Kajetan Grodecki

Platelet distribution width predicts left ventricular dysfunction in patients with acute coronary syndromes treated with percutaneous coronary intervention.

BACKGROUND The role of platelets in the pathophysiology of acute coronary syndromes (ACS) is undeniable, but precise relationships between platelet activity and treatment outcomes are a matter of continuant investigation. Among platelet indices, mean platelet volume (MPV) has proven to be a valuable predicting factor in cardiac patients. However, platelet distribution width (PDW) is reported to be a more specific marker of platelet reactivity. Thus, application of PDW in risk stratification of ACS treatment is an up-to-date subject of research. PDW values in the assessment of left ventricular (LV) function have not been previously studied. AIM The aim of the study was to evaluate whether admission PDW can predict LV systolic function in patients with ACS treated with stent implantation. METHODS On-admission PDW was measured in 278 consecutive patients with diagnosis of ACS, who underwent stent(s) implantation. Echocardiogram with LV ejection fraction (LVEF) estimation was performed within 24 h of percutaneous coronary intervention. Additionally, patients were under one-year follow-up, and one-year all-cause mortality was assessed. RESULTS According to receiver-operating characteristics (ROC) analysis, a PDW value greater than 12.8 fL could predict LVEF ≤ 35% with sensitivity of 81% and specificity of 39% (AUC 0.614; p = 0.0177). Only a trend was noted in ROC for PDW and one-year mortality (AUC 0.608; p = 0.0815). Multivariate logistic regression analysis has shown that the PDW parameter correlates independently with both systolic heart failure with LVEF ≤ 35% (PDW cut-off: 12.8 fL, OR 2.8107, CI 1.1401-6.9293, p = 0.0248) and one-year mortality (PDW cut-off: 16 fL, OR 2.6750, CI 1.0190-7.0225, p = 0.0457). CONCLUSIONS Admission PDW may serve as a simple and widely available predictor of impaired LV function in patients with ACS. Association between PDW and mortality needs to be confirmed in larger studies.

Gender-related differences in post-discharge bleeding among patients with acute coronary syndrome on dual antiplatelet therapy: A BleeMACS sub-study

INTRODUCTION Bleeding is an independent risk factor of mortality in patients with acute coronary syndromes (ACS). BleeMACS project focuses on long-term bleeding events after hospital discharge, thus we evaluated gender-related differences in post-discharge bleeding among patients with ACS. MATERIALS AND METHODS We investigated 13,727 ACS patients treated with percutaneous coronary intervention and discharged on dual antiplatelet therapy (either with clopidogrel or prasugrel/ticagrelor). Endpoint was defined as intracranial bleeding or any other bleeding leading to hospitalization and/or red blood transfusion. RESULTS Post-discharge bleeding was reported more frequently in females as compared with males (3.7% vs. 2.7%, log-rank P = 0.001). Females (n = 3165, 23%) were older compared to men (69.0 vs. 61.5 years, P < 0.001) and with more comorbidities. Hence, in multivariate analysis female sex was not identified as an independent risk factor of bleeding (HR 1.012, CI 0.805 to 1.274, P = 0.816). Administration of newer antiplatelet agents compared to clopidogrel was associated with over twofold greater bleeding rate in females (7.3% vs. 3.5%, log-rank P = 0.004), but not in males (2.6% vs. 2.7%, log-rank P = 0.887). Differences among females remained significant after propensity score matching (7.2% vs 2.4%, log-rank P = 0.020) and multivariate analysis confirmed that newer antiplatelet agents are independent risk factor for bleeding only in women (HR 2.775, CI 1.613 to 4.774, P < 0.001). CONCLUSIONS Bleeding events occurred more frequently in women, but female sex itself was not independent risk factor. Administration of newer antiplatelet agents was identified as independent risk factor of bleeding after hospital discharge in female gender, but not in male patients.

Holographic imaging during transcatheter aortic valve implantation procedure in bicuspid aortic valve stenosis

We present a case of an 80-year-old male patient with symptomatic aortic stenosis, admitted to the 1st Department of Cardiology, Medical University of Warsaw for valve replacement. His prior medical history included: non-obstructive coronary artery disease, transurethral prostatectomy, right-sided hernia, and right-sided nephrolithiasis surgery. Transthoracic echocardiography showed mean aortic pressure gradient of 40 mm Hg, aortic valve area (AVA) of 0.77 cm2, and peak velocity of 4.3 m/s. For precise aortic annulus measurement, transoesophageal echocardiography (TEE) and a multi-sliced computed tomography (MSCT; Fig. 1) scan were performed. On TEE the aortic annulus perimeter was 83 mm, with diameters 24 × 29 mm. On MSCT annulus perimeter was 87 mm with diameters of 23 × 32 mm. Both imaging techniques revealed that the patient had bicuspid aortic valve with raphe between left and right coronary cusps (Type I L-R) and protruding calcium to the left ventricular outflow tract. The “prospected” annulus perimeter based on MSCT was 79.3 mm. The patient was referred by the local Heart Team to transcatheter aortic valve implantation (TAVI) via the femoral route. To better visualise the complex anatomy of the patient with bicuspid AS the use of holographic imaging was applied. CarnaLife Holo® (MedApp S.A., Krakow, Poland) visualises the individual patient’s heart as an interactive holographic image based on computed tomography (CT) or a magnetic resonance imaging (MRI) scan of the patient (Fig. 2A–C). Possible interactions using voice commands and hand gestures include visualising the structure of the heart (3D), also during its cardiac cycle (4D), slicing, and partitioning. Users see and interact with those images via a Microsoft HoloLens® head-mounted display (Fig. 2D), which creates the visual illusion of a solid 3D object by recreating depth cues (perspective, occlusion, convergence, and parallax). The software supports loading of the medical data sets in common DICOM file format and adjusting the transfer function to achieve effective visualisation of skin, hard tissues like bones, and soft tissue organs like heart, based on methods well-established in the medical visualisation field. This method allows for the use of raw medical data acquired from CT and MRI devices, in contrast to the common approach with additional surface reconstruction to polygonal models, as in the case of typical surgery approaches with head-mounted displays. The periprocedural use of CarnaLife Holo® enabled the operator to view holographic image during the course of the procedure, facilitating precise visualisation of the aortic root. Ultimately the patient was implanted with a 29-mm Evolut R (Medtronic Int.) valve with small paravalvular leak (AVA 1.74 cm2, mean pressure gradient 9 mm Hg, Vmax 2.4 m/s) and no conduction disturbances. The patient was discharged home on day 2 after the procedure in good clinical condition. Figure 1. Multi-sliced computed tomography (MSCT) curved three-dimensional multiplanar reconstruction (3D MPR); A. Cross-section of the aortic valve at the level of the sinus of Valsalva showing bicuspid anatomy with raphe between left and right coronary cusps; B. Preprocedural 3D MPR maximal intensity projection (MIP) showing heavily calcified aortic valve with calcification extending into the left ventricular outflow tract; C. Post-procedural 3D MPR MIP with correct apposition of implanted bioprosthesis

Successful percutaneous coronary intervention after transcatheter aortic valve implantation with CoreValve bioprosthesis

We present a case of an 84-year-old male patient who was admitted to our department due to recurrent angina 17 months after transcatheter aortic valve implantation (TAVI) with a 29 mm CoreValve bioprosthesis (Figure 1). Symptoms were increasing in the past several weeks, and on admission the patient was in Canadian Cardiovascular Society class 3. His past medical history included hypertension and chronic atrial fibrillation. Non-invasive diagnostics was initially started with trans-thoracic echocardiography, which did not show signs of left ventricle wall motion abnormalities. Secondly, single-photon emission computed tomography (SPECT) was performed, showing a significant perfusion drop in the left ventricle anterior wall after dipyridamole administration. The patient was referred for coronary angiography. During the examination a critical ostial lesion of the left anterior descending (LAD) artery was discovered with impaired myocardial flow to the distal portion of the artery (TIMI 2). On examination performed 2 months prior to TAVI there were no significant lesions in coronary arteries. Percutaneous intervention (PCI) started with the positioning of a 6 Fr EBU 3.5 catheter between aortic bioprosthesis struts and into the ostium of the left coronary artery (LCA). Afterwards standard PCI with stent implantation was performed. Percutaneous coronary intervention result was good with no significant residual stenosis and restored normal TIMI flow. At discharge, triple antithrombotic therapy was recommended (aspirin, clopidogrel, vitamin K antagonist (VKA)) for 1 month, which should be followed by dual therapy for up to 1 year (aspirin/clopidogrel, VKA). Even though the nitinol frame of the CoreValve bioprosthesis extends to the ascending aorta, the space between the struts is wide enough to ensure coronary access. Navigating through the struts may be burdened with additional difficulties depending on the bioprosthesis final position in relation to the coronary ostia, which may be hidden behind the frame struts or behind the parts of the leaflets sewn to the nitinol frame. Crossing through the gaps may not be necessary when it comes to diagnostic angiography. In some cases sub-selective contrast injection may fully visualize the coronary sinus and coronary arteries, and may be helpful when struts are crossing the coronary ostia. In terms of TAVI, PCI performed prior to the valve implantation is believed to be gold standard, yet the optimal timing of PCI relative to TAVI is still uncertain and is the subject of constant discussion regardless of growing experience. However, due to improvement of long-term TAVI outcomes, increase of frequency of post-TAVI PCI dictated by the progression of coronary artery disease (CAD) is expected. The above-mentioned procedure is achievable, but may prove demanding – especially when valve prostheses’ elements/struts are in the close vicinity of the coronary ostia, making it difficult to gain optimal support. Different types of new generation bioprosthesis may have valve-specific crossing and support issues, which make intervention more challenging. Further investigations are necessary to assess the safety of post-TAVI PCI and to develop the best solutions for different patients [1–4]. Figure 1 Steps of the procedure: coronary angiography showing critical lesion in the proximal LAD (A); catheter placement and wire crossing (B); stent implantation (C); final result (D); *possibile locations of the coronary ostia (RCA – NCC); – ...

Thromboelastography for predicting bleeding in patients with aortic stenosis treated with transcatheter aortic valve implantation

BACKGROUND Bleeding complications are frequent and independently impact mortality after transcatheter aortic valve implantation (TAVI). Thromboelastography (TEG) measures viscoelastic properties of clot formation and is currently best known for perioperative management to reduce blood transfusion in cardiac surgery. AIM We sought to determine whether TEG may be predictive of bleeding in patients treated with TAVI. METHODS AND RESULTS Overall, 54 consecutive patients with severe aortic stenosis treated with TAVI were prospectively included. In all patients, two blood samples were obtained for TEG measurement (the first - 12 h prior to procedure tested with citrated kaolin [CK] TEG assay, and the second - immediately after prosthesis deployment tested with CK and citrated heparinised kaolin assay [CHK]). Major or life-threatening bleeding (MLTB) was diagnosed in 13 (24%) patients. In receiver-operating characteristic (ROC) curve analysis the only TEG parameters showing significant sensitivity and specific-ity for predicting MLTB were those obtained in the CK sample at the end of the procedure: R value (reaction time, time to initiation of clot formation) area under the curve (AUC) 0.69, 95% confidence interval (CI) 0.49-0.88, p = 0.04; angle (the rate of clot formation), AUC 0.75, 95% CI 0.59-0.92, p = 0.007, and maximum amplitude (MA, ultimate strength of fibrin clot), AUC 0.77, 95% CI 0.62-0.93, p = 0.003. After controlling for confounding factors on multivariate logistic regression, MA remained as the only TEG parameter that significantly correlated with bleeding after TAVI, both as a continuous variable (p = 0.004; 95% CI 0.92-0.98; odds ratio [OR] 0.95 per 1 mm increment) and after using the cut-off value derived from ROC analysis; MA < 46.6 mm (OR 10.4; 95% CI 2.1-51.8; p = 0.004). CONCLUSIONS Low strength of fibrin clot measured by TEG immediately after TAVI may serve as an independent predictor of short-term major and life-threatening bleeding complications.

Transcatheter aortic valve-in-valve implantation in failed stentless bioprostheses

OBJECTIVE To compare the safety and efficacy of transcathether aortic valve-in-valve implantation (ViV-TAVI) in degenerated stentless bioprostheses with failed stented valves and degenerated native aortic valves. INTRODUCTION Little is known about ViV-TAVI in degenerated stentless valves. METHODS Out of 45 ViV-TAVI procedures reported in the POL-TAVI registry, 20 failed stentless valves were compared with 25 stented prostheses and propensity-matched with 45 native TAVI cases. The mean follow-up was 633 (95% confidence interval [CI], 471-795) days and Valve Academic Research Consortium-2 (VARC-2) definitions were applied. RESULTS Patients with degenerated stentless valves were younger (65.6, CI 58-73.1 years vs 75.6, CI 72.2-78 [stented] vs 80.1, CI 78.7-81.6 y. [native], P < 0.001). Implantation was required later after surgery (11.5, CI 8-14.9 years) in the stentless cohort as compared with the stented one (6.2, CI 4.7-7.6 years, P = 0.006). ViV-TAVI in the stentless group was also associated with larger amount of contrast (211, CI 157-266 mL vs 135, CI 104-167 mL [stented] vs 132 (119-145) mL [native], P = 0.022). Using VARC-2 composite endpoints, ViV-TAVI in stentless prostheses was characterized by a lower device success (50% vs 76% in stented vs 88.9% in native TAVI, P < 0.001), but comparable early safety up to 30 days (73.7% vs 84% vs 81.8%, respectively, log-rank P = 0.667) and long-term clinical efficacy beyond 30 days (72.2% vs 72% vs 73.8%, respectively, log-rank P = 0.963). CONCLUSIONS Despite technical challenges and a lower device success, ViV-TAVI in stentless aortic bioprostheses achieves similar safety, efficacy, and functional improvement as in stented or degenerated native valves.

Concomitant coronary artery disease and its management in patients referred to transcatheter aortic valve implantation

Coronary artery disease (CAD) and degenerative aortic stenosis often coexist. However, the impact of CAD and its management on the prognosis after transcatheter aortic valve implantation (TAVI) remains uncertain. We sought to evaluate the impact of obstructive CAD, SYNTAX score (Ss), and percutaneous coronary intervention (PCI) prior to TAVI on short‐term outcome.

Challenging Diagnosis of Myocardial Infarction Due to Anomalous Left Circumflex Artery

DOI: 10.5935/abc.20180093 A 45-year-old male without past medical history presented with retrosternal chest pain and ST-segment elevation in inferolateral leads at ECG. Invasive coronary angiography, along with optical coherence tomography performed as part of the clinical study, showed normal coronaries, and myocardial infarction with non-obstructive coronary arteries (MINOCA) was diagnosed (Figure 1 A-B). Due to ongoing chest pain, triple-rule-out computed tomography angiography (CTA) was undertaken to exclude aortic dissection and pulmonary embolism. Incidentally, anomalous left circumflex artery (LCx) originating from the right sinus of Valsalva with a suspicion on severe stenosis was detected (Figure 1 C-E). Selective angiography of the LCx confirmed severe lesion in the distal vessel segment (Figure 1 F), however given the resolution of patient’s symptoms, a decision on medical therapy with dual antiplatelet agents was undertaken. At discharge, cardiac magnetic resonance disclosed mildly reduced left ventricular ejection fraction (53%) with myocardial edema and transmural infarction of the basal-to-mid lateral wall (Figure 1 G-H). LCx arising from the right aortic sinus is the most frequent coronary artery anomaly (CAA) found in up to 0.7% of the population. Although anomalous LCx is considered benign, the severe angle and tortuous vessel course may predispose it to accelerated atherosclerosis. Herein, the anomalous LCx was overlooked due to super-selective cannulation of the right coronary artery, and a large intermediate branch was incorrectly classified as LCx leading to deferred revascularization and irreversible myocardial injury. This case highlights that CAA could be included in the differential diagnosis of MINOCA, and unveils the potential for triple-rule-out CTA in detecting CAA.

Patient-prosthesis mismatch in patients treated with transcatheter aortic valve implantation – predictors, incidence and impact on clinical efficacy. A preliminary study

Introduction Patient-prosthesis mismatch (PPM) is relatively frequent after surgical aortic valve replacement (SAVR) and negatively impacts prognosis. Aim We sought to determine the frequency and clinical effects of PPM after transcatheter aortic valve implantation (TAVI). Material and methods Overall, 238 patients who underwent TAVI were screened. Moderate PPM was defined as indexed effective orifice area (EOAi) between 0.65 and 0.85 cm2/m2, and severe PPM as < 0.65 cm2/m2. All-cause mortality and the Valve Academic Research Consortium 2 (VARC-2) defined composite of clinical efficacy at 1 year were the primary endpoints. Results Finally, 201 patients were included (mean age: 79.6 ±7.4 years, 52% females). The femoral artery served as the delivery route in 79% and most of the prostheses were self-expanding (68%). Any PPM was present in 48 (24%) subjects, and only 7 (3.5%) had severe PPM. Body surface area (BSA) independently predicted any PPM (OR = 16.9, p < 0.001) whereas post-dilation tended to protect against PPM (OR = 0.46, p = 0.09). All-cause mortality was similar in patients with moderate or severe PPM as compared to those with no PPM (14.6% vs. 14.3% vs. 13.1%, respectively, log-rank p = 0.98). Neither moderate (OR = 1.6, 95% CI: 0.8–3.2, p = 0.16) nor severe PPM (OR = 1.67, 95% CI: 0.36–7.7, p = 0.51) had a significant impact on composite endpoint, or its elements, with the exception of transvalvular pressure gradient > 20 mm Hg. Conclusions Severe PPM after TAVI is rare, can be predicted by larger BSA and does not seem to affect mid-term mortality or composite clinical outcome. Larger studies are needed to find different independent predictors of PPM and elucidate its impact in terms of device durability and long-term clinical efficacy.

TCT-651 Impact of preprocedural coronary artery disease assessed by SYNTAX score on TAVI outcome

nos: 647 760