Antiplatelet therapy prior to COVID-19 infection impacts on patients mortality: a propensity score-matched cohort study

One of the major pathomechanisms of COVID-19 is the interplay of hyperinflammation and disruptions in coagulation processes, involving thrombocytes. Antiplatelet therapy (AP) by anti-inflammatory effect and inhibition of platelet aggregation may affect these pathways. The aim of this study was to investigate if AP has an impact on the in-hospital course and medium-term outcomes in hospitalized COVID-19 patients. The study population (2170 COVID-19 patients: mean ± SD age 60 ± 19 years old, 50% male) was divided into a group of 274 patients receiving any AP prior to COVID-19 infection (AP group), and after propensity score matching, a group of 274 patients without previous AP (non-AP group). Patients from the AP group were less frequently hospitalized in the intensive care unit: 9% vs. 15%, 0.55 (0.33-0.94), developed less often shock: 9% vs. 15%, 0.56 (0.33-0.96), and required less aggressive forms of therapy. The AP group had more coronary revascularizations: 5% vs. 1%, 3.48 (2.19-5.55) and strokes/TIA: 5% vs. 1%, 3.63 (1.18-11.2). The bleeding rate was comparable: 7% vs. 7%, 1.06 (0.54-2.06). The patients from the AP group had lower 3-month mortality: 31% vs. 39%, 0.69 (0.51-0.93) and didn't differ significantly in 6-month mortality: 34% vs. 41%, 0.79 (0.60-1.04). When analyzing the subgroup with a history of myocardial infarction and/or coronary revascularization and/or previous stroke/transient ischemic attack and/or peripheral artery disease, AP had a beneficial effect on both 3-month: 37% vs. 56%, 0.58 (0.40-0.86) and 6-month mortality: 42% vs. 57%, 0.63 (0.44-0.92). Moreover, the favourable effect was highly noticeable in this subgroup where acetylsalicylic acid was continued during hospitalization with reduction of in-hospital: 19% vs. 43%, 0.31 (0.15-0.67), 3-month: 30% vs. 54%, 044 (0.26-0.75) and 6-month mortality: 33% vs. 54%, 0.49 (0.29-0.82) when confronted with the subgroup who had acetylsalicylic acid suspension during hospitalization. The AP may have a beneficial impact on hospital course and mortality in COVID-19 and shouldn't be discontinued, especially in high-risk patients.

Performance of the 32 mm Myval transcatheter heart valve for treatment of aortic stenosis in patients with extremely large aortic annuli in real-world scenario: First global, multicenter experience

BACKGROUND

Extremely large aortic valve anatomy is one of the remaining limitations leading to exclusion of patients for transcatheter aortic valve replacement (TAVR).

AIMS

The newly approved Myval 32 mm device is designed for use in aortic annulus areas up to 840 mm2 . Here we want to share the initial worldwide experience with the device.

METHODS AND RESULTS

Retrospective data were collected from 10 patients with aortic stenosis and very large annular anatomy (mean area 765.5 mm2 ), who underwent implantation with 32 mm Myval transcatheter heart valve at eight centers. Valve Academic Research Consortium-2 device success was achieved in all cases. Mild paravalvular leak was observed in three patients and two patients required new pacemaker implantation. One patient experienced retroperitoneal hemorrhage caused by the contralateral 6 F sheath and required surgical revision. No device-related complications, stroke, or death from any cause occurred within the 30-day follow-up period. In a studied cohort of 2219 consecutive TAVR-screened patients from a central European site, only 0.27% of patients showed larger anatomy than covered by the 32 mm Myval device by instructions for use without off-label use of overexpansion. This rate was significantly higher for the 34 mm Evolut Pro (1.8%) and 29 mm Sapien 3 (2.1%) devices.

CONCLUSIONS

The Myval 32 mm prosthesis showed promising initial results in a cohort of patients who previously had to be excluded from TAVR. It is desirable that all future TAVR systems accommodate larger anatomy to allow optimal treatment of all patients.

Multicenter registry of Impella-assisted high-risk percutaneous coronary interventions and cardiogenic shock in Poland (IMPELLA-PL)

BACKGROUND

Impella is a percutaneous mechanical circulatory support device for treatment of cardiogenic shock (CS) and high-risk percutaneous coronary interventions (HR-PCIs). IMPELLA-PL is a national retrospective registry of Impella-treated CS and HR-PCI patients in 20 Polish interventional cardiological centers, conducted from January 2014 until December 2021.

AIMS

We aimed to determine the efficacy and safety of Impella using real-world data from IMPELLA-PL and compare these with other registries.

METHODS

IMPELLA-PL data were analyzed to determine primary endpoints: in-hospital mortality and rates of mortality and major adverse cardiovascular and cerebrovascular events (MACCE) at 12 months post-discharge.

RESULTS

Of 308 patients, 18% had CS and 82% underwent HR-PCI. In-hospital mortality rates were 76.4% and 8.3% in the CS and HR-PCI groups, respectively. The 12-month mortality rates were 80.0% and 18.2%, and post-discharge MACCE rates were 9.1% and 22.5%, respectively. Any access site bleeding occurred in 30.9% of CS patients and 14.6% of HR-PCI patients, limb ischemia in 12.7% and 2.4%, and hemolysis in 10.9% and 1.6%, respectively.

CONCLUSIONS

Impella is safe and effective during HR-PCIs, in accordance with previous registry analyses. The risk profile and mortality in CS patients were higher than in other registries, and the potential benefits of Impella in CS require investigation.

Latest-iteration balloon- and self-expandable transcatheter valves for severe bicuspid aortic stenosis: the TRITON study

INTRODUCTION AND OBJECTIVES

No comparisons have been published yet regarding the newest iteration of balloon- and self-expandable transcatheter heart valves for the treatment of bicuspid aortic valve (BAV) stenosis.

METHODS

Multicenter registry of consecutive patients with severe BAV stenosis treated with balloon-expandable transcatheter heart valves (Myval and SAPIEN 3 Ultra, S3U) or self-expanding Evolut PRO+(EP+). TriMatch analysis was carried out to minimize the impact of baseline differences. The primary endpoint of the study was 30-day device success, and the secondary endpoints were the composite and individual components of early safety at 30 days.

RESULTS

A total of 360 patients (age 76.6±7.6 years, 71.9% males) were included: 122 Myval (33.9%), 129 S3U (35.8%), and 109 EP+(30.3%). The mean STS score was 3.6±1.9%. There were no cases of coronary artery occlusion, annulus rupture, aortic dissection, or procedural death. The primary endpoint of device success at 30 days was significantly higher in the Myval group (Myval: 100%; S3U: 87.5%; and EP+: 81.3%), mainly due to higher residual aortic gradients with S3U and greater≥moderate aortic regurgitation (AR) with EP+. No significant differences were found in the unadjusted rate of pacemaker implantation.

CONCLUSIONS

In patients with BAV stenosis deemed unsuitable for surgery, Myval, S3U and EP+showed similar safety but balloon-expandable Myval had better gradients than S3U, and both balloon-expandable devices had lower residual AR than EP+, suggesting that, taking into consideration the patient-specific risks, any of these devices can be selected with optimal outcomes.

Usefulness of the Veterans Health Administration COVID-19 (VACO) Index for Predicting Short-Term Mortality among Patients of the COLOS Study

Advanced age is known to be a predictor with COVID-19 severity. Understanding of other disease progression factors may shorten the time from patient admission to applied treatment. The Veterans Health Administration COVID-19 (VACO index) was assumed to additionally anticipate clinical results of patients hospitalized with a proven infection caused by the SARS-CoV-2 virus.

METHODS

The medical records of 2183 hospitalized patients were retrospectively analyzed. Patients were divided into four risk-of-death categories: low risk, medium risk, high-risk, and extreme risk depending on their VACO index calculation.

RESULTS

Significant differences in the mortality at the hospital after three months of discharge and six months after discharge were noticed. For the patients in the extreme-risk group, mortality reached 37.42%, 62.81%, and 78.44% for in-hospital, three months of discharge, and six months of discharge, respectively. The mortality marked as high risk reached 20.38%, 37.19%, and 58.77%. Moreover, the secondary outcomes analysis acknowledged that patients classified as extreme risk were more likely to suffer from cardiogenic shock, myocardial infarction, myocardial injury, stroke, pneumonia, acute kidney injury, and acute liver dysfunction. Patients at moderate risk were more often admitted to ICU when compared to other patients.

CONCLUSIONS

The usage of the VACO index, combined with an appropriate well-defined medical interview and past medical history, tends to be a helpful instrument in order to predict short-term mortality and disease progression based on previous medical records.

Association of serum vitamin D concentration with the final course of hospitalization in patients with COVID-19

Background

Vitamin D deficiency is a substantial public health problem. The present study evaluated the association between vitamin D concentration and hospitalization and mortality risk in patients with coronavirus disease 19 (COVID-19).

Methods

This study used the COronavirus in LOwer Silesia (COLOS) dataset collected between February 2020 and June 2021. The medical records of 474 patients with confirmed severe acute respiratory syndrome 2 (SARS-CoV-2) infection, and whose vitamin D concentration was measured, were analyzed.

Results

We determined a significant difference in vitamin D concentration between discharged patients and those who died during hospitalization (p = 0.0096). We also found an effect of vitamin D concentration on the risk of death in patients hospitalized due to COVID-19. As vitamin D concentration increased, the odds ratio (OR) for death slightly decreased (OR = 0.978; 95% confidence interval [CI] = 0.540-0.669). The vitamin D concentration cutoff point was 15.40 ng/ml. In addition, patients with COVID-19 and serum 25-hydroxyvitamin D (25(OH)D) concentrations < 30 ng/ml had a lower survival rate than those with serum 25(OH)D ≥ 30 ng/ml (log-rank test p = 0.0018). Moreover, a Cox regression model showed that patients with an estimated glomerular filtration rate (eGFR) ≥ 60 ml/min/1.73 m2 and higher vitamin D concentrations had a 2.8% reduced risk of mortality (hazard ratio HR = 0.972; CI = 0.95-0,99; p = 0.0097).

Conclusions

The results indicate an association between 25(OH)D levels in patients with COVID-19 and the final course of hospitalization and risk of death.

Native Renal Arteries Denervation as a Therapy of Refractory Hypertension in Patient after Heart and Kidney Transplantation-5 Years of Observation

This case report describes a 59-year-old male patient after heart and kidney transplantation, subsequently diagnosed with refractory hypertension since implemented antihypertensive pharmacotherapy consisting of six agents did not provide a substantial therapeutic response. Elevated blood pressure and its impact on a hypertrophied transplanted heart and impaired renal graft function have led to a significant deterioration in the patient's cardiovascular risk profile. To address this issue, a native renal arteries denervation was performed. It resulted in a noteworthy decrease in both systolic and diastolic pressure values, thus manifesting a positive hypotensive effect. Furthermore, a sustainable reduction of left ventricular mass and stabilization in kidney graft function were noticed. The presented case provides evidence that renal denervation can be an efficacious complementary treatment method in individuals who received kidney and heart grafts as it leads to a decrease in cardiovascular risk.

Dysnatremia in COVID-19 Patients-An Analysis of the COLOS Study

BACKGROUND

Sodium imbalance is one of the most common electrolyte disturbances encountered in the medical practice, and it may present with either hyponatremia or hypernatremia. Both sodium abnormalities are related with unfavorable outcomes.

OBJECTIVE

Elucidation of the prevalence of dysnatremia among COVID-19 patients and its impact on 30- and 90-day mortality and need for ICU admission was the goal.

DESIGN AND PARTICIPANTS

A single-center, retrospective, observational study was conducted. A total of 2026 adult, SARS-CoV-2 positive patients, admitted to Wroclaw University Hospital between 02.2020 and 06.2021, were included. On admission, patients were divided into groups: normonatremic (N), hyponatremic (L), and hypernatremic (H). Acquired data was processed, and Cox hazards regression and logistic regression were implemented.

KEY RESULTS

Hyponatremia on admission occurred in 17.47% (n = 354) of patients and hypernatremia occurred in 5.03% (n = 102). Dysnatremic patients presented with more comorbidities, used more drugs, and were statistically more often admitted to the ICU. Level of consciousness was the strongest predictor of ICU admission (OR = 1.21, CI: 1.16-1.27, p < 0.001). Thirty-day mortality was significantly higher in both the L and H groups (28.52%, p = 0.0001 and 47.95%, p < 0.0001, respectively), in comparison to 17.67% in the N group. Ninety-day mortality showed a similar trend in all study groups: 34.37% in the L group (p = 0.0001), 60.27% (p < 0.0001) in the H group, and 23.32% in the N group. In multivariable analyses, hypo- and hypernatremia were found to be independent predictors of 30- and 90-day mortality.

CONCLUSIONS

Both hypo- and hypernatremia are strong predictors of mortality and disease severity in COVID-19 patients. Extraordinary care should be taken when dealing with hypernatremic, COVID-positive patients, as this group exhibits the highest mortality rates.

Efficacy and Safety of Percutaneous Access Via Large-Bore Sheaths (22-26F Diameter) in Endovascular Therapy

PURPOSE

To evaluate the closure success rate's outcomes with suture-mediated vascular closure device Perclose ProGlide in patients undergoing aortic or iliac artery endovascular repair using large delivery systems (>21F).

MATERIALS AND METHODS

We screened all the patient records in aortic databases at 2 centers who had undergone vascular interventions via ProGlide for percutaneous femoral access >21F between 2016 and 2020. Patients were divided into 2 groups according to the delivery system size: large (L) (22F-23F) and extra-large (XL) (24F-26F). Demographics, anatomical details, and outcome of percutaneous access were evaluated.

RESULTS

Included were 239 patients: 121 in the L group and 118 the XL group. Intraprocedural conversion to open surgery because of bleeding was necessary in 2% L and 6% XL patients (p=0.253). Severe femoral artery calcification was the sole risk factor for converting to open surgery (odds ratio=23.44, 95% confidence interval=1.49-368.17, p=0.025). In all, 2% of L and 3% of XL (p=0.631) did require late percutaneous intervention due to stenosis (all treated with balloon angioplasty). Overall, 3% developed pseudoaneurysm treated conservatively in all except one patient requiring surgical repair. Hematoma and groin infection were observed in 9% and 1%, respectively; none required surgical therapy.

CONCLUSION

A femoral arterial defect after accessing the artery via a large bore sheath (22F-26F) can be closed successfully with ProGlide in more than 90% of patients. Severe femoral artery calcification is a risk factor for conversion to open surgery caused by bleeding.

CLINICAL IMPACT

This study adds evidence on efficacy of accessing the artery via a large bore sheath (22-26F) secured by ProGlide. In more than 200 patients conversion to open surgery was necessary in only 4%. Severe femoral artery calcification was the sole risk factor for converting to open surgery. Our findings encourage physicians to choose the percutaneous access even in patients requiring the use of large bore sheath.

Early Heart Rate Recovery after a 6-min Walking Test Predicts Clinical Benefits in Patients after Percutaneous Aortic Valve Implantation

BACKGROUND

It was hypothesized that the time-appropriate return to a resting heart rate (HR) after cessation of exercise could be a marker for predicting outcomes in patients with heart failure (HF). We aimed to evaluate the prognostic value of HR recovery in functional improvement among adults with severe aortic stenosis undergoing percutaneous aortic valve implantation (TAVI).

METHODS

We performed a 6 min walk test (6MWT) in 93 individuals before TAVI and 3 months after the procedure. The change in walking distance was calculated. During the pre-TAVI 6MWT, we analyzed the differences between baseline HR, HR at the end of the test, and HR at the 1st, 2nd, and 3rd minute of recovery.

RESULTS

After 3 months, 6MWT distances improved by 39 ± 63 m and reached a total of 322 ± 117 m. Multiple linear regression proved the differences between HR after 2 min of recovery and baseline HR in pre-TAVI after a 6MWT was the only significant predictor of waking distance improvement during follow-up.

CONCLUSIONS

Our study suggests that analysis of HR recovery after a 6MWT may be a helpful and easy parameter to assess improvements in exercise capacity after TAVI. This simple method can help to identify patients in whom no significant benefit in functional improvement can be expected despite successful valve implantation.

Impact of Enterococci vs. Staphylococci Induced Infective Endocarditis after Transcatheter Aortic Valve Implantation

BACKGROUND

The two most common organisms found in infective endocarditis following transcatheter aortic valve implantation (TAVI-IE) are enterococci (EC-IE) and staphylococci (SC-IE). We aimed to compare clinical characteristics and outcomes of patients with EC-IE and SC-IE.

METHODS

TAVI-IE patients from 2007 to 2021 were included in this analysis. The 1-year mortality was the primary outcome measure of this retrospective multi-center analysis.

RESULTS

Out of 163 patients, 53 (32.5%) EC-IE and 69 (42.3%) SC-IE patients were included. Subjects were comparable with regard to age, sex, and clinically relevant baseline comorbidities. Symptoms at admission were not significantly different between groups, except for a lower risk for presenting with septic shock in EC-IE than SC-IE. Treatment was performed in 78% by antibiotics alone and in 22% of patients by surgery and antibiotics, with no significant differences between groups. The rate of any complication, in particular heart failure, renal failure, and septic shock during treatment for IE, was lower in EC-IE compared with SC-IE (p < 0.05). In-hospital (EC-IE: 36% vs. SC-IE: 56%, p = 0.035) and 1-year mortality (EC-IE: 51% vs. SC-IE: 70%, p = 0.009) were significantly lower in EC-IE compared with SC-IE.

CONCLUSIONS

EC-IE, compared with SC-IE, was associated with a lower morbidity and mortality. However, absolute numbers are high, a finding that should trigger further research in appropriate perioperative antibiotic management and improvement of early IE diagnosis in the case of clinical suspicion.

Role of catheter-directed therapies in the treatment of acute pulmonary embolism. Expert opinion of the Polish PERT Initiative, Working Group on Pulmonary Circulation, Association of Cardiovascular Interventions, and Association of Intensive Cardiac Care of the Polish Cardiac Society

Thanks to advances in interventional cardiology technologies, catheter-directed treatment has become recently a viable therapeutic option in the treatment of patients with acute pulmonary embolism at high risk of early mortality. Current transcatheter techniques allow for local fibrinolysis or embolectomy with minimal risk of complications. Therefore, these procedures can be considered in high-risk patients as an alternative to surgical pulmonary embolectomy when systemic thrombolysis is contraindicated or ineffective. They are also considered in patients with intermediate-high-risk pulmonary embolism who do not improve or deteriorate clinically despite anticoagulation. The purpose of this article is to present the role of transcatheter techniques in the treatment of patients with acute pulmonary embolism. We describe current knowledge and expert opinions in this field. Interventional treatment is described in the broader context of patient care organization and therapeutic modalities. We present the organization and responsibilities of pulmonary embolism response team, role of pre-procedural imaging, periprocedural anticoagulation, patient selection, timing of intervention, and intensive care support. Currently available catheter-directed therapies are discussed in detail including standardized protocols and definitions of procedural success and failure. This expert opinion has been developed in collaboration with experts from various Polish scientific societies, which highlights the role of teamwork in caring for patients with acute pulmonary embolism.

Aneurysm Sac Pressure during Branched Endovascular Aneurysm Repair versus Multilayer Flow Modulator Implantation in Patients with Thoracoabdominal Aortic Aneurysm

Open thoracoabdominal repair is the gold standard in the TAAA treatment. However, there are endovascular techniques, that sometimes may be an alternative, such as branched endovascular aneurysm repair (BEVAR) or implantation of the multilayer flow modulator (MFM). In this study, we aimed to assess differences in the aneurysm sac pressure (ASP) between patients undergoing BEVAR and MFM implantation. The study included 22 patients with TAAA (14 patients underwent BEVAR, while eight MFM implantation). The pressure sensor wire was placed inside the aneurysm. A measurement of ASP and aortic pressure (AP) was performed during the procedure. The systolic pressure index (SPI), diastolic pressure index (DPI), and pulse pressure index (PPI) were calculated as a quotient of the ASP and AP values. After the procedure, SPI and PPI were lower in the BEVAR group than in the MFM group. During a procedure, a drop in SPI and PPI was noted in patients undergoing BEVAR, while no changes were revealed in the MFM group. This indicates that BEVAR, but not MFM, is associated with a reduction in systolic and pulse pressure in the aneurysm sac in patients with TAAA.

Incremental value of myocardial work in predicting beneficial response to aortic valve replacement in patients with aortic stenosis

 

The predictors of favorable clinical response to aortic valve replacement (AVR) in aortic stenosis (AS) are still insufficiently defined. The increased LV afterload in AS affects the interpretation of the majority of LV systolic indices, which are load-dependent. The estimation of myocardial work (MW) is a newly developed approach, which, allowing correction of global longitudinal strain (GLS) for LV afterload, gives a more adequate insight into the intrinsic LV contractility.

Aim

To investigate whether the assessment of MW can improve the prediction of clinical and neurohormonal improvement post AVR in patients with AS.

Methods

We evaluated 126 patients (75±9 years) with severe AS who underwent transcatheter AVR (n=100) or surgical AVR (n=26). Transthoracic echocardiography, blood sampling and 6 min walk test (6MWT) were performed pre and 3 months post AVR. The following indices of MW were assessed: global work index (GWI), global constructive work (GCW), global wasted work (GWW), global work efficiency (GWE).

Results

Post-AVR changes in the clinical and echocardiographic profile are presented in Table. Post-treatment increase in 6MWT distance was noted in 95 patients, and decrease in NT-proBNP in 94 patients. In multivariable analysis including clinical parameters and echocardiographic indices of cardiac function, morphology and aortic valve hemodynamic, baseline GWW was the only independent echocardiographic predictor of post-AVR improvement in 6MWT distance (beta=−0.24, SE 0.09, p=0.01), whereas baseline GWE was, in addition to tricuspid regurgitation pressure gradient (TRPG) and E/e' ratio, independently associated with the post-AVR decrease in NT-proBNP (beta=0.27, SE 0.09, p=0.004).

Conclusions

In patients with severe AS undergoing AVR, higher values of GWW do not favor post-treatment functional improvement as assessed by 6MWT. The beneficial neurohormonal response to AVR is more pronounced in patients with less efficient LV contraction at baseline.

Funding Acknowledgement

Type of funding sources: None.

The Usefulness of the COVID-GRAM Score in Predicting the Outcomes of Study Population with COVID-19

BACKGROUND

The COVID-GRAM is a clinical risk rating score for predicting the prognosis of hospitalized COVID-19 infected patients.

AIM

Our study aimed to evaluate the use of the COVID-GRAM score in patients with COVID-19 based on the data from the COronavirus in the LOwer Silesia (COLOS) registry.

MATERIAL AND METHODS

The study group (834 patients of Caucasian patients) was retrospectively divided into three arms according to the risk achieved on the COVID-GRAM score calculated at the time of hospital admission (between February 2020 and July 2021): low, medium, and high risk. The Omnibus chi-square test, Fisher test, and Welch ANOVA were used in the statistical analysis. Post-hoc analysis for continuous variables was performed using Tukey's correction with the Games-Howell test. Additionally, the ROC analysis was performed over time using inverse probability of censorship (IPCW) estimation. The GRAM-COVID score was estimated from the time-dependent area under the curve (AUC).

RESULTS

Most patients (65%) had a low risk of complications on the COVID-GRAM scale. There were 113 patients in the high-risk group (13%). In the medium- and high-risk groups, comorbidities occurred statistically significantly more often, e.g., hypertension, diabetes, atrial fibrillation and flutter, heart failure, valvular disease, chronic kidney disease, and obstructive pulmonary disease (COPD), compared to low-risk tier subjects. These individuals were also patients with a higher incidence of neurological and cardiac complications in the past. Low saturation of oxygen values on admission, changes in C-reactive protein, leukocytosis, hyperglycemia, and procalcitonin level were associated with an increased risk of death during hospitalization. The troponin level was an independent mortality factor. A change from low to medium category reduced the overall survival probability by more than 8 times and from low to high by 25 times. The factor with the strongest impact on survival was the absence of other diseases. The medium-risk patient group was more likely to require dialysis during hospitalization. The need for antibiotics was more significant in the high-risk group on the GRAM score.

CONCLUSION

The COVID-GRAM score corresponds well with total mortality. The factor with the strongest impact on survival was the absence of other diseases. The worst prognosis was for patients who were unconscious during admission. Patients with higher COVID-GRAM score were significantly less likely to return to full health during follow-up. There is a continuing need to develop reliable, easy-to-adopt tools for stratifying the course of SARS-CoV-2 infection.

Preliminary Assessment of Intra-Aneurysm Sac Pressure During Endovascular Aneurysm Repair as an Early Prognostic Factor of Aneurysm Enlargement

Purpose

Numerous cases of abdominal aortic aneurysm (AAA) enlargement, and even rupture, despite endovascular aneurysm repair (EVAR), have been documented. This has been linked to increased aneurysm sac pressure (ASP). We decided to conduct further research with the aim to identify correlations between ASP during EVAR and subsequent aneurysm enlargement.

Patients and Methods

This experimental prospective study included 30 patients undergoing EVAR of infrarenal AAAs. Invasive ASP measurements were done using a thin pressure wire. Aortic pressure (AP) was measured using a catheter placed over the wire. Systolic pressure index (SPI), diastolic pressure index (DPI), mean pressure index (MPI), and pulse pressure index (PPI) were calculated both for ASP and AP. The results of follow-up computed tomography angiography (CTA) at 3 months were compared with baseline CTA findings.

Results

During EVAR, a significant reduction was observed for SPI (from 98% to 61%), DPI (from 100% to 87%), MPI (from 99% to 74%), and PPI (from 97% to 34%). There were no significant correlations of pressure indices with an aneurysm diameter, cross-sectional area, velocity, thrombus shape and size, number of patent lumbar arteries, length and diameter of aneurysm neck, diameter of the inferior mesenteric artery, as well as diameter and angle of common iliac arteries. On the other hand, aneurysm neck angulation was significantly inversely correlated with reduced PPI. After combining CTA findings with pressure measurements, we identified a positive correlation between PPI and aneurysm enlargement (ratio of the cross-sectional area at the widest spot at baseline and at 3 months after EVAR).

Conclusion

The study showed that ASP can be successfully measured during EVAR and can facilitate the assessment of treatment efficacy. In particular, PPI can serve as a prognostic factor of aneurysm enlargement and can help identify high-risk patients who remain prior monitoring.

The Usefulness of the C2HEST Risk Score in Predicting Clinical Outcomes among Hospitalized Subjects with COVID-19 and Coronary Artery Disease

Background: Even though coronary artery disease (CAD) is considered an independent risk factor of an unfavorable outcome of SARS-CoV-2-infection, the clinical course of COVID-19 in subjects with CAD is heterogeneous, ranging from clinically asymptomatic to fatal cases. Since the individual C₂HEST components are similar to the COVID-19 risk factors, we evaluated its predictive value in CAD subjects. Materials and Methods: In total, 2183 patients hospitalized due to confirmed COVID-19 were enrolled onto this study consecutively. Based on past medical history, subjects were assigned to one of two of the study arms (CAD vs. non-CAD) and allocated to different risk strata, based on the C₂HEST score. Results: The CAD cohort included 228 subjects, while the non-CAD cohort consisted of 1956 patients. In-hospital, 3-month and 6-month mortality was highest in the high-risk C₂HEST stratum in the CAD cohort, reaching 43.06%, 56.25% and 65.89%, respectively, whereas in the non-CAD cohort in the high-risk stratum, it reached: 26.92%, 50.77% and 64.55%. Significant differences in mortality between the C₂HEST stratum in the CAD arm were observed in post hoc analysis only for medium- vs. high-risk strata. The C₂HEST score in the CAD cohort could predict hypovolemic shock, pneumonia and acute heart failure during hospitalization, whereas in the non-CAD cohort, it could predict cardiovascular events (myocardial injury, acute heart failure, myocardial infract, carcinogenic shock), pneumonia, acute liver dysfunction and renal injury as well as bleedings. Conclusions: The C₂HEST score is a simple, easy-to-apply tool which might be useful in risk stratification, preferably in non-CAD subjects admitted to hospital due to COVID-19.

Liver Function Tests in COVID-19: Assessment of the Actual Prognostic Value

Deviations in laboratory tests assessing liver function in patients with COVID-19 are frequently observed. Their importance and pathogenesis are still debated. In our retrospective study, we analyzed liver-related parameters: aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), gamma-glutamyltransferase (GGT), total bilirubin (TBIL), albumin, comorbidities and other selected potential risk factors in patients admitted with SARS-CoV-2 infection to assess their prognostic value for intensive care unit admission, mechanical ventilation necessity and mortality. We compared the prognostic effectiveness of these parameters separately and in pairs to the neutrophil-to-lymphocyte ratio (NLR) as an independent risk factor of in-hospital mortality, using the Akaike Information Criterion (AIC). Data were collected from 2109 included patients. We created models using a sample with complete laboratory tests n = 401 and then applied them to the whole studied group excluding patients with missing singular variables. We estimated that albumin may be a better predictor of the COVID-19-severity course compared to NLR, irrespective of comorbidities (p < 0.001). Additionally, we determined that hypoalbuminemia in combination with AST (OR 1.003, p = 0.008) or TBIL (OR 1.657, p = 0.001) creates excellent prediction models for in-hospital mortality. In conclusion, the early evaluation of albumin levels and liver-related parameters may be indispensable tools for the early assessment of the clinical course of patients with COVID-19.

Usefulness of C2HEST Score in Predicting Clinical Outcomes of COVID-19 in Heart Failure and Non-Heart-Failure Cohorts

Background: Patients with heart failure represent a vulnerable population for COVID-19 and are prone to having worse prognoses and higher fatality rates. Still, the clinical course of the infection is dynamic, and complication occurrence in particular in patients with heart failure is fairly unpredictable. Considering that individual components of the C2HEST (C2: Coronary Artery Diseases (CAD)/Chronic obstructive pulmonary disease (COPD); H: Hypertension; E: Elderly (Age ≥ 75); S: Systolic HF; T: Thyroid disease) are parallel to COVID-19 mortality risk factors, we evaluate the predictive value of C2HEST score in patients with heart failure (HF) Material and Methods: The retrospective medical data analysis of 2184 COVID-19 patients hospitalized in the University Hospital in Wroclaw between February 2020 and June 2021 was the basis of the study. The measured outcomes included: in-hospital mortality, 3-month and 6-month all-cause-mortality, non-fatal end of hospitalization, and adverse in-hospital clinical events. Results: The heart failure cohort consists of 255 patients, while 1929 patients were assigned to the non-HF cohort. The in-hospital, 3-month, and 6-month mortality rates were highest in the HF cohort high-risk C2HEST stratum, reaching 38.61%, 53.96%, and 65.36%, respectively. In the non-HF cohort, in-hospital, 3-month, and 6-month mortalities were also highest in the high-risk C2HEST stratum and came to 26.39%, 52.78%, and 65.0%, respectively. An additional point in the C2HEST score increased the total death intensity in 10% of HF subjects (HR 1.100, 95% CI 0.968−1.250 p = 0.143) while in the non-HF cohort, the same value increased by 62.3% (HR 1.623, 95% CI 1.518−1.734 p < 0.0001). Conclusions: The C2HEST score risk in the HF cohort failed to show discriminatory performance in terms of mortality and other clinical adverse outcomes during hospitalization. C2HEST score in the non-HF cohort showed significantly better performance in terms of predicting in-hospital and 6-month mortality and other non-fatal clinical outcomes such as cardiovascular events (myocardial injury, acute heart failure, myocardial infarction, cardiogenic shock), pneumonia, sepsis, and acute renal injury.

Sex-Dependent Differences in Predictive Value of the C2HEST Score in Subjects with COVID-19—A Secondary Analysis of the COLOS Study

Background: Since the outbreak of the COVID-19 pandemic, a growing number of evidence suggests that COVID-19 presents sex-dependent differences in clinical course and outcomes. Nevertheless, there is still an unmet need to stratify the risk for poor outcome at the beginning of hospitalization. Since individual C₂HEST components are similar COVID-19 mortality risk factors, we evaluated sex-related predictive value of the score. Material and Methods: A total of 2183 medical records of consecutive patients hospitalized due to confirmed SARS-CoV-2 infections were analyzed. Subjects were assigned to one of two of the study arms (male vs. female) and afterward allocated to different stratum based on the C₂HEST score result. The measured outcomes included: in-hospital-mortality, three-month- and six-month-all-cause-mortality and in-hospital non-fatal adverse clinical events. Results: The C₂HEST score predicted the mortality with better sensitivity in female population regarding the short- and mid-term. Among secondary outcomes, C₂HEST-score revealed predictive value in both genders for pneumonia, myocardial injury, myocardial infarction, acute heart failure, cardiogenic shock, and acute kidney injury. Additionally in the male cohort, the C₂HEST value predicted acute liver dysfunction and all-cause bleeding, whereas in the female arm-stroke/TIA and SIRS. Conclusion: In the present study, we demonstrated the better C₂HEST-score predictive value for mortality in women and illustrated sex-dependent differences predicting non-fatal secondary outcomes.

Usefulness of the C2HEST Score in Predicting the Clinical Outcomes of COVID-19 in Diabetic and Non-Diabetic Cohorts

BACKGROUND

Diabetes mellitus is among the most frequent comorbidities worsening COVID-19 outcome. Nevertheless, there are no data regarding the optimal risk stratification of patients with diabetes and COVID-19. Since individual C₂HEST components reflect the comorbidities, we assumed that the score could predict COVID-19 outcomes.

MATERIAL AND METHODS

A total of 2184 medical records of patients hospitalized for COVID-19 at the medical university center were analyzed, including 473 diabetic patients and 1666 patients without any glucose or metabolic abnormalities. The variables of patients' baseline characteristics were retrieved to calculate the C₂HEST score and subsequently the diabetic and non-diabetic subjects were assigned to the following categories: low-, medium- or high-risk. The measured outcomes included: in-hospital mortality; 3-month and 6-month all-cause mortality; non-fatal end of hospitalization (discharged home/sudden-deterioration/rehabilitation) and adverse in-hospital clinical events.

RESULTS

A total of 194 deaths (41%) were reported in the diabetic cohort, including 115 in-hospital deaths (24.3%). The 3-month and 6-month in-hospital mortality was highest in the high-risk C₂HEST stratum. The C₂HEST score revealed to be more sensitive in non-diabetic-group. The estimated six-month survival probability for high-risk subjects reached 0.4 in both cohorts whereas for the low-risk group, the six-month survival probability was 0.7 in the diabetic vs. 0.85 in the non-diabetic group-levels which were maintained during whole observation period. In both cohorts, receiver operating characteristics revealed that C₂HEST predicts the following: cardiogenic shock; acute heart failure; myocardial injury; and in-hospital acute kidney injury.

CONCLUSIONS

We demonstrated the usefulness and performance of the C₂HEST score in predicting the adverse COVID-19 outcomes in hospitalized diabetic subjects.

History of Heart Failure in Patients Hospitalized Due to COVID-19: Relevant Factor of In-Hospital Complications and All-Cause Mortality up to Six Months

Background: Patients with heart failure (HF) are at high risk of unfavorable courses of COVID-19. The aim of this study was to evaluate characteristics and outcomes of COVID-19 patients with HF. Methods: Data of patients hospitalized in a tertiary hospital in Poland between March 2020 and May 2021 with laboratory-confirmed COVID-19 were analyzed. The study population was divided into a HF group (patients with a history of HF) and a non-HF group. Results: Out of 2184 patients (65 ± 13 years old, 50% male), 12% had a history of HF. Patients from the HF group were older, more often males, had more comorbidities, more often dyspnea, pulmonary and peripheral congestion, inflammation, and end-organ damage biomarkers. HF patients had longer and more complicated hospital stay, with more frequent acute HF development as compared with non-HF. They had significantly higher mortality assessed in hospital (35% vs. 12%) at three (53% vs. 22%) and six months (72% vs. 47%). Of 76 (4%) patients who developed acute HF, 71% died during hospitalization, 79% at three, and 87% at six months. Conclusions: The history of HF identifies patients with COVID-19 who are at high risk of in-hospital complications and mortality up to six months of follow-up.

Transcatheter aortic valve-in-valve implantation for failed surgical bioprostheses: results from Polish Transcatheter Aortic Valve-in-Valve Implantation (ViV-TAVI) Registry

INTRODUCTION

Transcatheter aortic valve-in-valve implantation (ViV-TAVI) emerged recently as an alternative to re-do surgery for patients with failed surgical aortic valve (SAV).

OBJECTIVES

To evaluate the safety and efficacy of transcatheter aortic valves (TAV) in failed SAV in Poland.

PATIENTS AND METHODS

Data was acquired using a nationwide, multicenter (n=14) Polish Transcatheter Aortic Valve-in-Valve Implantation (ViV-TAVI) Registry (ClinicalTrials.gov Identifier, NCT03361046) with online form collection and 1-year follow-up.

RESULTS

ViV-TAVI procedures (n=130) constituted 1.9% of all TAVI in Poland with increasing numbers since 2018 (n=59, 45% of all). Hancock II® (21%), Freestyle® (13%), and homograft (11.5%) were identified as the most frequently treated SAV's with self-expanding, supra-annular Corevalve/Evolut® TAV used in the majority of cases (76%). Average post-procedural pressure gradient (average PG) >20 mmHg was found in 21% and 1-year all-cause mortality was 10.8%. SAV stenosis compared to regurgitation/mixed disease was associated with higher average (16, IQR 13.5 - 22.5 vs 14.5, IQR 10-19 mmHg, p=0.004) whereas implantation of supra-annular TAV resulted in lower average PG (14, IQR 10.5-20 vs. intra-annular 19, IQR 16-26 mmHg, P=0.004). After introduction of 2nd generation TAV, shorter procedure time (120, IQR 80-165 min. vs. 135, IQR 108-200 min., P=0.04), less frequent need for additional TAV (2% vs. 10%, P=0.04) and better 1-year freedrom from cardiovascular deaths (95% vs. 82.8%, hazard ratio 0.25, 95% confidence intervals 0.17-0.88, P=0.03) was observed vs. 1st generation.

CONCLUSIONS

Transcatheter treatment of failed SAV is becoming more frequent, showing the best hemodynamic effect with the use of supra-annular TAV and improved procedural as well as clinical results with the introduction of 2nd generation TAV.

Resistin levels in perivascular adipose tissue and mid-term mortality in patients undergoing coronary artery bypass grafting

Higher serum resistin levels were reported to be associated with increased mortality risk. We aimed to assess the predictive value of resistin levels in perivascular adipose tissue (PVAT) around the left main coronary artery (LMCA) for mid-term survival of patients with advanced coronary artery disease (CAD).This was a prospective study including patients referred for elective coronary artery grafting in 2016 and 2017, performed using a standard approach. A sample of PVAT was harvested and resistin levels were measured using an enzyme-linked immunosorbent assay. Patients were followed from the day of the procedure until March 2021. In each patient, the SYNTAX score and EuroSCORE II were calculated. The study included 108 patients aged 68.1 ±7.9 years, including 83 men (76.9%). The duration of follow-up was 731 (range, 275-1020) for nonsurvivors and 1418 median (range, 1174-1559) for survivors (p <0.001). Patients who died had a higher SYNTAX score, higher EuroSCORE II, and lower resistin levels in PVAT than survivors (p <0.001, p = 0.004, and p = 0.041, respectively). A stepwise regression analysis revealed that survival was related to resistin concentrations above the median value (hazard ratio [HR], 4.67; 95% CI, 1.02-21.4; p = 0.048) and EuroSCORE II (used as continuous variable; HR, 1.55; 95% CI, 1.16-2.07; p = 0.003). The mid-term mortality in patients with advanced CAD is associated with low resistin concentrations in PVAT surrounding the LMCA.

Non-calcific aortic tissue quantified from computed tomography angiography improves diagnosis and prognostication of patients referred for transcatheter aortic valve implantation

AIMS

We aimed to investigate the role of aortic valve tissue composition from quantitative cardiac computed tomography angiography (CTA) in patients with severe aortic stenosis (AS) for the differentiation of disease subtypes and prognostication after transcatheter aortic valve implantation (TAVI).

METHODS AND RESULTS

Our study included 447 consecutive AS patients from six high-volume centres reporting to a prospective nationwide registry of TAVI procedures (POL-TAVI), who underwent cardiac CTA before TAVI, and 224 matched controls with normal aortic valves. Components of aortic valve tissue were identified using semi-automated software as calcific and non-calcific. Volumes of each tissue component and composition [(tissue component volume/total tissue volume) × 100%] were quantified. Relationship of aortic valve composition with clinical outcomes post-TAVI was evaluated using Valve Academic Research Consortium (VARC)-2 definitions.High-gradient (HG) AS patients had significantly higher aortic tissue volume compared to low-flow low-gradient (LFLG)-AS (1672.7 vs. 1395.3 mm3, P < 0.001) as well as controls (509.9 mm3, P < 0.001), but increased non-calcific tissue was observed in LFLG compared to HG patients (1063.6 vs. 860.2 mm3, P < 0.001). Predictive value of aortic valve calcium score [area under the curve (AUC) 0.989, 95% confidence interval (CI): 0.981-0.996] for severe AS was improved after addition of non-calcific tissue volume (AUC 0.995, 95% CI: 0.991-0.999, P = 0.011). In the multivariable analysis of clinical and quantitative computed tomography parameters of aortic valve tissue, non-calcific tissue volume [odds ratio (OR) 5.2, 95% CI 1.8-15.4, P = 0.003] and history of stroke (OR 2.6, 95% CI 1.1-6.5, P = 0.037) were independent predictors of 30-day major adverse cardiovascular event (MACE).

CONCLUSION

Quantitative CTA assessment of aortic valve tissue volume and composition can improve detection of severe AS, differentiation between HG and LFLG-AS in patients referred for TAVI as well as prediction of 30-day MACEs post-TAVI, over the current clinical standard.

Original and generic clopidogrel: A comparison of antiplatelet effects and active metabolite concentrations in patients without polymorphisms in the ABCB1 gene and the allele variants CYPC19*2 and *3

BACKGROUND

Ticagrelor and prasugrel are widely used as antiplatelet therapy after coronary angioplasty. However, there is a group of patients with indications for clopidogrel treatment. This population includes patients with chronic or acute coronary syndrome who are treated invasively and have contraindications to the use of novel antiplatelet drugs due to antithrombotic treatment (particularly with non-vitamin K antagonist oral anticoagulants). A wide range of generic forms of clopidogrel are available on the market. However, it is unclear whether they are as effective as the originator drug.

OBJECTIVES

In the current study, we aimed to assess the concentrations of the active metabolite of clopidogrel and its effect on platelet aggregation inhibition in patients receiving the originator drug in comparison with those receiving generic clopidogrel.

MATERIAL AND METHODS

We enrolled 22 healthy individuals without polymorphisms in the ABCB1 gene and the allele variants CYPC19*2 and CYPC19*3. All participants received a loading dose of clopidogrel (600 mg), followed by a maintenance dose of 75 mg for the next 3 days. On day 3, blood samples were obtained 1 h after drug administration to assess active metabolite concentrations using liquid chromatography with tandem mass spectrometry. In each participant, platelet aggregation was assessed with light transmission aggregometry after 5-μmol/L and 10-μmol/L adenosine diphosphate (ADP) stimulation. Assays were performed for the originator clopidogrel and 2 different generic groups.

RESULTS

The mean ± standard deviation (SD) concentrations of active clopidogrel did not differ between the originator drug and 2 generic products with clopidogrel (12.7±5 pg/μL compared to 13.0 ±4 pg/μL compared to 14.4 ±4 pg/μL). Platelet aggregation inhibition after stimulation with 5 μmol/L and 10 μmol/L ADP was similar for all preparations.

CONCLUSIONS

In comparison with original clopidogrel, the use of its generic form does not affect the blood concentrations of the active metabolite or its antiplatelet effect.

Pressure gradient measurement to verify hemodynamic results of the chimney endovascular aortic repair (chEVAR) technique

PURPOSE

The use of the pressure gradient measurements to assess the renal artery flow hemodynamics after chimney endovascular aortic repair (chEVAR).

METHODS

The study was a prospective analysis of 37 chEVAR procedures performend in 24 patients with perirenal aortic aneurysm. In all patients the measurement of: distal renal artery pressure (Pd), aortic pressure (Pa), Pd/Pa ratio (Pd/Pa) and mean gradient (MG) between the aorta and the distal renal artery were performed. Measurements were taken with 0.014 inch pressure wire catheter before and after the chEVAR procedure. MG greater than 9 mmHg and Pd/Pa ratio below 0.90 were considered as the measures of a significant decrease in distal pressure that limited flow in renal arteries. The 6 month follow-up computed tomographic angiography (CTA) was performed in all patients to diagnose potential endoleak presence and to verify the patency of the chimney stent-grafts.

RESULTS

All procedures were successful, and no periprocedural complications were observed in any of the patients. The mean gradient values before and after the chimney implantation did not change significantly (6,2±2,0 mmHg and 6,8±2,2 mmHg, respectively). Similarly, no significant change in Pd/Pa values was noted with the value of 0.9 observed both before and after the procedure. All chimney stents were patent on the control CTA. Type Ia endoleak was found in 4 (10.8%) patients.

CONCLUSIONS

The application of the described technique seems to be a safe method which allows a direct measurement of renal artery flow hemodynamics before and after chimney implantation during the chEVAR technique. The use of covered balloon expandable stents, ensures the proper blood flow in the renal arteries during the chEVAR technique.

Intra-aneurysm sac pressure measurement using a thin pressure wire during endovascular aneurysm repair

BACKGROUND

An endoleak is a typical complication of endovascular aneurysm repair (EVAR). It is characterized by persistent blood flow between a stent graft and the aneurysm sac. Usually, it can be visualized during primary EVAR, but in many cases, this remains impossible. Therefore, other methods of endoleak assessment are urgently needed. The measurement of aneurysm sac pressure (ASP) seems to be a promising direction of research in this area.

OBJECTIVES

We aimed to evaluate the safety and efficacy of a new method for invasive pressure measurement inside the abdominal aortic aneurysm (AAA) during EVAR. We also assessed a correlation between pressure values and early angiographic occurrence of an endoleak after the procedure.

MATERIAL AND METHODS

A total of 20 patients with AAA were included in this experimental prospective study. During EVAR, systolic, diastolic and mean pressure values were recorded both for ASP and aortic pressure (AP) before procedure, after stent graft opening and after final stent graft ballooning.

RESULTS

The measurements were successfully obtained in all participants without any complications. There were no significant differences between all ASP and AP before procedure. After the procedure, blood pressure significantly decreased in the aneurysm sac but not in the aorta. Systolic ASP was significantly lower than systolic AP both after stent graft opening (80.4 ±20.9 mm Hg compared to 110.7 ±21.6 mm Hg, p < 0.01) and after its balloon post-dilatation (65.6 ±26.1 mm Hg compared to 107.4 ±22.1 mm Hg, p < 0.001). Diastolic ASP decreased significantly in comparison to diastolic AP only after stent graft ballooning (48.0 ±14.6 mm Hg compared to 56.4 ±13.6 mm Hg, p < 0.05).

CONCLUSIONS

Our study confirmed that the novel method for the measurement of ASP during EVAR, using a thin pressure wire, is feasible and safe.

Incidence of Adverse Events at 3 Months Versus at 12 Months After Dual Antiplatelet Therapy Cessation in Patients Treated With Thin Stents With Unprotected Left Main or Coronary Bifurcations

Incidence and predictors of adverse events after dual antiplatelet therapy (DAPT) cessation in patients treated with thin stents (<100 microns) in unprotected left main (ULM) or coronary bifurcation remain undefined. All consecutive patients presenting with a critical lesion of an ULM or involving a main coronary bifurcation who were treated with very thin strut stents were included. MACE (a composite end point of cardiovascular death, myocardial infarction [MI], target lesion revascularization [TLR], and stent thrombosis [ST]) was the primary endpoint, whereas target vessel revascularization (TVR) was the secondary endpoint, with particular attention to type and occurrence of ST and occurrence of ST, CV death, and MI during DAPT or after DAPT discontinuation. All analyses were performed according to length of DAPT dividing the patients in 3 groups: Short DAPT (3-months), intermediate DAPT (3 to 12 months), and long DAPT (12-months). A total of 117 patients were discharged with an indication for DAPT ≤3 months (median 1: 1 to 2.5), 200 for DAPT between 3 and 12 months (median 8: 7 to 10), and 1,958 with 12 months DAPT. After 12.8 months (8 to 20), MACE was significantly higher in the 3-month group compared with 3 to 12 and 12-month groups (9.4% vs 4.0% vs 7.2%, p ≤0.001), mainly driven by MI (4.4% vs 1.5% vs 3%, p ≤0.001) and overall ST (4.3% vs 1.5% vs 1.8%, p ≤0.001). Independent predictors of MACE were low GFR and a 2 stent strategy. Independent predictors of ST were DAPT duration <3 months and the use of a 2-stent strategy. In conclusion, even stents with very thin strut when implanted in real-life ULM or coronary bifurcation patients discharged with short DAPT have a relevant risk of ST, which remains high although not significant after DAPT cessation.

Distribution of polymorphisms in the CYP2C19 and ABCB1 genes among patients with acute coronary syndrome in Lower Silesian population

BACKGROUND

Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel administered to treat patients with acute coronary syndrome (ACS) is still being used. However, despite the proven efficacy of this treatment regimen, thromboembolic complications have been observed in some individuals. The reason for this phenomenon is linked to the so-called increased responsiveness of platelets despite high platelet resistance (HPR). A significant role in HPR is attributed to genetically determined differences in the absorption and activation of clopidogrel.

OBJECTIVES

The aim of the study was to assess the incidence of polymorphisms of the ABCB1 and CYPC19 genes that encode proteins involved in the absorption and metabolism of clopidogrel.

MATERIAL AND METHODS

The analysis was performed in 199 consecutive patients from Lower Silesian voivodeship (Poland) who underwent coronary angioplasty with stenting for ACS. The single nucleotide polymorphism of the CYP2C19 and ABCB1 genes was performed using a mini sequencing or restriction fragment length polymorphism method.

RESULTS

The results of this study revealed the high incidence of patients who may be unresponsive to antiplatelet treatment due to genetic causes. The CYPC19*2 allele in the form of homozygote or mutation heterozygote appeared in 26.1% of the study population. ABCB1 (C3435C> T) polymorphism was associated with 84% of patients. The total incidence of allelic disorders of low drug absorption and metabolism reached 14.6%.

CONCLUSIONS

The data obtained should prompt clinicians to use more recent antiplatelet agents (ticagrelor or prasugrel) first, instead of clopidogrel.

P972A subgroup analysis from the RAIN-CARDIOGROUP VII study: incidence of adverse events after DAPT cessation in patients treated with ultrathin stents in ULM or coronary bifurcations

Introduction

Incidence and predictors of adverse events after dual antiplatelet therapy (DAPT) cessation in patients treated with ultrathin stents in unprotected left main (ULM) or coronary bifurcation remain undefined.

Methods

All consecutive patients presenting with a critical lesion of an ULM or a lesion involving a main coronary bifurcation and treated with very thin strut stents were included. MACE (a composite end point of cardiovascular death, myocardial infarction (MI), target lesion revascularization (TLR) and stent thrombosis (ST) was the primary endpoint, while target vessel revascularization (TVR) was the secondary endpoint. Moreover, type and occurrence of ST and occurrence of ST, CV death and MI during DAPT or after DAPT discontinuation were also evaluated. All analyses were performed according to length of DAPT dividing the patients in 3 groups: short DAPT (3-months), intermediate DAPT (3–12 months) and long DAPT (12-months).

Results

117 patients were discharged with an indication for DAPT≤3 months (median 1:1–2.5), 200 for DAPT between 3 and 12 months (median 8:7–10) and 1958 with 12 months DAPT. After 12.8 months (8–20), MACE was significantly higher in the 3-month group compared to 3–12 and 12-month groups (9.4% vs. 4.0% vs. 7.2%, p≤0.001), mainly driven by MI (4.4% vs. 1.5% vs. 3%, p≤0.001) and overall ST (4.3% vs. 1.5% vs. 1.8%, p≤0.001). ST post DAPT cessation were comparable (1.7% vs. 0% vs. 0.7%, p=0.42) with a median time to ST post DAPT discontinuation of 1.67 months (0.48–4.7). At multivariate analysis, DAPT of 12-months compared to 3-months reduces the risk of overall ST (OR 0.103: 0.019–0.0563, 95% CI) while only a trend was noted for DAPT between 3 and 12 months (OR 0.61: 0.186–2.005, 95% CI). When analysed by stent strategy a 2-stent strategy predicted ST post DAPT cessation (OR 3.241: 1.048–10.026, 95% CI), which was reduced by use of FKB (OR 0.101:0.01–0.872, 95% CI).

Conclusion

Even stents with very thin strut when implanted in real-life ULM or coronary bifurcation patients discharged with short DAPT have a relevant risk of ST, which remains high although not significant after DAPT cessation. The correct identification before PCI of the more fragile patients who may receive a shorter DAPT regimen could help identify the safest PCI technique: provisional stenting and use of final kissing balloon (FKB) are the safest options.

P1750YKL-40 in patients with myocardial infarction is associated with survival rate

Background

YKL-40 is a protein released locally by inflammatory cells. Since inflammation has been implicated in the pathogenesis of atherosclerosis, YKL-40 is also considered as a potential biomarker and prognostic factor in cardiovascular diseases.

Purpose

The aim of the study was to analyze serum concentration of YKL-40 in patients with ischemic heart disease, and to verify if this parameter could be considered as a potential biomarker and prognostic factor in cardiovascular diseases.

Methods

The study included 158 participants, among them 52 patients with stable ischemic heart disease, 67 with acute coronary syndrome, and 39 controls without abnormalities in coronary vessels. Prior to the coronarography, a 5-ml sample of venous blood was collected from a peripheral vein of each patient. Serum concentration of YKL-40 was determined once, with an immunoenzymatic assay. For the next 4 years follow-up of patients was conducted, including hospitalizations and deaths.

Results

Patients with myocardial infarction presented with significantly higher serum concentrations of YKL-40 (ng/ml) than persons with stable ischemic disease (249.6±110.9 vs. 86.0±62.7; p<0.001) and the controls (249.6±110.9 vs. 60.2±20.1; p<0.001). No statistically significant differences were found in YKL-40 protein concentrations in patients with ST elevation (STEMI) and non-ST elevation myocardial infarction (NSTEMI) (255.1±110.3 vs. 236.6±113.9; p=NS).

In the ROC analysis YKL-40 value above 360 ng/ml (AUC 0.93; 95% CI 0.86–0.98; p=0.00012) with 80% sensitivity and specificity predicted higher mortality up to 4 years after acute coronary syndrome (p=0.0014) (Figure 1).

4-year probability of survival

Conclusion

Higher serum concentration of YKL-40 at admission in patients with myocardial infarction is associated with higher mortality up to 4 years after acute coronary syndrome.

Rotational Atherectomy Plus Drug-Coated Balloon Angioplasty for the Treatment of Total In-Stent Occlusions in Iliac and Infrainguinal Arteries

PURPOSE

To analyze the long-term outcomes of a hybrid treatment method combining rotational atherectomy with drug-coated balloon (DCB) angioplasty in patients with total in-stent occlusion in the iliac and/or infrainguinal arteries.

MATERIALS AND METHODS

Between April 2014 and June 2017, 74 consecutive patients (mean age 66.7±9.7 years; 49 men) with total occlusion of a previously implanted stent underwent endovascular recanalization using the Rotarex system and DCB angioplasty. Half (37, 50%) of the patients had critical limb ischemia (CLI), and 30 (41%) of the procedures were performed in emergency. Mean lesion length was 22±15 cm.

RESULTS

Overall procedure success was achieved in 73 (98.6%) patients. Six (8.1%) CLI patients developed distal embolism that responded to thrombolysis. Three (4.1%) dissections did not require treatment, while 1 (1.4%) perforation necessitated stent-graft implantation. In all, 33 (44.6%) patients had an additional stent implanted, mainly due to a suboptimal outcome (n=28) or complications (n=5 including the stent-graft). The restenosis rate assessed by duplex ultrasound at 12 months was 20.5% (15/73); 4 (5.5%) patients underwent target lesion revascularization. Recurrent restenosis was more frequent in patients with Rutherford category 5 ischemia (p=0.005), in emergency procedures (p=0.021), after extensive procedures involving 3 independent vessel segments (p=0.016), and if a complication arose during the procedure (p<0.001). In multivariate analysis, only occurrence of a procedural complication was an independent predictor of recurrent restenosis at 1 year (OR 63.3, 95% CI 5.7 to 701.5).

CONCLUSION

These findings imply that rotational atherectomy and DCB angioplasty may provide satisfactory outcomes in the treatment of total in-stent occlusion, with a satisfactory recurrent restenosis rate at 12 months.

Daily risk of adverse outcomes in patients undergoing complex lesions revascularization: A subgroup analysis from the RAIN-CARDIOGROUP VII study (veRy thin stents for patients with left mAIn or bifurcatioN in real life)

INTRODUCTION

Percutaneous coronary intervention (PCI) for complex lesions, including unprotected left main (ULM) and bifurcations, is gaining a relevant role in treating coronary artery disease with good outcomes, also thanks to new generation stents. The daily risk of adverse cardiovascular events and their temporal distribution after these procedures is not known.

METHODS

All consecutive patients presenting with a critical lesion of ULM or bifurcation treated with very thin struts stents, enrolled in the RAIN-Cardiogroup VII study, were analyzed. The daily risk of major acute cardiovascular events (MACE), target lesion revascularization (TLR) and stent thrombosis (ST) and their temporal distribution in the first year of follow-up was the primary endpoint. Differences among subgroups (ULM, patient presentation, kind of stent polymer) were the secondary endpoint.

RESULTS

2745 patients were included, mean age 68 ± 11 years, 33.3% diabetics, 54.5% had an acute coronary syndrome (ACS); 88.5% of treated lesions were bifurcations, 27.2% ULM. Average daily risk was 0.022% for MACE, 0.005% for TLR and 0.004% for ST, in the first year. Bimodal distribution of adverse events, especially TLR, with an early peak in the first 50 days and a late one after 150 days, was observed. Patients with ULM presented a significantly higher daily risk of events, and ACS patients presented higher MACE risk. No difference emerged according to the type of stent polymer.

CONCLUSIONS

The daily risk of adverse events in the first year after complex PCI in our study is acceptably low. PCI on ULM carries a higher risk of complications.

High incidence and clinical characteristics of fibromuscular dysplasia in patients with spontaneous cervical artery dissection: The ARCADIA-POL study

The association between fibromuscular dysplasia (FMD) and spontaneous cervical artery dissection (SCeAD) has been recognized, but the available evidence on this relationship is scant. Therefore, the main goal of our study was to systematically evaluate FMD frequency, clinical characteristics and vascular bed involvement in patients with SCeAD. Among 230 patients referred to the ARCADIA-POL study, 43 patients (mean age 44.1 ± 8.9 years; 15 men and 28 women) with SCeAD were referred. Also, 135 patients with FMD were compared to patients with and without SCeAD. Patients underwent: ambulatory blood pressure measurements, biochemical evaluation, echocardiographic examination, and whole body computed tomographic angiography. FMD changes were found in 39.5% of patients with SCeAD. There were no differences in clinical characteristics between patients with SCeAD and FMD and those without FMD, except for a tendency towards a higher female ratio in SCeAD patients with FMD. There were no differences in other parameters describing target organ and SCeAD characteristics. Patients with SCeAD and FMD compared to those without SCeAD were characterized by a lower frequency of hypertension and a higher frequency of hyperlipidemia and history of contraceptive hormone use. Our study indicates a high incidence (39.5%) of FMD in subjects with SCeAD. Since there are no distinctive discriminating factors between patients with SCeAD and FMD and those without FMD, FMD should be suspected in all patients with SCeAD.

Renal Artery Denervation Due to Refractory Hypertension in a Patient After Kidney Transplantation-3 Years of Observation: A Case Report

INTRODUCTION

Hypertension is prevalent in most patients after renal transplantation, and it is the main factor contributing to cardiovascular diseases that cause death of a significant number of these patients. Up to 95% of patients after transplantation have hypertension, and among them are patients with refractory hypertension. Elevated blood pressure is one of the causes of deterioration of transplant function and may accelerate transplant loss.

CASE REPORT

We present the first case in the world of a patient (who was 61 years old) in whom denervation of native renal arteries was performed after renal transplantation (2004). The patient was suffering from uncontrolled refractory hypertension. Antihypertensive therapy was used but the effect was not satisfactory. The patient received amlodipine, bisoprolol, clonidine, furosemide, and doxazosin in high doses. Clinical assessments with ambulatory blood pressure monitoring revealed a predominant blood pressure 149/96 with incidents of hypertensive crises. High blood pressure is a cardiovascular risk factor and it also has a significant influence on transplant failure, which was the reason for performing the denervation. The procedure was carried out through the femoral artery with the use of a 6F guiding catheter. During a 3-year observation, significant decreases in ambulatory blood pressure monitoring systolic and diastolic blood pressures were observed after the procedure (149/96 mm Hg vs 134/91 mm Hg before and after the denervation, respectively). There was a significant regression of left ventricle mass (577 g before denervation vs 470 g after 3 years). The functioning of the renal transplant became stable after 3 years of observation (38 mL/min before denervation and 38 mL/min after 3 years).

CONCLUSIONS

The first case in the world of a renal transplant patient who had denervation of native renal arteries has demonstrated a positive effect in controlling blood pressure over a 3-year observation. Three years after denervation, a reduction of heart hypertrophy and stabilization of renal function were noted. The presented case shows that denervation of native renal arteries denervation may be successful and safe in kidney transplant recipients.

Plasma YKL-40 levels correlate with the severity of coronary atherosclerosis assessed with the SYNTAX score

Introduction YKL‑40 is a protein released locally by inflammatory cells. Thus, it may constitute a biomarker of inflammatory conditions, such as atherosclerosis. Objectives The aim of the study was to determine YKL‑40 levels in patients with ischemic heart disease and to analyze the correlation of this biomarker with the severity of coronary atherosclerosis. Patients and methods The study included 158 patients: 52 with stable ischemic heart disease and 67 with acute coronary syndrome: ST‑segment elevation myocardial infarction (STEMI; n = 47) or non-ST‑segment elevation myocardial infarction (NSTEMI; n = 20). The control group included 39 individuals without abnormalities in coronary vessels. We evaluated plasma YKL‑40 levels and their correlation with the severity of coronary atherosclerosis assessed with the SYNTAX score. Results Patients with myocardial infarction had higher plasma YKL‑40 levels than those with stable ischemic disease (median [range], 235.3 [161.6-366.1] ng/ml vs 61.2 [53.1-83.1] ng/ml; P <0.001) or controls (median [range], 235.3 [161.6-366.1] ng/ml vs 55.7 [51.2-75.2] ng/ml; P <0.001). No differences were found in YKL‑40 concentrations between STEMI and NSTEMI patients (median [range], 263 [150.3-363.7] ng/ml and 214.9 [163.4-367.6] ng/ml, respectively; P = 0.7). The SYNTAX score in patients with ischemic heart disease correlated positively with YKL‑40 concentrations (R = 0.34; P <0.001). Conclusions YKL‑40 can be considered a potential biomarker of coronary atherosclerosis severity.

Use of vascular closure devices for endovascular interventions requiring a direct puncture of PETE grafts

Abstract. Background: Effectiveness of vascular closure devices during endovascular procedures requiring a direct puncture of a vascular prosthesis placed in the inguinal region is unknown. Patients and methods: The retrospective analysis included 134 patients with a history of polyethylene terephthalate (PETE) graft implantation in the inguinal region. In 20 (15 %) patients, haemostasis was achieved with manual compression, in 21 (16 %) with the StarClose™, and in 93 (69 %) with the AngioSeal™ device. Results: The incidence of vascular complications in the manual compression group was higher (at a threshold of statistical significance) than in the device closure group (45.0 vs. 24.5 %, p = 0.059). The difference was considered statistically significant when manual compression was compared with the AngioSeal™ closure group (45.0 vs. 13.9 %, p < 0.01). The vascular complication rate in the StarClose™ group was significantly higher than in the AngioSeal™ group (71.4 vs. 13.9 %, p < 0.000001). While haematomas were the only vascular complications observed after application of AngioSeal™, both haematomas and pseudoaneurysms were found in the StarClose™ group. Conclusions: The AngioSeal™ vascular closure device provides better local haemostasis than the StarClose™ device or manual compression during endovascular interventions requiring a direct puncture of PETE grafts

Effect of endovascular coronary low-level laser therapy during angioplasty on the release of endothelin-1 and nitric oxide

BACKGROUND

Nitric oxide (NO) and endothelin-1 are potentially significant factors contributing to the pathogenesis of post-angioplasty restenosis. It may be postulated that low-level laser therapy (LLLT) can favorably influence the process of restenosis by affecting those factors.

OBJECTIVES

The aim of the study was to evaluate the effect of LLLT applied during percutaneous coronary intervention (PCI) on the factors participating in the homeostasis of vascular tone - NO and endothelin-1.

MATERIAL AND METHODS

In a randomized, prospective study of 52 subjects undergoing PCI, an additional 808 nm intravascular LLLT was applied at a dose of 9 J/cm2 in the lesion part. The control group was 49 subjects with PCI only. We assessed the concentration of nitrites/nitrates reflecting NO metabolism as well as endothelin-1 in both groups before PCI, and at 6 h, 12 h and 1 month after the procedure. In addition, half a year after PCI, a follow-up angiography was performed.

RESULTS

Statistically higher nitrite/nitrate concentrations were observed in the laser group as compared to the control group in all tests except the pre-PCI assays. Endothelin-1 levels were significantly higher in the laser group 6 h after PCI with a significant decrease in subsequent tests, which was not observed in the control group. The restenosis rate was 15.0% in the laser group and 32.4% in the control group (however the difference was not statistically significant).

CONCLUSIONS

LLLT applied during the PCI procedure can influence the process of restenosis by modifying NO and endothelin-1 concentrations.

Is Transcatheter Tricuspid Valve-In-Valve Implantation Feasible in the Presence of Right Atrial Thrombus?

The case is reported of a successful transcatheter implantation of an Edwards SAPIEN 3 valve (29 mm) into a failing tricuspid bioprosthesis (Sorin Pericarbon, 31 mm). The procedure was performed in a 69-year-old woman with post-rheumatic mitral and tricuspid valve disease. Multiple previous cardiac surgeries precluded the use of another surgical approach. A large, organized, two-piece thrombus in the enlarged right atrium was not considered an absolute contraindication to the procedure. The SAPIEN 3 valve was implanted under general anesthesia, via a femoral venous access, under three-dimensional transesophageal echocardiography guidance. Postoperatively, the systolic right ventricular pressure was increased from 35 to 52 mmHg, but good function of the implanted valve was confirmed with transthoracic echocardiography. The clinical outcome was favorable and the patient was discharged home 72 h after the intervention. Video 1: Transthoracic echocardiography. Tricuspid color Doppler flow after the procedure. Video 2: Fluoroscopy. Fully expanded Edwards SAPIEN 3 valve in the tricuspid position. Video 3: Fluoroscopy. Expansion of the Edwards SAPIEN 3 valve on the balloon. Video 4: Fluoroscopy. Introduction of the Edwards SAPIEN 3 valve into the right atrium. Video 5: Transthoracic echocardiography. Tricuspid color Doppler flow before the procedure.

Effects of intravascular low-level laser therapy during coronary intervention on selected growth factors levels

OBJECTIVE

The objective of this study was to evaluate the effect of intravascular low-level laser therapy (LLLT) on selected growth factor levels in subjects undergoing percutaneous coronary interventions (PCI).

BACKGROUND DATA

Restenosis remains the main problem with the long-term efficacy of PCI, and growth factors are postulated to play a crucial role in the restenosis cascade.

MATERIALS AND METHODS

In a randomized prospective study, an 808 nm LLLT (100 mW/cm2, continuous wave laser, 9 J/cm2, illuminated area 1.6-2.5 cm2) was delivered intracoronarily to patients during PCI. Fifty-two patients underwent irradiation with laser light, and 49 constituted the control group. In all individuals, serum levels of insulin-like growth factor-1 (IGF-1), vascular endothelial growth factor (VEGF), transforming growth factor-β1 (TGF-β1), and fibroblast growth factor-2 (FGF-2) were measured before angioplasty, then 6 and 12 h and 1 month after the procedure. In all patients, a control angiography was performed 6 months later.

RESULTS

There were no significant differences in IGF-1 and VEGF levels between the groups. While evaluating FGF-2, we observed its significantly lower levels in the irradiated patients during each examination. There was a significant increase in TGF-β1 level in control group after 12 h of observation. In the irradiated individuals, control angiography revealed smaller late lumen loss and smaller late lumen loss index as compared with the control group. The restenosis rate was 15.0% in the treated group, and 32.4% in the control group, respectively.

CONCLUSIONS

LLLT decreases levels of TGF-β1 and FGF-2 in patients undergoing coronary intervention, which may explain smaller neointima formation.

Renal Artery Denervation in Patient After Heart and Kidney Transplantation With Refractory Hypertension

We describe the case of a 54-year-old patient after renal and heart transplantation in whom uncontrolled hypertension was diagnosed. Despite combined antihypertensive therapy, no significant therapeutic effect was achieved. Clinical assessment of ambulatory blood pressure monitoring (ABPM) revealed the ineffectiveness of a bisoprolol, nitrendypin, klonidyn, ramipryl, furosemide, and doxasosine combination used at high doses. High blood pressure levels with their effect on a hypertrophic transplanted heart (left ventricular mass 254 g) and poor renal graft function (39 mL/kg/min) posed an extremely high risk of future cardiovascular complications, and were the reason to perform a native renal arteries denervation. The procedure was carried out through the right femoral artery with the use of a 6F guiding catheter. During a 1-year observation, significant decreases in ABPM systolic and diastolic blood pressures were observed after the procedure (168/88 mm Hg vs 154/77 mm Hg, respectively). Moreover a significant regression of left ventricular mass (215 g/m(2)) and stable renal graft function were noted. The presented case shows that native renal arteries denervation may be successful and safe in kidney and heart transplant recipients. Moreover, during the 1-year follow-up, the reduction in blood pressure was followed by a reduction in transplanted heart hypertrophy, both leading to regression of cardiovascular risk for the patient.