Piotr Ścisło

Detection of patients at risk for recurrence of atrial fibrillation after successful electrical cardioversion by signal-averaged P-wave ECG

The aim of the study was to assess the value of signal-averaged ECG of P-wave in predicting recurrence of atrial fibrillation after direct-current electrical cardioversion of chronic atrial fibrillation. The signal-averaged ECG triggered by P-wave was recorded in 35 patients after successful electroconversion. Duration of the high frequency P-wave and the root mean square voltages for the last 20 ms (RMS20) P-wave of the vector magnitude were calculated. After 6 months follow-up recurrence of atrial fibrillation was observed in 11 patients (group I) and in 24 patients sinus rhythm was maintained (group II). A filtered P-wave was significantly longer in group I with recurrence of atrial fibrillation, than in patients from group II who maintained sinus rhythm (145+/-11.8 vs 130+/-10.8 ms, p<0.001). RMS20 was significantly lower in group I than in patients from group II (1.6+/-0.6 vs 2.2+/-0.9 microV, p<0.02). A filtered P-wave of duration >q37 ms associated with a RMS 20 ms <1.9 microV had a sensitivity of 73% and specificity of 71% for the detection of patients with recurrence of atrial fibrillation after successful direct-current electrical cardioversion of chronic atrial fibrillation. These results suggest that signal-averaged ECG of P-wave may be helpful for identification of patients with recurrence of atrial fibrillation after successful direct-current electrical cardioversion.

Incidence, Predictors and Impact of Severe Periprocedural Bleeding According to VARC-2 Criteria on 1-Year Clinical Outcomes in Patients After Transcatheter Aortic Valve Implantation

There are differences in reporting bleeding complications after transcatheter aortic valve implantation (TAVI), which is a consequence of the lack of consensus for their definition. Furthermore, the amount of data on the impact of peri-procedural bleeding on the mid-term prognosis is still limited. The aim of this study was to investigate the incidence, predictors, and impact of life-threatening and major bleedings as defined by the Valve Academic Research Consortium 2 (VARC-2) in patients after TAVI over the mid-term prognosis.Consecutive patients who underwent TAVI from March 2010 to December 2013 were included. All data were classified according to the VARC-2 criteria. We assessed the incidence and the predictors of serious bleeding events (SBE), defined as life-threatening/disabling (LT/D) or major bleeding, and analyzed their impact on 30-day and 1-year clinical outcome.A total of 129 patients were included (79.1 ± 8.3 years; mean EuroSCORE = 17.8 ± 12.7). The SBE occurred in 25 patients (19.4%), of which 9 (7.0%) had LT/D and 16 (12.4%) had major bleeding. Trans-subclavian (TS) access (OR 4.38, 95% CI 2.13-14.29, P = 0.01) and diabetes (OR 2.93, 95% CI 1.08-7.93, P = 0.03) were identified as independent predictors of SBE. Patients with SBE had higher 30-day mortality (20.0% versus 4.0% P = 0.02) and 1-year mortality (40.0% versus 11.1%, P < 0.002). SBE independently predicted 1-year, all-cause mortality (HR 5.88, 95% CI 1.7319,94, P = 0.005).SBE are frequent after TAVI and are associated with decreased short and mid-term survival. Diabetes and TS access are independent risk factors for SBE.

Early partial clip detachment following transcatheter mitral valve repair

A 71-year-old man with a history of dyspnoea in New York Heart Association functional class III, due to heart failure and severe mitral regurgitation, was admitted to hospital for the treatment of valvular heart disease. The patient, diagnosed with type 2 diabetes in the past, had undergone two coronary artery bypass surgeries (in 1998 and 2014), the latter complicated by periprocedural myocardial infarction. Heart failure, which developed subsequently, led to the implantation of a cardioverter-defibrillator. Transthoracic echocardiography (TTE) confirmed impairment of left ventricular function (LVDD 66 mm; EF 26%) and the presence of severe functional mitral regurgitation (ERO 0.42 cm2, MRvol 51 mL). In a transoesophageal echocardiography (TEE) examination, the patient was found to be amendable for the percutaneous mitral valve repair. Due to the high risk of open heart surgery (EUROSCORE II 12.82%), the patient was scheduled for MitraClip implantation. The procedure was carried out successfully. A single MitraClip device was implanted in the area of the largest regurgitation jet. It led to a significant reduction of mitral insufficiency (Fig. 1A, B). The following hospitalisation was uneventful. However, on the third day after the procedure, in a pre-discharge TTE followed by immediate TEE, loss of posterior leaflet insertion into the MitraClip device and the recurrence of severe mitral regurgitation was found (Fig. 2A). Moreover, three-dimensional TEE showed a small indentation in the posterior leaflet edge, indicating the area of possible device-related leaflet damage (Fig. 2B). Because of the asymptomatic course of the event, after careful consideration of therapeutic options, the patient was discharged home without further interventions. Clinical evaluation, as well as TTE examination, was planned for the following weeks. Partial clip detachment (PCD), a complication observed in 2–4.8% of MitraClip procedures, usually occurs within the first six months following the implantation. In most the cases, loss of insertion involves posterior mitral valve leaflet. There are no specific guidelines regarding the treatment of this phenomenon. In a large European registry (ACCESS-EU), out of 27 patients in whom PCD was diagnosed, 11 underwent another clip implantation, most of them as a separate procedure. Pharmacological treatment was continued in 10 cases, whereas only six patients were referred for open heart surgery. However, repeat MitraClip therapy is associated with a significantly lower success rate when compared to the first procedure (62% vs. 95%) and heart surgery requires valve replacement more often than annuloplasty. On the other hand, clip embolisation, a potentially life threatening complication, is a very rare phenomenon, and most of the registries do not report such cases following PCD. Taking that into consideration, in our opinion, further pharmacological treatment and a watchful-waiting strategy remains a possible therapeutic option in clinically stable high-risk patients with diagnosed PCD following MitraClip implantation.

Bilateral, progressive coronary ostial stenosis following valve sparing aortic root replacement

A 63-year-old man with ascending aorta aneurysms was scheduled for valve sparing aortic root replacement (David procedure). Preoperative angiography showed normal coronary arteries. The operation was carried out according to the standard procedure and aorto-coronary anastomoses were strengthened with surgical adhesive. The patient was discharged home on the 14th day after the procedure. There were no signs of ischaemia in the electrocardiography (ECG), and echocardiography showed a positive result of the operation with preserved left ventricular (LV) function. Three days later he was brought to the emergency department following a syncope episode preceded by prolonged chest pain. An ECG showed signs of anterior and lateral wall ischaemia and troponins were elevated. Echocardiography revealed severe depression of LV function with an ejection fraction (EF) of 25% and an atypical mass surrounding the aortic bulb (Fig. 1A, B). The patient was referred for coronary angiography in which borderline stenosis of the proximal right coronary artery (Fig. 1C) and critical lesion in the left main were found (Fig. 1D). The left main coronary artery was immediately stented (Fig. 1E) and the ECG, as well as EF, returned in subsequent days to baseline. Three months later, the patient was readmitted for a routine check-up. He complained of gradual symptom recurrence during the previous weeks, described mainly as shortness of breath during mild exertion. Echocardiography findings were comparable to those previously reported. Because of an elevated lesion recurrence risk, the patient was scheduled for invasive coronary angiography. The examination showed the sustained result of left main coronary artery stenting (Fig. 2A), but significant progression of right coronary artery ostial stenosis with slow epicardial flow was noted (Fig. 2B). The patient underwent subsequent percutaneous coronary intervention. The right coronary ostium was stented, and complete patency, as well as rapid artery flow, were restored (Fig. 2C). Significant stenosis of coronary artery ostium is a rare but a potentially life-threatening complication of aortic root and valve surgery. There are several possible causes of this phenomenon, such as surgical error or vessel injury caused by artery cannulation during the infusion of cardioplegic solution. Compression of the artery by the external mass, for example, through overuse of surgical adhesive or later in time, fibrotic tissue formation, seems to be another likely reason. Current literature provides numerous cases of coronary artery stenosis following aortic root and valve surgery. Most of them describe left main artery lesions. Bilateral coronary stenosis is less frequent, but this phenomenon might be under-reported due to the potential high risk of fatality. Figure 1. A, B. Atypical mass surrounding the aortic bulb in the area of left main coronary artery origin; C. Borderline stenosis of the proximal right coronary artery; D. Critical lesion in the left main coronary artery; E. Immediate result of the left main coronary artery stenting

Unusual thrombo-embolic event after radiofrequency ablation

We present an otherwise healthy 21-year old man, after successful radiofrequency ablation of the slow pathway due to atrioventricular nodal re-entry tachycardia. The procedure lasted 145 min, and there were seven applications of RF current (253 s). During ablation, the patient received heparin 1000 IU iv. In control echocardiography (6 …