Results of aortic valve replacement for aortic stenosis and moderate functional mitral regurgitation

Background: Referral and admission echocardiography (ECHO) in patients scheduled for aortic valve replacement (AVR) with aortic stenosis (AS) may differ in the assessment of moderate functional mitral regurgitation (FMR). Aims: Our study was to determine the truly moderate-FMR and evaluate its impact on survival. Methods: We conducted an observational study of patients referred for AVR with AS and up to moderate FMR, between 2014 and 2019. Patients were divided into three groups: (1) no/mild (N-FMR); (2) moderate-FMR on one ECHO (either at referral or admission) termed incidental (I-FMR); (3) moderate FMR in two studies (both at referral and admission) termed permanent (PM-FMR). Results: The referral and admission assessment were performed median 35 days apart. Of the 679 elective patients who underwent elective isolated AVR, 516 patients had N-FMR, 102 patients had I-FMR, and 61 patients had PM-FMR. Median follow-up was 46 months (22.5–58.5); max 73.3. 30-day mortality was 2.5% vs. 1% vs. 8.2% (N-FMR vs. I-FMR vs. PM-FMR, respectively; P = 0.01). Five-year survival was 84.1% in N-FMR vs. 88.5% in I-FMR vs. 60.6% in PM-FMR group, where was the lowest (P <0.001). In multivariable modeling PM-FMR increased mortality (hazard ratio [HR], 1.88 [1.05–3.37]; P = 0.03). The I-FMR had no effect on mortality (HR, 0.67 [0.32–1.37]; P = 0.28). Five-year survival after excluding 30-day mortality was 86.3% vs. 89.4% vs. 66.0%; (N-FMR vs. I-FMR vs. PM-FMR, respectively; P = 0.02). The PM-FMR increased late mortality (HR, 2.17 [1.14–4.15]; P = 0.01). Conclusions: In patients undergoing isolated AVR for AS, the presence of permanent moderate FMR significantly impacts 30-day and mid-term survival

Epicardial, paracardial, and perivascular fat quantity, gene expressions, and serum cytokines in patients with coronary artery disease and diabetes

INTRODUCTION Obesity and diabetes mellitus (DM) are common disorders that increase cardiovascular risk and lead to coronary artery disease (CAD). OBJECTIVES The aim of our study was to assess the link between epicardial fat (EF) volume and paracardial fat (PF) volume, relative expressions of several genes in epicardial, paracardial, and perivascular fat and corresponding serum cytokines in patients with CAD in relation to DM. PATIENTS AND METHODS A total of 66 consecutive patients (33 with DM) with multivessel CAD were included. We obtained cardiac magnetic resonance, serum cytokines levels, and their relative mRNA expressions in EF, PF, and perivascular fat samples of the following: adrenomedullin (ADM), fibroblast growth factor 21 (FGF21), transforming growth factor β (TGFβ), phospholipid transfer protein (PLTP), receptor for advanced glycation endproducts (RAGE), thrombospondin 1 (THSB1), and uncoupling protein 1 (UCP1). RESULTS There were no differences in the anthropometric parameters or fat depots, except for higher epicardial fat volume in patients with DM (mean [SD], 105.6 [38.5] ml vs 84 [29.2] ml; P = 0.02). Patients with DM exhibited a significantly increased RAGE expression in EF (median [Q1–Q3], 0.17 [0.06–1.48] AU vs 0.08 [0.02–0.24] AU, P = 0.03). Diabetes was also associated with increased expression of ADM in EF and PF and decreased expression of FGF21 compared with patients without DM. CONCLUSIONS Patients with multivessel CAD and DM revealed increased volume and more dysfunctional profile of gene expressions in EF and significantly decreased expression of cardioprotective FGF21

Safety and efficacy of embolic protection devices in saphenous vein graft interventions : a propensity score analysis-multicenter SVG PCI PROTECTA study

Background: Evidence concerning the efficacy of the embolic protection devices (EPDs) in saphenous vein graft (SVG) percutaneous coronary intervention (PCI) is sparse. The study was designed to compare major cardiovascular events of all-comer population of SVG PCI with and without EPDs at one year of follow-up. Methods and results: A multi-center registry comparing PCI with and without EPDs in consecutive patients undergoing PCI of SVG. The group comprised 792 patients, among which 266 (33.6%) had myocardial infarction (MI). The primary composite endpoint was major adverse cardiac and cerebrovascular event (MACCE) defined as death, MI, target vessel revascularization (TVR), and stroke assessed at one year. After propensity score analysis, there were no differences in MACCE (21.9% vs. 23.9%; HR 0.91, 95% CI 0.57–1.45, p = 0.681, respectively) nor in secondary endpoints of death, MI, TVR, target lesion revascularization (TLR) and stroke at one year in EPDs PCI group vs. no-EPDs PCI group. Similarly, there were no differences between groups in the study endpoints at 30 days follow-up. Conclusions: There were no clinical benefit for routine use of EPDs during SVG PCI in short and long-term follow-up. Further studies are warranted to explore the effect of individual types of EPDs on clinical outcomes

Total arterial revascularization coronary artery bypass surgery in patients with atrial fibrillation

Background: Atrial fibrillation (AF) is a relatively common comorbidity among patients referred for coronary artery bypass grafting (CABG) associated with poorer prognosis. However, little is known about how surgical technique influences survival in this population.Aim: The aim of the current analysis was to determine whether total arterial revascularization (TAR) is associated with improved long-term outcomes in patients with preoperative AF.Methods: We analyzed patient’s data from a HEIST (HEart surgery In atrial fibrillation and Supraventricular Tachycardia) registry. The registry, to date, involves five tertiary high-volume centers in Poland. Between 2006 and 2019, 4746 patients presented with pre-operative AF and multivessel coronary artery disease and underwent CABG. We identified cases of TAR and used propensity score matching to determine non-TAR controls. Median follow-up was 4.1 years (IQR, 1.9–6.8).Results: Propensity matching resulted in 295 pairs of TAR vs. non-TAR. The mean (standard deviation [SD]) number of distal anastomoses was 2.5 (0.6) vs. 2.5 (0.6) (P = 0.94) respectively. Operative and 30-day mortality were not different between TAR and non-TAR patients (hazard ratio [HR] and 95% confidence intervals [CIs], 0.17 (0.02–1.38); P = 0.12 and 0.74 [0.40–1.35]; P = 0.33), respectively. On contrary, TAR was associated with a nearly 30% improved late survival: HR, 0.72 (0.55–0.93); P = 0.01. This benefit was sustained in subgroup analyses, yet most appraised in low-risk patients (<70 years old; EuroSCORE II <2; no diabetes) and when off-pump CABG was performed.Conclusions: TAR in patients with pre-operative AF is safe and associated with improved survival with particular survival benefit in younger low-risk patients undergoing off-pump CABG

Perivascular adipose tissue from the internal mammary artery in patients with severe coronary artery atherosclerosis

Background: he internal mammary artery (IMA) is routinely used as an arterial graft for coronary artery bypass grafting with an excellent long‑term patency rate, but its protective mechanism is unclear. Aims: We evaluated the differences between the expression of several gene in perivascular adipose tissue from the IMA (PVAT‑IMA) as compared with other fat depots in patients with severe coronary artery disease. Methods: A total of 53 patients (13 women) with severe coronary artery disease and preserved left ventricular ejection fraction were scheduled for coronary artery bypass grafting. Clinical assessment, anthropometric parameters, and quantification of fat depots were performed in all patients. The relative expression of the following genes were obtained in PVAT‑IMA, as well as epicardial, pericardial, and subcutaneous (SF) fat samples: angiotensinogen (AGT), angiotensin I converting enzyme 1 and 2 (ACE1and ACE2), glucagon‑like peptide receptors type 1 and 2 (GLP1R and GLP2R), phospholipid transfer protein (PLTP), adiponectin (ADIPOQ), omentin‑1 (ITLN1), and uncoupling protein 1 (UCP1). Results: The expression of UCP1 (median [interquartile range [IQR], 2.5 [0.91–16.6]; P < 0.01) and AGT(2.22 [0.65–6.2]; P < 0.01) was higher in PVAT‑IMA compared with the SF depot. ADIPOQ expression was lower in pericardial and epicardial fat depots (median [IQR], 0.44 [0.23–2.3]; P < 0.01). The expression of ITLN1 was increased in PVAT‑IMA as compared with epicardial and pericardial fat (P < 0.001). Conclusions: PVAT‑IMA revealed differences in the expression of selected genes in relation to SF. We found a higher expression of ITLN1 in PVAT‑IMA compared with other adipose tissue depots, which could be associated with protective mechanisms against atherosclerosis in IMA. However, this remains a subject for further studies

Hartowanie na odległość ludzkiej mięśniówki serca — protokół badania klinicznego

Background: Remote preconditioning has been shown to be a potent protective phenomenon in many animals. Several studies aimed to demonstrate it was feasible in humans by trying to show its protective effect during cardiac surgery. Of these, some small studies and one larger trial were positive while two other bigger studies showed no effectiveness of remote preconditioning as assessed by levels of postoperatively released cardiac markers. Recently, two large clinical trials also failed to prove the benefit of remote preconditioning in cardiac surgery. No study showed that remote preconditioning actually increases resistance of human myocardium to standardised ischaemic and reperfusion stimulus in experimental settings. In animal studies, remote preconditioning was shown to improve mitochondrial function and structure, but such data on human myocardium are scarce. Aim: The aim of the study is to determine whether remote preconditioning protects human myocardium against ischaemia-reperfusion injury in both in vivo and in vitro conditions. Methods: The trial is designed as a single-centre, double-blinded, sham-controlled trial of 120 patients. We randomise (1:1) patients referred for coronary artery bypass grafting for stable coronary artery disease to remote preconditioning or “sham” intervention. The remote preconditioning is obtained by three cycles of 5 min inflation and 5 min deflation of a blood pressure cuff on the right arm. Postoperative course including myocardial enzymes profile will be analysed. Moreover, in the in-vitro arm the clinically preconditioned myocardium will be assessed for function, mitochondria structure, and mitochondria-dependent apoptosis. The informed consent of all patients is obtained before enrolment into the study by the investigator. The study conforms to the spirit and the letter of the declaration of Helsinki. Results and conclusions: In case the effect of remote preconditioning is not measurable in ex-vivo assessment, any future attempt at implementing this phenomenon in clinical practice may be futile and should not be continued until the effect can be confirmed in a controlled experimental setting. The study might therefore indicate future directions in trials of clinical implementation of remote preconditioning. Trial Registration: Clinical Trials Register (Clinicaltrials.gov) identifier: NCT01994707. The study was approved by Institutional Review Board of the Medical University of Silesia (KNW/0022/KB1/160/12).Wstęp: Hartowanie na odległość traktowane jest jako zjawisko mogące wywierać potencjalnie efekty ochronne u różnych zwierząt. Kilka badań zostało zaprojektowanych w celu wykazania występowania tego efektu u człowieka podczas operacji kardiochirurgicznych. Wśród tych badań można znaleźć kilka małych badań i jedno większe, których wyniki były pozytywne, podczas gdy dwa inne większe badania wykazały brak skuteczności hartowania na odległość. Ich efekt oceniano poprzez stężenie enzymów martwicy mięśnia sercowego w okresie pooperacyjnym. W ostatnich dwóch dużych badaniach klinicznych z 2015 r. nie wykazano zalet hartowania na odległość w przypadku zabiegów kardiochirurgicznych. Dotychczas nie przeprowadzono badań wykazujących, że hartowanie na odległość rzeczywiście zwiększa odporność serca u ludzi na standaryzowane niedokrwienie i reperfuzję wywoływane w warunkach doświadczalnych. W badaniach przeprowadzonych na zwierzętach wykazano hartowanie na odległość mitochondriów i poprawę struktury mitochondriów, ale takie dane o ludzkich kardiomiocytach są rzadkie. Cel: Celem badania było określenie, czy hartowanie na odległość chroni ludzką mięśniówkę serca przed urazem niedokrwienno-reperfuzyjnym w warunkach in-vivo i in-vitro. Metody: Badanie zostało zaprojektowane jako jednoośrodkowe, podwójnie zaślepione, z grupą badaną i kontrolną obejmującą łącznie 120 pacjentów. Chorych zakwalifikowanych do zabiegu pomostowania aortalno-wieńcowego ze stabilną postacią choroby wieńcowej randomizowano (1:1) do grupy hartowania na odległość lub do grupy kontrolnej. Procedura hartowania na odległość obejmowała 3 cykle 5-minutowego napełnienia i 5-minutowego spuszenia powietrza z mankietu do mierzenia ciśnienia założonego na prawę ramię pacjenta. W okresie pooperacyjnym analizowano wartości enzymów martwicy mięśnia sercowego. Ponadto w warunkach in-vitro oceniano funkcję hartowanego miokardium, strukturę mitochondriów oraz stopień zachodzącej apoptozy. Uzyskanie pisemnej zgody od pacjentów było warunkiem włączenia do badania. Badanie realizowano zgodnie z zasadami deklaracji helsińskiej. Wyniki i Wnioski: W sytuacji gdy efekt hartowania na odległość nie okazałby się być mierzalny w warunkach oceny ex-vivo, próby stosowania niniejszego zjawiska w praktyce klinicznej w przyszłości mogą być nieskuteczne i nie powinny być kontynuowane, dopóki efekt hartowania na odległość nie zostanie potwierdzony w warunkach eksperymentalnych. Badanie może tym niemniej wskazać przyszłe kierunki badań klinicznych nad hartowaniem na odległość. Rejestracja badania: Clinical Trials Register (Clinicaltrials.gov) identyfikator: NCT01994707. Badanie uzyskało zgodę Komisji Bioetycznej Śląskiego Uniwersytetu Medycznego w Katowicach (KNW/0022/KB1/160/12)