Jacek Piątek

The combined use of transmyocardial laser revascularisation and intramyocardial injection of bone-marrow derived stem cells in patients with end-stage coronary artery disease: one year follow-up

BACKGROUND There are a growing number of patients with end-stage coronary artery disease (CAD) and refractory angina. Angiogenesis may be induced by intramyocardial injection of autologous bone marrow stem cells, intensified by inflammation around channels performed by laser. AIM To assess the effect of a combined treatment consisting of transmyocardial laser revascularisation (TLMR) and intramyocardial injection of bone-marrow derived stem cells (bone marrow laser revascularisation, BMLR) in patients with refractory angina one year after the procedure. METHODS Five male patients (age 49-78 years) with end-stage diffuse CAD, severe angina (CCS III/IV) despite intensive medical therapy and disqualified from prior coronary artery bypass grafting (CABG) or percutaneous coronary intervention were included. After heart exposure, at sites where CABG was impossible, TMLR was performed with the Holmium: YAG laser combined with injection of 1 mL of bone marrow concentrate into the border zone of a laser channel using a Phoenix handpiece. RESULTS No deaths in the follow-up period were observed. All patients were in I CCS Class. One year after the procedure,left ventricular (LV) segments treated by BMLR tended to demonstrate stronger myocardial thickening compared to baseline(53.0 ± 7.5% vs. 45.0 ± 9.5%; p = 0.06). Using late gadolinium-enhanced imaging, new myocardial infarction was found after one year only in one LV segment treated by BMLR. The BMLR treated regions in the remaining subjects, as well as regions subtended by left internal thoracic artery in two subjects, did not show new myocardial infarction areas. In contrast,all subjects who underwent only BMLR procedure revealed new and/or more extensive myocardial infarct in regions not treated by BMLR. CONCLUSIONS Intramyocardial delivery of bone marrow stem-cells together with laser therapy is a safe procedure, with improvement in quality of life during follow-up. One year after the procedure, myocardial regions where BMLR was performed tended to demonstrate stronger myocardial thickening observed in cardiac magnetic resonance imaging.

Profound accidental hypothermia - systematic approach to active recognition and treatment

We sought to organize a functional system of recognition and advanced treatment of hypothermic patients with extracorporeal rewarming as a treatment option. All patients with suspected hypothermia are consulted with the hypothermia coordinator (HC), whose role is to provide expertise on hypothermia recognition and treatment to all rescue and medical services. Patients with Swiss staging system of hypothermia class III and IV are subjected to extracorporeal rewarming. Patients with class I and II are managed in local hospitals, after the HC provides instructions. From program initiation (July 29, 2013) to November 1, 2015, HC consulted 104 hypothermic patients; 21 in hypothermia class III and IV were subjected to extracorporeal rewarming in the John Paul II Hospital in Cracow, Poland. The remaining people were rewarmed in the referring hospitals. Cardiac arrest upon referral was present in 10 cases (resuscitation times from arrest to extracorporeal membrane oxygenation implantation ranged 107–345 minutes). Seven patients died, and the remaining 14 have been rewarmed with the restoration of hemodynamic stability. Systematic approach to active recognition and treatment of profound accidental hypothermia patients, on the basis of HC cooperation with emergency medical services, enables advanced management with good outcomes, especially in patients with cardiac arrest.

Use of adipose-derived stromal cells in the treatment of chronic ischaemic heart disease: safety and feasibility study

1Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland 2Jagiellonian University Collegium Medicum, Krakow, Poland 3Department of Plastic and Reconstructive Surgery, Rydygier Hospital, Krakow, Poland 4Students’ Scientific Group, Jagiellonian University Collegium Medicum, Krakow, Poland 5Centre for Diagnosis, Prevention, and Telemedicine, John Paul II Hospital, Krakow, Poland 6Department of Cardiac and Vascular Diseases, John Paul II Hospital, Krakow, Poland 7Department of Transplantation, Jagiellonian University Collegium Medicum, Krakow, Poland

Midterm outcomes of transmyocardial laser revascularization with intramyocardial injection of adipose derived stromal cells for severe refractory angina

Introduction Refractory angina has limited effective therapeutic options and often contributes to frequent hospitalizations, morbidity and impaired quality of life. Aim We sought to examine midterm results of a bio-interventional therapy combining transmyocardial laser revascularization (TMLR) and intramyocardial injection of adipose derived stem cells (ADSC) in patients with refractory angina not amenable to percutaneous or surgical revascularization. Material and methods We included 15 patients with severe refractory angina and anterior wall ischemia who were ineligible for revascularization strategies. Adipose tissue was harvested and purified, giving the stem cell concentrate. All patients underwent left anterior thoracotomy and TMLR using a low-powered holmium : yttrium–aluminum–garnet laser and intramyocardial injection of ADSC using a combined delivery system. Results No deaths or major adverse cardiovascular or cerebrovascular events were observed in the 6-month follow-up. Mean ejection fraction increased from 35% to 38%, and mean Canadian Cardiovascular Society Angina Score decreased from 3.2 to 1.4, with decreased necessity of nitrate usage. Seventy-three percent of patients reported health improvement particularly regarding general health and bodily pain. Improvement in endocardial movement, myocardial thickening and stroke volume index (35.26 to 46.23 ml/m2) on cardiac magnetic resonance imaging (MRI) was observed in 3 patients who had repeat CMR imaging after 6 months. Conclusions Our study suggested that interventional therapy combining TMLR with intramyocardial implantation of ADSC may reduce symptoms and improve quality of life in patients with refractory angina. These early findings need further validation in large scale randomized controlled trials.

Hybrid one-day coronary artery bypass grafting and carotid artery stenting – cardiac surgeons’ perspective on the procedure’s safety

1Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland 2Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland 3Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland 4Cardiosurgical Students’ Scientific Group, Jagiellonian University Medical College, Krakow, Poland 5Department of Cardiac and Vascular Diseases, John Paul II Hospital, Krakow, Poland

Early onset and persistent progression of coronary artery disease of unknown etiology in a 30‑year‑old man

698 a non ‐ST ‐segment elevation myocardial infarc‐ tion in March 2011. He also suffered from par‐ oxysmal atrial fibrillation and preexcitation syn‐ drome. A family history of cardiovascular diseas‐ es and diabetes was negative. The predicted 4 ‐year mortality assessed with the SYNTAX II score was 6.4% for percutaneous coronary intervention and 0.7% for coronary artery bypass grafting (coronary angiography is presented in FIGURE 1A and 1B). The patient thus underwent emergent coronary artery bypass surgery with 3 arterial grafts, using the left and right internal mamma‐ ry arteries (LIMA and RIMA) and the radial ar‐ tery (RA): RIMA to the LAD, LIMA to the first The prevalence of coronary artery disease (CAD) in young patients is difficult to establish as most cases remain subclinical.1 The etiology and patho‐ genesis of atherosclerosis is complex. Its progres‐ sion is particularly rapid when environmental fac‐ tors coexist with genetic ones. An early and accu‐ rate identification of individuals at increased risk of CAD is critical for effective prevention and in‐ tervention, such as statin treatment.2 Neverthe‐ less, young smokers with hypertension and high fasting glucose levels have a higher probability of unsatisfactory results of lipid ‐lowering therapy.3 A 29 ‐year ‐old man with risk factors of hy‐ pertension and smoking was diagnosed with CLINICAL IMAGE

Difficulties in funding of VA-ECMO therapy for patients with severe accidental hypothermia

BACKGROUND Severe accidental hypothermia is defined as a core temperature below 28 Celsius degrees. Within the last years, the issue of accidental hypothermia and accompanying cardiac arrest has been broadly discussed and European Resuscitation Council (ERC) Guidelines underline the importance of Extracorporeal Rewarming (ECR) in treatment of severely hypothermic victims. The study aimed to evaluate the actual costs of ECR with VA-ECMO and of further management in the Intensive Care Unit of patients admitted to the Severe Accidental Hypothermia Centre in Cracow, Poland. METHODS We carried out the economic analysis of 31 hypothermic adults in stage III-IV (Swiss Staging) treated with VA ECMO. Twenty-nine individuals were further managed in the Intensive Care Unit. The actual treatment costs were evaluated based on current medication, equipment, and dressing pricing. The costs incurred by the John Paul II Hospital were then collated with the National Health Service (NHS) funding, assessed based on current financial contract. RESULTS In most of the cases, the actual treatment cost was greater than the funding received by around 10000 PLN per patient. The positive financial balance was achieved in only 4 (14%) individuals; other 25 cases (86%) showed a financial loss. CONCLUSION Performed analysis clearly shows that hospitals undertaking ECR may experience financial loss due to implementation of effective treatment recommended by international guidelines. Thanks to new NHS funding policy since January 2017 such loss can be avoided, what shall encourage hospitals to perform this expensive, yet effective method of treatment.

Minimally invasive coronary artery bypass as a safe method of surgical revascularization. The step towards hybrid procedures

Introduction Coronary artery disease is nowadays responsible for approximately 15% of hospitalizations in Poland. Minimally invasive coronary artery bypass (MIDCAB) represents an attractive alternative to a sternotomy, and at the same time provides better life quality and facilitates quick rehabilitation. Aim To evaluate whether MIDCAB can be performed with similar early and mid-term results as off-pump coronary artery bypass (OPCAB) and therefore can be considered as a safe stage in hybrid revascularization. Material and methods In a retrospective cohort study, we analyzed 73 consecutive patients who underwent coronary artery bypass grafting (left internal mammary artery to left anterior descending artery) between 2013 and 2016 in the Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow. Thirty-eight (52.1%) MIDCAB and 35 (47.9%) OPCAB patients were enrolled. Results Short-term results did not significantly differ between groups and similar 30-day mortality was observed (MIDCAB 2.6% vs. OPCAB 2.9%, p = 1). The median follow-up period was 21 months. There were no statistical differences in terms of overall survival or cardiac mortality between groups (94.7% vs. 88.6%, p = 0.42; 2.6% vs. 2.9%, p = 1, respectively). The rate of hospitalization due to cardiac causes was similar in both groups (7.9% vs. 5.1%, p = 1) and there were no differences in current exacerbation of angina or heart failure, with median NYHA class I and CCS class I in both groups. Conclusions Despite higher technical difficulty, MIDCAB procedures can be performed with similar safety results as OPCAB procedures. No differences in terms of mortality, repeat revascularization or recurrent angina are observed.

Incomplete oral sanation as a risk factor for elevated leucocytosis and postoperative infection

BACKGROUND Patients after cardiac surgery are particularly at risk of infections. The oral cavity is a potential source of bacteria. AIM To assess of influence of incomplete oral sanation on the probability of occurrence of infection in the postoperative period. METHODS The study subjects (n = 240) were patients undergoing cardiac surgery, with (n = 185) and without (n = 55) complete oral sanation. Complete oral sanation - patients had treated and eradicated all potential inflammatory foci in the oral cavity. Dental treatment: conservative dental treatment (70%), endodontic treatment (30%), and surgical dental treatment (85%), depending on treatment needs. RESULTS Patients with incomplete oral cavity sanation had more infections (7.27% vs. 1.62%, p = 0.062) in the postoperative period. The risk of infection was six times higher compared to the patients with complete sanation (p = 0.042), which correlated with higher level of leucocytosis in the early postoperative period (10.11 vs. 10.96 × 103/μL, p = 0.059). CONCLUSIONS Incomplete oral sanation is associated with higher levels of leucocytosis and greater risk of infection in the early postoperative period.

Coronary Artery Disease in Young Adults: Who Needs Surgical Revascularization? A Retrospective Cohort Study.

BACKGROUND Coronary artery disease (CAD) is a major cause of death and disability in developed countries. Despite the fact that prevalence accrues with age, an increasing number of young patients suffering from CAD is being observed worldwide. The aim of this study is to describe the population of young adults suffering from CAD and requiring coronary artery bypass grafting (CABG), and to assess early outcomes after the procedure. METHODS A retrospective cohort study analyzed 190 consecutive patients aged ≤50 years old that underwent CABG between 2010 and 2014. Baseline characteristics and operative data were presented in the study. Postoperative complications, such as major adverse cardiac and cardiovascular events (MACCE), prolonged mechanical ventilation (>72 hours), bleeding requiring reexploration, sternal dehiscence, and others were assessed. RESULTS A population comprising mostly overweight or obese males with a mean age of 46 ± 4.1 years was analyzed. Patients suffered mostly from three-vessel disease (81%), hypertension (74.7%), and had previous history of myocardial infarction (MI) (60%). The majority of patients had normal left ventricle ejection fraction (LVEF) (83.1%). 22.6% of cases were emergent procedures. Perioperative mortality was low (1%) and overall MACCE rate stood at 2.6%. Emergent surgery was associated with a higher incidence of postoperative complications (P = .007). The number of diseased vessels, LVEF, and CCS/NYHA class-on-admission was not associated with a higher incidence of postoperative complications (P > .05 for all). CONCLUSION CAD in young patients remains an issue described insufficiently in the literature. Among our study cohort of younger patients undergoing CABG, the majority of the patients had multivessel disease and were slightly symptomatic with normal LVEF. Although the postoperative complication rate was low, the percentage of emergent surgeries was alarmingly high in this population. Consistent with the literature, we highlight the importance of CAD screening in the young population to detect subclinical disease, which might be treated therapeutically or operated electively.