Mechanical extraction of implantable cardioverter-defibrillator leads with a dwell time of more than 10 years: insights from a single high-volume centre.

AIMS: To analyze and compare the effectiveness and safety of transvenous lead extraction (TLE) of implantable cardioverter-defibrillator (ICD) leads with a dwell time of >10 years (Group A) vs. younger leads (Group B) using mechanical extraction systems. METHODS AND RESULTS: Between October 2011 and July 2022, we performed TLE in 318 patients. Forty-six (14.4%) extracted ICD leads in 46 (14.5%) patients that had been implanted for >10 years. The median dwell time of all extracted ICD leads was 5.9 years. Cardiovascular implantable electronic device-related infection was an indication for TLE in 31.8% of patients. Complete ICD leads removal and complete procedural success in both groups were similar (95.7% in Group A vs. 99.6% in Group B, P = 0.056% and 95.6% in Group A vs. 99.6% in Group B, P = 0.056, respectively). We did not find a significant difference between major and minor complication rates in both groups (6.5% in Group A vs. 1.5% in Group B and 2.2% in Group A vs. 1.8% in Group B, P = 0.082, respectively). One death associated with the TLE procedure was recorded in Group B. CONCLUSION: The TLE procedures involving the extraction of old ICD leads were effective and safe. The outcomes of ICD lead removal with a dwell time of >10 years did not differ significantly compared with younger ICD leads. However, extraction of older ICD leads required more frequent necessity for utilizing multiple extraction tools, more experience and versatility of the operator, and increased surgery costs.

Transvenous extraction of very old (over 20-year-old) pacemaker leads using mechanical systems: Effectiveness and safety.

OBJECTIVE: To analyze and compare the effectiveness and safety of transvenous lead extraction (TLE) with mechanical systems of pacing leads older than 20 years (group A) versus younger leads (group B). METHODS: We performed TLE of 591 pacing leads in 377 patients. Fifty (8.5%) leads in 43 (11.4%) patients were implanted for equal to or more than 20 years. The mean dwell time of all extracted leads was 8.9 years (range, 0.1-36.0). Infection related to cardiovascular implantable electronic device was an indication for TLE in 18.3% of patients. RESULTS: Complete lead removal and complete procedural success rates were similar between both groups (94.7% in group A vs 97.1% in group B, P = 0.445, and 90.7% in group A vs 95.8% in group B, P = 0.329, respectively). Incomplete lead removal in group A was observed only in leads older than 20 years. Removal of leads in group A was associated with significantly longer fluoroscopy time compared with group B (4.6 vs 1.9 minutes, P < 0.001). We did not find a significant difference in major and minor complication rates between groups (2.3% in group A vs 0.9% in group B and 2.3% in group A vs 2.2% in group B, P = 0.687, respectively). There were no deaths associated with the TLE procedure within 30 days after the procedure in either group. CONCLUSION: This study shows that TLE of leads older than 20 years conducted at an experienced center seems to be comparably safe and effective as extraction of younger leads but requires longer fluoroscopy time.

The analysis of indications and early results of transvenous lead extraction in patients with a pacemaker, ICD and CRT - single-center experience.

INTRODUCTION: Transvenous lead extraction (TLE) is a recognized method of treatment in the case of permanent stimulation complication. OBJECTIVES: The objective of this study was to analyse the indications and presentation of the early experience of TLE procedures in a group of patients with old pacing systems. PATIENTS AND METHODS: Patients with a relevant history of stimulation (at least 12 months in case of a pacemaker) qualified for the research. Indications, effectiveness and complications of TLE procedures were analysed. RESULTS: Two hundred patients at the age of 66.4 (19.1-86.2 years) were enrolled and 278 leads with dwell time 76.2 months (2.1-327.4) were removed. The indications for TLE were: lead-dependent infective endocarditis in 13 cases (6.5%), pocket infection in 29 cases (14.5%), lead damage in 120 cases (60.0%), and upgrade of device system in 38 cases (19.0%). Manual traction was used to remove 66 active fixation leads (23.7%). A femoral approach was required to extract 4 leads (1.4%). Two hundred and eight leads (74.8%) were extracted using the mechanical (Cook) system and subclavian approach. Laser technique, and an electrosurgical sheath were not used. Complete procedural success was achieved in 96% of cases and overall clinical success was 98.5%. Complication rate was 5.5% (11 patients): minor and major complication rate was 3.0% (6 patients) and 2.5% (5 cases), respectively. Low body mass index (BMI) was associated with a higher rate of complications. CONCLUSIONS: The dominant indication to TLE procedures was lead dysfunction. Transvenous lead extraction has a high success rate and a low complication rate. Low BMI increased the complication rate.

Atrial septal defect surgery in adults--populational and epidemiological analysis.

UNLABELLED: Atrial septal defect (ASD) is one of the most common congenital heart diseases found in adolescents and adults. Shunt may lead to serious further complications, such as pulmonary hypertension and right heart chambers overload. The aim of this study was the analysis of the population of adult patients with ASD together with the frequency of the annuloplasty tricuspid ring implantation in ASD II and the necessity of anterior mitral valve cusp suturing due to the cleft accompanying ASD I. MATERIALS AND METHODS: The study group consisted of 58 males and 122 females aged 17 to 77. Individuals were divided into three age brackets: 17-30 years old--22%; 31-50--38,5% and 51-77--39,5%. RESULTS: In 92,8% of cases median sternotomy was performed. Other approaches were: right mini- thoracotomy 5%, 2,2% underwent lower hemisternotomy. There were 16 annuloplasties accompanying ASD closure: 13 in ASD II patients, 1 in PFO patient, 2 in ASD I patients. Average size of the pericardiac patch used to ASD type II correction was bigger in patients, who also underwent annuloplasty tricuspid ring implantation (Mann- Whitney U test: -2,25, p=0,024). CONCLUSION: Repair of ostium secundum and sinus venosus ASD can be performed safely via minithoracotomy endoscopic approach with similar outcomes as sternotomy. Beside the mitral cleft suturing in ASD I patients, annuloplasty tricuspid ring implantation is the most common additional procedure. ASD II patients, who had undergone such annuloplasties needed the bigger pericardial patches.

[Body mass index influence on aortic valve stenosis]. / Wskaznik masy ciala, a naturalny przebieg zwezenia lewego ujscia tetniczego.

AIM: The 12 months' observation of body mass index (BMI) influence on natural course of aortic valve stenosis (AVS). PATIENTS: 60 AVS patients who did not agree for operational treatment were divided into group A (n = 15) with BMI 20-25, group B (n = 27) with BMI 25,01-30 and group C BMI > 30. METHODS: Plasma Lp(a), total cholesterol, HDL-cholesterol, LDL-cholesterol, triglycerides and C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor (TNF-alpha) as well as titers of immunoglobulin (Ig) class G, A, M against chlamydia pneumoniae were measured every 12 months. Echo-cardiographic evaluation of aortic valve was also done every 12 months. RESULTS: Means serum CRP at 12 month was the highest in group C. No differences in mean serum TNF-alpha and IL-6 levels as well as in Ig titers between groups A, B, C were found. At 12 month of observation HDL/total cholesterol ratio as well as HDL/LDL-cholesterol ratio were the lowest in group B. Left atrium diameter and right ventricle diameter were bigger in groups B and C compared to group A at the visit I and after 12 months of observation. Systolic intraventricular septum (IVS syst) thickness was the highest in group C at visit I. Diastolic left ventricle posterior wall thickness (LVPW) was the highest in group C during 12 months of observation. CONCLUSION: The increase in fat tissue mass may lead to increase in inflammatory process and cardiac muscle remodeling in AVS patients.

Architecture of intraluminal thrombus removed from abdominal aortic aneurysm.

Little is known about architecture of intraluminal thrombus (ILT) in abdominal aortic aneurysm (AAA). We present a 74-year-old woman with AAA and high cardiovascular risk. Scanning electron microscopy of ILT removed during surgery showed that its luminal layer is relatively rich in fibrin fibers forming irregular compact structure with low amounts of erythrocytes and platelets, while abluminal portion is composed of densely packed fibrin with caniculi. The structure of ILT may differ largely among AAA patients contrary to previous findings and may reveal large dense fibrin-rich areas deprived of cells, which impair fibrinolysis and stabilize the thrombus size.

[One year observation of natural course of aortic valve stenosis in patients with normal and abnormal lipoprotein (a) plasma level]. / Roczna obserwacja naturalnego przebiegu zwezenia lewego ujscia tetniczego u chorych z prawidlowym i podwyzszonym stezeniem lipoproteiny (a) w osoczu.

AIM: The observation of natural course of aortic valvae stenosis (AVS) in patients with high lipoprotein (a) [Lp(a)]. PATIENTS: 60 AVS patients who did not agree for operational treatment were divided into group A (n = 19) with high serum Lp(a) level and into group B (n = 41) with normal plasma Lp(a) level. METHODS: Plasma Lp(a), total cholesterol, HDL-cholesterol, LDL-cholesterol, triglycerides and C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor (TNF-alpha) as well as titers of immunoglobulin (Ig) class G, A, M against chlamydia pneumoniae were measured every 12 months. Echocardiographic evaluation of aortic valve was also done every 12 months. RESULTS: Means serum CRP at 12 month was higher in group A. Mean serum TNF-alpha level was also higher at visit I and at 12 month (visit II) in group A. Mean serum IL-6 level did not differ between groups. IgG titer was higher in group A at visit I and visit II. At 12 month of observation HDL-cholesterol plasma level was lower in group A. HDL/total cholesterol ratio as well as HDL/LDL-cholesterol ratio was laso lower in group A at 12 month of observation. No statistically significant differences in echocardiographic parameters were founf between groups. CONCLUSION: The results may suggest risk factors similarity of AVS and atherosclerosis.

[Natural course of aortic valve stenosis in patients with normal and abnormal lipid profile]. / Porównanie rocznej obserwacji naturalnego przebiegu zwezenia lewego ujscia tetniczego u pacjentów z prawidlowym i podwyizszonym stezeniem lipidów.

AIM: Comparison of echocardiographic findings in AVS patients with and without hypercholesterolemia during 12 months' observation of AVS natural course. PATIENTS: 60 AVS patients who did not agree for operational treatment were divided into group A (n = 47) with high serum total cholesterol and into group B (n = 13) with normal plasma cholesterol. METHODS: plasma total cholesterol, HDL-cholesterol, LDL-cholesterol, tri-glycerides and lipoprotein (a) were measured every 12 months and echocardiographic evaluation of aortic valve was also done every 12 months. RESULTS: Means total cholesterol did not change in group A, while increased in group B. HDL-cholesterol decreased in group A and LDL-cholesterol increased in group B. Mean TG and Lp(a) levels did not change in both groups. Increase in AOG max and AOG mean as well as V max were found only group A. LVPW syst increase was found in group A. LA diameter increased and AVA decreased only in group A. CONCLUSION: The results may suggest risk factors similarity of AVS progression and atherosclerosis.

Indications for transvenous lead extraction and its procedural and early outcomes in elderly patients: a single-center experience.

INTRODUCTION: Due to the prolonged survival of patients with cardiovascular implantable electronic devices, leads often need to be removed in elderly individuals. OBJECTIVES: We aimed to analyze indications for transvenous lead extraction (TLE), procedure effectiveness and safety, as well as 30­day follow­up in younger patients (≤80 years) and octogenarians (>80 years). PATIENTS AND METHODS: This prospective study included 667 patients who underwent TLE: 90 octogenarians (13.5%) at a mean age of 83.8 (range, 80.4-93) years and 577 younger patients (86.5%) at a mean age of 64.2 (range, 18.9-79.9) years. RESULTS: Octogenarians had a greater number of comorbidities, fewer implantable cardioverter­defibrillators implanted, and more frequently had infection as an indication for TLE, as compared with younger patients (33.3% vs 17.1%; P <0.001). In octogenarians, 138 leads were extracted, as compared with 894 leads in younger patients. Octogenarians and younger patients had similar rates of complete lead removal (98.6% and 97.1%, respectively; P = 0.48), total procedural success (97.8% and 96%, respectively; P = 0.7), major complications (0% and 1.6%, respectively; P = 0.45), and minor complications (2.2% and 1.6%, respectively; P = 0.45). There was 1 death associated with TLE in younger patients. Non-procedure­related deaths within 30 days after TLE were more frequent in octogenarians than in younger patients (5.6% vs 1.9%; P = 0.04). CONCLUSION: We showed that TLE in patients older than 80 years seems to be as effective as in younger patients; however, it is associated with significantly higher non-procedure­related 30­day mortality.

Sutureless aortic valve bioprothesis '3F/ATS Enable'--4.5 years of a single-centre experience.

BACKGROUND: Management of patients with acquired heart malformations, including aortic valve disease, is still challenging. Due to ageing of population, patients undergoing valve surgery are older than in the past. The 3F Therapeutics, conducting a programme of construction of heart valves for transarterial or transapical implatation, prepared the 'Enable' bioprosthetic valve for sutureless insertion in the aortic position. The first world implantation was performed in our Department on 13 January 2005. AIM: To present our experience, qualification criteria and methods of implantation of sutureless bioprosthesis of aortic valve 'Enable'. METHODS: The 'Enable' valve is a tubular structure, tailored and sutured of equine pericardium, treated with glutaraldehyde, and mounted on an openwork Nitinol" alloy stent. It consists of two distal rings connected with three vertical sticks. The characteristic property of nitinol is thermoplaticity: due to refrigeration it becomes elastic and easy to bend, after rewarming returns to the initial dimensions and shape, remaining stable at the body temperature. Distension of the nitinol ring make possible strong mounting of the valve in aortic annulus. The examined group consised of 27 patients (16 males, 11 females), aged 60-78 years (average 69.5), with advanced aortic valve disease, left ventricular hypertrophy, and aortic gradient up to 102 mmHg. Exclusion criteria were: severe annular deformations or bicuspid aortic valve, other valves' malformations, coronary disease, severe other comorbidities or no agreement for 'Enable' valve implantation. The patients were operated using extracorporeal circulation, general moderate hypothermia and cold crystalloid cardioplegia. Care was taken to remove calcifications, estimate of aortic annulus geometry, valve size selection, and orientation of the valve toward coronary ostia The mounting time was approximately one min, and the aorta cross-clamp time was reduced to 26-56 min, mean 30 min. RESULTS: There was no mortality in the perioperative period, and during 3 months to 4.5 years of follow-up. No severe complications were present after surgery. One patient needed reoperation on post operative day 4 due to severe perivalvular leak. One other patient presented discrete leak with no need for intervention. The clinical improvement of one to three NYHA classes was observed. Echocardiographic and MSCT examinations confirmed adequate position of the valves, no structural deteriorations, normal movement and coaptation of the leaflets. The average maximal transvalvular gradient was 11.6 mmHg and the mean gradient--6.8 mmHg, which remained stable during the follow-up period. No thromboembolic or infective complications were present. CONCLUSIONS: (1) The 'Enable' aortic bioprosthetic valve has very good hemodynamic properties. (2) Self-expanding thermoplastic nitinol-made ring allows permanent stable mounting. (3) The quick fixation (about 1 min) significantly shortens the operation time. (4) The 'Enable' valve seems to be suitable for patients with increased periopertive risk.

Effectiveness and safety of transvenous extraction of single- versus dual-coil implantable cardioverter-defibrillator leads at single-center experience.

The available literature lacks data concerning direct comparison of the effectiveness and safety of single- versus dual-coil implantable cardioverter-defibrillator (ICD) leads transvenous extraction. Certainly, additional shocking coil in superior vena cava adds to the amount of metal in the vascular system. Adhesions developing around the superior vena cava coil add to the difficulty of extraction of ICD lead if lead removal is required. The aim of the study was to assess the effectiveness and safety of single- and dual-coil ICD leads transvenous extraction using mechanical systems. We performed transvenous lead extraction (TLE) of 197 ICD leads in 196 patients. There were 46 (23.3%) dual-coil leads removed from 46 (23.5%) patients. Cardiovascular implantable electronic device-related infection was an indication for TLE in 25.0% of patients. The following extracting techniques were used: manual direct traction, mechanical telescopic sheaths, controlled-rotation mechanical sheaths, and femoral approach. Complete ICD lead removal and complete procedural success in both groups were similar (99.3% in single-coil vs 97.8% in dual-coil, P = .41 and 99.3% in single-coil vs 97.8% in dual-coil, P = 0.41, respectively). We did not find significant difference between major and minor complication rates in both groups (2.0% in single-coil vs 4.3% in dual-coil, and 0.7% in single-coil vs 0.0% in dual-coil, P = .58, respectively). There was 1 death associated with the TLE procedure of single-coil lead.This study shows that extraction of dual-coil leads seems to be comparably safe and effective to extraction of single-coil leads. On the other hand, it requires longer fluoroscopy time and frequent utilization of advanced tools.

Age effect on human aortic valvular glycoproteins.

BACKGROUND: The aortic valve has been the subject of many hemodynamic studies but, to our knowledge, posttranslational modification of human valve proteins has not yet been studied. Thus, the aim of this study was to determine whether any age-related changes in the protein composition of normal human aortic valves and their glycosylation pattern could be observed. METHODS: Aortic valves harvested from male cadaveric donors free of cardiovascular diseases were divided into four age groups: I, mean age 21 years; II, 30 years; III, 41 years; IV, 51 years. Proteins were separated by SDS-PAGE and transferred to PVDF membranes. Identification of monosaccharide moieties or oligosaccharide units was performed with the use of eight lectins of narrow specificity: Galantus nivalis agglutinin, Sambucus nigra agglutinin, Maackia amurensis agglutinin, Datura stramonium agglutinin, Aleuria aurantia agglutinin, Arachis hypogeae agglutinin, Phaseolus vulgaris agglutinin, and Lycopersicon esculentum agglutinin. RESULTS: Isolated proteins showed no age-related changes in SDS-PAGE protein profile, contrary to their glycosylation. Protein sialylation, number of tri/tetraantennary complex glycans, proteins having terminal galactose and polylactosaminyl units increased with age, whereas protein fucosylation showed the opposite relationship. Moreover, groups III and IV possessed a larger number of proteins bearing high-mannose and/or hybrid-type glycans, and the quantity of these structures seemed to change, in particular proteins, with the age of donors. CONCLUSIONS: Our results clearly demonstrate that glycosylation profile in human aortic proteins is associated with the age of the donor.

Clinical outcomes in patients after surgical and transcatheter aortic valve replacement.

INTRODUCTION: Transcatheter aortic valve implantation (TAVI) and minimally invasive aortic valve replacement (minithoracotomy and ministernotomy) have become a valuable alternative to conventional surgical treatment of severe aortic stenosis (AS) in high-risk patients. OBJECTIVES: The aim of the study was to evaluate long-term results and complications in patients with symptomatic AS treated with TAVI, surgical aortic valve replacement (SAVR), minithoracotomy, or ministernotomy. PATIENTS AND METHODS: A total of 173 patients with symptomatic AS were enrolled to the study between the years 2011 and 2013. Propensity scores were calculated for TAVI and each surgical method separately. Differences in clinical outcomes between patients treated with TAVI and those treated with surgical methods were adjusted for propensity scores using a logistic regression analysis and presented as adjusted odds ratios with 95% confidence intrervals. RESULTS: A median follow-up was 583.5 days (interquartile range, 298-736 days). Before aortic valve replacement (AVR), no significant differences in ejection fraction (EF) were observed between the groups. At 1 week after AVR, mean EF values were significantly higher in patients after TAVI in comparison with the other groups (TAVI, 50.2% ±13.1%; minithoracotomy, 44.1% ±13.4%; ministernotomy, 37.8% ±12.8%; SAVR, 40.3% ±12.5%; P = 0.001). There were no differences in the longest available follow-up mortality between the analyzed groups (P = 0.8). To our best knowledge, this is the first study comparing minithoracotomy, ministernotomy, and SAVR with TAVI in terms of long-term outcomes such as the longest available follow-up mortality, left ventricular (LV) function, complications after the procedure, and conduction disturbances and arrhythmias after the procedure. CONCULSIONS: Patients undergoing TAVI show more beneficial long-term outcomes in comparison with patients undergoing minithoracotomy, ministernotomy, and SAVR and do not differ in terms of the longest available follow-up mortality. TAVI seems to have a more favorable effect on LV function and an increase in EF in comparison with the surgical methods.

Mineralization and organic phase modifications as contributory factors of accelerated degeneration in homograft aortic valves.

BACKGROUND AND AIM OF THE STUDY: The study aim was to assess histological and mineralogical properties of leaflets in human, antibiotic-preserved aortic homograft valves (recovered during surgical replacement) in order to identify factors accounting for pathological changes leading to accelerated graft dysfunction. A comparison was made with aortic valves prepared for grafting, with a view to assessing morphological and mineralogical characteristics as a potential preimplantation risk factor. METHODS: Valve leaflets were examined with light and scanning electron microscopy. Mineralization was assessed histochemically, and also physicochemically by atomic absorption spectroscopy (AAS). RESULTS: All explanted homograft valve leaflets revealed prominent degenerative changes seen as decreased surface area, fibrosis, mineralization and focal thrombosis. Substantial loss of endothelium and fibroblasts, reduced collagen bundles crimping, inflammation (81%) and disappearance of layered structure (59%) was identified. The elastic elements were relatively stable, though a gradual age-dependent loss was observed in both groups. Accelerated mineralization was seen in all explanted homografts; inorganic deposits were composed mainly of hydroxyapatite. Two types of mineralization were identified: large limited nodular structures, and diffuse mineral deposits. Homografts with moderately elevated mineralization, well-preserved layered structure and sporadic infective changes proved to have the greatest durability. Homograft durability was also affected by the difference in host and donor age. CONCLUSION: Preimplantation factors affecting pathological changes determining homograft durability included morphological status of the graft itself and donor age; host-related factors included recipient age, endocarditis, native valve calcification, and host-donor matching (age difference between host and donor). A limited molecular mineralization may increase valvular durability, provided that no focal nodular calcifications exist that might adversely affect overall homograft integrity.

[Surgical treatment of mitral valve malformations--25 years of experience]. / Chirurgiczne leczenie wad zastawki mitralnej--25 lat doswiadczen.

During a period of 25 years (1979-2004), 24060 operations with extracorporeal circulation were performed. Of them 9536 (39.6%) were valvular procedures and 763 were combined with coronary bypass grafting. 4315 pts were operated (45.3% of valvular operations) because of mitral valve disease 5559 mitral valves were corrected, including multivalvular and combined procedures. Initially, mitral surgeries were predominant, but currently aortic valves are operated two times more frequently. In 85.5% of cases mitral valve replacement was necessary (with prosthetic valve), but 803 pts underwent reconstructive surgery (445 commissurotomies and 358 valvo/annuloplasties, including 135 implantations of annuloplasty rings). Additionally, 421 DeVega tricuspid valve annuloplasties were performed, and 15 tricuspid rings were implanted. Because of infective endocarditis 182 mitral valves were corrected, including the replacement of 78 infected prostheses. The pts age varied between 10 and 85. In 1980 the mean age was 40, but currently it has increased to 55, and the pts with coronary artery disease are approximately 10 years older. The general mortality among pts with ECC was 4.2% in 2003, and after valvular procedures 4%. The mortality after mitral valve replacement diminished from 12% to 4.5-5%, and after reconstructions was two times lower. The mortality among pts with endocarditis was 11.8%. Several characteristic trends were observed: increase of the number of elder pts, decrease of mitral valve procedures in comparison with aortic ones, more common coincidence of coronary artery disease, better preoperative status of the pts, and decrease of the operative risk.

[Asymptomatic carotid stenosis: ACS]. / Asymptomatyczna stenoza tetnic szyjnych.

Asymptomatic carotid stenosis (ACS) is the lesion located in the vicinity of the common carotid artery branching, without neurological symptoms caused by insufficient blood flow to the brain. Cerebrovascular diseases represent an important medical as well as social problem, since this is one of the leading causes of mortality and serious invalidity worldwide. Majority of brain insults are caused by stenosing atherosclerotic lesions of the carotid arteries. Thus, early surgical treatment may contribute to lessen this problem. Routine diagnosis of ACS include auscultation and ultra-sonographic examination of carotid arteries. Early detection of the disease enables proper medical prophylaxis and decision for surgical treatment (providing that expected benefit for the patient exceeds possible operative risk, i.e. < 3% of complication rate in experienced surgical wards). That's why of particular importance is to formulate multidisciplinary programs of insult prevention and to conduct multiinstitutional studies in order to establish clear cut indications for surgical treatment, particularly for the group of asymptomatic patients.

[Low ejection fraction as risk factor after aortic valve replacement]. / Niska frakcja wyrzutowa jako czynnik ryzyka w operacji wszczepiania sztucznej zastawki aortalnej.

UNLABELLED: The aim of the study is to estimate the operative risk of aortic valve replacement for severe aortic valve stenosis in patients with distinctly impaired left ventricular function (ejection fraction below 40%). From the population of 2512 pts, who underwent aortic valve replacement in the years 1990 to 1999 because of acquired malformation, a group of 108 pts (4.3%), fulfilling the above mentioned conditions was selected. Between them prevailed men, 92 (85.2%), and the average age was 53.4 +/- 14.5. All pts remained in the NYHA functional class III/IV. The average ejection fraction was estimated 28.2 +/- 14.3%. The pts demonstrated concentric left ventricular hypertrophy, severe aortic valve calcifications, the average valvular area was 0.91 cm2, and the pressure gradient over the valve was 71 +/- 44 mmHg. The pts were operated on by different surgeons but after the same protocol of extracorporeal circulation and cardioplegia administration. Low output syndrome occurred in ca 40% of pts, and cardiac failure was the main cause of death. The hospital mortality was 8.6%, and it was over two times higher then the whole population of pts, who underwent aortic valve replacement. All survivors (91.4%) demonstrated clinical improvement already during the early observation. CONCLUSIONS: Low ejection fraction is an important risk factor of surgery for aortic valve stenosis. However, the elevated operative mortality, comparable to other institutions, may be accepted taking for consideration, that surgery is the only way of treatment and improvement may be expected in about 90% of pts, including anatomical and hemodynamic parameters, as well as life longevity and comfort. In the extreme cases the HTX should be considered.

The risk of cholelithiasis in patients after heart transplantation.

INTRODUCTION: Extended immunosuppressive treatment in patients after heart transplantation modifies etiopathogenesis and occurrence of many diseases in this population. The aim of the present study was to evaluate the frequency and to define risk factors for cholelithiasis after heart transplantation (HTX). MATERIAL AND METHODS: The study population consisted of 176 subjects. Of them, 24 patients (group A) presented with symptomatic cholelithiasis. Another group of 24 patients without cholelithiasis (group B) served as controls. Both groups were similar with respect to age, gender and follow-up after the transplant. Clinical interview, surgical and hospitalization data were collected from medical records. RESULTS: The groups did not differ in demographic features. There were statistical differences (p < 0.05) between group A and B in rejection reaction, doses of immunosuppressive drugs, type 2 diabetes, serum lipid disorders and acute rejection episodes. These events were caused by modification of treatment, especially the immunosuppressive regimen. Group A consisted of 75% men and 25% women. The frequency of symptomatic cholelithiasis was 11.7% in men and 27.3% in women, on average 19.5%. Mean time to cholelithiasis following HTX was 37.9 ±4.9 (Me = 41.5) months, 27.7 ±8.2 (Me = 30.0) months in women and 41.3 ±5.9 (Me = 41.5) months in men. The female to male ratio was 2.3: 1. CONCLUSIONS: Cholelithiasis following HTX was significantly more frequent as compared with the non-transplant population. Patients with cholelithiasis required more aggressive immunosuppression because of more frequent episodes of acute transplant rejection. Patients with cholelithiasis significantly more frequently showed increased glycemia and blood lipids, which could be the side effect of intensive immunosuppressive therapy.