Gintaras Kalinauskas

Percutaneous coronary angioplasty versus coronary artery bypass grafting in treatment of unprotected left main stenosis (NOBLE): a prospective, randomised, open-label, non-inferiority trial

BACKGROUND Coronary artery bypass grafting (CABG) is the standard treatment for revascularisation in patients with left main coronary artery disease, but use of percutaneous coronary intervention (PCI) for this indication is increasing. We aimed to compare PCI and CABG for treatment of left main coronary artery disease. METHODS In this prospective, randomised, open-label, non-inferiority trial, patients with left main coronary artery disease were enrolled in 36 centres in northern Europe and randomised 1:1 to treatment with PCI or CABG. Eligible patients had stable angina pectoris, unstable angina pectoris, or non-ST-elevation myocardial infarction. Exclusion criteria were ST-elevation myocardial infarction within 24 h, being considered too high risk for CABG or PCI, or expected survival of less than 1 year. The primary endpoint was major adverse cardiac or cerebrovascular events (MACCE), a composite of all-cause mortality, non-procedural myocardial infarction, any repeat coronary revascularisation, and stroke. Non-inferiority of PCI to CABG required the lower end of the 95% CI not to exceed a hazard ratio (HR) of 1·35 after up to 5 years of follow-up. The intention-to-treat principle was used in the analysis if not specified otherwise. This trial is registered with ClinicalTrials.gov identifier, number NCT01496651. FINDINGS Between Dec 9, 2008, and Jan 21, 2015, 1201 patients were randomly assigned, 598 to PCI and 603 to CABG, and 592 in each group entered analysis by intention to treat. Kaplan-Meier 5 year estimates of MACCE were 29% for PCI (121 events) and 19% for CABG (81 events), HR 1·48 (95% CI 1·11-1·96), exceeding the limit for non-inferiority, and CABG was significantly better than PCI (p=0·0066). As-treated estimates were 28% versus 19% (1·55, 1·18-2·04, p=0·0015). Comparing PCI with CABG, 5 year estimates were 12% versus 9% (1·07, 0·67-1·72, p=0·77) for all-cause mortality, 7% versus 2% (2·88, 1·40-5·90, p=0·0040) for non-procedural myocardial infarction, 16% versus 10% (1·50, 1·04-2·17, p=0·032) for any revascularisation, and 5% versus 2% (2·25, 0·93-5·48, p=0·073) for stroke. INTERPRETATION The findings of this study suggest that CABG might be better than PCI for treatment of left main stem coronary artery disease. FUNDING Biosensors, Aarhus University Hospital, and participating sites.

Characterisation and validity of inflammatory biomarkers in the prediction of post-operative atrial fibrillation in coronary artery disease patients

Atrial fibrillation (AF) is a common complication of coronary artery bypass grafting (CABG). We sought to determine the diagnostic validity of plasma biomarkers of i) inflammation (marked by interleukin-6 [IL-6] and high-sensitivity C-reactive protein [hs-CRP]), ii) extracellular matrix remodelling (matrix metalloproteinase [MMP-9], tissue inhibitor of matrix metalloproteinase [TIMP-1]) and iii) the prothrombotic state (tissue factor and von Willebrand factor [vWF]) in the risk prediction of post-operative AF. Samples were obtained preoperatively from peripheral/femoral vein and from intracardiac chambers (right atrium [RA], the right atrial appendage [RAA], the left atrium [LA] and the left atrial appendage [LAA]) amongst 100 consecutive patients free of AF and inflammatory disease undergoing elective CABG. Biomarker concentrations were related to incident AF (30 days). At 30 days post CABG, 30 patients were proven to have had AF. Concentrations of tissue factor (TF) and vWF were unrelated to postoperative AF. Peripheral (p=0.018), and intracardiac levels (RAA (p=0.029) and LA (p=0.026)) of hs-CRP were associated with the presence of AF after CABG. Intracardiac levels of IL-6 in samples from the RAA (p=0.031), LA (p=0.042) and LAA (p=0.006), and MMP-9 in the LAA sample were also associated with AF (p=0.007). Our data suggest that an intra-cardiac inflammatory environment that is manifest peri-operatively may predispose to the development of post-operative AF. This intracardiac inflammatory state was reflected by increased peripheral hs-CRP levels. These differences may indicate local substrate abnormalities contributing to the development of AF post-operatively.

Intracardiac expression of markers of endothelial damage/dysfunction, inflammation, thrombosis, and tissue remodeling, and the development of postoperative atrial fibrillation

Summary.  Background: Atrial fibrillation (AF) is a common complication of coronary artery bypass grafting (CABG), and may have an inflammatory and/or thrombotic etiology. We sought to determine the expression of inflammatory (interleukin [IL]‐6), thrombotic (tissue factor and von Willebrand factor [VWF]) and remodeling (matrix metalloproteinase [MMP]‐9 and tissue inhibitor of metalloproteinase [TIMP]‐1) markers by left atrial appendage (LAA) and right atrial appendage (RAA) tissue in the prediction of postoperative AF. We determined whether the tissue expression of markers of certain different pathophysiologic mechanisms predicted the development of AF after CABG. Methods: LAA and RAA tissue was excised during CABG in 100 patients free of AF and inflammation. Tissue marker expression was quantified by immunohistochemistry and was related to 30‐day postoperative AF. Results: Overall, there were no significant differences in staining intensity of any marker between LAA tissue and RAA tissue. However, more intense expression of VWF by LAA tissue predicted the 30 patients with postoperative AF as compared with those free of AF (P = 0.006). IL‐6, MMP‐9 and TIMP‐1 expression by RAA and LAA epicardial tissue was stronger than expression by endocardium or cardiomyocytes (all P < 0.025) but failed to predict AF. Conclusion: In this study, one of the largest to investigate tissue expression of pathophysiologic markers in relation to postoperative AF, we show that more intense expression of VWF by LAA tissue is a significant predictor of postoperative AF. This points towards a possible role of endothelial damage/dysfunction (as reflected by VWF changes) in the pathogenesis of postoperative AF.

Predictors of ischaemic mitral regurgitation recurrence in patients undergoing combined surgery: additional value of cardiovascular magnetic resonance imaging†

OBJECTIVES We aimed to evaluate (i) the effectiveness of combined surgery (coronary artery bypass grafting with restrictive mitral valve annuloplasty) and (ii) the late gadolinium enhancement cardiovascular magnetic resonance-based predictors of ischaemic mitral regurgitation (IMR) recurrence. METHODS The prospective analysis included 40 patients with multivessel coronary artery disease, IMR >II° and left ventricular (LV) dysfunction undergoing combined surgery. The degree of IMR and LV parameters were assessed preoperatively by transthoracic echocardiography, 3D transoesophageal echocardiography and cardiovascular magnetic resonance and postoperatively by transthoracic echocardiography. The effective mitral valve repair group (n = 30) was defined as having recurrent ischaemic mitral regurgitation (RIMR) ≤II° at the end of follow-up (25 ± 11 months). RESULTS The surgery was effective: freedom from RIMR >II° at 1 and 2 years after surgery was 80% and 75%, respectively. Using multivariable logistic regression, 2 independent predictors of RIMR >II° were identified: ≥3 non-viable LV segments (odds ratio 22, P = 0.027) and ≥1 non-viable segment in the LV posterior wall (odds ratio 11, P = 0.026). Using classification trees, the best combinations of cardiovascular magnetic resonance-based and 3D transoesophageal echocardiography-based predictors for RIMR >II° were (i) posterior mitral valve leaflet angle >40° and LV end-systolic volume index >45 ml/m2 (sensitivity 100%, specificity 89%) and (ii) scar transmurality >68% in the inferior LV wall and EuroSCORE II >8 (sensitivity 83%, specificity 78%). CONCLUSIONS There is a clear relationship between the amount of non-viable LV segments, especially in the LV posterior and inferior walls, and the recurrence of IMR after the combined surgery.

Kairiojo skilvelio geometrijos ir tūrio atkūrimo operacija: priešoperaciniai ir operaciniai rizikos veiksniai

Gintaras Kalinauskas 1 , Robertas Samalavicius 2 , Arūnas Valaika 1 , Gediminas Norkūnas 1 , Jurgis Verižnikovas 3 , Giedrius Uždavinys 1 1 Vilniaus universiteto Sirdies chirurgijos centras, Santariskių g. 2, LT-08661 Vilnius 2 Vilniaus universiteto ligoninės Santariskių klinikos, Anesteziologijos, intensyviosios terapijos ir skausmo gydymo centras, Santariskių g. 2, LT-08661 Vilnius 3 Vilniaus universiteto ligoninės Santariskių klinikos Sirdies chirurgijos centras, Santariskių g. 2, LT-08661 Vilnius El pastas: chirurgai@santa.lt Įvadas / tikslas Ligoniams, kuriems yra poinfarktinė kairiojo skilvelio remodeliacija, reikalinga kairiojo skilvelio geometrijos ir tūrio atkūrimo operacija (Dor procedūra). Parenkant ligonius operacijai svarbu issiaiskinti, kurie is priesoperacinių ir operacinių rizikos veiksnių labiausiai turi įtakos operaciniam mirstamumui. Ligoniai ir metodai Tai retrospektyvus tyrimas. Ligoniai buvo operuoti laikotarpiu nuo 2000 metų sausio 1 dienos iki 2006 metų gruodžio 31 dienos. Isnagrinėti 88 ligonių, 69 vyrų ir 19 moterų, kurių amžiaus vidurkis 64,5±9,8 metų ir jiems atliktos aortos vainikinių arterijų jungcių suformavimo ir kairiojo skilvelio geometrijos ir tūrio atkūrimo operacijos (Dor procedūra), priesoperaciniai ir operaciniai duomenys. Rezultatai Is 88 operuotų ligonių sesi ligoniai mirė, mirstamumas 6,8%. Mirusių ligonių priesoperacinės būklės EuroSCORE įvertinimo balas reiksmingai skyrėsi nuo isgyvenusiųjų (p = 0,0180), tai buvo sunkesni, didesnės rizikos ligoniai. Isaiskėjo, kad mire ligoniai buvo dažniau operuoti skubos tvarka (p = 0,0077). Jų operacijos truko ilgiau, ilgesnė buvo ir jų dirbtinė kraujo apytaka. Isvados EuroSCORE balais vertinamas priesoperacinės būklės sunkumas, skubi operacija, ilgas operacijos ir dirbtinės kraujo apytakos laikas yra gana reiksmingi veiksniai vertinant operacijos riziką. Pagrindiniai žodžiai: kairiojo skilvelio geometrijos ir tūrio atkūrimo operacija Left ventricular reconstruction: preoperative and operative risk factors Gintaras Kalinauskas 1 , Robertas Samalavicius 2 , Arūnas Valaika 1 , Gediminas Norkūnas 1 , Jurgis Verižnikovas 3 , Giedrius Uždavinys 1 1 Vilnius University, Cardiac Surgery Centre, Santariskių str. 2, LT-08661 Vilnius, Lithuania 2 Vilnius University Hospital „Santariskių klinikos“, Centre of Anaesthesiology, Intensive Therapy and Pain Management, Santariskių str. 2, LT-08661 Vilnius, Lithuania 3 Vilnius University Hospital „Santariskių klinikos“,Cardiac Surgery Centre, Santariskių str. 2, LT-08661 Vilnius, Lithuania E-mail: chirurgai@santa.lt Background / objective The dor procedure is a surgical option in patients with coronary artery disease and postinfarction left ventricular aneurysm. The aim of this study was to evaluate our clinical experience in this procedure and determine risk factors for in-hospital mortality. Patients and methods This was a retrospective investigation. From January 1, 2000 to December 31, 2006, surgical ventricular restoration was performed in 88 patients (69 males), mean age 64.5 ± 9.8 (42–80) years. Patient with valve repair or replacement were excluded from the study. Results All patients underwent the Dor procedure with coronary artery bypass grafting. Crude mortality rate was 6.8%. Higher EuroSCORE, longer operation and cardiopulmonary bypass time and emergency surgery were univariate predictors of in-hospital mortality. Conclusions The Dor procedure with myocardial revascularization can be performed with acceptable mortality in this high risk group of patients. Higher EuroSCORE, longer operation and cardiopulmonary bypass time and emergency surgery increase the risk of in-hospital mortality. Key words: Dor procedure