Retrograde Open Mesenteric Stenting for Acute and Chronic Mesenteric Ischaemia: Results from an Intestinal Stroke Centre.

OBJECTIVE: To report the intra-operative adverse events (IOAEs) and the initial and one year outcomes of retrograde open mesenteric stenting (ROMS) using balloon expandable covered stents for acute and chronic mesenteric ischaemia. METHODS: Clinical data and outcomes of all consecutive patients treated with ROMS for acute and chronic mesenteric ischaemia at an intestinal stroke centre between November 2012 and September 2019 were reviewed. ROMS was performed using balloon expandable covered stents. Endpoints included IOAEs, in hospital mortality, post-operative complications, and re-interventions. One year overall survival, freedom from re-intervention, primary patency and assisted primary patency rates were analysed using the Kaplan-Meier time to event method. RESULTS: During the study period, 379 patients were referred to the centre for acute or chronic mesenteric ischaemia. Thirty-seven patients who underwent the ROMS procedure were included. All the patients had severe atherosclerotic mesenteric lesions. The ROMS technical success rate was 89% in this cohort. The rate of IOAEs was 19% and included four cases of retrograde recanalisation failure. All ROMS failures occurred in patients presenting with flush superior mesenteric artery occlusion and they were treated by mesenteric bypass. Ten patients (27%) underwent bowel resection, four of which resulted in a short bowel syndrome (11%). The in hospital mortality rate was 27%. Post-operative complications and re-intervention rates were 67% (n = 25) and 32% (n = 12), respectively. The median follow up was 20.2 months (interquartile range 29). The estimated one year overall survival for the cohort was 70.1% (95% confidence interval [CI] 52.5% - 82.2%). The estimated freedom from re-intervention at one year was 61.1% (95% CI 42.3 - 75.4). The one year primary patency and assisted primary patency rates were 84.54% (95% CI 63.34 - 94) and 92.4% (95% CI 72.8 - 98), respectively. CONCLUSION: ROMS procedures offer acceptable one year outcomes for mesenteric ischaemia but are associated with frequent stent related complications. Precise pre-operative planning, high quality imaging, and meticulous stent placement techniques may limit the occurrence of such events.

The induction of heme oxygenase 1 decreases contractility in human internal thoracic artery and radial artery grafts.

OBJECTIVE: Spasm remains a potential problem encountered during the use of arterial grafts in coronary artery bypass surgery. Heme oxygenase plays a role in the control of arterial vasoreactivity. Heme oxygenase exists in 2 constitutive isoforms (heme oxygenase 2 and 3) and an inducible isoform (heme oxygenase 1). The aim of our study was to induce heme oxygenase 1 by using hemin in human internal thoracic and radial arteries and to evaluate the effect of this induction on the contractility of these arterial grafts. METHODS: Segments of human arterial grafts obtained from patients undergoing isolated coronary artery bypass surgery were incubated in organ chambers for 4 hours in the presence of 10(-4) mol/L hemin. Concentration-response curves to norepinephrine were obtained in control and hemin-treated arterial rings. Heme oxygenase 1 expression was evaluated by using enzyme-linked immunosorbent assays and immunohistochemical staining. RESULTS: The contractility of the arterial rings to norepinephrine was significantly reduced after incubation with hemin. Zinc protoporphyrin (an inhibitor of heme oxygenase) reversed the effect of hemin, whereas the inhibitor of nitric oxide synthase had no effect. The inhibitor of soluble guanylate cyclase blocked the decrease in contractility induced by hemin. Immunohistochemical staining revealed a large expression of heme oxygenase 1 in all vascular layers of hemin-treated internal thoracic artery and radial artery rings. Enzyme-linked immunosorbent assay studies showed a significant increase in heme oxygenase 1 levels in hemin-treated internal thoracic artery and radial artery rings. CONCLUSION: Hemin caused in vitro induction of heme oxygenase 1 in human internal thoracic artery and radial artery grafts. This induction resulted in a reduced contractility to norepinephrine, partially through the cyclic guanosine monophosphate-dependent pathway. This effect was independent from nitric oxide synthesis.

Long-term results of mitral valve repair in active endocarditis.

BACKGROUND: Several investigators have reported the feasibility of mitral valve repair in active endocarditis, but the long-term results are still unknown. METHODS AND RESULTS: We reviewed 37 consecutive patients who underwent mitral valve repair with the Carpentier technique for active endocarditis in our center between 1989 and 1994. This repair involved prosthetic annuloplasty in 31 patients (84%), valve resection in 31 (84%), chordal shortening or transposition in 19 (51%), pericardial patch in 16 (43%), and direct suture of leaflet perforation in 4 (11%). Associated procedures were primarily aortic valve repair or replacement in 11 (30%) and tricuspid repair in 2 (6%). Early complications included 1 operative death (3%; 95% CI, 0 to 15.5) and 1 reoperation for pericardial patch dehiscence. Recurrence of endocarditis was observed in 1 patient (3%; 95% CI, 0 to 16). The 10-year survival rate and freedom from mitral valve reoperation were 80% (95% CI, 66 to 94) and 91% (95% CI, 81 to 100), respectively. At 10 years, most patients (96%) were in good functional status (NYHA class I to II) with no or trivial mitral regurgitation (92%) on echocardiography. CONCLUSIONS: Mitral valve repair using Carpentier's techniques in patients with active endocarditis offers very good long-term results with a low rate of recurrence or reoperation.