Michał Krejca

Fully automatic algorithm for the analysis of vessels in the angiographic image of the eye fundus

BackgroundThe available scientific literature contains descriptions of manual, semi-automated and automated methods for analysing angiographic images. The presented algorithms segment vessels calculating their tortuosity or number in a given area. We describe a statistical analysis of the inclination of the vessels in the fundus as related to their distance from the center of the optic disc.MethodsThe paper presents an automated method for analysing vessels which are found in angiographic images of the eye using a Matlab implemented algorithm. It performs filtration and convolution operations with suggested masks. The result is an image containing information on the location of vessels and their inclination angle in relation to the center of the optic disc. This is a new approach to the analysis of vessels whose usefulness has been confirmed in the diagnosis of hypertension.ResultsThe proposed algorithm analyzed and processed the images of the eye fundus using a classifier in the form of decision trees. It enabled the proper classification of healthy patients and those with hypertension. The result is a very good separation of healthy subjects from the hypertensive ones: sensitivity - 83%, specificity - 100%, accuracy - 96%. This confirms a practical usefulness of the proposed method.ConclusionsThis paper presents an algorithm for the automatic analysis of morphological parameters of the fundus vessels. Such an analysis is performed during fluorescein angiography of the eye. The presented algorithm automatically calculates the global statistical features connected with both tortuosity of vessels and their total area or their number.

Totally epicardial cardiac resynchronization therapy system implantation in patients with heart failure undergoing CABG

Systolic dyssynchrony is present in a considerable number of patients with heart failure (HF) undergoing coronary artery bypass grafting (CABG). Surgical revascularization offers an optimal setting for totally epicardial cardiac resynchronization therapy (CRT) system implantation.

Preoperative quantification of aortic valve stenosis: comparison of 64-slice computed tomography with transesophageal and transthoracic echocardiography and size of implanted prosthesis

Precise measurements of aortic complex diameters are essential for preoperative examinations of patients with aortic stenosis (AS) scheduled for aortic valve (AV) replacement. We aimed to prospectively compare the accuracy of transthoracic echocardiography (TTE), transoesophageal echocardiography (TEE) and multi-slice computed tomography (MSCT) measurements of the AV complex and to analyze the role of the multi-modality aortic annulus diameter (AAd) assessment in the selection of the optimal prosthesis to be implanted in patients surgically treated for degenerative AS. 20 patients (F/M: 3/17; age: 69xa0±xa06.5xa0years) with severe degenerative AS were enrolled into the study. TTE, TEE and MSCT including AV calcium score (AVCS) assessment were performed in all patients. The values of AAd obtained in the long AV complex axis (TTE, TEE, MSCT) and in multiplanar perpendicular imaging (MSCT) were compared to the size of implanted prosthesis. The mean AAd was 24xa0±xa03.6xa0mm using TTE, 26xa0±xa04.2xa0mm using TEE, and 26.9xa0±xa03.2 in MSCT (Pxa0=xa00.04 vs. TTE). The mean diameter of the left ventricle out-flow tract in TTE (19.9xa0±xa02.7xa0mm) and TEE (19.5xa0±xa02.7xa0mm) were smaller than in MSCT (24.9xa0±xa03.3xa0mm, Pxa0<xa00.001 for both). The mean size of implanted prosthesis (22.2xa0±xa02.3xa0mm) was significantly smaller than the mean AAd measured by TTE (Pxa0=xa00.0039), TEE (Pxa0=xa00.0004), and MSCT (Pxa0<xa00.0001). The implanted prosthesis size correlated significantly to the AAd: rxa0=xa00.603, Pxa0=xa00.005 for TTE, rxa0=xa00.592, Pxa0=xa00.006 for TEE, and rxa0=xa00.791, Pxa0<xa00.001 for MSCT. Obesity and extensive valve calcification (AV calcium scorexa0≥xa03177Ag.U.) were identified as potent factors that caused a deterioration of both TTE and MSCT performance. The accuracy of AAd measurements in TEE was only limited by AV calcification. In multivariate regression analysis the mean value of the minimum and maximum AAd obtained in MSCT-multiplanar perpendicular imaging was an independent factor (rxa0=xa00.802, Pxa0<xa00.0001) predicting the size of implanted prosthesis. In patients with AS echocardiography remains the main diagnostics tool in clinical practice. MSCT as a 3-dimentional modality allows for accurate measurement of entire AV complex and facilitates optimal matching of prosthesis size.

Gentamicin-containing collagen implant reduces sternal wound complications after cardiac surgery: A retrospective analysis

INTRODUCTIONnThe majority of evidence for use of gentamicin-containing collagen implants (GCCI) demonstrates a positive impact on infection prophylaxis despite the equivocal results of a recently published large-scale study. The primary aim of the study was to evaluate the impact of prophylactic use of GCCI on SWI following cardiac surgery in a routine clinical setting. A secondary aim was to identify the risk factors for SWI among the patient cohort.nnnMETHODSnA consecutive series of patients who had undergone sternotomy were analysed on a retrospective basis. Patient characteristics, risk factors and procedure-related variables were analysed for Group I (superficial sternal wound infection [SSWI]) and Group II (deep sternal wound infection [DSWI]) in relation to patients with complete wound healing.nnnRESULTSnA total of 1118 patients met the inclusion criteria. The bivariate analysis demonstrated that the SSWI rate was significantly reduced by 43% in the GCCI group vs. standard treatment. Multivariate analysis demonstrated that addition of GCCI to standard treatment reduced the DSWI rate by 59% vs. standard treatment alone. Arterial hypertension, permanent/persistent atrial fibrillation and chest revision were identified as new risk factors for SSWI and pulmonary hypertension and chest revision were identified as new risk factors for DSWI.nnnDISCUSSIONnThis study confirms the positive results with GCCI seen in the majority of published studies in cardiac surgery.nnnCONCLUSIONnIn routine clinical practice the addition of GCCI to standard infection prophylaxis reduces the risk of both SSWI and DSWI in high-risk patients undergoing cardiac surgery.

Survival after surgical ablation for atrial fibrillation in mitral valve surgery: Analysis from the Polish National Registry of Cardiac Surgery Procedures (KROK)

Objectives: Surgical ablation for atrial fibrillation (AF) performed at the time of other valvular‐ or nonvalvular cardiac procedure is a mainstay of therapy; yet the data regarding its influence on remote survival are sparse. We aimed to evaluate late survival in patients undergoing mitral valve (MV) surgery with concomitant surgical ablation for AF. Methods: Procedure‐related data from the Polish National Registry of Cardiac Surgery Procedures (Krajowy Rejestr Operacji Kardiochirurgicznych) were retrospectively collected. A total of 11,381 patients with baseline AF (46.6% men; mean age 65.6 ± 9.0 years) undergoing MV surgery between 2006 and 2017 in 37 reference centers across Poland and included in the registry were analyzed. Median follow‐up was 5 years (mean, 4.6 years; interquartile range, 1.9‐7.9 years). Cox proportional hazards models were used for computations. Propensity score matching for the comparison of MV + ablation versus MV alone was performed. Results: Of included patients, 2449 (21.5%) underwent surgical ablation for AF. Patients in this group were significantly younger (63.8 ± 8.7 years vs 66.1 ± 9.0 years; P < .001) and were at lower baseline surgical risk (EuroSCORE, 2.86 vs 3.69; P < .001). During the 12‐year study period, there was a significant survival benefit (hazard ratio, 0.71; 95% confidence interval, 0.63‐0.79; P < .001) for MV + ablation compared with MV alone. After rigorous propensity matching (logit model, 1784 pairs) surgical ablation was associated with nearly 20% improved survival (hazard ratio, 0.82; 95% confidence interval, 0.70‐0.96; P = .011). Benefit of surgical ablation was maintained in subgroup analyses, yet most benefit was appraised in low‐risk patients such as those with EuroSCORE of 2 to 5 or age < 50 years. Conclusions: Concomitant surgical ablation for AF in patients undergoing mitral valve procedures is safe, feasible, and significantly improves late survival.

Neointima development in externally stented saphenous vein grafts

Introduction The main limitation of coronary artery bypass grafting (CABG) is rapid neointimal hyperplasia leading to graft failure. Aim To assess plaque formation in saphenous vein grafts (SVG) covered by an external Dacron stent in comparison with the classical technique. Material and methods In the study group vein grafts covered by external stent mesh made of Dacron were implanted. An intravascular ultrasonography (IVUS) study was performed in 35 aorto-coronary SVG covered by an external Dacron stent and in 64 normal SVG during the first year after CABG. In each SVG 25 mm of good quality IVUS image, volumes of lumen, plaque (neointima), outer border of the vein graft (external SVG) and adventitia were calculated in three time periods: 0–130 days, 130–260 days and 260–390 days. Results Between the first and second time period, lumen volume (mm3) was reduced from 10.33 ±4.4, to 6.80 ±2.23 in the second period and 5.69 ±1.26 in the third one. This effect was much less marked in normal grafts. The corresponding lumen volume (mm3) was: 10.90 ±3.9, 9.15 ±2.94 and 8.92 ±2.93 in consecutive time periods. Plaque volume (mm3) did not change in control grafts during the course of the study, but it increased very significantly in stented grafts from 0.86 ±1.24 in the first period to 2.70 ±1.58 in the second and 3.29 ±2.66 in the third one. Conclusions The experimental technique of implanting SVG covered with an external elastic Dacron stent seems to be inferior to traditional ones. This is probably due to the more complicated process of vein implantation and higher micro-injury occurrence during the surgery.

A next-generation self-expandable valve implantation in a patient with failed aortic bioprosthesis

Conflict of interest: none declared Figure 1. Fluoroscopy and echocardiography; A. Severe aortic bioprosthesis stenosis; B. Corevalve positioned at bioprosthesis level. Visible bioprosthetic ring (white arrow); C. Partially released Corevalve prosthesis (white arrow). Inappropriate position over bioprosthetic ring; D. Recaptured Corevalve prosthesis; E. Early phase of second deployment; F. Corevalve completely released; G. Visible Corevalve prosthesis in left ventricular outflow track and ascending aorta (white arrows) A A next-generation self-expandable valve implantation in a patient with failed aortic bioprosthesis

Hybrid approach for acute limb ischaemia after transcatheter aortic valve implantation

A 79-year-old woman with a history of aortic valve replacement with a 21-mm Sorin Pericarbon More bioprosthetic valve (Sorin, Sallugia, Italy) was admitted to our hospital because of recurrent symptoms of congestive heart failure New York Heart Association class III–IV. Echocardiography revealed degenerated aortic bioprosthesis with maximal and mean pressure gradient of 74 mm Hg and 37 mm Hg, respectively, and calculated aortic valve area of 0.6 cm2 with good ejection fraction. The pre-procedural logistic EuroScore I was 18% and the Society of Thoracic Surgeons score 18.2%. Taking into account the high surgical risk, the Heart Team decided to perform valve-in-valve transcatheter aortic valve implantation (TAVI). The procedure was performed under general anaesthesia. After placing a pigtail catheter via the left common femoral artery (CFA), the right CFA was punctured under fluoroscopic guidance and a Prostar XL closure device (Abbott Vascular, Santa Clara, CA, USA) was introduced in a standard manner. A Corevalve 23-mm (Medtronic, Minneapolis, MN, USA) prosthesis was positioned and implanted at aortic bioprosthesis level with an excellent result (Fig. 1A). The access site was closed with a Prostar XL; however, control peripheral angiography revealed moderate contrast leakage at the puncture site (Fig. 1B). The access site was manually compressed for 10 min. Anticoagulation was also reversed. Control contrast injection showed thrombotic occlusion of the right external iliac artery (EIA) (Fig. 1C). From the left CFA, using cross-over technique, a long 6 F sheath was advanced into the right EIA and the occlusion was crossed with a standard 0.35 J guide wire. Angioplasty of EIA was not performed because control contrast injection revealed patent EIA, but there was still no pulse in the patient’s right foot. Peripheral angiography confirmed continuous severe contrast leakage at the puncture site and complete embolic blockage of the popliteal artery (Fig. 1D, E). The CFA and the damaged distal part of the EIA were exposed using a surgical approach. The EIA was repaired and after CFA cut-down, popliteal embolectomy with a 5-mm Fogarty catheter was performed. The popliteal artery was opened with good flow towards the anterior tibial artery; however, the tibioperoneal trunk was still occluded (Fig. 1F). Attempts to reopen the tibioperoneal trunk with smaller Fogarty embolectomy catheters were unsuccessful, which triggered insertion of 6 F sheath via the CFA in an antegrade direction. The tibioperoneal trunk was crossed with a coronary wire, and thrombectomy of the tibioperoneal trunk using multipurpose catheter was done, leading to restoration of distal blood flow (Fig. 1G). Further in-hospital course was uneventful and the patient was discharged on the 8th day after TAVI. Figure 1. Aortogram and peripheral angiography; A. Optimal Corevalve position; B. Moderate contrast leakage at puncture site (arrow); C. Thrombotic occlusion of the right external iliac artery (arrow); D. External iliac artery reopened with wire, severe contrast extravasation (arrow); E. Embolic occlusion of popliteal artery (arrow); F. Patent popliteal and anterior tibial artery. Tibioperoneal trunk still occluded (arrow); G. Final result after tibioperoneal trunk thrombectomy A

A novel peritoneum derived vascular prosthesis formed on a latex catheter in an SDF-1 chemokine enriched environment: a pilot study.

Introduction Although saphenous vein grafts are widely used conduits for coronary artery bypass graft surgery, their clinical value remains limited due to high failure rates. The aim of the study was to evaluate feasibility, safety, and biocompatibility of peritoneal derived vascular grafts (PDVG) formed on a silicone-coated, latex, Foley catheter in a stromal cell-derived factor (SDF-1)- enriched environment. Methods Foley catheters were implanted into the parietal wall of 8 sheep. After 21 days the peritoneal cavity was re-opened and the newly formed tissue fragments were harvested. The animals were randomly assigned into: (1) study group in which conduits were incubated in a solution containing SDF-1, (2) control group without SDF-1 incubation. Left carotid arteries were accessed and “end-to-side” anastomoses were performed. Biological materials for histological examination were taken at 4, 7, 10, and 14 days. Results and Conclusions The study proved safety, feasibility, and biocompatibility of PDVG formed on the basis of a silicone-coated, latex catheter in an SDF-1 chemokine-enriched environment. These biological grafts effectively integrated with the native high-pressure arterial environment in an ovine model and provided favorable vascular profile. The potential clinical value of this technology needs to be further elucidated in long-term preclinical and clinical studies.

Surgical extraction of cardiac resynchronization therapy system with concomitant implantation of a new system with the use of epicardial leads in a patient with endocarditis

Endocarditis related to a transvenously implanted cardiac resynchronization therapy (CRT) system is a rare but serious therapeutic challenge, particularly in those patients in whom interruption of biventricular stimulation induces dramatic deterioration of their hemodynamic status.