Left Ventricular Diastolic Dysfunction Predicts Global Longitudinal Strain Recovery after Surgical Aortic Valve Replacement.

BACKGROUND AND OBJECTIVES: In patients with severe aortic stenosis (AS), left ventricular systolic dysfunction is one of the main predictors of adverse events after surgical aortic valve replacement (SAVR). However, more patients undergo surgery earlier, often with preserved systolic function. In these cases, global longitudinal strain (GLS) has been proposed as a marker of ventricular remodeling post-surgery. This study aims to evaluate GLS variation in patients undergoing SAVR and explore differences across the diastolic dysfunction classes. METHODS: From June 2020 to March 2023, patients with AS and preserved ejection fraction (EF) requiring SAVR were enrolled. Echocardiographic evaluations were conducted preoperatively, seven days post-surgery, and twelve months after surgery. Patients were divided into two groups based on the severity of diastolic dysfunction: Group A (grade I) and Group B (grades II-III). RESULTS: The final analysis included 108 patients (mean age 71.3 ± 7.2 years). Twenty-two patients (20.4%) also underwent coronary artery bypass grafting (CABG). The preoperative EF averaged 61.6 ± 6.03%, with no significant differences between groups. Preoperative GLS was 16 ± 4.3%, decreasing to 12.8 ± 3.4% postoperatively (p < 0.0001). GLS was comparable between the groups preoperatively (p = 0.185) and postoperatively (0.854). After twelve months, GLS improved in both groups (Group A: 17.7 ± 3.4%, Group B: 15.7 ± 3.2%, p < 0.0001), but only Group A showed significant improvement from preoperative values (p = 0.018). SAVR improved GLS regardless of CABG intervention. CONCLUSIONS: SAVR in patients with preserved LVEF results in an early reduction in GLS, regardless of diastolic dysfunction. After twelve months, GLS improved significantly, with significant recovery only in patients with mild dysfunction.

Endocarditis with spondylodiscitis: clinical characteristics and prognosis.

BACKGROUND: The association of infective endocarditis (IE) with spondylodiscitis (SD) was first reported in 1965, but few data are available about this issue. This study aimed to evaluate the prevalence of SD in patients with IE, and to determine the clinical features and the prognostic impact of this association. METHODS: We retrospectively analysed 363 consecutive patients admitted to our Department with non-device-related IE. Radiologically confirmed SD was revealed in 29 patients (8%). Long-term follow-up (average: 3 years) was obtained by structured telephone interviews; in 95 cases (13 of whom had been affected by SD), follow-up echocardiographic evaluation was also available. RESULTS: At univariable analysis, the combination of IE with SD was associated with male gender (p = 0.017), diabetes (p = 0.028), drug abuse (p = 0.009), Streptococcus Viridans (p = 0.009) and Enterococcus (p = 0.015) infections. At multivariable analysis, all these factors independently correlated with presence of SD in patients with IE. Mortality was similar in patients with and without SD. IE relapses at 3 years were associated with the presence of SD (p = 0.003), Staphylococcus aureus infection (p < 0.001), and drug abuse (p < 0.001) but, at multivariable analysis, only drug abuse was an independent predictor of IE relapses (p < 0.001; HR 6.8, 95% CI 1.6-29). At echocardiographic follow-up, SD was not associated with worsening left ventricular systolic function or valvular dysfunction. CONCLUSIONS: The association of IE with SD is not rare. Hence, patients with IE should be screened for metastatic infection of the vertebral column, especially if they have risk factors for it. However, SD does not appear to worsen the prognosis of patients with IE, either in-hospital or long-term.

Impact of renal function impairment assessed by CKDEPI estimated glomerular filtration rate on early and late outcomes after coronary artery bypass grafting.

BACKGROUND: We explore the association between short- and long- term adverse outcomes following coronary artery bypass grafting (CABG) and the degree of preoperative renal dysfunction classified on glomerular fraction estimated with Chronic Kidney Disease-Epidemiology Collaboration equation (eGFRCKD-EPI). We also try to identify cut-off values of eGFRCKD-EPI able to predict post-CABG unfavorable events and assess whether a reclassification with new thresholds is necessary. METHODS: One-thousand-one-hundred-eighty-six consecutive patients undergoing CABG between 2005 and 2014 were categorized in 4 groups according to the eGFRCKD-EPI: Group 1 (≥60ml/min/1.73m2; n=1199), Group 2 (45-59ml/min/1.73m2; n=358), Group 3 (30-44ml/min/1.73m2; n=171) and Group 4 (≤29ml/min/1.73m2; n=126). Median follow-up was 66months [IQR 46-84]. RESULTS: eGFRCKD-EPI ≤30ml/min/1.73m2, ≤41ml/min/1.73m2, ≤27ml/min/1.73m2 and ≤29ml/min/1.73m2 were strong predictors of early mortality (OR 5.88 [95% CI 2.59-11.25]), stroke (2.59 [1.43-3.71]), prolonged length of stay (3.49 [1.24-5.92]) and postoperative dialysis (3.68 [1.34-4.91]), respectively. In addition, eGFRCKD-EPI ≤26ml/min/1.73m2, ≤25ml/min/1.73m2, ≤35ml/min/1.73m2 and ≤29ml/min/1.73m2 predicted all-cause death (hazard ratio 2.74 [95% CI 2.10-3.92] cardiovascular death (sub-hazard ratio 2.11 [95% CI 1.42-3.90]), myocardial infarction (2.01 [1.32-3.70]) and heart failure (2.24 [1.41-3.93]), respectively. Analyses corrected by age and left ventricular ejection fraction confirmed these findings. CONCLUSIONS: In our experience, the use of the eGFRCKD-EPI equation led to categorization with a significantly lower number of patients at risk for post-CABG complications. This might have important clinical repercussions on allocation of healthcare resources and more targeted prevention and management of CABG complications.

Surgical ablation in patients undergoing mitral valve surgery: impact of lesion set and surgical techniques on long-term success.

AIMS: To assess the results and impact of lesion set and surgical technique on long-term success of surgical ablation during mitral surgery. METHODS AND RESULTS: The patient population consisted of 685 subjects with persistent and long-standing persistent atrial fibrillation (AF) undergoing cardiac surgery for mitral valve disease as the primary indication and concomitant ablation between January 2003 and January 2012 at three institutions. One hundred and sixty-six underwent unipolar (24.2%), 371 (54.2%) bipolar, and 148 (21.6%) had combined ablation. Median follow-up was 58.4 months (interquartile range 43.3-67.9). To appropriately account for death, a competing risk model was employed to identify predictors of cumulative incidence of recurrent AF among lesion set and surgical techniques. Eight-year freedom from recurrent arrhythmia without antiarrhythmic drugs was 0.60 ± 0.02. Success rate was higher using bipolar radiofrequency (RF) (P < 0.001), after performing mitral isthmus line (P = 0.003) and following the biatrial technique (P < 0.001). Competing risk regression revealed that use of unipolar RF [sub-hazard ratio (SHR) 2.41 (1.52-3.43), P < 0.001], combined unipolar/bipolar ablation [SHR 1.93 (0.89-2.57), P = 0.003] and the absence of right atrial ablation [SHR 2.79 (1.27-3.48), P < 0.001] were predictors of cumulative incidence of long-term recurrence. CONCLUSIONS: Our experience suggests that the use of bipolar clamp improves long-term results in surgical treatment of AF and that right-sided ablation should be routinely added. Randomized studies are necessary to confirm our findings.

Wide-Angle Tissue Doppler Imaging at High Frame Rate Using Multi-Line Transmit Beamforming: An Experimental Validation In Vivo.

Color tissue Doppler imaging (TDI) is a well-established methodology to assess local myocardial motion/deformation. Typically, a frame rate of ∼ 200 Hz can be achieved by imaging a narrow sector (∼ 30°, covering one cardiac wall) at moderate line density, using a dedicated pulse sequence and multi-line acquisition. However, a wide angle field-of-view is required in some clinical applications to image the whole left ventricle, which implies a drop in temporal resolution. Hereto, the aim of this study was to propose a novel imaging sequence using a multi-line transmit (MLT) beamforming approach to achieve high frame rate color TDI while preserving a wide field-of-view (i.e., 90° sector). To this end, a color MLT-TDI sequence achieving a frame rate of 208 Hz with a 90°-sector was implemented on an ultrasound experimental scanner interleaved with a conventional color TDI sequence achieving the same frame rate but only with a 22.5°-sector. Using this setup, the septal wall of 9 healthy volunteers was imaged and the corresponding velocity was extracted. The M-mode velocity images and the velocity profiles obtained from the MLT-TDI images presented physiologic patterns, very similar to those from conventional TDI. Moreover, for the peak systolic/diastolic velocities, good agreement and strong correlation between MLT-TDI and conventional TDI were found. The results thus demonstrate the feasibility of the novel MLT based TDI methodology to achieve high frame rate color TDI without compromising the field-of-view. This may open the opportunity to simultaneously assess regional myocardial function of the whole left ventricle at high temporal resolution.

Left ventricular dyssynchrony is associated with recurrence of ischemic mitral regurgitation after restrictive annuloplasty.

BACKGROUND: In our study, we investigated the impact of papillary muscle systolic dyssynchrony (DYS-PAP) obtained by 2D speckle-tracking echocardiography (2D-STE) in the prediction of recurrent ischemic mitral regurgitation (MR) after restrictive annuloplasty. METHODS: The study population consisted of 524 consecutive patients who survived coronary artery bypass grafting (CABG) and restrictive annuloplasty, performed between 2001 and 2010 at 3 different Institutions and who met inclusion criteria. The assessment of DYS-PAP was performed preoperatively and at follow-up (median 45.3 months [IQR 26-67]) by 2D-STE in the apical four-chamber view for the anterolateral papillary muscle (ALPM) and apical long-axis view for the posteromedial papillary muscle (PMPM). RESULTS: Recurrence of MR (≥ 2+ in patients with no/trivial MR at discharge) was found in 112 patients (21.3%) at follow-up. Compared to patients without recurrence of MR, these patients had higher DYS-PAP values at baseline (60.6 ± 4.4 ms vs. 47.2 ± 2.9 ms, p<0.001) which significantly worsened at follow-up (74.4 ± 5.2 ms, p=0.002 vs. baseline). In contrast, in patients with no MR recurrence, DYS-PAP was significantly reduced (25.3 ± 4.4 ms, p=0.002 vs. baseline). At logistic regression analysis DYS-PAP (odds ratio [OR]: 4.8, 95% Confidence Interval [CI]: 3.4-8.2, p<0.001), was the strongest predictor of recurrent MR with a cutoff ≥ 58 ms (95%CI 51-66 ms). The model showed an area under the Receiver Operating Characteristic (ROC) curve of 0.97 (CI 0.94-0.99 [optimism-corrected 0.94; CI 0.89-0.95]) with 98% sensitivity (CI 96-100% [optimism-corrected 95%; CI 91-96%]) and 90% specificity (CI 85-94% [optimism-corrected 87%; CI 82-90%]). CONCLUSIONS: DYS-PAP represents a reliable tool to identify patients with ischemic MR who can benefit from restrictive annuloplasty.

Impact of preoperative anterior leaflet tethering on the recurrence of ischemic mitral regurgitation and the lack of left ventricular reverse remodeling after restrictive annuloplasty.

BACKGROUND: The aim of this multicenter study was to investigate the impact of the preoperative anterior mitral leaflet tethering angle, α', on the recurrence of mitral regurgitation (MR) and left ventricular (LV) reverse remodeling (LVRR) after undersized mitral ring annuloplasty. METHODS: The study population consisted of 362 patients, who were divided into two groups by baseline α': group 1, α' < 39.5° (n = 196), and group 2, α' ≥ 39.5° (n = 166). End points were recurrent MR ≥ 2+; LVRR, defined as a reduction in end-systolic volume index > 15%; and LV geometric reverse remodeling, defined as a reduction in systolic sphericity index to a normal value of <0.72 in patients with altered baseline geometry. RESULTS: MR occurred in 9.6% (n = 19) and 43.3% (n = 72) of the patients in groups 1 and 2, respectively (P < .001). LVRR (85.7% vs 22.2%) at follow-up was higher in group 1 (P < .001). On multivariate regression analysis, α' ≥ 39.5° was a strong predictor of MR recurrence, lack of LV reverse remodeling and lack of LV geometric reverse remodeling (all P values < .001). In contrast, the posterior mitral leaflet tethering angle, ß', was not significant (all P values > .05). When we allowed for interactions between α' and other risk factors, this effect occurred also in low-risk subgroups, and it was equivalent or generally attenuated in higher risk patients. There were no significant interactions between α' and any of the covariates (all P values > .05). CONCLUSIONS: Anterior mitral leaflet tethering is a powerful predictor of MR recurrence and lack of LVRR after undersized mitral ring annuloplasty. Evaluation of leaflet tethering should be incorporated into clinical risk assessment and prediction models.

Acute infection-inflammation and coronary stent thrombosis: an observational study.

Coronary stent thrombosis (CST) is a major concern of interventional cardiology. Several risk factors for CST have been identified, but as a whole they do not explain the pathophysiology of CST. This study was designed to investigate whether acute infection-inflammation could facilitate the occurrence of CST. Forty-one patients, aged 66.6 +/- 11 years, consecutively admitted to our catheterization laboratory for acute, subacute or late CST, were retrospectively analysed. Transient acute infection-inflammation on admission for CST was diagnosed by predefined criteria. Prevalence of known risk factors for CST was also investigated. Twenty-one patients (51%) met predefined criteria for the occurrence of acute infection-inflammation. On admission, in these patients, levels of systemic humoral and cellular inflammatory markers were significantly higher than those of patients without recent or ongoing acute infection-inflammation (p < 0.05 for all). 62% of patients with acute infection-inflammation had less than two known risk factors for CST whereas only 37% patients without infection-inflammation showed less than two risk factors (p = 0.03) and showed more frequent interruption of antiplatelet treatment (17 vs. 2.4%, p = 0.02), mean longer stent length (20.5 +/- 4.8 vs. 16.5 +/- 5.1 mm, p = 0.02) and lower left ventricular ejection fraction before CST (42.9 +/- 14 vs. 47.3 +/- 11%, p = 0.02). In conclusion, acute infection-inflammation could play a role in facilitating the occurrence of CST in a subgroup with low risk profile for known risk factors. Our findings, if confirmed, could suggest new opportunities for prevention and treatment of CST.

Does preoperative tethering symmetry affect left ventricular reverse remodeling after restrictive annuloplasty?

BACKGROUND: We hypothesized that a preoperative symmetric pattern with anterior mitral leaflet (AML) tethering predominance is related to lack of LVRR after restrictive annuloplasty. METHODS: In 300 patients with surgical annuloplasty for chronic ischemic mitral regurgitation the AML and posterior mitral leaflet (PML) tethering angles were quantified and patients were divided on the basis of the preoperative anterior/posterior tethering angle ratio: there were 144 patients with symmetric (Group 1) and 156 with asymmetric (Group 2) preoperative tethering pattern patients underwent echocardiography preoperatively, at discharge and at follow-up appointments (6 months [IQR 5-8 months]; late, 48 months [15-63 months]). Reverse remodeling was defined as a reduction in left ventricular end systolic volume index >15%. RESULTS: LVRR was higher in the asymmetric group at discharge (69.2% vs. 9.7%, p<0.001), early (70.55% vs. 10.45%, p<0.001 and late follow up (81.4% vs. 4.8%, p<0.001). At multivariable regression analysis corrected by significant key factors of LVRR, symmetric leaflet tethering (OR, 4.8 [95% CI 2.9-5.6], p<0.001), anterior tethering angle alpha'<39.5 degrees (OR, 5.0 [95% CI 2.0-6.6], p<0.001), coaptation height<11 mm (OR, 2.5 [95% CI 1.1-3.3], p=0.006) and coaptation length > or =8 mm at the end of procedure (OR, 2.0 [CI 0.8-3.0], p=0.01) were independent predictors of LVRR. Compared with patients with asymmetric pattern (adjusted OR 0.2 [95% CI 0.03-1.6), those with symmetric pattern had >4-fold odds for lack of LVRR. CONCLUSIONS: The preoperative symmetric pattern with AML prevalence was strongly associated with lack of reverse remodeling after annuloplasty. An accurate echocardiographic evaluation of the tethering mechanisms should be incorporated into clinical risk assessment and prediction models.

Severe hypoplasia of the posterior mitral leaflet.

A rare case of a 14-year-old child with congenital mitral insufficiency secondary to hypoplasia of the posterior leaflet is reported. Echocardiography revealed the almost complete absence of the posterior mitral leaflet, which determined massive regurgitation. At surgical inspection the posterior leaflet was almost completely absent, represented only by tags of fibrous tissue that strictly adhered to the posterior annulus with a total absence of chordae inserting into the hypoplastic leaflet. The mitral valve was successfully repaired by restrictive annuloplasty, which gained a satisfactory surface of coaptation between the anterior leaflet and the primordial posterior structure, resulting in stable valve continence.

[Bivalirudin and cardiac surgery: two case reports]. / Bivalirudina e chirurgia cardiaca: descrizione di due casi clinici.

Immune reactions to heparin and in particular heparin-induced thrombocytopenia are not rare and potentially fatal complications of heparin treatment. These conditions are frequently underdiagnosed in cardiac surgery. Moreover, few data are available in the literature about the use of alternative anticoagulants to heparin in this setting. We describe the successful use of bivalirudin in 2 patients with hypersensitivity to heparin who underwent cardiac surgery.

Insights on left ventricular and valvular mechanisms of recurrent ischemic mitral regurgitation after restrictive annuloplasty and coronary artery bypass grafting.

BACKGROUND: We investigated leaflet and subvalvular configurations to identify mechanisms leading to recurrent mitral regurgitation after combined undersized mitral annuloplasty and coronary artery bypass and to preoperatively recognize patients who are unlikely to benefit from this approach. METHODS: Among 261 subjects with chronic ischemic mitral regurgitation undergoing undersized annuloplasty and coronary bypass surgery at one institution between September 2001 and September 2007, 31 were excluded: 4 had intraoperative annuloplasty failure, 12 showed residual regurgitation, and 15 had incomplete echocardiograms available. The study population consisted of 230 patients who were divided into 2 groups: patients without (group 1, n = 176) or with (group 2, n = 54) late recurrent mitral regurgitation. Fifty healthy subjects were used as control subjects. Serial echocardiographic analysis was performed preoperatively, at discharge, and at follow-up appointments (early: median, 6 months [interquartile range, 5-6 months; late: median, 33 months [interquartile range, 17-51 months]). RESULTS: Subjects with late regurgitation had preoperatively more symmetric tethering (P < .001), more accentuated anterior mitral leaflet tethering (P < .001), and more restricted anterior leaflet excursion (P = .003) than patients in group 1. Postoperatively, tethering of the posterior leaflet increased (P < .001) and was predominant in both groups, whereas tethering of the anterior leaflet was reduced at discharge (P = .01 and P = .03, respectively), remaining constant afterward. Multivariable analysis showed an anterior tethering angle of 39.5 degrees or greater (P < .001), an anterior/posterior tethering angle ratio of 0.76 or greater (P < .001), an anterior leaflet excursion angle of 35 degrees or less (P = .001), and a coaptation height of 11 mm or greater (P = .04) to be predictors of recurrent mitral regurgitation. CONCLUSIONS: Preoperative symmetric tethering with anterior mitral leaflet predominance was strongly associated with recurrence of mitral regurgitation. Measures of leaflet tethering resulted in fundamental findings to identify ischemic patients who can really benefit from restrictive annuloplasty. Further larger studies are necessary to confirm our results.

Prognostic value of Doppler-derived mitral deceleration time on left ventricular reverse remodelling after undersized mitral annuloplasty.

AIMS: This study was aimed at exploring the predictive value of Doppler-Derived Mitral Deceleration Time (DT) on left ventricular reverse remodelling (LVRR) in patients with chronic ischaemic mitral regurgitation (CIMR) undergoing combined undersized mitral annuloplasty (UMRA) and coronary artery bypass grafting (CABG). METHODS AND RESULTS: Two hundred and fifteen patients undergoing combined UMRA and CABG for CIMR between September 2001 and September 2007 in our Institution were divided into four groups on the basis of baseline DT: Group 1, normal (n = 48), Group 2, impaired relaxation (n = 61), Group 3, pseudonormal (n = 50), and Group 4, restrictive (n = 56). Echocardiograms were performed, pre-operatively, at discharge and at follow-up appointments (100% complete, early, median 6 months [interquartile range 4-8 months]) and late, median 38 months (17-61 months). Left ventricular reverse remodelling, defined as a reduction in ESV > 15%, occurred in 95.7, 96.3, 88.3, and 0% in Groups 1, 2, 3, and 4, respectively (P < 0.001). Logistic regression analysis showed that DT

Coronary embolism following valve surgery.

A 55-year-old man experienced chest pain on the seventh day after valve surgery. Coronary angiography showed embolic occlusion of the left anterior descending coronary artery. The lesion was treated successfully with thrombectomy using the angiojet rheolytic thrombectomy system, resulting in rapid mechanical thrombolysis and removal via the effluent lumen of the catheter. Thrombolysis in Myocardial Infarction 3 flow was restored.

Five-year echocardiographic results of combined undersized mitral ring annuloplasty and coronary artery bypass grafting for chronic ischaemic mitral regurgitation.

AIMS: We present 5-year echocardiographic results of combined undersizing mitral ring annuloplasty (UMRA) and coronary artery bypass grafting (CABG) in chronic ischaemic mitral regurgitation (CIMR). METHODS AND RESULTS: Two hundred and fifty-one patients (aged 68.4 +/- 8.1, 62.5% male) undergoing combined CABG and UMRA in our Institution (Cardiac Surgery, Careggi Hospital, Florence, Italy) between September 2001 and March 2007 were prospectively enrolled in the study. Median follow up was 32.9 months [interquartile range (IQR) 17.5-51.6]. Fourteen patients with significant residual mitral regurgitation (MR) needing immediate intraoperative revision (n = 3) or at discharge (n = 11) were excluded from the study. Serial echocardiograms were performed in 220 survivors at baseline, discharge, and annually thereafter. Additionally, 17 patients died (2 early and 15 late deaths) and were also excluded from the study. MR remained stable at 1 year and re-increased at 3 years (P < 0.001) and 5 years (P < 0.001). Five-year actuarial survival was 83.2 +/- 4.4. Five-year freedom from re-operation for failed repair was 78.2 +/- 4.9%. Mean systolic and diastolic diameters decreased significantly at discharge (P = 0.001 and P = 0.01, respectively) and at early follow up (P = 0.004 and P = 0.02) but raised at 3 years (P < 0.001) and 5 years (P < 0.001). Systolic and diastolic sphericity indexes improved at discharge (P < 0.001) remained stable at 1 year but they re-increased at 3-year control (P = 0.006 and P = 0.03, respectively) with a late raise exceeding the pre-operative value (P < 0.001). Left ventricular reverse remodelling was observed in 44.2% of the study population with 10.3% of patients showing further left ventricular dilatation. At multivariable model, end-systolic volume > or =145 mL, systolic sphericity index > or =0.7, myocardial performance index > or =0.9, and wall motion score index > or =1.5 were predictors of recurrent MR. CONCLUSION: Our findings emphasize the need for improved repair technique and better patient selection to identify patients with anticipated repair failure who could benefit more from valve replacement or other procedure directly addressing ventricular tethering.

NT-proBNP and the anti-inflammatory cytokines are correlated with endothelial progenitor cells' response to cardiac surgery.

OBJECTIVE: We used cardiac surgery as a model of acute inflammatory response to evaluate the role of the inflammatory mediators in influencing the number of circulating endothelial progenitor cells (EPCs). METHODS: In 38 coronary artery by-pass grafting (CABG) [28M/10F] and in 54 valvular [28M/26F] patients the numbers of EPCs and the serum levels of IL-1ra, IL-6, IL-8, IL-10, vascular endothelial growth factor (VEGF), high sensitivity C-reactive protein (hsCRP) and NT-proBNP were determined before (T1), 72h (T2), and 10 days after cardiac intervention (T3). Peripheral blood EPCs were measured by flow cytometric analysis and were defined as CD34+KDR+, CD133+KDR+ and CD34+CD133+KDR+. RESULTS: We demonstrate that the cardiac surgery reduces, 72h after intervention, the number of all the three types of EPCs with a contemporary marked increase of pro-inflammatory and anti-inflammatory cytokines and NT-proBNP levels. At baseline, EPC number was inversely related with age. At multiple linear regression analysis, after adjusting for age, cardiovascular risk factors and medications, age and IL-8 serum levels were significantly related to EPC number. At T2, an inverse relationship between NT-proBNP and the number of EPCs was found in the whole study population. At T3, 10 days after the intervention, at multivariate linear regression analysis, IL-10 and IL-1ra serum levels were significantly and positively associated with EPC number. CONCLUSIONS: This study provides new insights into the relationship between inflammatory activation and mobilisation of EPCs in patients underwent cardiac surgery, by showing that NT-ProBNP and cytochemokines mediate the EPC changes in acute and post-acute response to the inflammatory stimulus of intervention.

A complex triple valve repair in a young rheumatic patient.

We report a case of a 22-year-old Ethiopian female presenting with multiple rheumatic valve disease. She was admitted to hospital because of dyspnea at rest. She underwent open mitral commissurotomy associated with splitting of the postero-medial papillary muscle, aortic right-coronary-left coronary commissural resuspension with resection of fibrous tissue from the free-edge cusps and open tricuspid commissurotomy of all three commissures completed with chordal shortening of the anterior leaflet. The postoperative course was uneventful. The patient was asymptomatic without recurrence of symptoms at 2 months. Echocardiography confirmed the satisfactory outcome of the multiple repair with no residual insufficiency. Multiple repair is advisable for patients living in many areas of the Third World, where the safety of long-term anticoagulation cannot be assured.