Dawid Miśkowiec

Independent predictors of early mortality after coronary artery bypass grafting in a single centre experience — does gender matter?

BACKGROUND It is commonly believed that women undergoing isolated coronary artery bypass graft surgery (CABG) are subject to a higher risk of perioperative complications and death. AIM To evaluate the effect of sex as a risk factor on early complications and mortality after isolated CABG performed with cardiopulmonary bypass, and to evaluate the profile of the risk determined by the patients sex. METHODS Data derived from 2,194 surgical procedures performed in the Department of Cardiac Surgery at the Medical University of Lodz between January 2009 and March 2011 was analysed. The database was constructed on the basis of retrospective analysis of variables contained in a form of the National Registry of Cardiac Surgery. RESULTS Isolated CABG with cardiopulmonary bypass was carried out in 1,303 patients (59.4% of all procedures). Women constituted the minority of patients (24.2%), and were significantly older (mean age 67.3 vs. 62.8 years, p < 0.001). They more often suffered from concomitant diabetes (43.1% vs. 33.41%, p = 0.003), had impaired renal function (median eGFR 88.5 vs. 95.0 mL/min1/1.73 m2, p < 0.001), and had a history of smoking in fewer cases (54.1% vs. 83.0%, p < 0.001). Internal mammary artery was more rarely used as arterial graft in the group of women (84.8% vs. 95.0%, p < 0.001). Women were subject to a higher risk of recent postoperative myocardial infarction (5.5% vs. 2.9%, p = 0.03) and required reoperation more rarely than men (4.5% vs. 8.1%, p = 0.04). Higher 30-day mortality was observed among women (7.6% vs. 2.8%, p < 0.001) and female sex appeared to be an independent predictor of death in the multiple logistic regression analysis (OR = 1.8; 95% CI 1.2-2.7). CONCLUSIONS Women undergoing isolated CABG are subject to higher 30-day mortality. Female sex is an independent risk factor for death after isolated CABG. Further studies are necessary to identify causes of differences in prognoses among women.

Bicuspid aortic valve morphology and its impact on aortic diameters-A systematic review with meta-analysis and meta-regression

To evaluate the impact of the 2 most common bicuspid aortic valve (BAV) morphology patterns [right‐left (RL) vs right‐noncoronary (RN) cusp fusion] on the aortic diameters and the impact of gender, aortic stenosis (AS), aortic regurgitation (AR), and age on the observed effects.

The differences in the relationship between diastolic dysfunction, selected biomarkers and collagen turn-over in heart failure patients with preserved and reduced ejection fraction.

BACKGROUND The aim of the study was to assess the correlation of the selected biomarkers and collagen turn-over indices with advanced echocardiographic parameters among patients with preserved and reduced ejection fraction (EF). METHODS We included 62 patients with the symptomatic heart failure. The patients were divided in to two groups according to the evaluated ejection fraction (EF - Simpson method): heart failure with reduced ejection fraction (HFrEF) group - 30 patients with low EF - 35-50% (16 male, mean age 54.9 ± 12.6), heart failure with preserved ejection fraction (HFpEF) group - 32 patients with EF > 50% (16 male, mean age 62.3 ± 7.6). Clinical evaluation included 6-min walk test, biochemistry, procollagen type I N-terminal propeptide (PINP), procollagen type III N-terminal propetide (PIIINP), matrix metaloproteinase-2 (MMP2), ghrelin, and galectin-3 levels measurements. Echocardiographic examination was performed with analysis of diastolic function and global longitudinal strain (GLS). RESULTS The GLS in the HFrEF group was significantly lower than in the HFpEF group at the baseline (GLS: 9.56 vs. 16.03, p < 0.01). There was a strong negative correlation of the PIIINP and GLS in HFrEF group (r = -0.74, p = 0.005), but only a moderate negative correlation in HFpEF (r = -0.55, p = 0.02). In the HFrEF group, there was a moderate negative correlation between the baseline level of galectin-3 and GLS (r = -0.59, p = 0.03). The correlation of ghrelin and tissue inhibitor of matrix metalloproteinase-1 with EF in the HFrEF group was moderate and statistically significant (r = 0.62, p = 0.02 and r = -0.63, p = 0.02, respectively). CONCLUSIONS Procollagen type III peptide has a strong negative correlation with left ventricular GLS. Galectin-3 relationship with strain may indicate novel pathophysiological pathways and requires further investigation.

Bicuspid aortic valve morphology and its association with aortic diameter: an echocardiographic study

BACKGROUND Bicuspid aortic valve (BAV) is strongly associated with aortopathy. Previous studies have suggested that various types of bicuspid aortic valve morphology may differently affect the aortic dilatation. AIM To evaluate the impact of BAV cusp fusion morphology (type I - right-left coronary cusp fusion; type II - right-noncoronary cusp fusion) on the diameters of the aorta. METHODS BAV morphology was evaluated retrospectively in a group of 67 consecutive patients with BAV. The control group comprised 1000 randomly selected patients with normal tricuspid aortic valve. Aortic dimensions and other echocardiographic parameters were obtained from the echocardiography database of our department. The diameters of aorta in both BAV sub-types were evaluated at the level of: annulus, the sinus of Valsalva, the sinotubular junction, and the ascending aorta and at the level of the ascending aorta in the control group. RESULTS Patients with BAV were mainly male (78%), with a mean age of 55.3 ± 16.7 years. The dominant morphology of BAV in the study group was type I (n = 46; 69%). It was associated with increased aortic dimension in comparison to type II BAVs at the level of the sinuses of Valsalva (38.4 ± 5.2 vs. 34.0 ± 4.6 mm, p = 0.002), the sinotubular junction (33.1 ± 5.8 vs. 29.6 ± 5.0 mm, p = 0.035), and the ascending aorta (41.6 ± 7.1 vs. 36.6 ± 6.1 mm, p = 0.006). Indexed aortic diameter was also increased in type I BAV at the level of sinuses of Valsalva (19.6 ± 2.7 vs. 18.1 ± 1.6 mm/m2, p = 0.008) and the ascending aorta (21.3 ± 3.4 vs. 19.3 ± 3.4 mm/m2, p = 0.048). The dimensions of the ascending aorta exceeding the upper normal range limit based on control-group measurements (44.3 mm) were observed more frequently in type I than in type II (33% vs. 10%, p = 0.044). Aortic regurgitation (moderate or severe) occurred in similar percentages of both BAV subtypes (type I: 37% vs. type II: 33%, p = 0.774). There were also no significant differences in aortic valve area (2.2 ± 1.1 vs. 2.0 ± 1.4 cm2, p = 0.163), indexed aortic valve area (1.1 ± 0.6 vs. 1.0 ± 0.6, p = 0.337), peak transvalvular gradient (35.3 ± 20.5 vs. 39.1 ± 28.9 mm Hg, p = 0.862), and mean gradient (18.6 ± 12.3 vs. 22.7 ± 18.2 mm Hg, p = 0.571) and left ventricular ejection fraction (51.8 ± 11.6 vs. 51.8 ± 12.2%, p = 0.978) between type I and type II BAV groups. CONCLUSIONS Type I BAV cusp fusion morphology is more commonly associated with dilatation of the aorta than type II, especially at the level of the sinus of Valsalva and the ascending aorta.

Left Atrial Dysfunction Assessed by Two-Dimensional Speckle Tracking Echocardiography in Patients with Impaired Left Ventricular Ejection Fraction and Sleep-Disordered Breathing.

To evaluate the relationship between left atrial (LA) structure and deformation obtained by two‐dimensional speckle tracking echocardiography (2DSTE): peak longitudinal systolic strain (LAs), peak longitudinal systolic strain rate (LAS‐SR), peak longitudinal early diastolic strain rate (LAE‐SR), peak longitudinal late diastolic strain rate (LAA‐SR), and sleep‐disordered breathing (SDB) estimated by means of apnea–hypopnea index (eAHI).

Diabetes as an independent predictor of left ventricular longitudinal strain reduction at rest and during dobutamine stress test in patients with significant coronary artery disease

Aims Diabetes (DM) is a strong cardiovascular risk factor modifying also the left ventricular (LV) function that may be objectively assessed with echocardiographic strain analysis. Although the impact of isolated DM on myocardial deformation has been already studied, few data concern diabetics with coronary artery disease (CAD), especially in all stages of dobutamine stress echocardiography (DSE). We compared LV systolic function during DSE in CAD with and without DM using state-of-the art speckle-tracking quantification and assessed the impact of DM on LV systolic strain. Methods and results DSE was performed in 250 patients with angina who afterwards had coronarography with ≥50% stenosis in the left main artery and ≥70% in other arteries considered as significant. In this analysis, we included 127 patients with confirmed CAD: 42 with DM [DM(+); mean age 64 ± 9 years] and 85 patients without DM [DM(-); mean age 63 ± 9 years]. The severity of CAD and LV ejection fraction (EF) were similar in both groups. Global and regional LV peak systolic longitudinal strain (PSLS) revealed in all DSE phases lower values in DM(+) group: 14.5 ± 3.6% vs. 17.4 ± 4.0% at rest; P = 0.0001, 13.8 ± 3.9% vs. 16.7 ± 4.0% at peak stress; P = 0.0002, and 14.2 ± 3.1% vs. 15.5 ± 3.5% at recovery; P = 0.0432 for global parameters, although dobutamine challenge did not enhance further resting differences. LV EF, body surface area, and diabetes were independent predictors for strain in 16-variable model (R2 = 0, 51, P < 0.001). Conclusion PSLS although diminished in both groups with CAD was lower in diabetics at all DSE stages, and DM was an independent predictor of this impairment. However, the dobutamine challenge did not deepen the resting differences, suggesting that the direct impact of coronary stenoses effaces the influence of DM during DSE. The comparison with our previous data revealed synergistic, detrimental effect of coexisting CAD and DM on myocardial strain.

Systolic longitudinal strain correlates with visual assessment of regional left ventricular function during dobutamine stress echocardiography and discriminates the segments with induced contractility impairment

The relationship between visual and strain assessment of left ventricular (LV) function during dobutamine stress echocardiography (DSE) remains poorly investigated. We assessed systolic longitudinal strain (SLS) and strain rate (SLSR) in segments visually graded as normokinetic, hypokinetic, or akinetic at baseline (0) and peak stage (1) of DSE and compared deformation changes between segments with and without induced contractility worsening.

Bicuspid aortic valve and aortopathy — conundrum still unsolved?

We would like to thank Dr Ozturk et al. [1] for their interest in our recent article regarding the impact of bicuspid aortic valve (BAV) morphology on the aortic diameter and for their insightful comments concerning the methodology of our study [2]. The reported echocardiographic measurements were obtained retrospectively from our echo-database. Importantly, however, the fact that measurements were taken by different, randomly assigned experienced echocardiographers and the random selection of a very large control group (one thousand patients) at least partially reduced potential measurement bias, and provided us with reliable averaged values of aortic diameters. We agree that the ideal methodological approach might involve repeated measurements done by at least two sonographers, including the analysis of intraand interobserver differences. Unfortunately, the retrospective character of our study limited this approach, but strict adherence to international quantification guidelines was, in our opinion, successful in reducing variability, as supported by local quality control measures. Although these data were not presented, there was no significant difference in the presence of arterial hypertension or in the left ventricular (LV) echocardiographic size (LV mass, end diastolic and systolic diameters, and interventricular septal (IVS) thickness — indexed and non-indexed to body surface area) between the two BAV subtypes. This corroborates published [2] data on aortic stenosis severity and transvalvular pressure gradient data (peak and mean), similar in both BAV phenotypes. We feel that this is also consistent with haemodynamic theory of BAV aortopathy, which is supported by growing literature evidence [3] and is mentioned by Dr Ozturk. Another important issue raised is that some occupational activities may alter the aortic diameter in BAV individuals, especially work related to everyday isometric-type strenuous activity [4]. Despite some reports regarding healthy individuals (with tricuspid aortic valve) suggesting that strenuous activity is associated with larger aortic diameters [4], there is still limited and inconclusive evidence that these activities might significantly alter the aortic diameter in BAV patients [5]. In their observational study in aviators with BAV exposed to prolonged extreme G-force and anti-G manoeuvres, Carter et al. [5] demonstrated that there was no relationship between the aviation environment (highvs. low-performance pilots) and aortic diameter progression over time. Interestingly, similar results in healthy pilots were presented by Dr Ozturk et al. [6]. Without systematic data about the occupational profile of the studied BAV patients, we can only indirectly hypothesise that the previously mentioned observation of no differences in LV echocardiographic parameters (LV mass, LV end-diastolic/systolic, and IVS diameter) may indicate that the studied subjects did not differ in their job intensity. However, further larger cohort studies in this field are warranted to more precisely determine whether occupation may have significant impact on aortopathy in BAV individuals.

Conscious sedation for transcatheter implantation of atrial septal occluders with two- and three-dimensional transoesophageal echocardiography guidance — a feasibility and safety study

BACKGROUND General anaesthesia may have negative impact on patient mortality and morbidity, as well as overall procedure costs, in atrial septal occluder (ASO) implantation. AIM We sought to evaluate the safety, efficacy, and feasibility of conscious sedation for transcatheter implantation of ASOs. METHODS A total of 122 patients referred for transcatheter implantation of ASO were included. Mean patient age was 51 ± 15 years, and 43 (35%) patients were male. The initial dose of midazolam was 2 mg and fentanyl dose was 25 μg. Additional doses of midazolam and fentanyl were administered, if necessary. Patient responsiveness was assessed every 10 min, and the sedatives doses were titrated in order not to exceed grade 3 sedation in the Ramsey scale. RESULTS Atrial septal occluders were successfully implanted in the majority of patients (98.4%). In two (1.6%) cases the proce-dure failed because of too small patent foramen ovale (PFO) diameter (n = 1, 0.8%) or device instability (n = 1, 0.8%). The mean duration of procedure was 47.6 ± 28.4 min and was similar for ASD and PFO closure (p = 0.522). The overall mean dose of midazolam was 4.7 ± 2.2 mg (63.9 ± 32.5 μg/kg) and fentanyl was 30.0 ± 11.9 μg (0.43 ± 0.17 μg/kg). Median entrance dose of radiation at the patient plane was 25 (interquartile range: 16-57) mGy, and did not differ between ASD and PFO procedures (p = 0.614). The majority of patients were free of complications (91.0%). The following early complications were observed: transient ischaemic attack (n = 2, 1.6%), supraventricular arrhythmias (n = 4, 3.3%), left atrial thrombus formation (n = 1, 0.8%), symptomatic bradycardia (n = 1, 0.8%), and femoral venous bleeding (n = 5, 4.1%). After mean follow-up of 386 days residual shunt was observed in eight (6.6%) patients. CONCLUSIONS Conscious sedation for transcatheter implantation of ASO is a feasible, safe, and efficient technique, allowing successful PFO and ASD closure in the majority of patients.

Isolated coronary artery bypass grafting in extracorporeal circulation in patients over 65 years old - does age still matter?

Introduction Coronary artery bypass grafting (CABG) is conducted more and more commonly in patients in advanced age. Aim of the study To analyze the influence of age and concurrent risk factors on the complications and early mortality after CABG. Material and methods Medical records of 2194 patients were analyzed retrospectively. A group of 1303 patients who had undergone isolated CABG was selected. 106 (4.8%) patients were excluded due to missing data in their medical records. The remaining 1197 patients were divided into two subgroups by age: 1st group < 65 years (n = 662; 55.3%); 2nd group ≥ 65 years (n = 535; 44.7%). Results The total 30-day mortality was 3.93% and was six times higher in the older group (1.21 vs. 7.29%; p < 0.001). Complications were observed in 176 (14.70%) patients, more often in the older group (10.42% vs. 20.0%; p < 0.001). In this group all kinds of complications were noted more often and in particular: postoperative myocardial infarction (1.96% vs. 5.42%; p = 0.001), respiratory dysfunction (1.36% vs. 4.11%; p = 0.005), neurological complications (1.81% vs. 3.74%; p = 0.04) and multi-organ dysfunction syndrome (0.30% vs. 1.68%, p = 0.03). The older patients required longer time under mechanical ventilation (24.0 ± 27.9 vs. 37.0 ± 74.1 hours; p = 0.004) and stayed longer in the intensive care unit: 2.5 ± 3.0 vs. 4.1 ± 7.84 days; p < 0.001. Independent predictors of death were: female sex [OR (95% CI) = 2.4 (1.2-4.5)], age ≥ 65 years [OR = 4.9 (2.1-11.1)], eGFR < 60 mL/min/1.73 m2 [OR = 2.2 (1.0-4.7)], time at extracorporeal circulation > 72 minutes [OR = 5.5 (2.7-10.9)] and left main stem stenosis (> 50%) [OR = 2.4 (1.3-4.6)]. Conclusions Age still significantly influences postoperative complications and mortality after isolated CABG.