-elevation (n = 10, 83%) and T-wave inversion (n = 2, 17%), other data are shown on Table 2. Among the all patients 8 of them (66%) had normal EF by the 1st follow up (47 +/- 51 days), and the rest 4 patients (34%) had normal EF by 68 +/- 96 days. CONCLUSION: Widespread uses of echocardiography has contributed to more frequent recognition of Takotsubo stress cardiomyopathy and highlight the central role of this noninvasive method from an echocardiographers' perspective.

Direct coronary stenting in reducing radiation and radiocontrast consumption.

INTRODUCTION: Coronary stenting is the primary means of coronary revascularization. There are two basic techniques of stent implantation: stenting with balloon predilatation of stenosis and stenting without predilatation (direct stenting). Limiting the time that a fluoroscope is activated and by appropriately managing the intensity of the applied radiation, the operator limits radiation in the environment, and this saves the exposure to the patient and all personnel in the room. Nephrotoxicity is one of the most important properties of radiocontrast. The smaller amount of radiocontrast used also provides multiple positive effects, primarily regarding the periprocedural risk for the patients with the reduced renal function. The goal of the study was to compare fluoroscopy time, the amount of radiocontrast, and expenses of material used in direct stenting and in stenting with predilatation. PATIENTS AND METHODS: In a prospective study, 70 patients with coronary disease were randomized to direct stenting, or stenting with predilatation. RESULTS: Fluoroscopy time and radiocontrast use were significantly reduced in the directly stented patients in comparison to the patients stented with balloon-predilatation. The study showed a significant reduction of expenses when using a direct stenting method in comparison to stenting with predilatation. CONCLUSIONS: If the operator predicts that the procedure can be performed using direct stenting, he is encouraged to do so. Direct stenting is recommended for all percutaneous coronary interventions when appropriate conditions have been met. If direct stenting has been unsuccessful, the procedure can be converted to predilatation.

The effect of combined clopidogrel and aspirin therapy after off-pump coronary surgery: a pilot study.

OBJECTIVE: : The purpose of this randomized study was to evaluate the effect on graft patency by adding clopidogrel to aspirin in off-pump coronary artery bypass (OPCAB) grafting and the possible side effects of such therapy. METHODS: : Twenty patients who underwent standard OPCAB through median sternotomy were randomized immediately after surgery in two groups. Patients in group A (n = 10) received 100 mg of aspirin starting preoperatively, continuing indefinitely. Patients in group B received 100 mg of aspirin and, in addition, 75 mg of clopidogrel starting immediately after the operation and for 3 months. Postoperative bleeding and other perioperative parameters were compared. Angiography was repeated 3 months after surgery to determine the patency and quality of grafts. RESULTS: : Preoperative risk factors were similar in the two groups. There was no significant difference in average number of distal anastomosis (P = 0.572), operation time (P = 0.686), postoperative bleeding (P = 0.256), ventilation time (P = 0.635), and intensive care unit stay (P = 0.065). Length of stay was shorter in group B (P = 0.024). There was no postoperative complication in either groups. Eight of 27 grafts in group A and 2 of 29 grafts in group B (P = 0.037) were occluded at the time of control angiography. CONCLUSIONS: : Early administration of a combined regimen of clopidogrel and aspirin after OPCAB grafting is not associated with increased postoperative bleeding or other major complications. Despite the small number of patients in this study and small number of examined grafts, the results suggest that the addition of clopidogrel may increase graft patency after OPCAB grafting.

The interleukin-1 receptor antagonist gene and the inhibitor of kappa B-like protein gene polymorphisms are not associated with myocardial infarction in Slovene population with type 2 diabetes.

In this study we investigated the association of the interleukin-1 receptor antagonist gene variable number tandem repeat (IL1RN VNTR) polymorphism and of the inhibitor of kappa B-like protein (IKBL) gene polymorphism with myocardial infarction (MI) in a group of patients with type 2 diabetes. The IL1RN VNTR and the IKBL+ 738T > C gene polymorphisms were tested in 374 Caucasians: 151 cases with MI and 223 subjects with no history of coronary artery disease. The IL1RN VNTR polymorphism was not a risk factor for MI in Caucasians with type 2 diabetes (genotype 22 vs. the rest: odds ratio (OR) 1.6; 95% confidence interval (CI) = 0.8-3.5; p = 0.2). We also failed to demonstrate that IKBL+ 738T > C gene polymorphism was associated with MI in patients with type 2 diabetes (OR = 0.9; 95% CI = 0.3-2.6; p = 0.9). We provide evidence that the IL1RN VNTR and the IKBL + 738T > C gene polymorphisms are not risk factors for MI in Caucasians with type 2 diabetes.

Training of cardiac surgeons for Bosnia and Herzegovina: outcomes in coronary bypass grafting surgery.

BACKGROUND: Bosnia and Herzegovina did not have invasive cardiac diagnosis or cardiac surgery before the recent war. With assistance from the United States and Norway, a cardiovascular clinic was developed. This study reports center-specific and surgeon-specific clinical outcomes. Since off-pump coronary bypass grafting surgery was prioritized in the treatment of coronary disease, a comparison was made between operations performed with and without cardiopulmonary bypass. METHODS: Surgeons and key staff members were trained in the United States. A Norwegian data management system for cardiac surgery was implemented and cases entered after quality review of the data. A total of 1276 patients were entered; operations were performed with cardiopulmonary bypass in 540 and without in 736. The primary surgeon was entered as a variable in an anonymous fashion. RESULTS: Overall mortality for coronary bypass grafting surgery was 1.6%, and the major complication rate was 4.5%. Patients operated on off-pump received fewer grafts and had a shorter length of stay. Unfavorable outcome was more common in patients when cardiopulmonary bypass was used in the operation. Regression analysis demonstrated that the European System for Cardiac Operative Risk Evaluation (EuroSCORE) and use of cardiopulmonary bypass were predictors of poor outcome. The individual surgeon factor did not impact on outcomes. CONCLUSIONS: Our study confirms that coronary artery bypass grafting surgery may be performed safely in a poor country in a hospital without experience with cardiac surgery. Selection of talented staff and cooperation with international cardiac centers are crucial. Off-pump coronary artery bypass grafting surgery is suitable for a new center and does not require more training than standard procedures.

[The place of the electrophysiology examination and radiofrequent ablation in cardiac arrhythmias]. / Znacaj elektrofizioloskog testiranja i radiofrekventne ablacije u lijecenju supraventrikularnih aritmija.

Intracardial electrophysiology testing is in use to estimate mechanism of heart rate dysfunction, and is the most useful procedure in treatment of arrhythmias and dysfunction in impulse conduction. QRS complex is main electrocardiographically characteristic for supraventricular and ventricular tachycardia, because of that tachycardia can be with narrow QRS complex or with wide QRS complex. Tachycardia with narrow QRS complex is one where the QRS complex last <120 millisecond. Atrioventricular node reentry tachycardia in reentry flow involves atrioventriculare node and surrounding atrial tissue. Wide QRS tachycardia (120 millisecond) can be supraventricular arrhythmias with continuous or frequent dependent aberrant intraventricular conduction and supraventricular arrhythmias with anterograde preexcitacion and ventricular arrhythmia.Safety and cost effectiveness of radiofrekvent ablation, made ablation method of choise in most patients with supraventricular rhythm disorders.

Frequency of HFE gene mutations C282Y and H63D in Bosnia and Herzegovina.

Genetic epidemiology studies of hereditary hemochromatosis (HHC) have shown a high prevalence of the C282Y mutation in individuals of the North Western European origin, whereas lower prevalence of HFE gene mutations was detected in the populations from southern European countries. However, no HFE mutation prevalence data have been provided for the population of Bosnia-Herzegovina so far. Therefore, the aim of this study was to determine the frequency of the C282Y and H63D HFE gene mutations in the population of Bosnia-Herzegovina. Among 200 analysed subjects 8 (4%) were C282Y heterozygotes; no C282Y homozygotes were found. The frequency of the H63D allele was 11.5%. There were 33 (16.5%) heterozygotes and 6 (3%) homozygotes for the H63D mutation. One (0.5%) compound heterozygote C282Y/H63D was identified. The observed C282Y and H63D allele frequency was 2.25% (95% confidence interval: 1.2-4.2) and 11.5% (95% confidence interval: 8.7-14.9), respectively. The prevalence of the C282Y and H63D mutations was estimated in Bosnia-Herzegovina, which fit well in the European northwest-to-southeast gradient of the C282Y mutation distribution. In addition, these results have an important implication for clinical evaluation of HHC in Bosnia-Herzegovina.

[Atrial fibrillation after surgical myocardial revascularisation]. / Fibrilacija atrija nakon hirurske revaskularizacije miokarda.

Atrial fibrillation characterized by uncoordinated atrial activation. On the electrocardiogram is described by the replacement of consistent P waves by rapid oscillations or fibrillatory waves that vary in size and shape. The incidence of atrial fibrillation in patients under 22 years old is 2%, whereas for patients under 60 years old, the incidence is 8.8%. The most common cause of death in patient with atrial fibrillation is stroke, and occurs in 1% to 5% patients in the age group 50 to 59 years, whereas 30% patients in the age group 80 to 89 years. The incidence of atrial fibrillation after coronary artery bypass surgery occurs in 20% to 40% patients. We examined the incidence atrial fibrillation in patients after coronary artery bypass surgery, most common risk factors for occurs atrial fibrillation. Prospective study was conducted on 100 patients, who were divided in two groups, which had similar age structure, gender and they had disease coronary artery which required coronary artery bypass surgery. We established that incidence atrial fibrillation after coronary artery bypass surgery was 24%. Age was one of main risk factors that is responsible for appearance of atrial fibrillation. Gender like risk factor at 60 year old persons does not have statistical significance, while at persons which are younger then 60 years male has greater statistical significance like risk factor. Patients with triple vessel disease after coronary artery bypass surgery had most common atrial fibrillation.

[Intracoronary radiotherapy]. / Intrakoronarna radioterapija.

Intervenient cardiology is significantly more represented in attempts to solve problems of heart coronary artery disease in comparison to aortocoronary bypass procedures. Resthenoses of coronary artery blood vessel after PTCA, or PTCA and stent placement are frequent. The main causes are: neointimal hyperplasia, late contraction, and remodelling. The application of brachitherapy offers the possibility to prevent resthenosis especially stent resthenosis. Our report encompasses eight patients diseased from coronary artery occlusionn. Half of there patients had a stent resthenosis. The average degree of blood vessel occlusionn before the intervenient manipulation was 78%, and after treatment 25%-30%. Early results after recanalisation of coronary blood vessel are thus fat satisfactory, but results are to be followed carefully.

Insertion/deletion polymorphism of angiotensin-converting enzyme gene--risk factor for coronary artery disease in the Tuzla region population (Bosnia and Herzegovina).

Angiotensin II is the major effector molecule of renin-angiotensin system; its production can be conveniently interrupted by angiotensin-converting enzyme (ACE). Typical plasma levels of ACE accompany the I/D polymorphism; however, a controversy exists as to whether the DD genotype of the ACE polymorphism affects the risk for the development of coronary artery disease (CAD) and to what extent the ACE polymorphism is associated with CAD in different populations. We compared the I/D polymorphism in 212 CAD patients younger than 50 years with 165 healthy control individuals. They were all from the Tuzla region in Bosnia and Herzegovina. Patients with CAD had a higher prevalence of the DD genotype (36.3%) than controls (25.6%). The odds ratio for the ACE DD genotype in CAD patients was 1.7 (95% confidence interval 1.0-2.7; p < 0.05). We may conclude that the D/D genotype of the ACE gene polymorphism is associated with an increased risk for CAD in the Bosnian population.