Piotr Suwalski

Surgical and interventional management of mitral valve regurgitation: a position statement from the European Society of Cardiology Working Groups on Cardiovascular Surgery and Valvular Heart Disease

Mitral regurgitation (MR) has a prevalence of 2% in the general population and is even more common in the elderly.[1][1] Organic (or primary) MR arises as a result of pathology affecting one or more components of the mitral valve (MV) apparatus, whereas functional (or secondary) MR is a consequence

Assessment of Nonlinear Heart Rate Dynamics after Beating-Heart Revascularization

BACKGROUND Advanced nonlinear methods of measuring heart rate variability (HRV) derived from the mathematics of complex dynamics and fractal geometry have provided new insights into the abnormalities of heart rate behavior in various pathologic conditions. These methods have provided additional prognostic information compared with traditional HRV measures and clearly have complemented the conventional linear methods. Knowledge about the behavior of complex cardiac dynamics indices after different cardiac procedures is very limited, however. We aimed to clarify how nonlinear heart rate dynamics are affected by beating-heart revascularization (off-pump coronary artery bypass graft [CABG] surgery) within the first week after the procedure. METHODS Included in the study were 66 patients who had isolated stable multivessel coronary artery disease and were in normal sinus rhythm. The patients were on chronic beta-blocker therapy and were scheduled for off-pump CABG. We performed 15-minute high-resolution electrocardiographic recordings preoperatively and on the third and seventh postoperative days to assess linear and nonlinear heart rate dynamics. Frequency-domain measurements, detrended fluctuation analysis (DFA) with short-term (<or=11 beats, alpha1) and long-term (>11 beats, alpha2) correlation properties of RR-intervals, and fractal dimension (FD) measurements (average, high, and low) were made. Arrhythmia was monitored preoperatively with 24-hour Holter recordings, postoperatively by continuous monitoring for the first 4 days after the procedure, and subsequently by clinical monitoring; 24-hour Holter recordings were obtained again on the seventh postoperative day. We used the paired-samples Student t test, the Mann-Whitney U test, and the Fisher exact test for statistical analyses. Differences in arrhythmia occurrence before and after the procedure were tested with the Wilcoxon signed rank test and the McNemar test. A P level < .05 was considered statistically significant. RESULTS Values for all frequency-domain parameters decreased significantly after off-pump CABG (P< .001). Values for the alpha1 and high FD parameters decreased significantly after the procedure (P= .028 and .001, respectively), whereas alpha2 increased significantly (P= .023). DFA alpha1 was significantly lower in patients with postoperative atrial fibrillation than in patients remaining in sinus rhythm (mean +/- SD, 0.79+/-0.32 versus 1.13+/-0.45 [P= .003] on the third postoperative day; 0.89+/-0.31 versus 1.22+/-0.34 [P< .001] on the seventh postoperative day), whereas low and average FDs were significantly higher (1.84+/-0.16 versus 1.68+/-0.19 [P= .003] on the third postoperative day and 1.77+/-0.18 versus 1.66+/-0.17 [P= .01] on the seventh postoperative day for the low FD; 1.83+/-0.09 versus 1.76+/-0.10 [P= .011] on the third postoperative day and 1.80+/-0.11 versus 1.73+/-0.10 [P= .014] on the seventh postoperative day for the average FD). The low FD was significantly higher on the third postoperative day in patients with postoperative deterioration of ventricular ectopy than in patients with improved ventricular ectopy (1.74+/-0.17 versus 1.48+/-0.08, [P= .03]). CONCLUSION The decreases in alpha1, average FD, and high FD indicate that a profound decay of cardiac complexity and fractal correlation can be observed after off-pump CABG. Furthermore, a more extensive impairment of nonlinear indices was observed in patients who developed postoperative arrhythmias than in those who remained in stable sinus rhythm. Our findings suggest that the postoperative hyperadrenergic setting acts as a preliminary condition in which both reduced and enhanced vagal activity may predispose patients to arrhythmia, indicating that postoperative rhythm disturbances are an end point associated with divergent autonomic substrates.

Endocardial Laser Ablation for the Treatment of Atrial Fibrillation in an Acute Sheep Model

Abstract  Background: The purpose of this study was to test the feasibility, effectiveness, and safety of the use of a new laser energy catheter for linear endocardial ablation in an acute sheep model. Methods: Bipolar pacing electrodes were positioned on the left atrial appendage (LAA) and the pulmonary veins (PVs). Laser ablation within the left atrium was performed around the LAA and PVs in six sheep. The temperature in the esophagus was measured continuously during ablation. The animals were weaned from cardiopulmonary bypass (CPB) and were sacrificed two hours after ablation. The heart, lungs, and esophagus were retrieved for histological examination. Results: Aortic cross clamp time was 26.2 ± 6.1 minutes and CPB time was 81 ± 29 minutes. Electrical isolation of the LAA and PVs was confirmed in all sheep. On histological analysis, there was an extensive transmural alteration of the left atrial tissue including vascular lesions, myocardial degeneration, and necrosis, and epi‐ and endocardial necrosis. In six out of six cases, extensive lesions of the esophagus (muscular layer) were also found. Significant changes in esophageal temperature were observed, reaching up to 70 °C. The epithelial layer of the esophagus was not affected by the laser energy, but mild focal degeneration of the subepithelial connective tissue was observed in all sheep. There were no injuries to the circumflex coronary artery. Conclusions: Laser is an effective tool in endocardial ablation, resulting in electrical isolation and transmurality. Future studies should more completely assess the safety of laser ablation, especially with regards to the nearby esophagus, as well as examine the results of epicardial application.

Management of tricuspid valve regurgitationPosition statement of the European Society of Cardiology Working Groups of Cardiovascular Surgery and Valvular Heart Disease

Tricuspid regurgitation (TR) is a very frequent manifestation of valvular heart disease. It may be due to the primary involvement of the valve or secondary to pulmonary hypertension or to the left-sided heart valve disease (most commonly rheumatic and involving the mitral valve). The pathophysiology of secondary TR is complex and is intrinsically connected to the anatomy and function of the right ventricle. A systematic multimodality approach to diagnosis and assessment (based not only on the severity of the TR but also on the assessment of annular size, RV function and degree of pulmonary hypertension) is, therefore, essential. Once considered non-important, treatment of secondary TR is currently viewed as an essential concomitant procedure at the time of mitral (and, less frequently, aortic valve) surgery. Although the indications for surgical management of severe TR are now generally accepted (Class I), controversy persists concerning the role of intervention for moderate TR. However, there is a trend for intervention in this setting, especially at the time of surgery for left-sided heart valve disease and/or in patients with significant tricuspid annular dilatation (Class IIa). Currently, surgery remains the best approach for the interventional treatment of TR. Percutaneous tricuspid valve intervention (both repair and replacement) is still in its infancy but may become a reliable option in future, especially for high-risk patients with isolated primary TR or with secondary TR related to advanced left-sided heart valve disease.

Meta-analysis of uninterrupted as compared to interrupted oral anticoagulation with or without bridging in patients undergoing coronary angiography with or without percutaneous coronary intervention

OBJECTIVES To assess safety and effectiveness of different periprocedural antithrombotic strategies in patients receiving long-term oral anticoagulation and undergoing coronary angiography with or without percutaneous coronary intervention (PCI). METHODS Studies comparing uninterrupted oral anticoagulation (UAC) with vit. K antagonists vs interrupted oral anticoagulation (IAC) with or without bridging anticoagulation before coronary procedures were eligible for inclusion in the current meta-analysis. Endpoints selected were 30-day composite of major adverse cardiovascular or cerebrovascular and thromboembolic events (MACCE) and major bleeding. RESULTS Eight studies (7 observational and 1 randomized controlled trial [N=2325pts.]) were included in the analysis. There was no difference in MACCE between UAC and IAC; RR (95%CIs): 0.74 (0.34-1.64); p=0.46 but there was a statistically significant MACCE risk reduction with UAC as compared to IAC with bridging: 0.52 (0.29-0.95); p=0.03. Likewise, there were no statistically significant differences between UAC vs IAC in regard to major bleeding: 0.62 (0.16-2.43); p=0.49; but as compared to IAC with bridging, UAC was associated with statistically significant 65% lower risk of major bleeding: 0.35 (0.13-0.92); p=0.03. Additionally, meta-regression analysis revealed significant linear correlation between log RR of MACCE (β=-4.617; p<0.001) and major bleeding (β=6.665; p=0.022) and mean value of target INR suggestive of higher thrombotic and secondary haemorrhagic risk below estimated INR cut-off of 2.17-2.27 within 30days. CONCLUSIONS Uninterrupted OAC is at least as safe as interrupted OAC, and seems to be much safer than interrupted OAC with bridging anticoagulation in patients undergoing coronary angiography with or without PCI.

Risk of stroke with “no-touch” — As compared to conventional off-pump coronary artery bypass grafting. An updated meta-analysis of observational studies

Please cite this article as: Kowalewski Mariusz, Suwalski Piotr, Pawliszak Wojciech, Benetti Federico, Raffa Giuseppe Maria, Malvindi Pietro Giorgio, Carrel Thierry, Paparella Domenico, Anisimowicz Lech, Risk of stroke with “no-touch” — As compared to conventional off-pump coronary artery bypass grafting. An updated metaanalysis of observational studies, International Journal of Cardiology (2016), doi: 10.1016/j.ijcard.2016.08.041

Circulatory support with Impella CP device during high-risk percutaneous coronary interventions: initial experience in Poland

Coronary revascularization is an important part of the treatment of patients with coronary artery disease. However, a significant proportion of patients are characterized by high-risk features. Many of these patients are referred for high-risk percutaneous coronary interventions (PCIs) due to the extremely high risk of surgery. To support such procedures and to facilitate the care of high-risk patients, percutaneous left ventricular assist devices (pLVAD) were developed. Due to confounding data and downgraded guidelines for use of the intra-aortic balloon pump (IABP), especially in cardiogenic shock caused by myocardial infarction (MI), there is currently growing interest in pLVAD [1, 2]. The use of pLVAD during high-risk PCI in Europe varies from country to country mainly due to different reimbursement policies.

Ventricular arrhythmic disturbances and autonomic modulation after beating-heart revascularization in patients with pulmonary normotension.

SummaryBACKGROUND: De-novo ventricular arrhythmias are potentially life-threatening complications after beating-heart revascularization (off-pump CABG). Whether pulmonary hypertension can influence initiation of ventricular arrhythmias through increased sympathetic activity is controversial. In order to determine the influence of pulmonary hypertension on its relative contribution to ventricular arrhythmia, we first had to define the role of cardiac autonomic modulation in patients with pulmonary normotension. We aimed to observe how parameters of linear and nonlinear heart rate variability are changed pre- and postoperatively in patients with pulmonary normotension undergoing off-pump CABG. METHODS: Fifteen-minute ECG recordings were collected before and after off-pump CABG in 54 patients with multivessel coronary artery disease and pulmonary normotension to determine linear (TP, HF, LF, LF:HF ratio) and nonlinear detrended fluctuation analysis (α1, α2) and fractal dimension (average, high and low) parameters of heart rate variability. Arrhythmia was monitored preoperatively in 24-hour Holter recordings and postoperatively by continuous monitoring and clinical assessment. RESULTS: Deterioration from simple (Lown I–II) to complex (Lown III–V) ventricular arrhythmia was observed in 19 patients, and improvement from complex to simple arrhythmia in five patients (P = 0.022). Patients with postoperative deterioration of ventricular arrhythmia had preoperatively significantly lower values of TP, HF and LF (P = 0.024–0.043) and postoperatively significantly higher values on the low fractal dimension index (P = 0.031) than patients with postoperative improvement of arrhythmia. CONCLUSION: Patients experiencing postoperative deterioration of ventricular arrhythmia already have impaired autonomic regulation before surgery. Higher postoperative values on the low fractal dimension index indicate that sympathetic predominance with or without concomitant vagal withdrawal is the underlying neurogenic mechanism contributing to ventricular arrhythmia.

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.

Comparative performance of transcatheter aortic valve-in-valve implantation versus conventional surgical redo aortic valve replacement in patients with degenerated aortic valve bioprostheses: systematic review and meta-analysis

The objective of this report was to directly compare, by means of a systematic review and meta-analysis, redo surgical aortic valve replacement (re-sAVR) with valve-in-valve transcatheter aortic valve implantation (ViV TAVI) for patients with failed degenerated aortic bioprostheses. Multiple databases were screened for all available reports comparing ViV TAVI with re-sAVR in patients with failing degenerated aortic bioprostheses. The primary outcome was all-cause mortality determined from the longest available survival data. Five observational studies (n = 342) were included in the meta-analysis; patients in the ViV TAVI group were older and had a higher baseline risk compared to those in the re-sAVR group. Although there was no statistical difference in procedural mortality [risk ratio (RR) 0.74, 95% confidence interval (CI) 0.18-2.97; P = 0.67], 30-day mortality (RR 1.29, 95% CI 0.44-3.78; P = 0.64) and cardiovascular mortality (RR 0.91, 95% CI 0.30-2.70; P = 0.86) at a mean follow-up period of 18 months, cumulative survival analysis favoured surgery with borderline statistical significance (ViV TAVI versus re-sAVR: hazard ratio 1.91, 95% CI 1.03-3.57; P = 0.039). ViV TAVI was associated with a significantly lower rate of permanent pacemaker implantations (RR 0.37, 95% CI 0.20-0.68; P = 0.002) and shorter intensive care unit (P < 0.001) and hospital stays (P = 0.020). In contrast, re-sAVR offered superior echocardiographic outcomes: lower incidence of patient-prosthesis mismatch (P = 0.008), fewer paravalvular leaks (P = 0.023) and lower mean postoperative aortic valve gradients in the prespecified analysis (P = 0.017). The ViV TAVI approach is a safe and feasible alternative to re-sAVR that may offer an effective, less invasive treatment for patients with failed surgical aortic valve bioprostheses who are inoperable or at high risk. Re-sAVR should remain the standard of care, particularly in the low-risk population, because it offers superior haemodynamic outcomes with low mortality rates.