Pre-procedural abnormal function of von Willebrand Factor is predictive of bleeding after surgical but not transcatheter aortic valve replacement.

Both transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) have been proven to effectively correct von Willebrand Factor (vWF) pathologies, however there is limited data simultaneously comparing outcomes of both approaches. We prospectively enrolled patients with severe aortic stenosis referred for TAVI (n = 52) or SAVR (n = 48). In each case, vWF antigen (vWF:Ag), vWF activity (vWF:Ac) and activity-to-antigen (vWF:Ac/Ag) ratio were assessed at baseline, 24 h and 72 h after procedure. VWF abnormalities were defined as reduced vWF:Ac/Ag ratio (< 0.8). Bleeding events in both arms were classified according to Valve Academic Research Consortium (VARC-2) definitions. Overall, there was no difference between patients referred for TAVI and SAVR in vWF:Ac (1.62 ± 0.52 vs 1.71 ± 0.64; p = 0.593), vWF:Ag (1.99 ± 0.81 vs 2.04 ± 0.81; p = 0.942) or vWF:Ac/Ag ratio (0.84 ± 0.16 vs 0.85 ± 0.12; p = 0.950). Pathological vWF:Ac/Ag ratio was found in 20 (38%) TAVI and 15 (31%) SAVR patients (p = 0.407). Normalization of vWF:Ac/Ag ratio at day 3 after procedure was achieved in 19 (95%) TAVI and 13 (87%) SAVR patients (p = 0.439). Similar prevalence of major or life-threatening bleedings (MLTB) after TAVI and SAVR in entire groups was observed (19% vs. 23%, p = 0.652). VWF abnormalities were associated with higher incidence of MLTB in SAVR (53% vs 9%, p < 0.001), but not TAVI (15% vs. 22%, p = 0.132). Accordingly, in receiver-operating characteristic curve analysis vWF:Ac/Ag ratio < 0.8 showed significant sensitivity and specificity for predicting MLTB in SAVR group (AUC 0.735, 95% CI 0.538-0.931, p = 0.019). We proved that abnormal function of vWF is corrected successfully after both TAVI and SAVR, but vWF abnormalities are predictive of MLTB only in surgical patients.

Changing Face of Inflammatory Activation in Complex Coronary Artery Disease during the COVID-19 Pandemic.

INTRODUCTION: The COVID-19 pandemic has changed the immunological status of the population, indicating increased activation. The aim of the study was to compare the degree of inflammatory activation in patients admitted for surgical revascularization in the period before and during the COVID-19 pandemic. MATERIALS AND METHODS: This retrospective analysis included an analysis of inflammatory activation assessed on the basis of whole blood counts in 533 patients (435 (82%) male and 98 (18%) female) with a median age of 66 (61-71) years who underwent surgical revascularization, including 343 and 190 patients operated on in 2018 and 2022, respectively. RESULTS: The compared groups were matched by propensity score matching analysis, obtaining 190 patients in each group. Significantly higher values of preoperative monocyte count (p = 0.015), monocyte-to-lymphocyte ratio (p = 0.004) and systemic inflammatory response index (p = 0.022) were found in the during-COVID subgroup. The perioperative and 12-month mortality rates were comparable, with 1% (n = 4) in 2018 vs. 1% (n = 2) in 2022 (p = 0.911), and 5.6 % (n = 11 patients) vs. 7% (n = 13 patients) (p = 0.413), in the pre-COVID and during-COVID subgroups, respectively. CONCLUSIONS: Simple whole blood analysis in patients with complex coronary artery disease performed before and during the COVID-19 pandemic indicates excessive inflammatory activation. However, the immune variation did not interfere with one-year mortality rate after surgical revascularization.

Simultaneous surgical treatment of hepatocellular carcinoma with tumor thrombus in the inferior vena cava and ischemic heart disease own research and literature review.

<b> Introduction:</b> Hepatocellular carcinoma (HCC) is the third leading cause of cancer-related death worldwide. Tumor penetration into the inferior vena cava/right atrium is rare, as it occurs only in 34% of HCC patients. There are no clear guidelines for the management of this stage of disease. </br></br> <b>Aim:</b> This is a case report of a patient with HCC and tumor thrombus in the inferior vena cava and with advanced coronary artery disease. </br></br> <b> Materials and methods:</b> The patient was qualified for a simultaneous cardiac surgery and liver resection with removal of the tumor thrombus from the inferior vena cava due to a high risk of sudden cardiac death. The first stage involved aortocoronary bypass followed by a right-sided hemihepatectomy with removal of the tumor thrombus from the inferior vena cava (this part of the operation was performed by extracorporeal circulation). The postoperative period was uneventful. Surgical treatment is one of the therapeutic options that offers a chance to radically remove the tumor and extend the patient's life. From a standpoint, these operations are extremely difficult and carry a high risk of perioperative complications (up to 40%). At the same time, the patient is at risk of complications due to cancer, such as pulmonary embolism, tricuspid stenosis, and congestive heart failure, which should be considered when choosing a treatment method. A significant number of patients also suffer from chronic conditions that worsen the prognosis. Cardiac diseases combined with tumor thrombus in the inferior vena cava may cause sudden cardiac death. </br></br> <b>Conclusions:</b> Surgical treatment should be considered in patients with HCC and tumor thrombus in the inferior vena cava, especially in patients with cardiovascular disease burden, as it is not only a chance to prolong life, but also to protect them against life-threatening cardiac complications.

Optimal Management of Patients with Severe Coronary Artery Disease following Multidisciplinary Heart Team Approach-Insights from Tertiary Cardiovascular Care Center.

Background: The purpose of this retrospective study was to investigate outcomes of patients with severe coronary artery disease (CAD) after implementing various treatment strategies following multidisciplinary Heart Team (MHT) discussion. Methods Primary and secondary endpoints and quality of life during a mean (SD) follow-up of 37 (14) months of patients with severe CAD (three-vessel [3-VD] or/and left main [LM] disease) qualified after MHT discussion to optimal medical treatment (OMT) alone, OMT and coronary artery bypass grafting (CABG), or OMT and percutaneous coronary intervention (PCI) were evaluated. As the primary endpoint, major adverse cardiac or cerebrovascular events (MACCE) (i.e., death from any cause, stroke, myocardial infarction, or repeat/need for revascularization) were considered. Result: From 2016 to 2019, 176 MHT meetings were held, and a total of 1286 participants with severe CAD and completely implemented MHT decisions (OMT, CABG, or PCI for 251, 356, and 679 patients, respectively) were included. The occurrence of the primary endpoint was significantly increased in OMT-group (154 (61.4%) vs. CABG and PCI groups­110 (30.9%) and 302 (44.5%) patients, respectively (p < 0.05). For interventional strategies only­CABG was associated with reduced rates of MACCE and repeat revascularization, while the superiority of PCI for stroke and disabling stroke was observed (p < 0.05). The general health status assessed at the end of the follow-up was significantly better for patients who underwent CABG or PCI than in the OMT group (p < 0.05). Conclusions: In this real-life study, we presented a single-center experience of providing optimal medical care for patients with severe CAD following MHT discussion.

Effects of ischaemic postconditioning in aortic valve replacement: a multicenter randomized controlled trial.

OBJECTIVES: The effect of ischaemic postconditioning (IPost) on postcardioplegic cardiac function is not known. We hypothesized that IPost was cardioprotective in adult patients undergoing elective aortic valve replacement. METHODS: In a multicentre, prospective, randomized trial, patients (n = 209) were randomized to either a standard operation (controls) or postconditioning. Immediately before the cross-clamp was released, patients in the postconditioning group underwent 3 cycles of flow/non-flow (2 min each) of normothermic blood via the antegrade cardioplegia line. The primary end point was cardiac index. Secondary end points included additional haemodynamic measurements, biomarkers of cardiomyocyte injury, renal function parameters, intra- and postoperative arrhythmias and use of inotropic agents. RESULTS: There was no significant difference between the groups regarding cardiac index [mean between-group difference, 95% confidence interval (CI), 0.11 (-0.1 to 0.3), P = 0.27]. Postconditioning had no effect on other haemodynamic parametres. There was no between-group difference regarding troponin T or creatine kinase MB. Postconditioning reduced the relative risk for arrhythmias by 45% (P = 0.03) when postoperative atrial fibrillation and intraoperative ventricular fibrillation were combined. There were no differences in patients with/without diabetes, patients above/below 70 years of age or between the centres. However, after postconditioning, the cardiac index [95% CI, 0.46 (0.2-0.7), P = 0.001], cardiac output (P < 0.001), mean arterial pressure (P < 0.001) and left ventricular stroke work index (P < 0.001) were higher in males compared to females. CONCLUSIONS: IPost had no overall cardioprotective effects in patients undergoing aortic valve replacement but improved postoperative cardiac performance in men compared to women.

Long-term outcomes and quality of life following implementation of dedicated mitral valve Heart Team decisions for patients with severe mitral valve regurgitation in tertiary cardiovascular care center.

BACKGROUND: This study was purposed to investigate which treatment strategy was associated with the most favourable prognosis for patients with severe mitral regurgitation (MR) following Heart Team (HT)-decisions implementation. METHODS: In this retrospective study, long-term outcomes of patients with severe MR qualified after HT discussion to: optimal medical treatment (OMT) alone, OMT and MitraClip (MC) procedure or OMT and mitral valve replacement (MVR) were evaluated. The primary endpoint was defined as cardiovascular (CV) death and the secondary endpoints included all-cause mortality, myocardial infarctions (MI), strokes, hospitalizations for heart failure exacerbation and CV events during a mean (standard deviation [SD]) follow-up of 29 (15) months. RESULTS: From 2016 to 2019, 176 HT meetings were held and a total of 157 participants (mean age [SD] = 71.0 [9.2], 63.7% male) with severe MR and completely implemented HT decisions (OMT, MC or MVR for 53, 58 and 46 patients, respectively) were included into final analysis. Comparing OMT, MC and MVR groups statistically significant differences between the implemented procedures and occurrence of primary and secondary endpoints with the most frequent in OMT-group were observed (p < 0.05). However, for interventional strategy MC was non-inferior to MVR for all endpoints (p > 0.05). General health status assessed at the end of follow-up were significantly the lowest for MVR, then for MC and the highest for OMT-group (p < 0.01). CONCLUSIONS: In the present study it was demonstrated that after careful HT evaluation of patients with severe MR at high risk of surgery, percutaneous strategy (MC) can be considered as equivalent to surgical treatment (MVR) with non-inferior outcomes.

Echocardiographic photorealistic imaging of leiomyomatosis intravascularis.

We present a case of patient with leiomyomatosis intravascularis. To diagnose, we used 3D photorealistic imaging which allowed us better visualisation of pathological structures as well as planning the surgical procedure in greater detail. The main advantage of this technique is the possibility to move the virtual light source and thus visualize the specific part of the heart.

Atherosclerosis Pathways are Activated in Pericoronary Adipose Tissue of Patients with Coronary Artery Disease.

PURPOSE: Perivascular release of inflammatory mediators may accelerate coronary lesion formation and contribute to plaque instability. Accordingly, we compared gene expression in pericoronary adipose tissue (PCAT) in patients with advanced coronary artery disease (CAD) and non-CAD controls. PATIENTS AND METHODS: PCAT samples were collected during coronary bypass grafting from CAD patients (n = 21) and controls undergoing valve replacement surgery, with CAD excluded by coronary angiography (n = 19). Gene expression was measured by GeneChip™ Human Transcriptome Array 2.0. Obtained list of 1348 transcripts (2.0%) that passed the filter criteria was further analyzed by Ingenuity Pathway Analysis software, identifying 735 unique differentially expressed genes (DEGs). RESULTS: Among the CAD patients, 416 (30.9%) transcripts were upregulated, and 932 (69.1%) were downregulated, compared to controls. The top upregulated genes were involved in inflammation and atherosclerosis (chemokines, interleukin-6, selectin E and low-density lipoprotein cholesterol (LDL-C) receptor), whereas the downregulated genes were involved in cardiac ischaemia and remodelling, platelet function and mitochondrial function (miR-3671, miR-4524a, multimerin, biglycan, tissue factor pathway inhibitor (TFPI), glucuronidases, miR-548, collagen type I, III, IV). Among the top upstream regulators, we identified molecules that have proinflammatory and atherosclerotic features (High Mobility Group Box 2 (HMGB2), platelet-derived growth platelet (PDGF) and evolutionarily conserved signaling intermediate in Toll pathways (ESCIT)). The activated pathway related to DEGs consisted of molecules with well-established role in the pathogenesis of atherosclerosis (TFPI, plasminogen activator, plasminogen activator, urokinase receptor (PLAUR), thrombomodulin). Moreover, we showed that 22 of the altered genes form a pro-atherogenic network. CONCLUSION: Altered gene expression in PCAT of CAD patients, with genes upregulation and activation of pathway involved in inflammation and atherosclerosis, may be involved in CAD development and progression.

Heart Team for Optimal Management of Patients with Severe Aortic Stenosis-Long-Term Outcomes and Quality of Life from Tertiary Cardiovascular Care Center.

BACKGROUND: This retrospective study was proposed to investigate outcomes of patients with severe aortic stenosis (AS) after implementation of various treatment strategies following dedicated Heart Team (HT) decisions. METHODS: Primary and secondary endpoints and quality of life during a median follow-up of 866 days of patients with severe AS qualified after HT discussion to: optimal medical treatment (OMT) alone, OMT and transcather aortic valve replacement (TAVR) or OMT and surgical aortic valve replacement (SAVR) were evaluated. As the primary endpoint composite of all-cause mortality, non-fatal disabling strokes and non-fatal rehospitalizations for AS were considered, while other clinical outcomes were determined as secondary endpoints. RESULTS: From 2016 to 2019, 176 HT meetings were held, and a total of 482 participants with severe AS and completely implemented HT decisions (OMT, TAVR and SAVR for 79, 318 and 85, respectively) were included in the final analysis. SAVR and TAVR were found to be superior to OMT for primary and all secondary endpoints (p < 0.05). Comparing interventional strategies only, TAVR was associated with reduced risk of acute kidney injury, new onset of atrial fibrillation and major bleeding, while the superiority of SAVR for major vascular complications and need for permanent pacemaker implantation was observed (p < 0.05). The quality of life assessed at the end of follow-up was significantly better for patients who underwent TAVR or SAVR than in OMT-group (p < 0.05). CONCLUSIONS: We demonstrated that after careful implementation of HT decisions interventional strategies compared to OMT only provide superior outcomes and quality of life for patients with AS.

Bioprosthetic or mechanical heart valves: prosthesis choice for borderline patients?-Results from 9,616 cases recorded in Polish national cardiac surgery registry.

BACKGROUND: In middle-aged patients undergoing aortic valve replacement (AVR), the selection of prosthesis type is a complex process. Current guidelines do not unequivocally indicate the type of prosthesis (bioprosthetic or mechanical) recommended for patients between 60-70 years of age. The aim of the study was to present the trends in AVR prosthesis selection in borderline patients over a 10-year period, based on real-life registry data. METHODS: The study population comprised of 9,616 consecutive patients aged between 60-70 years, who underwent isolated AVR between 2006 and 2016 in all cardiac surgery departments in Poland. Data were extracted from the Polish National Registry of Cardiac Surgery. RESULTS: Among 27,797 consecutive AVR procedures, patients aged 60-70 years represented 34.6% of the population operated on. From 2006 to 2016, bioprosthetic valves (BVs) were implanted in 53.9% cases, (and) mechanical valves (MVs) in 42.1%. The proportion of different valve types changed in time: from 77.5% of MVs vs. 22.5% of BVs in 2006 to 23.2% of MVs vs. 76.8% of BVs in 2016 (P<0.001). The most commonly implanted BV was the Hancock II (used in 36.4% of BV implantations), the most commonly used MV was the Saint Jude Mechanical prosthesis (implanted in 36.4% of MV implantation cases). A multivariable model identified smaller annulus [OR (95% CI) 0.89 (0.86-0.92), P<0.001], atrial fibrillation [OR (95% CI) 1.32 (1.05-1.67), P=0.017], male sex [OR (95% CI) 1.47 (1.24-1.74), P<0.001] and year of implantation [OR (95% CI) 0.75 (0.71-0.79), P<0.001] as predictors of MV implantation. CONCLUSIONS: Patients aged 60-70 years represent more than one-third of all AVR patients. Between 2006 and 2016, the proportion of implanted prostheses has changed dramatically. In 2016 BVs were implanted in nearly 75% of AVR cases, three times more often than in 2006.

Perioperative risk assessment with Euroscore and Euroscore II in patients with coronary artery or valvular disease.

Nowadays, both the European System for Cardiac Operative Risk Evaluation (EuroSCORE) logistic (ESL) and EuroSCORE II (ESII) models are used worldwide in predicting in-hospital mortality after cardiac operation. However, these scales are based on different populations and represent different medical approaches. The aim of the study was to assess the effectiveness of the ESL and the ESII risk scores in predicting in-hospital death and prolonged hospitalization in intensive care unit (ICU) after coronary artery bypass grafting (CABG), aortic valve replacement (AVR), and mitral valve replacement (MVR) by comparison of an estimated risk and a real-life observation at a reference cardiac surgery unit.This retrospective study was based on medical records of patients who underwent a CABG, AVR, or MVR at a reference cardiac surgery unit in a 2-year period. Primary endpoint was defined as in-hospital death. Secondary endpoint was a prolonged hospitalization at the ICU, defined as longer than 3 days.The study encompassed 586 patients [114 (23.1%) female, mean age 65.8 ±â€Š10.5 years], including 493 patients undergoing CABG, 66 patients undergoing AVR, and 27 patients undergoing MVR. The ESL and ESII risk scores were higher in MVR subgroup (31.7% ±â€Š30.5% and 15.3% ±â€Š19.4%) and AVR subgroup (9.7% ±â€Š11.6% and 3.2% ±â€Š4.2%) than in CABG subgroup (6.9% ±â€Š10.4% and 2.5% ±â€Š4.1%; P < .001). Subgroups of patients were significantly different in terms of clinical, biochemical, and echocardiography factors. Primary endpoint occurred in 36 (6.1%) patients: 21 (4.3%), 7 (10.6%), and 8 (29.7%) in CABG, AVR, and MVR subgroups, respectively. The ESII underestimated the risk of mortality. Secondary endpoint occurred in 210 (35.8%) patients: 172 (34.9%), 22 (33.4%), and 16 (59.3%) in CABG, AVR, and MVR subgroups, respectively.In the study, the perioperative risk estimated with the ESL and the ESII risk scores was compared with a real-life outcome among over 500 patients. Regardless of the type of surgery, result in the ESL was better correlated with the risk of in-hospital death.

Dual antiplatelet therapy is safe and efficient after left atrial appendage closure.

BACKGROUND: Despite results of the PROTECT AF trial, many patients undergoing left atrial appendage closure (LAAC) have unconditional contraindications to warfarin. AIM: We sought to investigate whether double antiplatelet therapy (DAPT) is safe in patients after LAAC. METHODS: Forty-four consecutive patients (22 males, mean age 74 ± 7.8 years) with non-valvular atrial fibrillation (NVAF) underwent LAAC procedure using a Watchman device followed by DAPT (75 mg/d aspirin and 75 mg/d clopidogrel). After the procedure and during 98 days' follow-up including transoesophageal echocardiography, peri-procedural complications and clinical outcomes were investigated. RESULTS: Mean CHA2DS2-VASc score was 4.9 ± 1.5 and mean HAS-BLED score was 3.6 ± 0.8. The main LAAC indication was contraindication to anticoagulation reflected by HAS-BLED score ≥ 3 observed in 95.5% cases (among them history of bleeding in 38 patients, 90.5%). 36.4% of patients have history of stroke or transient ischaemic attack. The procedure was successful in 97.7%. Peri-procedural complications were tamponade (2.3%) and one death (2.3%) unrelated to the procedure with no bleeding or vascular complications. During follow-up neither stroke nor bleeding were observed, whereas two device related thrombi and two unrelated deaths occurred. CONCLUSIONS: LAAC followed by DAPT seems to be a safe and efficient alternative for stroke prevention in patients with NVAF who have contraindications to anticoagulation therapy. This strategy may provide a significant reduction of events such as stroke and bleeding versus the score-predicted rate.

Conversion from cyclosporine to tacrolimus improves renal function and lipid profile after cardiac transplantation.

BACKGROUND: Calcineurin inhibitors (CNIs) have become the cornerstone of immunosuppressive regimens following heart transplantation, but their use is associated with nephrotoxicity. The impact on renal function after conversion from cyclosporine (CsA) to tacrolimus (TAC) is reported. PATIENTS AND METHODS: Fifteen patients (men age 42 +/- 11 years) after cardiac transplantation (HTX) were switched from CsA to TAC (mean time after HTX 21 +/- 6 months). There were 13 male and 2 female patients. Mean cholesterol and LDL level at the time of conversion were 217 +/- 65 ml/dl and and 136 +/- 51 mg/100 ml respectively. Indication for HTX was ischemic cardiomyopathy (CMP) in 8, congenital in 3 and dilatative CMP in the remaining 4 patients. RESULTS: Mean tacrolimus level (microg/dl) at 1, 3, 6 and 12 months were 8.6 +/- 3.3, 8.6 +/- 1.4, 9.2 +/- 2.8 and 9.8 +/- 2.5 respectively. There was a statistically significant improvement in creatinine levels at 1, 3, 6 and 12 months after conversion from baseline 1.9 +/- 0.7 mg/dl to 1.4 +/- 0.5 mg/dl, 1.4 +/- 0.4 mg/dl, 1.3 +/- 0.4 mg/dl and 1.2 +/- 0.4 mg/dl, respectively (p < 0.05). Furthermore, TAC decreased cholesterol as well as LDL-levels during this one-year time frame. CONCLUSION: This study shows that conversion from CsA to tacrolimus after orthotopic heart transplantation improves renal function.

A case of candida albicans mediastinitis after heart transplantation successfully treated with caspofungin.

Reported here is a case of mediastinitis caused by candida albicans and Staphylococcus aureus following a heart transplantation that was successfully treated with caspofungin, antibiotics and mediastinal lavage. A review of the literature revealed that Candida albicans as a cause of mediastinitis has been rarely described. In the few existing reports, evolution was generally fatal, especially in immunocompromised patients, despite treatment with antifungal drugs and antibiotics.