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Objectives: Clampless aortic anastomosis devices aim to lower stroke risk in off-pump coronary artery bypass grafting. Two main strategies for clampless anastomosis devices emerged with automated anastomosis punching and aortic sealing devices, prompting the question of perioperative outcome differences. Methods: All consecutive patients undergoing elective off-pump coronary artery bypass grafting with a clampless aortic anastomosis device between September 2014 and December 2021 in 2 centers were retrospectively included. Cohorts were divided by the use of an automated anastomosis punching device or an aortic sealing device to achieve proximal anastomosis on the ascending aorta. To reach group comparability propensity score matching was performed. The primary end point was defined as a composite of all-cause mortality, stroke and rethoracotomy. Secondary end points were perioperative outcome parameters. Results: A total of 3703 patients were enrolled of whom 575 and 3128 were included in the automated anastomosis punching and the aortic sealing device group, respectively. By propensity score matching a total of 1150 patients were included with 575 in each group. The primary composite endpoint showed no significant difference with 6.3% versus 5.9% events (odds ratio, 0.9; 95% confidence interval, 0.58-1.53, P = .81). All-cause mortality (P = .36), stroke (P = .81), and rethoracotomy (P = .89) also exhibit no disparity. Operation time was significantly longer in the aortic sealing device cohort with 220.0 ± 50.8 minutes and 204.6 ± 53.8 minutes (P < .01). Conclusions: Clampless aortic anastomosis strategies aortic sealing device and automated anastomosis punching did not differ in perioperative outcome parameters, whereas the implementation of aortic sealing devices were associated with a prolonged operation time without inducing any inferior clinical outcome.
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Objectives: Minimally-invasive direct coronary artery bypass (MIDCAB) is a less-invasive alternative to full sternotomy off-pump coronary artery bypass (FS-OPCAB) revascularization of the left anterior descending artery (LAD). Some studies suggested that MIDCAB is associated with a greater risk of graft occlusion and repeat revascularization than FS-OPCAB LIMA-to-LAD grafting. Data comparing MIDCAB to FS-OPCAB with regard to long-term follow-up is scarce. We compared short- and long-term results of MIDCAB vs. FS-OPCAB revascularization over a maximum follow-up period of 10 years. Patients and methods: From December 2009 to June 2020, 388 elective patients were included in our retrospective study. 229 underwent MIDCAB, and 159 underwent FS-OPCAB LIMA-to-LAD grafting. Inverse probability of treatment weighting (IPTW) was used to adjust for selection bias and to estimate treatment effects on short- and long-term outcomes. IPTW-adjusted Kaplan-Meier estimates by study group were calculated for all-cause mortality, stroke, the risk of repeat revascularization and myocardial infarction up to a maximum follow-up of 10 years. Results: MIDCAB patients had less rethoracotomies (n = 13/3.6% vs. n = 30/8.0%, p = 0.012), fewer transfusions (0.93 units ± 1.83 vs. 1.61 units ± 2.52, p < 0.001), shorter mechanical ventilation time (7.6 ± 4.7â h vs. 12.1 ± 26.4â h, p = 0.005), and needed less hemofiltration (n = 0/0% vs. n = 8/2.4%, p = 0.004). Thirty-day mortality did not differ significantly between the two groups (n = 0/0% vs. n = 3/0.8%, p = 0.25). Long-term outcomes did not differ significantly between study groups. In the FS-OPCAB group, the probability of survival at 1, 5, and 10 years was 98.4%, 87.8%, and 71.7%, respectively. In the MIDCAB group, the corresponding values were 98.4%, 87.7%, and 68.7%, respectively (RR1.24, CI0.87-1.86, p = 0.7). In the FS group, the freedom from stroke at 1, 5, and 10 years was 97.0%, 93.0%, and 93.0%, respectively. In the MIDCAB group, the corresponding values were 98.5%, 96.9%, and 94.3%, respectively (RR0.52, CI0.25-1.09, p = 0.06). Freedom from repeat revascularization at 1, 5, and 10 years in the FS-OPCAB group was 92.2%, 84.7%, and 79.5%, respectively. In the MIDCAB group, the corresponding values were 94.8%, 90.2%, and 81.7%, respectively (RR0.73, CI0.47-1.16, p = 0.22). Conclusion: MIDCAB is a safe and efficacious technique and offers comparable long-term results regarding mortality, stroke, repeat revascularization, and freedom from myocardial infarction when compared to FS-OPCAB.
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BACKGROUND: Surgical mitral valve repair is the gold standard treatment of severe primary mitral regurgitation (MR). In the light of rapidly evolving percutaneous technologies, current surgical outcome data are essential to support heart-team-based decision-making. METHODS: This retrospective, high-volume, single-center study analyzed in 1779 patients with primary MR early morbidity and mortality, postoperative valve function, and long-term survival after mitral valve (MV) repair. Surgeries were performed between 2009 and 2022. Surgical approaches included full sternotomy (FS) and right-sided minithoracotomy (minimally invasive cardiac [MIC] surgery). RESULTS: Of the surgeries (mean age: 59.9 [standard deviation:11.4] years; 71.5% males), 85.6% (n = 1,527) were minithoracotomies. Concomitant procedures were performed in 849 patients (47.7%), including tricuspid valve and/or atrial septal defect repair, cryoablation, and atrial appendage closure. The majority of patients did not need erythrocyte concentrates. Mediastinitis and rethoracotomy for bleeding rates were 0.1 and 4.3%, respectively. Reoperation before discharge for failed repair was necessary in 12 patients (0.7%). Freedom from more than moderate MR was > 99%. Thirty-day mortality was 0.2% and did not differ significantly between groups (p = 0.37). Median follow-up was 48.2 months with a completeness of 95.9%. Long-term survival was similar between groups (p = 0.21). In the FS and MIC groups, 1-, 5-, and 10-year survival rates were 98.8 and 98.8%, 92.9 and 94.4%, and 87.4 and 83.1%, respectively. CONCLUSION: MV surgery, both minimally invasive and via sternotomy, is associated with high repair rates, excellent perioperative outcomes, and long-term survival. Data underscore the effectiveness of surgical repair in managing MR, even in the era of advancing interventional techniques.
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Midventricular hypertrophic obstructive cardiomyopathy (HOCM) is characterized by hypertrophy of the interventricular septum (IVS) and - in rare cases - of the papillary muscles (PM), which subsequently can cause dynamic left ventricular outflow tract obstruction (LVOTO) and severe heart failure symptoms. We report on a rare case of a 44-year-old patient suffering from midventricular HOCM with hypertrophic anterolateral PM and an additional chorda between the PM and the IVS.We describe a new surgical approach via right anterolateral thoracotomy in 3-dimensional (3D) video-assisted minimal-invasive technique with resection of hypertrophic PMs as well as the entire mitral valve-apparatus and valve replacement avoiding septal myectomy and potentially associated complications. After an uneventful procedure clinical symptoms improved from NYHA III-IV at baseline to NYHA 0-I postoperatively and remained stable over a follow-up period of 24 months. Therefore, the presented technique may be considered as a new and alternative approach in patients with hypertrophic PMs and hypertrophic IVS as subtype of midventricular HOCM.
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Cardiomiopatia Hipertrófica , Obstrução do Fluxo Ventricular Externo , Humanos , Adulto , Valva Mitral/cirurgia , Músculos Papilares/cirurgia , Resultado do Tratamento , Cardiomiopatia Hipertrófica/complicações , Cardiomiopatia Hipertrófica/cirurgia , Hipertrofia/complicações , Obstrução do Fluxo Ventricular Externo/etiologia , Obstrução do Fluxo Ventricular Externo/cirurgiaRESUMO
In 873 propensity score-matched pairs of patients undergoing valvular heart surgery, we compared a "moderate dose" of tranexamic acid (TXA) protocol (group 1; median TXA dose: 24 mg/kg body weight) with a 1.5-g "bolus-only" protocol (group 2; median TXA dose: 19 mg/kg body weight). The number of transfused patients was higher in group 2 than in group 1 (74.5 vs 66.0%, p < 0.001), as was the number of transfused red blood cell concentrates (p = 0.001). The risks of re-exploration and convulsive seizures were similar between groups (p > 0.50). Data indicate an impaired efficacy following the "bolus-only" protocol, without a significant safety improvement.
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Antifibrinolíticos , Procedimentos Cirúrgicos Cardíacos , Ácido Tranexâmico , Humanos , Ácido Tranexâmico/efeitos adversos , Antifibrinolíticos/efeitos adversos , Resultado do Tratamento , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/métodos , Peso Corporal , Perda Sanguínea CirúrgicaRESUMO
BACKGROUND: The benefit of prophylactic left ventricular (LV) unloading during venoarterial extracorporeal membrane oxygenation (VA-ECMO) in selected patients at risk of developing LV distension remains unclear. METHODS: We enrolled 136 patients treated with Impella pump decompression during VA-ECMO therapy for refractory cardiogenic shock. Patients were stratified by specific indication for LV unloading in the prophylactic vs. bail-out group. The bail-out unloading strategy was utilized to treat LV distension in VA-ECMO afterload-associated complications. The primary endpoint was all-cause 30-day mortality after VA-ECMO implantation. The secondary endpoint was successful myocardial recovery, transition to durable mechanical circulatory support (MCS), or heart transplantation. RESULTS: After propensity score matching, prophylactic unloading was associated with a significantly lower 30-day mortality risk (risk ratio 0.38, 95% confidence interval 0.23-0.62, and p < 0.001) and a higher probability of myocardial recovery (risk ratio 2.9, 95% confidence interval 1.48-4.54, and p = 0.001) compared with the bail-out strategy. Heart transplantation or durable MCS did not differ significantly between groups. CONCLUSIONS: Prophylactic unloading compared with the bail-out strategy may improve clinical outcomes in selected patients on VA-ECMO. Nevertheless, randomized trials are needed to validate these results.
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BACKGROUND: The diagnosis and management of myocardial infarction are increasingly complex, and establishing the presence of intracoronary thrombosis has major implications for both the classification and treatment of myocardial infarction. OBJECTIVES: The aim of this study was to investigate whether positron emission tomographic (PET) and computed tomographic (CT) imaging could noninvasively detect in vivo thrombus formation in human coronary arteries using a novel glycoprotein IIb/IIIa receptor antagonist-based radiotracer, 18F-GP1. METHODS: In a single-center observational case-control study, patients with or without acute myocardial infarction underwent coronary 18F-GP1 PET/CT angiography. Coronary artery 18F-GP1 uptake was assessed visually and quantified using maximum target-to-background ratios. RESULTS: 18F-GP1 PET/CT angiography was performed in 49 patients with and 50 patients without acute myocardial infarction (mean age: 61 ± 9 years, 75% men). Coronary 18F-GP1 uptake was apparent in 39 of the 49 culprit lesions (80%) in patients with acute myocardial infarction. False negative results appeared to relate to time delays to scan performance and low thrombus burden in small-caliber distal arteries. On multivariable regression analysis, culprit vessel status was the only independent variable associated with higher 18F-GP1 uptake. Extracoronary cardiac 18F-GP1 findings included a high frequency of infarct-related intramyocardial uptake (35%) as well as left ventricular (8%) or left atrial (2%) thrombus. CONCLUSIONS: Coronary 18F-GP1 PET/CT angiography is the first noninvasive selective technique to identify in vivo coronary thrombosis in patients with acute myocardial infarction. This novel approach can further define the role and location of thrombosis within the heart and has the potential to inform the diagnosis, management, and treatment of patients with acute myocardial infarction. (In-Vivo Thrombus Imaging With 18F-GP1, a Novel Platelet PET Radiotracer [iThrombus]; NCT03943966).
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Trombose Coronária , Infarto do Miocárdio , Masculino , Humanos , Pessoa de Meia-Idade , Idoso , Feminino , Vasos Coronários/patologia , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada , Estudos de Casos e Controles , Valor Preditivo dos Testes , Infarto do Miocárdio/diagnóstico por imagem , Infarto do Miocárdio/terapia , Infarto do Miocárdio/patologia , Trombose Coronária/diagnóstico por imagem , Trombose Coronária/terapia , Inibidores da Agregação Plaquetária , Angiografia CoronáriaRESUMO
BACKGROUND: In valvular open-heart surgery, data regarding the effect of a moderate dose of tranexamic acid (TXA) on clinical outcomes are limited. METHODS: Out of a cohort of 13,293 patients, we performed a propensity-score-matched analysis in 6,106 patients and assessed the risk of convulsive seizures (CS, primary endpoint), stroke, renal replacement therapy, and mortality (secondary endpoints). In the entire study cohort of 13,293 patients, we also assessed the multivariable-adjusted association of CS with postoperative outcomes. RESULTS: The risk of CS was significantly higher in the TXA group (2.4%; n = 72) than in the non-TXA group (1.0%; n = 32), with a relative risk ratio (RR) of 2.28 (95% confidence interval [CI]: 1.50-3.47; p < 0.001). The risk of CS was also higher in patients receiving TXA doses ≥25 mg/kg body weight (3.7%; n = 40) than in patients receiving <25 mg/kg body weight (1.6%; n = 32; p < 0.001). Perioperative secondary clinical endpoints and 1-year mortality did not differ significantly between study groups (p-value > 0.05). Compared with non-CS patients (n = 13,000), patients with nonhemorrhagic, nonembolic CS (n = 253) revealed higher multivariable-adjusted in-hospital risks of stroke (RR: 3.82 [95% CI: 2.44-5.60; p < 0.001]) and mortality (RR: 2.07 [95% CI: 1.23-3.48; p = 0.006]), and a higher 1-year mortality risk (RR: 1.85 [95% CI: 1.42-2.41; p < 0.001]). CONCLUSION: A moderate TXA dose was associated with a significantly higher risk of seizure, but not with other clinical complications such as stroke, renal replacement therapy, and mortality. However, in the small group of patients experiencing a seizure, the risks of stroke and short- and mid-term mortality were substantially higher than in patients not experiencing a seizure, indicating that the use of a low-dose TXA protocol (<25 mg/kg body weight) should be considered.
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Antifibrinolíticos , Procedimentos Cirúrgicos Cardíacos , Acidente Vascular Cerebral , Ácido Tranexâmico , Humanos , Resultado do Tratamento , Convulsões/induzido quimicamente , Convulsões/tratamento farmacológico , Peso Corporal , Perda Sanguínea CirúrgicaRESUMO
We retrospectively compared transfusion rates and early outcomes in 1621 consecutive patients with preoperative anaemia undergoing off-pump coronary artery bypass grafting (OPCAB) or on-pump coronary artery bypass grafting (ONCAB) surgery using a propensity score analysis with inverse probability of treatment weighting. Endpoints were transfusions, early morbidity, and mortality. Surgeries were performed by 45 dedicated OPCAB and/or ONCAB surgeons during the 10-year study period. Operative data did not differ significantly between study groups with the exception of a more frequent use of bilateral internal mammary artery revascularization approach in OPCAB patients than ONCAB patients. OPCAB was associated with fewer transfusions and lower risk for the need of postoperative renal replacement therapy, but higher risk of wound infections than ONCAB. Perioperative stroke risk and 30-day and 1-year mortality did not differ significantly between the groups. Our data in a 'real-world setting' indicate that in patients with preoperative anaemia both ONCAB and OPCAB are feasible surgical approaches regarding early morbidity and mortality.
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Anemia , Ponte de Artéria Coronária sem Circulação Extracorpórea , Humanos , Estudos Retrospectivos , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária sem Circulação Extracorpórea/efeitos adversos , Transfusão de Sangue , Anemia/complicações , Anemia/diagnóstico , Anemia/terapiaAssuntos
Anemia , Ponte de Artéria Coronária sem Circulação Extracorpórea , Anemia/complicações , Anemia/diagnóstico , Ponte Cardiopulmonar , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária sem Circulação Extracorpórea/efeitos adversos , Humanos , Complicações Pós-Operatórias , Resultado do TratamentoRESUMO
We investigated whether in patients undergoing off-pump coronary artery bypass grafting surgery a single bolus of 1 g tranexamic acid (TXA) impacts the risk of postoperative delirium using the propensity score matching approach. In 2,757 pairs, the risk of delirium was 4.2% (TXA group) and 5.0% (non-TXA group), with a relative risk in the TXA versus the non-TXA group of 0.83 (95% confidence interval: 0.65-1.07; p = 0.16). There was no significant interaction between TXA administration and renal function on the risk of delirium (p = 0.12). Data indicate that a single bolus of 1 g TXA does not increase the risk of delirium in patients undergoing off-pump surgery.
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The course of COVID-19 patients may be complicated by thromboembolic events. We report on a 48-year-old female COVID-19 patient who underwent surgical removal of a large intracardiac thrombus. As per our centre protocol, critically ill COVID-19 patients are anticoagulated by the direct thrombin inhibitor Argatroban with close monitoring of anti-IIa activity. An intra-atrial thrombus formation fixed in a patent foramen ovale but also large mobile portions in both atria was diagnosed 4 days after weaning and removal of the jugular and femoral extracorporeal membrane oxygenation cannulas. The thrombus was removed surgically via median sternotomy and on cardiopulmonary bypass. The thrombus had a bizarre appearance with several finger-like appendices, and histological analysis revealed a mixed picture of acute and chronic thrombus portions. This case highlights the risk of life-threatening thrombus formation in COVID-19 patients despite therapeutic thrombin inhibition.
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COVID-19 , Forame Oval Patente , Cardiopatias , Embolia Pulmonar , Trombose , COVID-19/complicações , Feminino , Forame Oval Patente/complicações , Forame Oval Patente/diagnóstico por imagem , Forame Oval Patente/cirurgia , Átrios do Coração , Cardiopatias/complicações , Humanos , Pessoa de Meia-Idade , Embolia Pulmonar/cirurgia , Trombose/diagnóstico por imagem , Trombose/etiologia , Trombose/cirurgiaRESUMO
OBJECTIVES: We aimed to describe stroke and transient ischemic attacks (TIAs) after transcatheter aortic valve replacement (TAVR) and to identify associated risk factors. BACKGROUND: Stroke/TIA after TAVR is a major complication. METHODS: A total of 1919 concomitant patients underwent TAVR in a single center from 2007 to 2017. Pre-, intra-, and postprocedural data were collected prospectively in a database and analyzed retrospectively. Stroke and TIA were documented according to the Valve Academic Research Consortium-II criteria. Logistic regression was used to determine risk factors for stroke after TAVR. RESULTS: Mean age was 79.5 ± 6.8 years, mean logistic EuroScore was 17.6% ± 12.8%, and 51.8% (n = 994) of the patients were female. Stroke/TIA occurred in 76 patients (3.9%), 1.9% were disabling, and 1.6% nondisabling. The predominant type of stroke were territorial ischemic lesions (82.4%), with primary bleeding in 4.4% and border zone infarctions in 4.4%. Left-sided lesions were more common (45.6% left sided vs. 25% right sided) and 13.2% of the lesions were bilateral (4.4% no finding and 11.8% missing data). In multivariate logistic regression, prior stroke (odds ratio [OR] = 1.83, p = 0.046) and initial experience (first 300 TAVR implanted at our center) were identified as independent risk factors for stroke/TIA during the first 30 days (OR = 1.95, p = 0.045). Overall, the occurrence of stroke had a highly significant impact on a 30-day mortality (13.2% vs. 4.9% in patients without stroke (p = 0.005). CONCLUSION: Stroke within the first 30 days after TAVR severely impairs 30-day survival. We identified prior stroke and initial experience as significant independent risk factors for the occurrence of stroke after TAVR.
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Estenose da Valva Aórtica , Ataque Isquêmico Transitório , Acidente Vascular Cerebral , Substituição da Valva Aórtica Transcateter , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/cirurgia , Feminino , Humanos , Ataque Isquêmico Transitório/epidemiologia , Ataque Isquêmico Transitório/etiologia , Masculino , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/efeitos adversos , Resultado do TratamentoRESUMO
BACKGROUND: Bioprosthetic valve thrombosis may have implications for valve function and durability. OBJECTIVES: Using a novel glycoprotein IIb/IIIa receptor radiotracer 18F-GP1, we investigated whether positron emission tomography (PET)-computed tomography (CT) could detect thrombus formation on bioprosthetic aortic valves. METHODS: Ex vivo experiments were performed on human platelets and explanted bioprosthetic aortic valves. In a prospective cross-sectional study, patients with either bioprosthetic or normal native aortic valves underwent echocardiography, CT angiography, and 18F-GP1 PET-CT. RESULTS: Flow cytometric analysis, histology, immunohistochemistry, and autoradiography demonstrated selective binding of 18F-GP1 to activated platelet glycoprotein IIb/IIIa receptors and thrombus adherent to prosthetic valves. In total, 75 participants were recruited: 53 with bioprosthetic valves (median time from implantation 37 months [IQR: 12-80 months]) and 22 with normal native aortic valves. Three participants had obstructive valve thrombosis, and a further 3 participants had asymptomatic hypoattenuated leaflet thickening on CT angiography. All bioprosthetic valves, but none of the native aortic valves, demonstrated focal 18F-GP1 uptake on the valve leaflets: median maximum target-to-background ratio 2.81 (IQR: 2.29-3.48) vs 1.43 (IQR: 1.28-1.53) (P < 0.001). Higher 18F-GP1 uptake was independently associated with duration of valve implantation and hypoattenuated leaflet thickening. All 3 participants with obstructive valve thrombosis were anticoagulated for 3 months, leading to resolution of their symptoms, improvement in mean valve gradients, and a reduction in 18F-GP1 uptake. CONCLUSIONS: Adherence of activated platelets is a common and sustained finding on bioprosthetic aortic valves. 18F-GP1 uptake is higher in the presence of thrombus, regresses with anticoagulation, and has potential use as an adjunctive clinical tool. (18F-GP1 PET-CT to Detect Bioprosthetic Aortic Valve Thrombosis; NCT04073875).
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Bioprótese , Próteses Valvulares Cardíacas , Trombose , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Estudos Transversais , Humanos , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada , Tomografia por Emissão de Pósitrons , Valor Preditivo dos Testes , Estudos Prospectivos , Trombose/diagnóstico por imagem , Trombose/etiologiaRESUMO
OBJECTIVES: Patients in cardiogenic shock supported with venoarterial extracorporeal membrane oxygenation (VA-ECMO) may experience severe complications from reduced left ventricular (LV) unloading and increased cardiac afterload. These effects are usually modified by adding a percutaneous direct Impella vent or surgical LV vent on top of VA-ECMO in selected patients. However, direct comparisons between 2 LV unloading strategies in patients with cardiogenic shock due to myocardial infarction are lacking. Therefore, we sought to investigate the impact of these 2 different approaches. METHODS: We enrolled 112 patients treated with an Impella or surgical LV vent during VA-ECMO support between January 2014 and February 2020. The primary endpoint was 30-day mortality. Secondary endpoints included rates of myocardial recovery or transition to durable mechanical circulatory support. Additionally, we assessed adverse events such as peripheral ischaemic complications requiring intervention, sepsis and ischaemic stroke. RESULTS: At 30 days, 38 patients in the Impella group (54%) and 26 patients in the surgical LV vent group (63%) had died (relative risk with Impella 0.78, 95% confidence interval 0.47-1.30; P = 0.35). Impella group and the surgical LV vent group differed significantly with respect to the secondary end points including rates of myocardial recovery (24% and 7%, respectively; P = 0.022) and rates of durable mechanical circulatory support (17% and 42%, P = 0.012). Complication rates were not statistically different between the 2 groups. CONCLUSIONS: The use of Impella device as therapeutic unloading therapy during VA-ECMO did not significantly reduce 30-day mortality compared to surgical LV vent in patients with cardiogenic shock due to acute myocardial infarction.
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Oxigenação por Membrana Extracorpórea , Coração Auxiliar , Infarto do Miocárdio , Choque Cardiogênico , Isquemia Encefálica/etiologia , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/métodos , Coração Auxiliar/efeitos adversos , Humanos , Infarto do Miocárdio/complicações , Infarto do Miocárdio/terapia , Choque Cardiogênico/diagnóstico , Choque Cardiogênico/etiologia , Choque Cardiogênico/terapia , Acidente Vascular Cerebral/etiologiaRESUMO
Coronary artery bypass grafting (CABG) is the recommended type of revascularization procedure in patients with left main or three-vessel disease and is considered an alternative when percutaneous coronary intervention is not feasible. We evaluated registry data to obtain long-term outcome data.All patients ≤45 years in whom CABG was performed between 2009 and 2019 were selected from the Heart and Diabetes Center NRW, Germany. Cox regression analysis was applied to estimate the incidence risk of events after surgery.A total of 209 patients (81.8% male) were included. Mean (standard deviation) follow-up duration was 5.8 (3.1) years. The combined outcome of death, stroke, myocardial infarction, or repeated revascularization occurred in 31 patients (14.8%). Estimated mean time to event was 8.5 (standard error: 0.22) years. By the end of the follow-up period, 8 patients (3.8%) had died, among whom 2 (1.0%) died within 1 month after surgery, 1 (0.5%) within 1 year, 1 (0.5%) within 2 years, and 4 (1.9%) after 2 years.Risk factors independently associated with postsurgery events were angina pectoris CCS (Canadian Cardiovascular Society) class IV (adjusted hazard ratio [HR]: 4.954; 95% confidence interval [CI]: 1.322-18.563; p = 0.018) and STS (Society of Thoracic Surgeons) score (adjusted HR: 1.152 per scoring point; 95% CI: 1.040-1.276; p = 0.007).After performing CABG in patients ≤45 years, event-free long-term outcomes were observed in the majority of patients. Presence of angina pectoris CCS class IV and higher STS scores were independently associated with adverse postsurgery events.
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Doença da Artéria Coronariana , Stents Farmacológicos , Intervenção Coronária Percutânea , Angina Pectoris/etiologia , Canadá , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/métodos , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/cirurgia , Stents Farmacológicos/efeitos adversos , Feminino , Humanos , Masculino , Intervenção Coronária Percutânea/efeitos adversos , Prognóstico , Resultado do TratamentoRESUMO
The interactions and hemodynamic impact of transcatheter percutaneous mitral valve repair (TMR) have not yet been investigated in patients undergoing left ventricular assist device (LVAD) implantation, but hemodynamic adverse effects are feared in the combination of TMR and LVAD for altered mitral valve flow. This study investigated the hemodynamic interplay in combination of TMR and LVAD in 119 patients, and propensity score match analysis revealed no difference in both perioperative mortality and 2-year follow-up survival (p = 0.84). Nonetheless, postoperatively mean pulmonary arterial pressure, pulmonary capillary wedge pressure, and cardiac index improved, and multivariable cox regression analysis at 2 years identified preoperative total bilirubin and temporary right ventricular mechanical circulatory support as independent risk factors for all-cause mortality but not TMR. Prior TMR has no impact on mortality or cardiovascular complications in patients with LVAD.
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Procedimentos Cirúrgicos Cardíacos , Insuficiência Cardíaca , Coração Auxiliar , Disfunção Ventricular Direita , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/cirurgia , Coração Auxiliar/efeitos adversos , Humanos , Pressão Propulsora Pulmonar , Estudos Retrospectivos , Resultado do TratamentoRESUMO
AIMS: Targeting vascular inflammation represents a novel therapeutic approach to reduce complications of atherosclerosis. Neutralizing the pro-inflammatory cytokine interleukin-1ß (IL-1ß) using canakinumab, a monoclonal antibody, reduces the incidence of cardiovascular events in patients after myocardial infarction (MI). The biological basis for these beneficial effects remains incompletely understood. We sought to explore the mechanisms of IL-1ß-targeted therapies. METHODS AND RESULTS: In mice with early atherosclerosis (ApoE-/- mice on a high-cholesterol diet for 6 weeks), we found that 3 weeks of NACHT, LRR, and PYD domains-containing protein 3 (NLRP3)-inflammasome inhibition or anti-IL-1ß treatment (using either MCC950, an NLRP3-inflammasome inhibitor which blocks production and release of active IL-1ß, or a murine analogue of canakinumab) dampened accumulation of leucocytes in atherosclerotic aortas, which consequently resulted in slower progression of atherosclerosis. Causally, we found that endothelial cells from atherosclerotic aortas lowered expression of leucocyte chemoattractants and adhesion molecules upon NLRP3-inflammasome inhibition, indicating that NLRP3-inflammasome- and IL-1ß-targeted therapies reduced blood leucocyte recruitment to atherosclerotic aortas. In accord, adoptive transfer experiments revealed that anti-IL-1ß treatment mitigated blood myeloid cell uptake to atherosclerotic aortas. We further report that anti-IL-1ß treatment and NLRP3-inflammasome inhibition reduced inflammatory leucocyte supply by decreasing proliferation of bone marrow haematopoietic stem and progenitor cells, demonstrating that suppression of IL-1ß and the NLRP3-inflammasome lowered production of disease-propagating leucocytes. Using bone marrow reconstitution experiments, we observed that haematopoietic cell-specific NLRP3-inflammasome activity contributed to both enhanced recruitment and increased supply of blood inflammatory leucocytes. Further experiments that queried whether anti-IL-1ß treatment reduced vascular inflammation also in post-MI accelerated atherosclerosis documented the operation of convergent mechanisms (reduced supply and uptake of inflammatory leucocytes). In line with our pre-clinical findings, post-MI patients on canakinumab treatment showed reduced blood monocyte numbers. CONCLUSIONS: Our murine and human data reveal that anti-IL-1ß treatment and NLRP3-inflammasome inhibition dampened vascular inflammation and progression of atherosclerosis through reduced blood inflammatory leucocyte (i) supply and (ii) uptake into atherosclerotic aortas providing additional mechanistic insights into links between haematopoiesis and atherogenesis, and into the beneficial effects of NLRP3-inflammasome- and IL-1ß-targeted therapies.
Assuntos
Aterosclerose , Inflamassomos , Interleucina-1beta , Animais , Humanos , Camundongos , Anticorpos Monoclonais/farmacologia , Anticorpos Monoclonais/uso terapêutico , Aterosclerose/tratamento farmacológico , Aterosclerose/prevenção & controle , Fatores Quimiotáticos/uso terapêutico , Colesterol , Células Endoteliais/metabolismo , Inflamassomos/metabolismo , Inflamação/tratamento farmacológico , Inflamação/prevenção & controle , Interleucina-1beta/metabolismo , Camundongos Knockout para ApoE , Proteína 3 que Contém Domínio de Pirina da Família NLR/metabolismoRESUMO
Currently, little is known about the genetic background of restrictive cardiomyopathy (RCM). Herein, we screened an index patient with RCM in combination with atrial fibrillation using a next generation sequencing (NGS) approach and identified the heterozygous mutation DES-c.735G>C. As DES-c.735G>C affects the last base pair of exon-3, it is unknown whether putative missense or splice site mutations are caused. Therefore, we applied nanopore amplicon sequencing revealing the expression of a transcript without exon-3 in the explanted myocardial tissue of the index patient. Western blot analysis verified this finding at the protein level. In addition, we performed cell culture experiments revealing an abnormal cytoplasmic aggregation of the truncated desmin form (p.D214-E245del) but not of the missense variant (p.E245D). In conclusion, we show that DES-c.735G>C causes a splicing defect leading to exon-3 skipping of the DES gene. DES-c.735G>C can be classified as a pathogenic mutation associated with RCM and atrial fibrillation. In the future, this finding might have relevance for the genetic understanding of similar cases.