Janusz Konstanty-Kalandyk

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.

In-Hospital Mortality in Cardiac Surgery Patients After Readmission to the Intensive Care Unit: A Single-Center Experience with 10,992 Patients

OBJECTIVES Determine if readmission to the intensive care unit (ICU) after cardiac surgery procedures is associated with increased mortality. DESIGN This was a retrospective non-randomized study to evaluate the cause of readmission and mortality rate in patients readmitted to the ICU after cardiac surgery and to compare the clinical variables of patients readmitted to the ICU who died and those who survived. SETTING The study was performed in a single university hospital. PARTICIPANTS This was an analysis of 10,992 consecutive adult patients. Readmission rate to the ICU, mortality rate, the reason for readmission to the ICU, type of surgery, length of stay, cause of mortality, and day of the week of ICU readmission were analyzed. INTERVENTIONS All patients underwent cardiac surgery at a single center and were discharged after primary stay from the ICU. MEASUREMENTS AND MAIN RESULTS A total of 197 (1,8%) of 10,992 patients were readmitted to the ICU. In-hospital mortality rate for patients readmitted and not readmitted to the ICU was 23.9% and 4.7%, respectively. The main causes of ICU readmission were cardiac (40%) and respiratory (37%) complications. The mortality rate in readmitted patients who underwent coronary artery bypass graft (CABG) or valve surgery was 26% and 19%, respectively. CONCLUSIONS Patient readmission to the ICU following cardiac surgery was associated with a 5-fold increase in hospital mortality rate compared to non-readmitted patients. The highest mortality rate was observed among readmitted patients who underwent CABG. Older age, previous myocardial infarction, and initial long length of stay in the post-operative ward were independent risk factors for death after readmission to the ICU.

Clinical outcome of arterial myocardial revascularization using bilateral internal thoracic arteries in diabetic patients: a single centre experience.

OBJECTIVES The use of bilateral internal thoracic arteries (BITAs) grafting has been documented to be advantageous over left internal thoracic artery (LITA) grafting. It has been shown to significantly improve clinical outcomes and increase long-term survival in patients with diabetes. However, harvesting BITAs may result in a greater risk of superficial wound infection (SWI) or deep sternal wound infection (DSWI) and cardiovascular complications (major adverse cardiac and cerebrovascular events; MACCE) in such a patient group. The objective of this study was to compare the incidence of SWI or DSWI and cardiovascular events in a series of isolated coronary artery bypass grafting (CABG) patients who underwent BITA grafting vs LITA grafting. METHODS A total of 147 patients with coronary artery disease and diabetes underwent isolated CABG at John Paul II Hospital. Of these, 38 procedures were performed using BITA grafting and 109 with LITA-saphenous vein grafting. RESULTS MACCE were similar in bilateral groups (7.9%--BITA group and 9.2%--LITA group). No significant difference was found in mortality and length of stay between bilateral groups. The MACCE risk factor was age. The incidence of SWI and DSWI and sternal re-fixation did not differ between the BITA or LITA groups (5.2 vs 9.1%, 5.2 vs 7.3% and 5.2 vs 6.4%). The risk factors for DSWI were age (odds ratio 3.47, P = 0.032 for every 10 years) and body mass index >30 kg/m(2). CONCLUSIONS Perioperative complications do not increase with the use of BITAs in this group of diabetic patients. There are no statistically significant differences in the number of superficial or deep wound infections or number of sternal resuturing between the BITA and LITA groups.

Denervation of nerve terminals in renal arteries: one-year follow-up of interventional treatment of arterial hypertension

BACKGROUND Arterial hypertension is the most common cardiovascular system disease, affecting nearly one billion people worldwide. Despite the widespread use of antihypertensive medications, in some groups of patients an optimal blood pressure (BP) cannot be achieved. AIM To assess BP reduction in patients with resistant hypertension after a catheter-based renal sympathetic denervation procedure and to report vascular and kidney safety in one-year follow-up. METHODS Twenty eight patients with diagnosed resistant hypertension (median age 52.02 years, range 42-72) underwent percutaneous catheter-based renal denervation of nerve terminals in renal arteries. Arterial angiography and procedure of ablation was performed by Symplicity catheters and generator provided by Ardian (currently Medtronic Inc., USA). RESULTS Mean BP value before ablation was [mm Hg]: systolic 176.6, diastolic 100.28 and pulse pressure 73.4. After the procedure, reductions in the value of BP were reported [mm Hg]: systolic 154.8/152.54; diastolic 90.2/89.8, pulse pressure 64.66/62.73, respectively in nine-month and one-year follow-up. All results were statistically significant. No complications during one year observation were observed. CONCLUSIONS Percutaneous renal artery ablation procedure effectively reduces systolic BP, diastolic BP, and pulse pressure. No vascular or renal complications in any of the patients were observed. The results of a Polish research group showed no significant differences compared to the results obtained in the international studies Symplicity I and Symplicity II.

Dabigatran level monitoring prior to idarucizumab administration in patients requiring emergent cardiac surgery

Non-vitamin-K antagonist oral anticoagulants (NOACs), including dabigatran (a direct factor IIa [FIIa] inhibitor) increasingly replace the vitamin K antagonists (VKAs) for favorable risk–benefit profile [1] and lower risk of major bleeding [2] in atrial fibrillation. NOACs also significantly reduce the risk of recurrent venous thromboembolism (VTE), and compared with VKAs present lower risk of bleeding in this group [3]. The use of NOACs increases in VTE prevention, even though in the setting of surgical emergency or life-theratening bleeding, the NOAC therapy may be dangerous [4]. In 2015, the FDA approved idarucizumab for dabigatran reversal in emergency situations [5]. Idarucizumab is a monoclonal antibody fragment that binds dabigatran with high affinity, and presents good clinical outcomes [5, 6]. Current European Heart Rhythm Association (EHRA) practical guidelines recommend idarucizumab for life-threatening bleeding, or prior to emergency surgery in dabigatran treated patients [7]. Clinical experience with idarucizumab in cardiac surgery is currently limited. In our institution, we managed several dabigatran-treated patients in emergency cardiosurgical setting [8]. In previous cases, the clinical decision to administer idarucizumab was made following emergency laboratory assessment of baseline dabigatran level (both individuals required an open-heart surgery for acute aortic syndrome) [8]. However, in specific clinical scenarios, monitoring of dabigatran level may be challenging and potentially impede the decision to use the expensive idarucizumab preparation based just on uncertain dabigatran intake history, and exposing the patient to the risk of excessive (and potentially lethal) surgical bleeding, if dabigatran intake history is uncertain. We report a case of a 63-years-old patient who received dabigatran for VTE and required emergency coronary artery bypass grafting (CABG) for an acute coronary syndrome (ACS) with coronary anatomy precluding percutaneous coronary intervention (PCI), in whom the preoperative dabigatran level measurement was futile because of interferences with other thrombin inhibitors.

Acute myocardial infarction due to coronary embolisation as the first manifestation of left atrial myxoma

This report describes a 52 year-old women with an inferior myocardial infarction due to a coronary artery embolus. Coronary angiography revealed occlusion of right coronary artery and echocardiographic findings showed a large left intraatrial tumour. The tumour was removed surgically and pathological findings confirmed the diagnosis of myxoma. Aetiology of the occlusion was closely related to the left atrial tumour. Myocardial infarction was the first manifestation of left atrial myxoma.

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

Patient-prosthesis mismatch after minimally invasive aortic valve replacement

1Department of Cardiovascular Surgery and Transplantology, Jagiellonian University and John Paul II Hospital, Krakow, Poland 2Department of Pharmacology, Jagiellonian University, Krakow, Poland 3Department of Physiology, Jagiellonian University, Krakow, Poland 4Department of Cardiac and Vascular Surgery, Medical University of Gdansk, Gdansk, Poland 5CardioVascular Centre Frankfurt, Germany and Swedish Medical Centre Seattle, United States *Grzegorz Filip and Radoslaw Litwinowicz are first authors of this manuscript and have contributed equally to the content of this paper.

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.