Is There Room for Liposomal Irinotecan in Biliary Tract Cancer? A Meta-analysis of Randomised Trials.

AIMS: The combination of 5-fluorouracil/leucovorin (5-FU/LV) plus oxaliplatin (FOLFOX) is widely acknowledged as the standard regimen for second-line treatment in patients with advanced biliary tract cancer. Nanoliposomal irinotecan (nal-IRI) has demonstrated its activity in patients with advanced pancreatic cancer. Recent studies have investigated the activity of nal-IRI in combination with 5-FU/LV for biliary tract cancer. However, the results have been contradictory. We conducted a meta-analysis to assess survival outcomes and response rates in randomised trials investigating the activity of nal-IRI in previously treated biliary tract cancer patients. MATERIALS AND METHODS: We systematically collected potentially relevant findings from PubMed/Medline, the Cochrane library and EMBASE. Abstracts presented at major international oncological meetings were also reviewed. We extracted hazard ratios and 95% confidence intervals for progression-free survival and overall survival, as well as odds ratios and 95% confidence intervals for objective response rate. The outcomes of the accessible randomised studies evaluating the activity of nal-IRI plus 5-FU/LV were analysed. RESULTS: The combination therapy exhibited a statistically significant decrease in the risk of progression (hazard ratio 0.70; 95% confidence interval 0.50-0.97) when compared with 5-FU/LV alone. Additionally, the dual regimen yielded longer overall survival and a higher objective response rate. CONCLUSION: Our meta-analysis showed that nal-IRI plus 5-FU/LV had a superior activity in comparison with 5-FU/LV. Further investigations are required to elucidate the role of nal-IRI in this setting and to identify subgroups of patients who could derive the greatest benefit from its administration.

Encorafenib plus cetuximab with or without binimetinib in patients with BRAF V600E-mutated metastatic colorectal cancer: real-life data from an Italian multicenter experience.

BACKGROUND: Encorafenib plus cetuximab with or without binimetinib showed increased objective response rate (ORR), progression-free survival (PFS), and overall survival (OS) compared with chemotherapy plus anti-EGFR in previously treated patients with BRAF V600E-mutated (mut) metastatic colorectal cancer (mCRC). Although no formal comparison was planned, addition of binimetinib to encorafenib plus cetuximab did not provide significant efficacy advantage. PATIENTS AND METHODS: This real-life study was aimed at evaluating safety, activity, and efficacy of encorafenib plus cetuximab with or without binimetinib in patients with BRAF V600E-mut mCRC treated at 21 Italian centers within a nominal use program launched in May 2019. RESULTS: Out of 133 patients included, 97 (73%) received encorafenib plus cetuximab (targeted doublet) and 36 (27%) the same therapy plus binimetinib (targeted triplet). Most patients had Eastern Cooperative Group Performance Status (ECOG-PS) of 0 or 1 (86%), right-sided primary tumor (69%), and synchronous disease (66%). Twenty (15%) tumors were DNA mismatch repair deficiency (dMMR)/microsatellite instability (MSI)-high. As many as 44 (34%) patients had received two or more prior lines of therapy, 122 (92%) were previously exposed to oxaliplatin, and 109 (82%) to anti-vascular endothelial growth factor (anti-VEGF). Most frequent adverse events were asthenia (62%) and anti-EGFR-related skin rash (52%). Any grade nausea (P = 0.03), vomiting (P = 0.04), and diarrhea (P = 0.07) were more frequent with the triplet therapy, while melanocytic nevi were less common (P = 0.06). Overall, ORR and disease control rate (DCR) were 23% and 69%, respectively, with numerically higher rates in the triplet group (ORR 31% versus 17%, P = 0.12; DCR 78% versus 65%, P = 0.23). Median PFS and OS were 4.5 and 7.2 months, respectively. Worse ECOG-PS, peritoneal metastases, and more than one prior treatment were independent poor prognostic factors for PFS and OS. Clonality of BRAF mutation measured as adjusted mutant allele fraction in tumor tissue was not associated with clinical outcome. CONCLUSIONS: Our real-life data are consistent with those from the BEACON trial in terms of safety, activity, and efficacy. Patients in good general condition and not heavily pretreated are those more likely to derive benefit from the targeted treatment.

Strong impact of sarcopenia as a risk factor of survival in resected gastric cancer patients: first Italian report of a Bicentric study.

Gastric cancer (GC) accounts for 4% of all cancers in Europe. Sarcopenia is a complex syndrome characterized by a loss of muscle mass and function associated with age, often present in neoplastic patients. Recently, several studies have shown a significant association between sarcopenia and poor prognosis in various pathological conditions. The current observational retrospective study investigates the association between sarcopenia and overall survival (OS) and recurrence-free survival (RFS) in patients with GC undergoing up-front surgery with curative intent. Resected GC patients' clinical records and CT images were retrospectively assessed. The preoperative CT calculation of the skeletal muscle index (SMI) at L3 level allowed us to categorize patients as sarcopenic or not. Kaplan-Meyer and univariate and multivariate Cox regression analyses were performed to determine the difference in survival and presence of independent prognostic factors. Fifty-five patients, 28 male and 27 female, out of 298 studied for gastric cancer were enrolled in the current study from two cancer referral centers in Italy. The preoperative CT calculation of the SMI at L3 level allowed us to identify 39 patients with and 16 without sarcopenia. A statistically significant difference between the sarcopenic and non-sarcopenic groups was observed in both OS and RFS (p < 0.023; p < 0.006). Moreover, sarcopenia was strongly correlated to a higher risk of recurrence in univariate and multivariate analysis (p < 0.02). Sarcopenia can be considered a critical risk factor for survival in patients with resectable GC treated with up-front surgery. Identifying sarcopenic patients at the time of diagnosis would direct selection of patients who could benefit from early nutritional and/or physical treatments able to increase their muscle mass and possibly improve the prognosis. More extensive multicenter studies are needed to address this issue.

Role of poorly differentiated cluster in gastric cancer: is it a new prognosis factor?

BACKGROUND: Poorly differentiated Clusters (PDCs) of tumor cells composed of more than five elements have been recently described in gastrointestinal cancers and correlate with a worse prognosis. Our study aims to investigate PDC occurrence in a series of patients with gastric cancer and correlate it with lymph node status and clinical outcome. MATERIAL AND METHODS: 50 patients were included in the study; PDCs count was graduated as G1, G2, and G3 according to Ueno classification (PDCs count at 20× <5, 5-9 and ≥10 respectively). We collected several clinicopathologic variables such as tumor location, pTNM stage, vascular or perineural invasion, and lymph-node ratio for each case. RESULTS: The presence of PDCs was related to vascular invasion (p < .013) and recurrence event (p < .027). When the population was categorized according to the number of PDCs, a significant correlation was found with the presence of lymph node metastasis (p < .000), the Lymph Node Ratio (p < .002), WHO stage at the diagnosis (p < .000) and vascular invasion (p < .001). At the univariate and multivariate analysis, PDCs were found as an independent risk factor for recurrence (HR 1.94; CI 95% 1.209-3.121; p < .006 and HR 0.401; CI 95% 0.187-0.862; p < .017 respectively). The Kaplan-Meier curves for OS and DFS showed a significant association between PDCs and shorter time to recurrence or survival. CONCLUSION: PDC is a strong prognostic factor in gastric cancer, easily detectable, and feasible. As far as we know, this is the first report in Literature of a strong correlation between PDC and survival in patients with operated gastric cancer.

Characterization of tumor-derived mesenchymal stem cells potentially differentiating into cancer-associated fibroblasts in lung cancer.

PURPOSE: The goal of this study was to understand if mesenchymal stem cells isolated from lung tumor tissue (T-MSCs) may differentiate into cancer associated fibroblasts (CAFs), that promote neoplastic progression, angiogenesis and metastasis in the epithelial solid tumors, mimicking the tumor microenvironmental influence. METHODS: MSCs were been obtained from healthy (Control, C-MSCs) and tumor (T-MSCs) tissue of one patient who underwent a lobectomy for a lung adenocarcinoma pT1bN0. Isolated cells were characterized for the presence of molecular markers (identified by routine diagnostic characterization in differentiated tumoral cells), stemness properties, and CAF-related markers expression. Subsequently, cells were co-cultured with a lung adenocarcinoma cell line (A549 cells) to evaluate the effects on proliferation, oncogene expression and IL6 secretion. RESULTS: C- and T-MSCs did not present EGFR mutations unlike tumor tissue and showed a stem-like immunophenotype, characterized by the ability to differentiate towards osteo-, chondro- and adipogenic lineages. The expression of markers referred to CAFs (α-SMA, HI-1α, MMP11, VEGF, CXCL12, TGF-ß1, TGF-ßRII, IL6, TNFα) was significantly higher in T-MSCs than in C-MSCs. The co-cultures with A549 cells led to the over-expression of selected oncogenes and to the increase of IL6 secretion in T-MSCs but not in C-MSCs. CONCLUSIONS: MSCs isolated from tumor tissue displayed distinct properties compared to MSCs isolated from healthy tissue, suggesting T-MSCs differentiation towards a CAF-related phenotype under the influence of the tumoral microenvironment.

Effect of lung resection on pleuro-pulmonary mechanics and fluid balance.

The aim of the study was to determine in human patients the effect of lung resection on lung compliance and on pleuro-pulmonary fluid balance. Pre and post-operative values of compliance were measured in anesthetized patients undergoing resection for lung cancer (N=11) through double-lumen bronchial intubation. Lung compliance was measured for 10-12 cm H2O increase in alveolar pressure from 5 cm H2O PEEP in control and repeated after resection. No air leak was assessed and pleural fluid was collected during hospital stay. A significant negative correlation (r(2)=0.68) was found between compliance at 10 min and resected mass. Based on the pre-operative estimated lung weight, the decrease in compliance following lung resection exceeded by 10-15% that expected from resected mass. Significant negative relationships were found by relating pleural fluid drainage flow to the remaining lung mass and to post-operative lung compliance. Following lung re-expansion, data suggest a causative relationship between the decrease in compliance and the perturbation in pleuro-pulmonary fluid balance.

Low-technology exercise test in the preoperative evaluation of lung resection candidates.

Exercise tests are increasingly used in the preoperative functional evaluation of lung resection candidates. Low-technology exercise tests include six minute walking, shuttle walking and stair climbing. Conflicting evidence has been reported regarding 6 minute walking test. This test should not be used to select patients for lung resection. An incremental shuttle walk test is easier to replicate than 6 minute walking test. Most patients achieving 25 shuttles or 400 m have a maximum oxygen consumption measured at cardiopulmonary exercise test greater than 15 l/Kg/min. Although this test tends to underestimate performance at the lower range compared to peak oxygen consumption it can be used a screening test before lung resection. Excluding patients from operation based on this test alone is however not recommended and a formal cardiopulmonary exercise test should be always used in those walking less than 400 m. Stair climbing has been extensively studied in thoracic surgery. Several studies have found that poor performance in this test is indicative of cardiopulmonary complications and mortality after lung resection. In particular, climbing less than 12 m represents very high risk, whereas climbing more than 22 m is associated with a favourable outcome. Recent guidelines recommend referring all patients climbing lower than 22 m to cardiopulmonary exercise test. Stair climbing can be used as a screening test in cases cardiopulmonary exercise test is not readily available. In general, patients climbing more than 22 m can proceed to surgery without further evaluation.

First Report of Pseudoperonospora cubensis Causing Downy Mildew of Trichosanthes cucumerina in Malaysia.

In December 2008, infected leaves of Trichosanthes cucumerina were observed on commercial cucurbit farms located in Pontian, Johor (south of West Malaysia). Bright yellow and small necrotic lesions were observed on the adaxial surface of the leaves, whereas sporangiophores were observed on pale yellowish brown-to-brown lesions on the abaxial surface. The length and width of the sporangia ranged from 19 to 36 µm (28.6) and 11 to 23 µm (17.6), respectively. The length of the sporangiophores ranged from 310 to 450 µm, with an average length of 380 µm. The pathogen was identified as Pseudoperonospora cubensis on the basis of the morphological criteria described by Palti and Cohen (2). To confirm the morphological findings, DNA was extracted from symptomatic tissue and the internal transcribed spacer (ITS) region was PCR amplified using primers ITS5-P2 and ITS4 (3). The appropriate-sized amplicon was gel excised and column purified and then submitted for direct sequencing. The resulting 802 bp amplified ITS region was 100% identical to published P. cubensis sequences (GenBank Accession Nos. EU876603, EU876584, and AY198306). This sequence was deposited with NCBI GenBank under the Accession No. GU233293. In this study, pathogenicity tests were conducted using detached leaf disc assays (1) and a P. cubensis isolate obtained from T. cucumerina. For this purpose, leaf discs were excised from 6- to 8-week-old leaves of T. cucumerina using a 20-mm cork borer. Five leaf discs were placed with their abaxial surface facing upward on moist filter paper in petri dishes. Each of four leaf discs was inoculated with four 10-µl droplets of a 1 × 105 per ml sporangial suspension, whereas the fifth disc was inoculated with water droplets and served as a control. Three replications were completed. The leaf discs were placed in darkness at 14 ± 2°C for 24 h and subsequently incubated with a 12-h photoperiod. After 10 days, sporulation was observed on the sporangia-inoculated leaf discs with similar morphological features to the initial field samples. To our knowledge, this is the first report of P. cubensis causing downy mildew of T. cucumerina in Malaysia. References: (1) A. Lebeda and M. P. Widrlechner. J. Plant Dis. Prot. 110:337, 2003. (2) J. Palti and Y. Cohen. Phytoparasitica 8:109, 1980. (3) H. Voglmayr and O. Constantinescu. Mycol. Res. 112:487, 2008.

Prevalence and risk factors of gallstone disease in a high altitude Saudi population.

To study the prevalence of gallstone disease and related risk factors in a Saudi Arabian population a cross-sectional community-based study was made of 291 people from Abha district, Asir region. A structured interview collected background data and all participants had upper abdominal ultrasonography to detect gallstones. The overall prevalence of gallstone disease was 11.7%. Using logistic regression multivariate analysis, the following were significant risk factors for gallstone disease: female sex, family history of gallstone disease and past history of pancreatitis. Age, education, blood pressure, smoking, coffee intake, overweight, diabetes mellitus, number of pregnancies and use of oral contraceptives were not significant risk factors. Discriminant analysis of symptoms showed that only right hypochondrium pain was significantly associated with gallstone disease.

First Report on the Presence of Phoma Blackleg Pathogenicity Group 1 (Leptosphaeria biglobosa) on Brassica napus (Canola/Rapeseed) in Iran.

Canola/rapeseed (Brassica napus L.) is a new crop in Iran, grown since 1996. In 2006, 180,000 ha were planted. During the same year, leaf and upper stem lesions (3) were observed on cv. Hyola 401 at rosette and flowering stages in the Gorgan Province in northern Iran. Field disease incidence ranged from 1 to 40%. Several isolates from stem lesions were sent to the Department of Plant Science, Blackleg Research Lab, University of Manitoba, Canada from the Agricultural and Natural Resources Research Center of Golestan Province of Iran for pathogenicity group identification. The blackleg pathogen is divided into several pathogenicity groups on the basis of phenotypic interaction (IP) of isolates on differential cvs. Westar, Glacier, and Quinta. Isolates PG2, PG3, PG4, and PGT are highly virulent, but PG1, which recently has been named Leptosphaeria biglobosa (2), is weakly virulent. Colonies of the blackleg pathogen were reisolated from their original medium, potato dextrose agar, and grown onV8 agar medium and incubated under light for 2 weeks. Pure cultures of the pathogen were then characterized by colony morphology, pycnidia, and measurement and microscopic observation of pycnidio-spores. Fungal colonies formed with concentric rings containing pycnidia with pink ooze on V8 agar. Pycnidia were globose and as much as 200 µ 200 µm. They had a prominent beak on the ascomata that was enlarged, cylindrical, central, terete, erect, and 150 to 200 × 100 µm. Pycnidiospores were cylindrical, straight, 4 to 5 × 2 µm, and hyaline (2). To identify the pathogenicity group of the Iranian isolates, pycnidiospores were harvested from single-spore cultures after 14 days of incubation under continuous cool-white fluorescent light (1). One-week-old cotyledons from the differential cvs. Westar, Glacier, and Quinta were inoculated with pycnidiospore suspension concentration of 2 × 107 spores per ml of the four Iranian isolates. Each cotyledon lobe was punctured with forceps and inoculated with a 10-µl droplet of spore suspension. Disease evaluations were made 10 to 14 days after inoculation using a 0 to 9 rating scale. Inoculations were repeated twice with identical results yielding only the PG1 type reaction. To our knowledge, this is the first report of the presence of L. biglobosa (PG1; B-type) on canola in Iran. Differential testing fulfilled Koch's postulates. L. biglobosa seems to be less damaging compared with L. maculans, but severe phoma stem lesion epidemics have been associated with the L. biglobosa in Poland (3). The importance of this weakly virulent pathogen, whenever the relative humidity increases, has been demonstrated in greenhouse conditions (A. El-Hadrami, W. G. D. Fernando, and F. Daayf, unpublished data). Since the relative humidity in northern Iran is high, an epidemic may occur if appropriate management practices are not utilized to minimize inoculum levels. References: (1) W. G. D. Fernando and Y. Chen. Plant Dis. 87:1268, 2003. (2) R. A. Shoemaker and H. Brun. Can. J. Bot. 79:412, 2003. (3) J. S.West et al. Plant Pathol. 48:161, 2001.

First Report of Bean pod mottle virus in Soybean in Iran.

Soybean (Glycine max (L.) Merr.) has been increasing in importance and acreage for the past 5 years in Iran and is now planted on approximately 108,000 ha. Previous surveys in Iran of viruses infecting soybean failed to identify Bean pod mottle virus (BPMV), but the incidence of other common viruses of soybean in the field has been reported (1). During October 2004, symptoms characteristic of those caused by BPMV including mosaic, puckering of trifoliate leaves, and delayed maturity of stems or green stems were observed in soybean fields in the Takhti Mahaleh, Versen, and Hashemabad areas located in the Gorgan Province. Sporadic incidence of plants infected with BPMV has been usually of minor importance to growers. Symptoms were often overlooked or considered to be physiological disorders. A visual assessment was made to determine incidence of green stem in the commonly grown soybean cv. Sahar. Forty soybean plants showing symptoms of crinkling, mottling, green stem, and retaining green leaves were sampled by collecting one trifoliate leaf near the top of the plant. All samples were tested in parallel for BPMV using double-antibody sandwich enzyme-linked immunosorbent assay (DAS-ELISA). BPMV was detected in 40% of the samples. Seven of the samples shown to be infected with BPMV using DAS-ELISA were mechanically (2) transferred to soybean seedlings in the greenhouse. These plants developed systemic mottle symptoms typical of those caused by BPMV and tested positive for BPMV using DAS-ELISA. The distribution of BPMV within soybean-growing regions, exploration of potential virus reservoirs, and economic impact of this virus have yet to be determined. There is no published report on the presence of potential BPMV vectors including the bean leaf beetle (Cerotoma trifurcata) from soybean fields in Iran. To our knowledge, this is the first report of BPMV in Iran. References: (1) A. R. Golnaraghi et al. Plant Dis.88:1069, 2004. (2) R. Louie et al. Plant Dis.84:1133, 2000.

Stair-climbing test to evaluate maximum aerobic capacity early after lung resection.

BACKGROUND: The aim of this study was to investigate the extent of reduction in maximum oxygen consumption in the early postoperative period after lung resection for lung carcinoma. METHODS: A total of 115 patients who underwent lung resection (95 lobectomies, 20 pneumonectomies) performed a maximal stair-climbing test the day before operation and the day of discharge from the hospital (8 +/- 3.3 days after the operation). RESULTS: The postoperative test showed a 15% reduction in maximum oxygen consumption (VO2max) with respect to the preoperative test (Student's t test, p < 0.0001). This reduction was greater after pneumonectomy (21.4%) than after lobectomy (14%) (Student's t test, p < 0.05). A multiple regression analysis showed that the only significant independent predictors of both preoperative and postoperative VO2max were the age of the patient and the level of arterial oxygen content. CONCLUSIONS: The early postoperative reduction in VO2max was greater after pneumonectomy than after lobectomy and the exercise performance was significantly influenced by the level of arterial oxygen content both before and early after the operation.

Surgical treatment of left ventricular post-infarction aneurysm with endoventriculoplasty: late clinical and functional results.

OBJECTIVE: The temporal response to endoventriculoplasty (EVP) has not been well defined. We have evaluated the long-term clinical and functional results of this technique. METHODS: From 1988 to 1997, 121 patients underwent aneurysmectomy by EVP associated with myocardial revascularization for anteroapical left ventricular postinfarction aneurysm. Among these, 39 patients (43%) underwent early post-operative cardiac catheterization (within 3 months maximum), and were available to be revaluated after a mean follow-up time of 56+/-28 months, by means of a new hemodynamic study. Left ventricular silhouettes were analyzed by means of a special software. RESULTS: The mean New York Heart Association functional class decreased from 2.5+/-0.9 to 1.6+/-0.8 (P<0.001) late postoperatively. The global ejection fraction improved early postoperatively from 43+/-13 to 61+/-13% (P<0.001), and late postoperatively slightly decreased to 42+/-13% (ns) versus preoperative values. Left ventricular end diastolic pressure early postoperatively fell from 16.8+/-7 to 15.7+/-6.7 (ns), and late postoperatively increased to 21.6+/-8.8 (ns) versus preoperative values. Pulmonary artery pressure rose early postoperatively from 31.5+/-6.4 to 32.1+/-6.7 (ns), and late postoperatively to 34.9+/-8.9 (ns). The global contractility score decreased early postoperatively from 42.3+/-9.6 to 28.4+/-13.6 (P<0.001); the global late postoperative contractily was 35+/-14 (ns) versus preoperative values. Patients who benefit most from the operation were those with a normal postoperative contraction pattern, where ejection fraction improved respectively early postoperatively from 43+/-13 to 63+/-11% (P<0.001), and late postoperatively to 49+/-10% (P<0.001) versus preoperative values. Occlusion or critical stenosis of bypass grafts occurred in 10 patients (25.6%). There were no significant differences in hemodynamic data and hypokinesis score changes between patients with patent or occluded bypass graft, and between patients with mono or multivessel disease. The operative mortality was 6.3%, and 8.8% needed intraaortic balloon counterpulsation. The actuarial survival rates at 5 and 7 years were 73+/-6 and 61+/-6%. The mean follow-up period was 68 months (with 112 months maximum). CONCLUSIONS: We conclude that, in our patients group, EVP of left ventricular aneurysm associated with coronary grafting improves clinical status after operation. We registered a trend for a mild hemodynamic worsening, irrespective of coronary artery disease except in those patients who had shown a normal postoperative contraction pattern.

Free edge suture plication and remodeling: a technique for anterior mitral leaflet prolapse repair.

This is a selected series of 28 patients with myxomatous mitral regurgitation that underwent correction of the anterior leaflet prolapse caused by chordal elongation by means of a running suture involving the chordal-cusp junction. Postoperative echocardiograms showed correction of anterior leaflet prolapse and mitral regurgitation in all patients. This technique is effective and easy to perform, and increases the number of options for restoring mitral valvular function.

Chordal transposition for anterior mitral prolapse: early and long-term results.

OBJECTIVE: Chordal transposition was advocated for correction of anterior mitral prolapse. We have evaluated the early and late results of this technique in different anatomical presentations. METHODS: From 1986 to 1995, 185 mitral valve repairs were carried out for pure mitral regurgitation due to a degenerative disease. Eighty-nine patients had either an anterior prolapse (39) or prolapse of both leaflets (50) at initial presentation and underwent chordal transposition from the mural leaflet to the anterior leaflet. The corrective procedure was completed by polytetrafluoroethylene or pericardial posterior annuloplasty. Twenty patients presented a complex pathology and 26 had chordal elongation of mural leaflet. Annular calcifications were found in 9 patients. Seven patients required shortening of transposed chordae and two patients the additional shortening of an anterior chorda. RESULTS: Operative mortality was 3.3% and follow-up was 95% complete (average 41 months). There were five postreconstruction valve replacements (two earlier and three later) for a probability of freedom from late reoperation or 3+ mitral regurgitation of 88.6 +/- 4.8% at 5 years. Of the patients 79% presented no or trivial residual MR, 17% moderate MR and 4% severe MR. The presence of a complex pathology or posterior chordal elongation did not influence the entity of postoperative residual regurgitation. On the contrary, the patients with annular calcifications had a residual regurgitation/left atrium area ratio greater than patients without annular calcification (15.8 +/- 11.5% vs. 6.1 + 9.9%; P = 0.009). CONCLUSIONS: Chordal transposition is an effective and easily carried out technique for the correction of anterior mitral prolapse. The presence of a complex pathology or posterior chordal elongation do not rule out the procedure. The absence of annular calcification is important in order to obtain a satisfactory correction.

Myocardial revascularization in patients with ischemic cardiomyopathy: functional observations.

OBJECTIVE: A prospective angiographic study was undertaken to investigate, with an objective analysis, the global and regional wall response to myocardial revascularization. METHODS: Thirty-one patients (30 men and 1 woman, mean age, 61 years) with a left ventricular ejection fraction of less than 0.30 were admitted to our institution between 1992 and 1995 for two- or three-vessel coronary artery disease requiring myocardial revascularization. All patients underwent isolated coronary artery bypass grafting and were studied 3 months later with angiography. Preoperative and postoperative wall motion were analyzed using special software that computed a segmental left ventricular ejection fraction, generating a segmental score. Computerized analysis allowed us to distinguish patients with diffuse hypokinesis and a symmetric contraction pattern from patients with akinesis involving at least two segments and an asymmetric contraction pattern. RESULTS: There were no operative deaths and no patient required intraaortic balloon counterpulsation. One patient had postoperative enzymatic evidence of myocardial infarction. Postoperative angiography showed a graft patency rate of 84%. Global analysis showed a small but significant rise in the left ventricular ejection fraction (0.25 +/- 0.51 to 0.31 +/- 0.70, p < 0.001) and a fall in the left ventricular end-diastolic pressure (23.7 +/- 10 to 16.5 +/- 9 mm Hg, p < 0.01). Mean scores always have been lower after the operation than before it, with the best results obtained for the apex and the worst for the anterobasal segment. The group with a symmetric contraction pattern showed a trend toward a better hemodynamic response than the group with an asymmetric contraction pattern. Regression analysis revealed two important predictors of segmental functional improvement: (1) the absence of an echocardiographic scar, and (2) the presence of a collateral circulation. CONCLUSIONS: Coronary artery bypass grafting produced a small but substantial improvement in patients with ischemic cardiomyopathy. The greater benefit occurred in patients with a symmetric contraction pattern. The absence of an echocardiographic scar and the presence of a collateral circulation predicted segmental functional improvement.

Mitral annuloplasty: different surgical techniques.

Mitral annuloplasty has always been a target for the cardiac surgeon, even before the era of open heart surgery. We describe here commisural annuloplasty, annular reduction with rings, and supported annular reduction without rings, which are, at the present time, the three types of annuloplasties employed. The increasing incidence of mitral valve surgery for degenerative disease suggests reconstructive surgery with autologous patients tissue as the gold standard.