Danuta Sorysz

Left Ventricular Outflow Tract Gradient Provoked by Upright Position or Exercise in Treated Patients with Hypertrophic Cardiomyopathy without Obstruction at Rest

Objectives: The aim of the study was to assess inducibility of left ventricular outflow tract (LVOT) gradient by change of position from supine to upright and by treadmill exercise in treated patients with hypertrophic cardiomyopathy (HCM) without obstruction at rest. Methods: We studied 37 treated HCM patients (21 men and 16 women, mean age 44 ± 12 years) with LVOT gradient <30 mmHg at rest in supine position. The patients were then placed in upright position and the gradient was reexamined. The patients who developed LVOT gradient ≥30 mmHg during this maneuver were not exercised, whereas the remaining patients (nonobstructive in orthostatic position) performed moderate‐intensity exercise on a treadmill, with continuous monitoring of the LVOT gradient. For comparison with resting measurements, gradients at peak exercise (in upright position) and at recovery (in supine position) were used. The resting minimal distance between the mitral valve and ventricular septum at systole was used to assess the degree of narrowing of LVOT. Results: The orthostatic position provoked LVOT gradient ≥30 mmHg in 8 of 37 patients. At peak exercise, 10 of the remaining 29 patients developed significant LVOT gradient. At recovery in supine position, this significant gradient disappeared in 6 of 10 patients, despite only a short delay in measurement. Of resting echocardiographic parameters, only systolic mitral–septal distance differentiated between the provocable and nonprovocable subgroups. Patients with provocable gradient (either by changing position or by exercise) presented with lower values of this parameter than the nonprovacable subgroup. Conclusions: In nonobstructive HCM patients under treatment, the LVOT gradient was inducible by upright position in 21.6% and by upright moderate exercise in 34.5%. The minimal septal–mitral distance may be useful to identify patients with provocable obstruction.

Impact of frailty on mortality after transcatheter aortic valve implantation

Background We sought to investigate the relation between frailty indices and 12‐month mortality after transcatheter aortic valve implantation (TAVI). Methods We included 101 consecutive patients with severe aortic stenosis who have undergone TAVI. Frailty indices according to Valve Academic Research Consortium‐2 recommendations (5‐m walk test [5MWT] and hand grip strength) as well as other available scales of frailty (Katz index, Elderly Mobility Scale [EMS], Canadian Study of Health and Aging [CSHA] scale, Identification of Seniors at Risk [ISAR] scale) were assessed at baseline. The primary endpoint was 12‐month all‐cause mortality. Results Twelve‐month all‐cause mortality was 17.8%. According to 5MWT, 17.8% were frail; hand grip test: 6.9%; Katz index: 17.8%; EMS: 7.9%; CSHA scale: 16.9%; and ISAR scale: 52.5%. Associations between frailty indices and 12‐month all‐cause mortality after TAVI were significant in Cox regression analysis (frail vs not frail, presented as hazard ratio[95%CI] adjusted for logistic EuroSCORE): for 5MWT, 72.38 (15.95‐328.44); for EMS, 23.39 (6.89‐79.34); for CSHA scale, 53.97 (14.67‐198.53); for Katz index, 21.69 (6.89‐68.25); for hand grip strength, 51.54 (12.98‐204.74); and for ISAR scale, 15.94 (2.10‐120.74). Similarly, such relationship was confirmed when 5MWT, EMS, and CSHA were used as continuous variables (hazard ratio [95%CI] adjusted for logistic EuroSCORE: for 5MWT per 1‐second increase, 2.55 [1.94‐3.37]; for EMS per 1‐point decrease, 2.90 (1.99‐4.21); and for CSHA per 1‐point increase, 3.13 [2.17‐4.53]). Conclusions Our study confirmed a strong predictive ability of most of the proposed frailty indices for 12‐month mortality after TAVI. For patients scheduled for TAVI, the use of frailty indices, which are easy and quick to assess on clinical basis but with strong performance, for example, 5MWT, EMS, or hand grip test, may be advocated.

Short- and intermediate-term improvement of patient quality of life after transcatheter aortic valve implantation: a single-centre study

BACKGROUND Transcatheter aortic valve implantation (TAVI) is a treatment option for elderly high-risk patients with symptomatic severe aortic stenosis. Improvement of quality of life (QoL) is a relevant issue in this group of patients. AIM To assess changes in QoL after TAVI. METHODS Forty patients who underwent TAVI in our institution were included in this QoL study. All subjects were screened for TAVI in a standard fashion, including QoL assessment with the EQoL (EQ-5D-3L). The pre- and postprocedural scores obtained up to a 12-month follow-up were assessed. RESULTS Median of logistic EuroScore I was 21.5% (13.5-26.75%), and Society of Thoracic Surgeons score was 5.5% (4.0-10.75%). Comparison of baseline values with follow-up data at one, six and 12 months after TAVI showed significant improvement of QoL (p < 0.001). Visual Analogue Scale score (VAS score) was assessed. There was an incremental increase in VAS score during follow-up (p < 0.001). Median of six-minute walk test distance at baseline was 200 m (IQR 150-300) and 325 m (IQR 250-400) 12 months after TAVI (p < 0.001). CONCLUSIONS TAVI provides improved QoL and effectively relieves symptoms.

Circulating N-terminal brain natriuretic peptide precursor and endothelin levels in patients with syndrome X and left bundle branch block with preserved systolic function

BACKGROUND Deterioration of left ventricular function during follow-up was reported in some patients with syndrome X and concomitant left bundle branch block. The patients with syndrome X and left bundle branch block has been frequently presented with elevated Endothelin-1 (ET-1) level while brain natriuretic peptide (BNP) (a sensitive marker of left ventricular dysfunction) has not been measured in patients with syndrome X. METHODS The purpose of the present study was to assess left ventricular diastolic function, levels of N-terminal Brain Natriuretic Peptide (NT-proBNP) precursor and biochemical parameters of endothelial function in patients with syndrome X complicated by left bundle branch block but preserved left ventricular systolic function (group A, n=8). The echocardiographic and neurohormonal measures in these patients were compared to those in patients with syndrome X without left bundle branch block (group B, n=13), and controls (group C, n=15). RESULTS At rest and after exercise the serum concentration of NT-proBNP was significantly higher in group A than in the controls (at rest: 232+/-96 vs. 133+/-23 fmol/ml, P=0.03; after exercise: 313+/-96 vs. 180+/-33 fmol/ml, P=0.02). The highest concentration of endothelin-1 was also found in group A, being significantly higher than in the controls (6.81 vs. 4.52 pg/ml, P<0.05). Mitral flow abnormalities were detected in left bundle branch block patients. Accordingly, the lowest E/A ratio was in group A and it differed significantly from that in group C (0.85 vs. 1.1, P<0.05). E/A ratio inversely correlated with plasma NT-proBNP concentration in patients with left bundle branch block (r=-0.48, P=0.02). CONCLUSIONS Elevated NT-proBNP and endothelin-1 plasma concentrations were demonstrated in patients with syndrome X complicated by left bundle branch block even when left ventricular systolic function was still preserved. In this subgroup the magnitude of left ventricular diastolic dysfunction correlated with the increase of BNP level which reflects neurohormonal activation.

Early- and mid-term outcomes after transcatheter aortic valve implantation. Data from a single-center registry

Introduction Transcatheter aortic valve implantation (TAVI) is a less invasive treatment option for elderly, high-risk patients with symptomatic severe aortic stenosis (AS) than aortic valve replacement. More importantly, TAVI improves survival and quality of life as compared to medical treatment in inoperable patients. Aim To assess early- and mid-term clinical outcomes after TAVI. Material and methods All consecutive high-risk patients with severe symptomatic AS undergoing TAVI from November 2008 to August 2014 were enrolled. The clinical and procedural characteristics, as well as clinical outcomes including mortality during 12-month follow-up, were assessed. Results A total of 101 consecutive patients underwent TAVI for native aortic valve stenosis (100%). Patients were elderly, with a median age of 81.0 (76.0–84.0) years, 60.4% were female and 83.2% presented with NYHA III/IV. Median baseline EuroSCORE I and STS scores were 14.0 (10.0–22.5)% and 12.0 (5.0–24.0)%, respectively. The main periprocedural and in-hospital complications were minor vascular complications, bleeding requiring blood transfusions, and the need for a permanent pacemaker. In-hospital, 30-day, 6-month and 12-month mortality rates were 6.9%, 10.9%, 15.8% and 17.8%, respectively. Conclusions A mortality rate of < 20% after 12 months seems acceptable given the high-risk population enrolled.

Association Between Blood Transfusions and 12-Month Mortality After Transcatheter Aortic Valve Implantation

Blood transfusions are considered as an important predictor of adverse outcome in patients with severe aortic (AS) undergoing transcatheter aortic valve implantation (TAVI). We sought to investigate the association between blood transfusions and mortality after TAVI. We enrolled 101 consecutive patients with severe AS undergoing TAVI. Patients who required transfusion were defined as patients in whom at least one unit of packed red blood cells (PRBCs) was transfused in the perioperative period. Twelve-month outcomes were assessed based on Valve Academic Research Consortium definitions. A total of 28 (27.7%) patients required blood transfusion after TAVI. Baseline characteristics of the patients with and without a transfusion were similar. Median amount of PRBCs was 2 (interquartile range, 2-4). Twelvemonth all-cause mortality was higher in patients with than without a blood transfusion (39.3% versus 9.6%; P = 0.001). Importantly, the need for a blood transfusion after TAVI was an independent predictor of higher mortality rates after 12 months (hazard ratio (HR) 2.84 95%CI (1.06-7.63); P = 0.039; (HR for incomplete coronary revascularization 10.86, 95%CI 3.72-31.73; P < 0.001; HR for a history of stroke/TIA 3.93, 95%CI 1.39-11.07; P < 0.001). The duration of inhospital stay was longer in patients requiring transfusion (16.0 (14.0-22.0) versus 7.0 (7.0-11.5) days; P = 0.014). In conclusion, blood transfusions after TAVI were associated with higher mortality rates after 12 months, longer in-hospital stay, and were identified as an independent predictor of impaired clinical outcome.

Acute and long-term outcomes of percutaneous balloon aortic valvuloplasty for the treatment of severe aortic stenosis.

This study aimed to evaluate the indications, short‐ and long‐term outcomes of balloon aortic valvuloplasty (BAV) in patients with severe aortic stenosis (AS).

Long-term follow-up of mesh-covered stent implantation in patients with ST-segment elevation myocardial infarction

BACKGROUND The MGuard stent (a bare-metal stent wrapped externally in a polymer mesh sleeve) was introduced to reduce the risk of distal embolisation and no-reflow phenomenon during percutaneous coronary intervention (PCI) in thrombus containing lesions, including ST-segment elevation myocardial infarction (STEMI). However, data on the long-term performance of the MGuard stent is limited. AIM To assess the long-term safety and efficacy of MGuard stent implantation during primary PCI for STEMI. METHODS AND RESULTS In this multicentre study, a total of 60 patients with STEMI ≤12 h treated with the MGuard stent were enrolled. Angiographic success of PCI was achieved in 96.7%, with the final TIMI grade 3 flow in 90.0% of patients. At six months, the overall rate of major adverse cardiac and cerebrovascular events (MACCE; composite of cardiac death, nonfatal target vessel reinfarction, target lesion revascularisation, and stroke) was 1.7%. A long-term follow-up of the study was successfully performed in 57 patients (mean follow-up of 38.7 ± 3.1 months). The long-term cardiac mortality was 7.0%, with a MACCE rate of 8.8%. There was no decrease in the left ventricular ejection fraction and no enlargement of the left ventriclebetween index and long-term follow-up echocardiogram. CONCLUSIONS The early safety and efficacy of the MGuard stent was maintained during the long-term follow-up. However, comparative data from ongoing randomised clinical trials are still required to confirm the long-term efficacy of MGuard stent implantation in patients with STEMI.

Twelve-Month Quality of Life Improvement and All-Cause Mortality in Elderly Patients Undergoing Transcatheter Aortic Valve Replacement:

Purpose Restoration of quality of life (QoL) and improvement of clinical outcomes is crucial in elderly patients undergoing transcatheter aortic valve implantation (TAVI). We sought to evaluate changes in QoL and all-cause mortality 12 months after TAVI. Methods A total of 101 patients who underwent TAVI were included. Patients were followed for 12 months. QoL was assessed at baseline and at 1, 6 and 12 months after TAVI using EQ-5D-3L with a visual analog scale (VAS). Results Patients who reported some problems with mobility at baseline showed better mobility after 12 months (p = 0.001). On the other hand, those who reported issues with self-care, usual activity or pain did not show significant improvement (p = 0.41; p = 0.12; p = 0.27, respectively). Patients reporting anxiety at baseline improved 12 months later (p = 0.003). VAS score showed an incremental increase during follow-up (p<0.001). Transfemoral access was associated with higher VAS score values after 1 month (median (IQR): 65.0 (50.0–75.0) vs. 54.0 (50.0–60.0); p = 0.019) but not after 12 months (70.0 (62.5–80.0) vs. 67.5 (55.0–70.0); p = 0.07) as compared to non-transfemoral access. In multivariable regression analysis, only age and the presence of coronary chronic total occlusion were independently associated with VAS score at 12 months. In-hospital, 1-, 6- and 12-month mortality rates were 6.9%, 10.9%, 15.8 and 17.8%, respectively. Conclusions TAVI provides improved QoL with relatively good clinical outcomes. However, not all components of QoL may be improved. Patients treated with transfemoral access might have better QoL than those who had non-transfemoral access, especially early after TAVI.

Assessment of quality of life in patients after surgical and transcatheter aortic valve replacement.

Transcatheter aortic valve implantation (TAVI) and minimally invasive aortic valve replacement (mini‐thoracotomy, mini‐sternotomy, MIAVR) have become an appealing alternative to conventional surgical (SAVR) treatment of severe aortic stenosis (AS) in high‐risk patients.