Petr Stros

One-Year Coronary Bypass Graft Patency A Randomized Comparison Between Off-Pump and On-Pump Surgery Angiographic Results of the PRAGUE-4 Trial

Background—Off-pump coronary bypass surgery has become a widely used technique during recent years. However, limited data are available with regard to 1-year patency of bypass grafts implanted on the beating heart in unselected consecutive bypass surgery candidates. The aim of this study was to compare 1-year angiographic patency of bypass grafts done on the beating heart (off pump) with those done classically (on pump). Methods and Results—The PRAGUE-4 trial randomized 400 consecutive nonselected cardiac surgery candidates into group A (on pump; n=192) and group B (off pump; n=208). One-year follow-up coronary angiography was done in 255 patients. The arterial graft patency after 1 year was 91% in both groups. Saphenous graft patency was 59% (on pump) versus 49% (off pump; P=NS). Saphenous graft patency per patient was lower in the off-pump group: 0.7 patent anastomosis per patient versus 1.1 patent anastomosis in the on-pump group (P<0.01). There were 46% on-pump patients with all grafts patent versus 52% off-pump patients (P=NS). Grafts anastomosed distally to collateralized chronic total occlusions of native coronary arteries remained patent in 100% on the left anterior descending artery compared with 23% on other arteries (P<0.0001). Conclusions—The patency of arterial coronary bypass grafts done on the beating heart is excellent and equal to grafts done on pump. The off-pump procedure in the unselected patient population results in fewer patent saphenous grafts per patient.

Deactivation of implantable cardioverter-defibrillators: results of patient surveys

AIMS The indications for implantable cardioverter-defibrillators (ICDs) have been expanding, especially for primary prevention of sudden cardiac death. Implantable cardioverter-defibrillator saves lives; however, in near end-of-life situations linked to incurable diseases, the question arises as to whether or not to turn off the ICD to avoid excessive numbers of shocks as the heart begins to fail. This study examined the wishes of a cohort of ICD recipients. METHODS AND RESULTS Consecutive recipients of ICDs for primary or secondary prevention of sudden cardiac death were examined during a routine out-patient follow-up visit. Subjects completed a written survey about expected ICD benefits, feelings and circumstances under which they would want to deactivate the device. One hundred and nine patients fully completed the survey. Mean age was 67.6 ± 8.7 years, 91 (83.5%) were male and the mean systolic ejection fraction was 31.5 ± 10.9%. The severity of symptoms of heart failure according to the New York Heart Association classification was 2.1 ± 0.59 at implantation. Ninety-nine (90.8%) patients felt more secure and safe following ICD implantation and 66 (60.6%) patients reported a sense of improved health status after implantation. Thirty-one (28.4%) patients had experienced an ICD shock. Fifty (45.9%) patients indicated that they had never considered ICD deactivation during near end-of-life situations. This topic had been discussed with only eight (7.3%) patients. Forty-four (40.1%) patients wanted more information about ICD deactivation. On the other hand, 10 (41.7%) patients from secondary prevention and 19 (22.4%) from primary prevention groups categorically refused more information or further discussion on this topic (P = 0.058). CONCLUSION Most ICD recipients felt safer following ICD implantation and most wanted more information regarding ICD deactivation. However, a significant number of patients (especially, secondary prevention patients) had no interest in receiving additional information about this topic.

Changes and Prognostic Impact of Apoptotic and Inflammatory Cytokines in Patients Treated with Cardiac Resynchronization Therapy

Objectives: In patients with heart failure, increased apoptosis, inflammation and activation of the transforming growth factor (TGF)-β cytokine system have been documented. The aim of the present study was to establish (i) whether cytokine concentrations decrease in patients who respond to cardiac resynchronization therapy (CRT), and (ii) whether pre-implant values have any prognostic value. Methods: Eighty-one CRT candidates were prospectively studied. The success of CRT was assessed based on clinical and echocardiographic improvement 6 months after implantation. Mortality was assessed 2 years after implantation. Blood samples were drawn before and 6 months after implantation. Serum concentrations of Fas, TNF-related apoptosis-inducing ligand, tumor necrosis factor (TNF)-α, TNF-receptor 1, TGF-β1 and interleukin (IL)-6 were measured using ELISA. Results: At 6 months, 46 (56.8%) patients were classified as responders and 35 (43.2%) as nonresponders. Neither group differed with respect to baseline characteristics. In responders, the concentrations of IL-6, TNF-α and TGF-β1 decreased significantly. In nonresponders, the concentration of TGF-β1 even increased significantly. In multivariate analysis, the concentration of TGF-β1 was a significant predictor of death during follow-up. Conclusions: The response to CRT implantation was associated with a decrease of TGF-β1, IL-6 and TNF-α. Higher pre-implant concentrations of TGF-1β were independently associated with a poor prognosis in CRT patients.

The Insufficiency of Left Anterior Oblique and the Usefulness of Right Anterior Oblique Projection for Correct Localization of a Computed Tomography-Verified Right Ventricular Lead Into the Midseptum

Background—The aim of the study was to verify the correct anchoring location for the tip of the right ventricular lead using cardiac computed tomography and to assess the best fluoroscopic and ECG criteria associated with the correct location of the electrode into the midseptum. Methods and Results—Patients indicated to pacemaker implantation were prospectively enrolled. The right ventricular lead was implanted into the midseptum according to standard criteria in left anterior oblique 40 view. The cardiac shadow on the right anterior oblique 30 was divided into 4 quadrants perpendicular to the lateral cardiac silhouette and the position of the lead tip was analyzed. The exact position of the lead tip was assessed using computed tomography. Of 51 patients, the right ventricular lead was anchored midseptum in 21 (41.2%; MS group). In 30 patients (58.8%; non-MS group), the lead was anchored in the adjacent anterior wall. The angle between the lead and horizontal axis on the left anterior oblique was similar in both groups. The non-MS group was associated with shorter distances between the tip and the cardiac contours in the right anterior oblique 30 (96.7% of leads in the non-MS group were in the outer quadrant versus 9.6% in the MS group; P<0.001). The presence of the lead in the middle or inferior quadrants was independently associated with correct midseptum placement with positive predictive value of 94.7%. Conclusions—Despite the optimal shape of the left anterior oblique, substantial numbers of leads were not anchored in the midseptum. Knowing the right anterior oblique 30 lead position can ensure proper midseptal placement.

Changes in cytokine concentrations following successful ablation of atrial fibrillation

AIMS Atrial fibrillation is associated with the activation of inflammatory processes [e.g. higher concentrations of pro-inflammatory cytokines interleukin-6 (IL-6), C-reactive protein (CRP)], as well as a pro-thrombotic state [e.g. increased concentration of serum pro-thrombotic markers P-selectin and CD40 ligand (CD40L)]. The aim of the present study was to establish, whether successful epicardial ablation of AF leads to decreased concentrations of traditional inflammatory and thrombotic markers. METHODS Twenty-five patients with symptomatic paroxysmal or persistent AF were prospectively studied. All underwent epicardial isolation of pulmonary veins. The success of the ablation was assessed clinically and with three Holter recordings. Blood samples were drawn before, three and six months after surgery. Serum concentrations of IL-6, interleukin-10 (IL-10), CRP, CD40L and P-selectin were measured using ELISA. RESULTS AF was successfully ablated in 15 patients (SR group). In the other 10 patients (AF group), AF re-occurred during follow-up. Neither group differed with respect to age, gender, left ventricular ejection fraction, or preoperative concentrations of measured molecules. The concentrations of IL-6, CRP and CD40L decreased in successfully ablated patients; however, there was no change in the concentrations of these molecules in the AF group. The concentrations of IL-10 and P-selectin were unchanged in both groups during follow-up. CONCLUSION Successful ablation of AF, with sinus rhythm restoration and maintenance, is associated with decreased serum levels of markers of inflammation.

Decreased Apoptosis following Successful Ablation of Atrial Fibrillation

Objectives: Increased apoptotic processes in tissue samples from hearts in atrial fibrillation (AF) have been previously documented in animals. Whether the restoration of sinus rhythm is associated with decreased apoptosis is not known. The aim of the present study was to establish whether successful epicardial ablation of AF leads to changes in the concentration of serum markers of apoptosis. Methods: Twenty-five patients with AF were prospectively studied. All underwent epicardial isolation of pulmonary veins. The success of the ablation was assessed clinically and with 3 Holter recordings. Blood samples were drawn before surgery, and at 3 and 6 months after. Serum concentrations of Fas (apoptosis-stimulating fragment) and TRAIL (tumor necrosis factor-related apoptosis-inducing ligand) were measured using ELISA. Results: AF was successfully ablated in 15 patients (SR group). In the other 10 patients (AF group), AF recurred during follow-up. Neither group differed with respect to age, sex, left ventricular ejection fraction, or preoperative concentrations of measured molecules. While Fas decreased in successfully ablated patients, there was no change in the Fas concentration in the AF group. Similarly, the concentrations of TRAIL decreased in the SR group, but remained unchanged in the AF group. Conclusion: The ablation of AF is associated with decreased serum markers for apoptosis.

The Insufficiency of Left Anterior Oblique and the Usefulness of Right Anterior Oblique Projection for Correct Localization of a CT-Verified Right Ventricular Lead into the Midseptum

Background—The aim of the study was to verify the correct anchoring location for the tip of the right ventricular lead using cardiac computed tomography and to assess the best fluoroscopic and ECG criteria associated with the correct location of the electrode into the midseptum. Methods and Results—Patients indicated to pacemaker implantation were prospectively enrolled. The right ventricular lead was implanted into the midseptum according to standard criteria in left anterior oblique 40 view. The cardiac shadow on the right anterior oblique 30 was divided into 4 quadrants perpendicular to the lateral cardiac silhouette and the position of the lead tip was analyzed. The exact position of the lead tip was assessed using computed tomography. Of 51 patients, the right ventricular lead was anchored midseptum in 21 (41.2%; MS group). In 30 patients (58.8%; non-MS group), the lead was anchored in the adjacent anterior wall. The angle between the lead and horizontal axis on the left anterior oblique was similar in both groups. The non-MS group was associated with shorter distances between the tip and the cardiac contours in the right anterior oblique 30 (96.7% of leads in the non-MS group were in the outer quadrant versus 9.6% in the MS group; P<0.001). The presence of the lead in the middle or inferior quadrants was independently associated with correct midseptum placement with positive predictive value of 94.7%. Conclusions—Despite the optimal shape of the left anterior oblique, substantial numbers of leads were not anchored in the midseptum. Knowing the right anterior oblique 30 lead position can ensure proper midseptal placement.

In-hospital arrhythmias in patients with acute myocardial infarction - the relation to the reperfusion strategy and their prognostic impact.

Arrhythmias are frequent complication in patients with acute myocardial infarction (MI). The importance of accelerated idioventricular rhythm (AIVR), ventricular fibrillation or tachycardia (VF, VT), atrial fibrillation or flutter (AF) and bradycardias is considered and discussed in this review article. The value of the presence of AIVR as a marker of reperfusion is small, but in combination with other non‐invasive markers (ST‐segment resolution), its presence is connected with a high probability of successful reperfusion. Early ventricular arrhythmias are a serious complication of MI. However, if they are revealed and treated in time, they apparently do not represent a negative prognostic factor. Later occurred VF or VT are more a symptom of larger MI. AF, which is not directly life‐threatening for the patients, frequently occurs in patients with larger MI and it is an independent predictor of a poor long‐term prognosis of these patients. The early and successful reperfusion therapy is the best anti‐arrhythmic therapeutic method in patients with MI.

Cardiac resynchronization therapy implantation following transcatheter aortic valve implantation

The conduction defects in patients following transcatheter aortic valve implantation (TAVI) are common and difficult to predict. Whether a pacemaker (and which type) should be implanted in this particular group of patients remains a question. We report on the case of a TAVI patient initially implanted with a DDD pacemaker, who substantially profited from a later upgrade to a cardiac resynchronization therapy.

Higher platelet activity is present in patients with restenosis after percutaneous coronary intervention compared with patients with an occlusion of coronary artery bypass graft

The aim of the study was to compare platelet activity between patients with an occlusion of bypass graft after coronary artery bypass graft surgery and restenosis after percutaneous coronary intervention (PCI); that is, between patients with reappearance of ischemia after two different kinds of coronary revascularization. Thirty patients were studied in a cross-sectional designed study. Fifteen of them were patients with the worst bypass graft patency from Prague-4 study (control protocol-driven coronary angiography performed at 1 year after surgery; originally 47 bypass grafts implanted, 94% of venous grafts occluded). The remaining 15 were patients with restenosis 3–12 months after PCI. Blood samples were drawn at least 12 weeks after coronary angiography. Platelet activity was determined by membrane expression of P-selectin (CD62P, % of positive cells) by flow cytometry, aggregability by ADP aggregometry. Data are expressed as mean ± SEM. Both groups were similar with respect to age, BMI and presence of diabetes mellitus. No patient suffered from acute coronary syndrome. P-selectin expression was significantly higher in the patients with restenosis compared with patients with bypass graft occlusion (1.96 ± 0.07 vs. 0.77 ± 0.03, P < 0.001, Wilcoxon test). ADP aggregometry was not different between groups (55.5 ± 1.1 vs. 56.1 ± 0.8, P = NS). Higher platelet activity is present in the patients with restenosis after PCI compared with the patients with the occlusion of bypass graft. Platelet activity play more important role in the development of restenosis after PCI compared with the occlusion of bypass graft after coronary artery bypass graft surgery, at least in the period up to 1 year after revascularization.