Radosław Litwinowicz

In-Hospital Mortality in Cardiac Surgery Patients After Readmission to the Intensive Care Unit: A Single-Center Experience with 10,992 Patients

OBJECTIVES Determine if readmission to the intensive care unit (ICU) after cardiac surgery procedures is associated with increased mortality. DESIGN This was a retrospective non-randomized study to evaluate the cause of readmission and mortality rate in patients readmitted to the ICU after cardiac surgery and to compare the clinical variables of patients readmitted to the ICU who died and those who survived. SETTING The study was performed in a single university hospital. PARTICIPANTS This was an analysis of 10,992 consecutive adult patients. Readmission rate to the ICU, mortality rate, the reason for readmission to the ICU, type of surgery, length of stay, cause of mortality, and day of the week of ICU readmission were analyzed. INTERVENTIONS All patients underwent cardiac surgery at a single center and were discharged after primary stay from the ICU. MEASUREMENTS AND MAIN RESULTS A total of 197 (1,8%) of 10,992 patients were readmitted to the ICU. In-hospital mortality rate for patients readmitted and not readmitted to the ICU was 23.9% and 4.7%, respectively. The main causes of ICU readmission were cardiac (40%) and respiratory (37%) complications. The mortality rate in readmitted patients who underwent coronary artery bypass graft (CABG) or valve surgery was 26% and 19%, respectively. CONCLUSIONS Patient readmission to the ICU following cardiac surgery was associated with a 5-fold increase in hospital mortality rate compared to non-readmitted patients. The highest mortality rate was observed among readmitted patients who underwent CABG. Older age, previous myocardial infarction, and initial long length of stay in the post-operative ward were independent risk factors for death after readmission to the ICU.

Denervation of nerve terminals in renal arteries: one-year follow-up of interventional treatment of arterial hypertension

BACKGROUND Arterial hypertension is the most common cardiovascular system disease, affecting nearly one billion people worldwide. Despite the widespread use of antihypertensive medications, in some groups of patients an optimal blood pressure (BP) cannot be achieved. AIM To assess BP reduction in patients with resistant hypertension after a catheter-based renal sympathetic denervation procedure and to report vascular and kidney safety in one-year follow-up. METHODS Twenty eight patients with diagnosed resistant hypertension (median age 52.02 years, range 42-72) underwent percutaneous catheter-based renal denervation of nerve terminals in renal arteries. Arterial angiography and procedure of ablation was performed by Symplicity catheters and generator provided by Ardian (currently Medtronic Inc., USA). RESULTS Mean BP value before ablation was [mm Hg]: systolic 176.6, diastolic 100.28 and pulse pressure 73.4. After the procedure, reductions in the value of BP were reported [mm Hg]: systolic 154.8/152.54; diastolic 90.2/89.8, pulse pressure 64.66/62.73, respectively in nine-month and one-year follow-up. All results were statistically significant. No complications during one year observation were observed. CONCLUSIONS Percutaneous renal artery ablation procedure effectively reduces systolic BP, diastolic BP, and pulse pressure. No vascular or renal complications in any of the patients were observed. The results of a Polish research group showed no significant differences compared to the results obtained in the international studies Symplicity I and Symplicity II.

Dabigatran level monitoring prior to idarucizumab administration in patients requiring emergent cardiac surgery

Non-vitamin-K antagonist oral anticoagulants (NOACs), including dabigatran (a direct factor IIa [FIIa] inhibitor) increasingly replace the vitamin K antagonists (VKAs) for favorable risk–benefit profile [1] and lower risk of major bleeding [2] in atrial fibrillation. NOACs also significantly reduce the risk of recurrent venous thromboembolism (VTE), and compared with VKAs present lower risk of bleeding in this group [3]. The use of NOACs increases in VTE prevention, even though in the setting of surgical emergency or life-theratening bleeding, the NOAC therapy may be dangerous [4]. In 2015, the FDA approved idarucizumab for dabigatran reversal in emergency situations [5]. Idarucizumab is a monoclonal antibody fragment that binds dabigatran with high affinity, and presents good clinical outcomes [5, 6]. Current European Heart Rhythm Association (EHRA) practical guidelines recommend idarucizumab for life-threatening bleeding, or prior to emergency surgery in dabigatran treated patients [7]. Clinical experience with idarucizumab in cardiac surgery is currently limited. In our institution, we managed several dabigatran-treated patients in emergency cardiosurgical setting [8]. In previous cases, the clinical decision to administer idarucizumab was made following emergency laboratory assessment of baseline dabigatran level (both individuals required an open-heart surgery for acute aortic syndrome) [8]. However, in specific clinical scenarios, monitoring of dabigatran level may be challenging and potentially impede the decision to use the expensive idarucizumab preparation based just on uncertain dabigatran intake history, and exposing the patient to the risk of excessive (and potentially lethal) surgical bleeding, if dabigatran intake history is uncertain. We report a case of a 63-years-old patient who received dabigatran for VTE and required emergency coronary artery bypass grafting (CABG) for an acute coronary syndrome (ACS) with coronary anatomy precluding percutaneous coronary intervention (PCI), in whom the preoperative dabigatran level measurement was futile because of interferences with other thrombin inhibitors.

Stroke risk reduction after LAA occlusion in elderly patients with atrial fibrillation: long-term results

327 Patients were divided into 3 groups depending on age: <65 years, 65 to 74 years, and ≥75 years. Postprocedural anticoagulation and optimi‐ zation of anticoagulant therapy was individual‐ ized depending on the patient’s history, contra‐ indications, risk of stroke and bleeding, and pa‐ tient or physician preferences. Transesophageal echocardiography at 30 days after the procedure was performed to monitor for postoperative leak. Freixa et al2 reported adverse events during follow ‐up, based on VARC ‐2 criteria.3 In line with the study by Freixa et al,2 procedure efficacy to prevent thromboembolic events (stroke, tran‐ sient ischemic attack [TIA], and systemic embo‐ lism) was tested by comparing the actual event rate at follow ‐up with the event rate predicted by the CHA2DS2 ‐VASc score. 4 Individual patient an‐ nual risks were recorded, and the average annual risk for the whole study population was calculat‐ ed. The total number of thromboembolic events during the overall follow ‐up period was divided by the total number of patient‐years of follow‐ ‐up and multiplied by 100 to obtain the actual annual rate of thromboembolism. Thromboem‐ bolism rate reduction was calculated as follows: (estimated% – actual% event rate) / estimated% event rate. Bleeding reduction rate was based on the HAS ‐BLED score and was assessed using the same method as for stroke risk reduction. Differences with a P value of less than 0.05 were considered significant.

The use of stem cells in ischemic heart disease treatment

Ischemic heart disease is a major cause of death and disabilities worldwide. Unfortunately, not all patients are suitable for direct revascularization. Cell-based therapies may be alternative options because of their potential to promote neovascularisation and endothelial repair, improving myocardial perfusion. The success of cell-based therapies depends on the type of implanted stem cells, delivery method and underlying disease. Several different cell populations including bone marrow-derived mononuclear cells (MNCs), mesenchymal stromal cells (MSCs), CD34+, CD133+, endothelial progenitor cells, adipose-derived mesenchymal stromal cells (ASCs) and stem cells from placenta and umbilical cord have been investigated. Presently, no consensus exists about the best cell type for clinical regenerative therapy. Because the system of coronary arteries in the ischemic area is poor and most of the coronary artery is significantly narrowed or closed, direct implantation of stem cells in the ischemic area of the heart muscle appears an attractive method.

Patient-prosthesis mismatch after minimally invasive aortic valve replacement

1Department of Cardiovascular Surgery and Transplantology, Jagiellonian University and John Paul II Hospital, Krakow, Poland 2Department of Pharmacology, Jagiellonian University, Krakow, Poland 3Department of Physiology, Jagiellonian University, Krakow, Poland 4Department of Cardiac and Vascular Surgery, Medical University of Gdansk, Gdansk, Poland 5CardioVascular Centre Frankfurt, Germany and Swedish Medical Centre Seattle, United States *Grzegorz Filip and Radoslaw Litwinowicz are first authors of this manuscript and have contributed equally to the content of this paper.

Applications of low-cost 3D printing in left atrial appendage closure using epicardial approaches – initial clinical experience

Introduction Left atrial appendage occlusion procedure (LAAO) became an alternative method for stroke prevention in atrial fibrillation (AF) patients with contraindication or intolerance for oral anticoagulation therapy. However, LAA anatomy is complex with several different types of LAA morphology. Therefore matching the correct size of a delivery device to LAA morphology is difficult. In such circumstances, the 3D-printed model of LAA closure may be useful for preoperative planning which increases the efficacy of LAAO procedure. Material and methods We report as a first 2 cases of LAA occlusion procedure using 2 different systems: thoracoscopic AtriClip and the LARIAT device in which a 3D printed LAA model was used in preoperative planning. Results In the first patient, preoperative measurements of 3D LAA model were performed using a dedicated selection guide for AtriClip device were comparable with the intraoperative examination. Left atrial appendage was closed epicardial using 40 mm size AtriClip. In second patients, LAA closure was performed completely percutaneously using LARIAT device. For better visualization of LAA shape on fluoroscopy and TEE examination, intraoperatively sterilized 3D LAA model was used during the procedure. In both cases, intraoperative TEE examination confirmed complete LAA closure with no leak. Conclusions Left atrial appendage 3D model is a useful tool in preoperative planning of a left atrial appendage occlusion using epicardial approaches with thoracoscopic or percutaneous access using LARIAT device. The quality of low-cost 3D printed LAA model is sufficient in planning minimally invasive procedure.

Left atrial appendage occlusion for stroke prevention in diabetes mellitus patients with atrial fibrillation: Long-term results: Long-term results of LAAO in DM patients

Concomitant diabetes mellitus (DM) in atrial fibrillation (AF) may increase the risk of thromboembolism. Left atrial appendage occlusion (LAAO) is an alternative treatment in AF patients in whom antithrombotic therapy is ineffective or contraindicated. The aim of this study was to evaluate the long‐term efficacy of LAAO in DM patients with AF.

Clinical factors predicting blood pressure reduction after catheter-based renal denervation

Introduction Renal denervation (RD) can lead to a significant and sustained decrease in mean values of arterial blood pressure (BP). However, there is still a subset of patients without a significant BP drop after RD (non-responders). Aim To compare characteristics of RD responders to RD non-responders and to identify the clinical predictors of BP reduction. Material and methods Thirty-one patients with diagnosed resistant hypertension underwent RD. Three years after RD the analysis of BP reduction was performed in regard to the baseline patient characteristics. Results After 3 years’ follow-up a 10% or more reduction of systolic baseline BP was observed in 74% of patients. Ten percent or more reduction of diastolic baseline BP was observed in 71% of patients. Among responders we observed the following risk factors: hypercholesterolemia in 70%, body mass index (BMI) > 30 kg/m2 in 55%, diabetes mellitus in 35%, current smoking in 5%. Comorbidity included coronary artery disease (CAD) in 30%, cardiomyopathy in 10%, chronic obstructive pulmonary disease (COPD) in 10%, renal insufficiency in 10%, and ventricular arrhythmia in 5%. Among non-responders we observed the following risk factors: hypercholesterolemia in 38%, diabetes mellitus type 2 in 38% and BMI > 30 kg/m2 in 86%. Comorbidity included CAD in 50% and cardiomyopathy in 13% of patients. Conclusions A 10% reduction of systolic baseline BP was observed in 74% of patients 3 years after renal denervation. Clinical factors like COPD, chronic kidney disease 3a, female sex and hypercholesterolemia increase the chances of effective reduction of BP.

Coronary Perforation of Distal Diagonal Branch Followed by Prolonged Recurrent Cardiac Tamponade Finally Resolved with Pericardiotomy - the Potential Risk of Hydrophilic Guide-Wires

Purpose: Coronary artery perforation (CAP) is a complication of percutaneous coronary interventions (PCIs). Hydrophilic guide-wires have been shown to increase the probability of CAP. Depending on the size of perforations we adopt different treatments. Case: We present the case of a 73-year old male with coronary artery disease and severe aortic valve stenosis. The patient was in the process of qualifying for a transcatheter aortic valve implantation. Unfortunately, CAP of the first diagonal branch of the LAD occurred during PCI. Initially, abrupt bleeding to the pericardial sac was primarily restrained. However, in the following days, pericardial bleeding became silent, prolonged and finally resulted in surgical pericardiotomy and surgical aortic valve replacement. Conclusion: This case depicts that in some cases, more aggressive endovascular treatment of CAP during the acute phase could decrease the probability of future radical surgical treatment. Although, in other cases, avoiding radical endovascular treatment of CAP and secondary necrosis along the distribution of the artery culminates in a higher risk for conversion to a surgical cardiac procedure. Accurate primary assessment of CAP seriousness and careful observation after PCI could improve results and lead to avoiding severe complications.