Jarosław D. Kasprzak

Characteristics, management and five-year outcomes of patients with high risk, stable multivessel coronary heart disease

BACKGROUND Multivessel coronary artery disease (MCAD) is a common manifestation of advanced coronary atherosclerosis. AIM To determine the clinical characteristics and long term follow up prognostic factors in patients with high risk, stable MCAD from a single institution. METHODS We included in the final analysis 270 patients with stable MCAD. Patients were followed for the occurrence of death, stroke and myocardial infarction (MI). We defined a cumulative major adverse cardiac and cerebrovascular event (MACCE) asa composite of death, stroke, MI and urgent revascularisation. Median follow up was 5 years (4-5.5 years). 176 (65%) patients were treated surgically (coronary artery bypass grafting, CABG), 19 (7%) patients were treated percutaneously, while 75 (28%) patients were treated medically; this meant that 94 (35%) patients were treated non-surgically. RESULTS Predictors of MACCE in the study group of patients revealed by univariate logistic regression analysis were: diabetes mellitus (p = 0.04), kidney failure (p = 0.05), total cholesterol (p = 0.05), LDL-cholesterol (p = 0.02), chest pain symptoms in CCS III class (p = 0.05), heart rate (p = 0,02), NT-proBNP (p = 0.01), left ventricular diastolic (p = 0.003) and systolic diameter (p = 0.003), left ventricular ejection fraction (p = 0.001), Gensini score (p = 0.05) and CABG treatment strategy (p = 0.001). In Cox logistic regression analysis, non CABG treatment strategy (b = 0.06), heart rate (b = 0.02), and LDL cholesterol level (b = 0.006) were independent predictors of MACCE (p = 0.01). CONCLUSIONS Our study showed that patients with advanced MCAD who are qualified for complete surgical revascularisation benefitted more with regard to several primary end points at five-year follow-up than those who were not qualified for surgery and who were treated with medical therapy supplemented in selected cases with incomplete percutaneous revascularisation.

Aging Changes in Echocardiography

The progressive growing of the elderly population has become one of the most challenging global public health issues. Aging is a natural process where irreversible damage to the intracellular exceed the possibility of self-repair. The aging process is associated with degenerative processes on the heart valves, especially aortic and mitral. Age related changes include calcifications and amyloid deposition of both mitral and aortic valve; in advanced form it can lead to damage to the valves. The aorta dilates and tilts rightward on the interventricular septum. It is important to differentiate the cardiac manifestations of normal aging which do not require medical treatment of heart disease in an older patient and situations where the changes are considered pathologic and no longer “normal aging”.

Echocardiographic Assessment of Coronary Blood Flow

Echocardiography of coronary arteries is challenging, however current high–end systems offer sufficient quality for several clinically relevant applications of the method. Transesophageal echocardiography allows the imaging of proximal coronary arteries with high quality and power to detect stenotic flow. Transthoracic imaging of coronary ostia is feasible to define anomalous coronary arteries and other congenital abnormalities. This approach is also used for recording of distal coronary flow at rest and during vasodilator administration to calculate coronary flow reserve. Transthoracic detection of coronary stenosis is strongly dependent on acoustic window but is very specific based on the finding localized high velocity diastolic flow.

How to Assess the Left and Right Atria in Clinical Practice

Both, left atrial and right atrial sizes provide important diagnostic and prognostic information. Therefore, their assessment is a part of routine echocardiographic examination. Various techniques have been proposed—from linear measurement by M-mode to volume measurement by three-dimensional echocardiography—each having its strengths and limitations. Another part of routine echocardiographic examination is the assessment of inferior vena cava, reflecting right atrial pressures.

Ascending aortic dilatation as a late complication after implantation of a mechanical aortic valve performed 37 years earlier.

Aortic stenosis (AS) is the third most common cardiovascular disease. Aortic valve replacement (AVR) is the only effective method of treatment in most AS patients. In some patients, AS leads to poststenotic dilatation of the ascending aorta – most commonly, this occurs in patients with concurrent aortic regurgitation or bicuspid aortic valve (BAV) and in patients after aortic valve replacement. Cardiac surgeons face the dilemma whether to perform concurrent replacement of the dilated ascending aorta in patients qualified for AVR, as it is associated with an increased risk of perioperative complications and mortality. We report a case of a patient with an ascending aortic aneurysm, who had been implanted with an aortic mechanical valve (Lillehei-Kaster 16 ECC) 37 years earlier.