Zbigniew Chmielak

Periprocedural intravascular ultrasonography guidance for left main coronary artery stenting is well established. However, the role of this tool is also important at follow-up interventions. We present a case of a patient with previous history of left main coronary artery angioplasty. During a recent attempt to treat tight stenosis in the left anterior descending coronary artery, it was not possible to advance the stent into the left main coronary artery. Intravascular ultrasonography explained the difficulties encountered.

The outcome of percutaneous balloon mitral commissurotomy (BMC) has been reported as poor in patients with prior surgical commissurotomy. The study aim was to evaluate immediate and long-term follow up results of BMC in patients with restenosis after surgical commissurotomy compared to patients with 'de-novo' mitral stenosis. Between October 1988 and September 1999, a total of 1,027 patients underwent BMC. Of these patients, 169 (16.5%) were examined at 17+/-7 years (range: 2-33 years) after surgical commissurotomy (group 1), and 858 (83.5%) had de-novo mitral stenosis (group 2). Group 1 patients were older than group 2 patients (49.4+/-9.3 versus 47.3+/-9.6 years; p <0.05), and atrial fibrillation was seen more often in group 1 (53.9% versus 32.4%; p <0.005). Before BMC, mitral valve area (MVA) was similar in both groups (1.18+/-0.27 and 1.15+/-0.26 cm2 in groups 1 and 2 respectively; p = NS); following BMC, MVA was 1.82+/-0.3 and 1.93+/-0.40 cm2 respectively (p <0...

The aim of our study was to test the impact of acute lumen overdilation on neointimal hyperplasia and late lumen size after vascular brachytherapy for in-stent restenosis (ISR). Forty-seven ISR lesions located in 47 coronary arteries in 44 consecutive patients underwent beta brachytherapy with serial intravascular ultrasound studies. Vessel, lumen, and stent cross-sectional area were measured at 1-mm steps. Based on an interpolated reference cross-sectional area, each cross section was assessed as overdilated (lumen cross-sectional area>interpolated reference cross-sectional area) or not overdilated (lumen cross-sectional area <interpolated reference cross-sectional area). Overall, 502 sections were overdilated and 673 sections were not. Overdilated sections had a larger final lumen cross-sectional area (8.02+/-1.98 vs. 6.90+/-2.23 mm2, P<.001) and more recurrent neointimal hyperplasia (1.59+/-2.17 vs. 0.31+/-1.79 mm2, P<.001), but a smaller follow-up area stenosis (-1.03+/-32.99% vs. 22.15+/-20.75%, P<.001). This was especially true in smaller arteries (angiographic reference<3.0 mm) where larger follow-up lumen cross-sectional area and a corresponding smaller area stenosis were present (5.38+/-1.98 vs. 4.84+/-1.88 mm2 and 6.90+/-31.57% vs. 28.61+/-21.86%, P<.01 and P<.001, respectively). Especially in small arteries, the strategy of acute lumen overdilation during balloon angioplasty prior to beta vascular brachytherapy treatment of ISR lesions has a favorable long-term result.

Lymphorrhea due to classical and mini-invasive surgical interventions on femoral and popliteal arteries is a serious hindrance to patient treatment. Depending on the experience of a particular center, the incidence and frequency of this type of complication may constitute a serious clinical problem. While the level of lymphorrhea intensity and its duration result in certain foreseeable consequences, their treatment can be a time-consuming and multistep procedure. To compare different types of vascular interventions with lymphorrhea occurrence. The authors conducted a retrospective analysis of lymphatic complications based on the material collected between 2005 and 2012 at the Department of Vascular and Endovascular Surgery of the Military Institute of Medicine in Warsaw and in the Department of Interventional Cardiology and Angiology of the Institute of Cardiology in Anin, Warsaw, in 2009-2012. Maintaining due thoroughness when dissecting tissues and treating the cutting line in this area with ligatures and tissue puncture are the most reliable methods of minimizing the risk of lymphatic leakage after surgical procedures performed in a classical way. The lymphatic complication under analysis is far less likely to occur when procedures are performed as planned and an endovascular technique is used - statistical significance p < 0.05. Minimally invasive and fully percutaneous procedures performed via needle puncture, including the use of the fascial closure technique to close the femoral artery, eliminate the likelihood of the occurrence of this vascular complication - statistical significance was found with p value less than 0.05. We concluded that in every case by minimizing the vascular approach we protected the patient against lymphatic complications.

To systematically review reported cases of second transcatheter aortic valve deployment within a previously implanted prosthesis (TAV-in-TAV). TAV-in-TAV deployment is one of the rescue strategies undertaken due to an unsuccessful or suboptimal transcatheter aortic valve implantation (TAVI) result. Currently, there are no clear indications for second valve implantation and outcomes of patients with 2 prostheses deployed remain poorly known. The MEDLINE and PubMed databases were searched for cases of TAV-in-TAV implantations of aortic valve. Forty-three articles reporting on TAV-in-TAV deployment were included in the review. The most frequently observed indication for second valve implantation was aortic regurgitation (AR) occurring shortly after TAVI. There was a strong dominance of paravalvular over intravalvular AR, with prosthesis malposition being the main underlying cause of TAVI failure (81% of all identified cases). Perioperative echocardiographic images are crucial in identifying causes of failure and helpful in optimal rescue strategy selection. Success rate of TAV-in-TAV implantation varies from 90% to 100% with mortality rate of 0-14.3% at 30 days. Despite similar aortic valve function in follow-up, TAV-in-TAV may be an independent predictor of increased cardiovascular mortality. TAV-in-TAV implantation is feasible and results in favorable short- and mid-term outcomes in patients with acute failure of TAVI without recourse to open-heart surgery. Further studies are needed to establish algorithm of the management of unsuccessful or suboptimal implantation results.

To determine the relationship between baseline white blood cell (WBC) count, Thrombolysis in Myocardial Infarction (TIMI) risk index, and 30-day mortality in unselected patients with ST-elevation myocardial infarction (STEMI) treated with primary mechanical reperfusion (PCI). 903 patients from prospective registry admitted for primary PCI to a tertiary cardiological center. Both baseline WBC count and TIMI risk index data were dichotomized about the respective medians. Overall 30-day mortality was 4.3%. Higher WBC count was associated with adverse clinical outcome (6.3% vs. 2.4%; Kaplan-Meier p=0.004) as were higher TIMI risk index values (7.2% vs. 1.4%; Kaplan-Meier p<0.00001). In addition, median WBC count stratified patients within TIMI risk index strata into very low risk (0%), intermediate risk (3.3%) and high risk (11%) (Kaplan-Meier p=0.023 and p=0.005 for comparison of lower and higher WBC count within TIMI risk index stratas). In multivariate analysis WBC count provided independent and additional to TIMI risk index predictive information (Hosmer-Lemeshow p=0.57 and p=0.88 respectively for predictive value of TIMI risk index alone and combined with WBC count). Other independent predictors of death were current smoking (RR 0.33; 95% CI: 0.13-0.87) and previous MI (RR 3.13; 95% CI: 1.28-7.69). WBC count may be a simple and useful tool for risk stratification in STEMI patients, providing additional to established risk index prognostic information. Our findings stress the strong correlation of inflammation and poor outcome in STEMI patients, which may indicate directions of development of new therapies.

Hemoglobin (Hb) levels may interact with inflammatory activation, but it is unknown whether the interaction has any impact on clinical outcomes in acute coronary syndromes. The aim of this study was to assess the relationship between admission Hb levels, leukocytosis and clinical outcomes of ST-elevation myocardial infarction (STEMI) treated with primary angioplasty. Methods and Results The study group comprised 1,904 (1,380 men) patients with STEMI treated with primary percutaneous coronary intervention, enrolled in a prospective registry. The primary endpoint of in-hospital death occurred in 90 (4.7%) patients. According to univariate analysis, extreme values of Hb (for 1(st) and 5(th) vs mid quintiles respectively: hazard ratio (HR) =7.1, P<0.001 and HR =3.2, P=0.024) and leukocytosis above median (HR =2.09, P=0.001) significantly correlated with in-hospital death. After dividing patients into high and low white blood cell (WBC) count groups, a U-shaped relationship of Hb levels and mortality was observed for patients with higher leukocytosis (1(st) and 5(th) vs mid quintiles respectively: HR =8.1, P=0.001 and HR =4.4, P=0.022), whereas in patients with lower WBC count higher mortality was related solely to the lowest Hb quintile (HR =6.9, P=0.010 vs mid quintile). Conclusion Higher mortality associated with higher Hb levels in STEMI patients treated with primary angioplasty is limited to patients with increased leukocytosis.

The aim of our study was to test the impact of acute lumen overdilation on neointimal hyperplasia and late lumen size after vascular brachytherapy for in-stent restenosis (ISR). Forty-seven ISR lesions located in 47 coronary arteries in 44 consecutive patients underwent beta brachytherapy with serial intravascular ultrasound studies. Vessel, lumen, and stent cross-sectional area were measured at 1-mm steps. Based on an interpolated reference cross-sectional area, each cross section was assessed as overdilated (lumen cross-sectional area>interpolated reference cross-sectional area) or not overdilated (lumen cross-sectional area <interpolated reference cross-sectional area). Overall, 502 sections were overdilated and 673 sections were not. Overdilated sections had a larger final lumen cross-sectional area (8.02+/-1.98 vs. 6.90+/-2.23 mm2, P<.001) and more recurrent neointimal hyperplasia (1.59+/-2.17 vs. 0.31+/-1.79 mm2, P<.001), but a smaller follow-up area stenosis (-1.03+/-32.99% vs. 22.15+/-20.75%, P<.001). This was especially true in smaller arteries (angiographic reference<3.0 mm) where larger follow-up lumen cross-sectional area and a corresponding smaller area stenosis were present (5.38+/-1.98 vs. 4.84+/-1.88 mm2 and 6.90+/-31.57% vs. 28.61+/-21.86%, P<.01 and P<.001, respectively). Especially in small arteries, the strategy of acute lumen overdilation during balloon angioplasty prior to beta vascular brachytherapy treatment of ISR lesions has a favorable long-term result.

The correlation between cardiac computed tomographic (CT) and intravascular ultrasound (IVUS) assessment of saphenous vein graft (SVG) lesions has not been studied. The aim of this study was to evaluate the accuracy of dual-source computed tomography in quantitative assessment of significant SVG lesions scheduled for percutaneous coronary intervention (PCI). Preintervention dual-source CT (DSCT) scans were performed in consecutive patients before PCI of the SVG lesion. All subjects underwent IVUS examination of the target lesion before stent implantation. Lesion characteristics were described using dual-source computed tomography, quantitative coronary angiography, IVUS, and visual estimation. Luminal areas and diameters, lesion lengths, and DSCT suggested stent dimensions were compared. Twenty-two SVG lesions were assessed in 22 patients. Minimal lumen area measured by IVUS was larger than by dual-source computed tomography (3.5 ± 1.2 vs 3.0 ± 1.2 mm(2), p = 0.04), although there was close correlation between measurements (R = 0.7, p = 0.007). Proximal and distal reference lumen diameters by IVUS and dual-source computed tomography were similar (3.3 ± 0.4 vs 3.4 ± 0.6 mm, p = 0.5, and 3.4 ± 0.6 vs 3.5 ± 0.6 mm, p = 0.4, respectively) and were well correlated (R = 0.85, p <0.0001, and R = 0.81, p <0.0001, respectively). Lesion length by IVUS averaged 18.3 ± 6.1 versus 17.6 ± 5.3 mm by dual-source computed tomography (p = 0.1). There was good correlation between mean reference lumen diameter by dual-source computed tomography and diameter of the implanted stent (R = 0.84, p = 0.0009) and a very good correlation between stent length and lesion length as assessed by dual-source computed tomography (R = 0.9, p <0.0001). In conclusion, DSCT measurements in SVGs correlate with IVUS so that DSCT scan data before PCI of an SVG lesion may be helpful in stent size selection.