Open Conversion After Endovascular Abdominal Aneurysm Repair: An 8 year Single Centre Experience.

OBJECTIVE: To report experience with open conversion (OC) after previous failed EVAR and to compare outcomes of patients undergoing elective OC with those operated on in an urgent setting. METHODS: Patients undergoing OC after EVAR between August 2008 and September 2016 were included in this retrospective and observational single institution study. Indications, demographic, anatomical, intra-operative and post-operative data were collected prospectively. Primary endpoints were 30 day and in hospital mortality. Secondary endpoints included moderate to severe complications, secondary interventions, length of intensive care unit, and hospital stay. RESULTS: OC was performed in 31 patients over the study period: 19 elective and 12 emergency OC, including six ruptures. Median time from index EVAR to delayed OC was 35 months (0-228 months). The most common indications for OC were endoleaks (n = 24, 77%), followed by stent graft infection (n = 3, 10%), thrombosis (n = 3, 10%) and kinking (n = 1, 3%). Eight of the removed stent grafts were Endurant, two were Talent, five Excluder, six Nellix, two AFX, five Zenith, one Vanguard, one Anaconda, and one Seta. Overall in hospital mortality was 10%, with significantly increased in hospital mortality in the emergency group compared with the elective group (25% vs. 0%, p = .049). Renal and pulmonary complications were significantly higher in the emergency group (42% vs. 5%, p = .02 and 42% vs. 0%, p = .005, respectively). No late complication or death was recorded after a mean follow-up of 18 ± 13 months. CONCLUSIONS: Emergency OC is associated with significantly increased in hospital mortality and morbidity compared with elective OC. Elective OC appears to be safer and effective, and should be considered as the best option in cases of EVAR failure to avoid further emergency OC procedures.

Proximal Scallop in Thoracic Endovascular Aortic Aneurysm Repair to Overcome Neck Issues in the Arch.

OBJECTIVE: To evaluate initial experience with a custom made proximal scalloped stent graft for thoracic endovascular aortic repair (TEVAR) of aortic aneurysms involving the arch. METHODS: Between September 2012 and November 2014, patients presenting with a thoracic aortic aneurysm (TAA) with short or angulated neck were selected for treatment by custom made proximal scalloped Relay Plus stent grafts (ABS Bolton Medical, Barcelona, Spain). Prospectively acquired data relating to patient demographics, procedure details, clinical outcomes, and complications were analyzed retrospectively. RESULTS: Ten selected patients (50% male, mean age 77 ± 8 years) were treated using a thoracic custom made Relay Plus stent graft, three of whom underwent additional cervical supra-aortic trunk revascularizations. TAA were fusiform in four cases, saccular in three, and three patients were treated for proximal type I endoleaks after previous standard TEVAR. The graft was landed in zone 2 in 3 cases, in zone 1 in 4 cases, and in zone 0 in 3 cases. The custom made scallop was designed to preserve flow in the left subclavian artery in three patients, in the left common carotid artery in four, and in the innominate artery in three. No proximal type I endoleak occurred and proximal sealing was achieved in all cases, with a technical success rate of 100%. All targeted vessels were patent. During a mean follow up of 12 ± 5 months, no conversion to open surgical repair and no aortic rupture occurred. One patient died post-operatively from myocardial infarction and one patient suffered a stroke with complete recovery. One patient had a distal type I endoleak on the 6 month CT scan and is scheduled for distal extension. No paraplegia, retrograde dissection and no other aortic related complications were recorded. CONCLUSIONS: Proximal scalloped stent grafts appear to be an effective additional tool for TEVAR of TAA when dealing with short or angulated proximal necks.

Endovascular repair of acute uncomplicated aortic type B dissection promotes aortic remodelling: 1 year results of the ADSORB trial.

OBJECTIVES: Uncomplicated acute type B aortic dissection (AD) treated conservatively has a 10% 30-day mortality and up to 25% need intervention within 4 years. In complicated AD, stent grafts have been encouraging. The aim of the present prospective randomised trial was to compare best medical treatment (BMT) with BMT and Gore TAG stent graft in patients with uncomplicated AD. The primary endpoint was a combination of incomplete/no false lumen thrombosis, aortic dilatation, or aortic rupture at 1 year. METHODS: The AD history had to be less than 14 days, and exclusion criteria were rupture, impending rupture, malperfusion. Of the 61 patients randomised, 80% were DeBakey type IIIB. RESULTS: Thirty-one patients were randomised to the BMT group and 30 to the BMT+TAG group. Mean age was 63 years for both groups. The left subclavian artery was completely covered in 47% and in part in 17% of the cases. During the first 30 days, no deaths occurred in either group, but there were three crossovers from the BMT to the BMT+TAG group, all due to progression of disease within 1 week. There were two withdrawals from the BMT+TAG group. At the 1-year follow up there had been another two failures in the BMT group: one malperfusion and one aneurysm formation (p = .056 for all). One death occurred in the BMT+TAG group. For the overall endpoint BMT+TAG was significantly different from BMT only (p < .001). Incomplete false lumen thrombosis, was found in 13 (43%) of the TAG+BMT group and 30 (97%) of the BMT group (p < .001). The false lumen reduced in size in the BMT+TAG group (p < .001) whereas in the BMT group it increased. The true lumen increased in the BMT+TAG (p < .001) whereas in the BMT group it remained unchanged. The overall transverse diameter was the same at the beginning and after 1 year in the BMT group (42.1 mm), but in the BMT+TAG it decreased (38.8 mm; p = .062). CONCLUSIONS: Uncomplicated AD can be safely treated with the Gore TAG device. Remodelling with thrombosis of the false lumen and reduction of its diameter is induced by the stent graft, but long term results are needed.

Efficacy and safety of recombinant human C1-inhibitor for the treatment of attacks of hereditary angioedema: European open-label extension study.

BACKGROUND: Hereditary angioedema (HAE) owing to C1 inhibitor deficiency is an autosomal dominant disorder, characterized by recurrent, potentially life-threatening, localized attacks of tissue swelling. Current treatment involves the infusion of C1 inhibitor protein (C1-INH) isolated from human plasma. OBJECTIVES: This open-label extension to a European, Israeli and Argentinean randomized study (NCT00262301) aimed to investigate the efficacy and safety of recombinant human C1 inhibitor (rhC1-INH) as a first-line treatment following an HAE attack, together with its effect on subsequent attacks. METHODS: An HAE-specific visual analogue scale (VAS) 0-100 mm was used by patients to assess the severity of attack at four anatomical locations. Patients were treated with one, single-vial, fixed-dose of rhC1-INH (2100 U), followed by up to two further vials at the investigators discretion. The primary end-point was the time from first rhC1-INH injection to first onset of relief of symptoms (≥ 20 mm decrease on VAS). Response to treatment was defined as the onset of relief within 4 h. RESULTS: A total of 57 patients were treated for 194 HAE attacks. Overall, sustained relief of symptoms was achieved in 87% of rhC1-INH-treated patients within 4 h of treatment, with 57% of attacks requiring only one vial of rhC1-INH. When categorized by successive attacks experienced by individual patients, the response rate to rhC1-INH treatment was 96%, 83%, 87%, 80% and 80% for attacks 1-5 respectively. Treatment with rhC1-INH was well tolerated, with no discontinuations owing to treatment-emergent adverse events and no adverse events relating to immunogenicity. CONCLUSIONS AND CLINICAL RELEVANCE: Treatment with rhC1-INH provides fast-onset relief for an HAE attack, with a high rate of therapeutic response maintained throughout subsequent attacks.

Very late heart transplant rejection is associated with microvascular injury, complement deposition and progression to cardiac allograft vasculopathy.

In heart transplants, the significance of very late rejection (after 7 years post-transplant, VLR) detected by routine endomyocardial biopsies (EMB) remains uncertain. Here, we assessed the prevalence, histopathological and immunological phenotype, and outcome of VLR in clinically stable patients. Between 1985 and 2009, 10 662 protocol EMB were performed at our institution in 398 consecutive heart transplants recipients. Among the 196 patients with >7-year follow-up, 20 (10.2%) presented subclinical ≥3A/2R-ISHLT rejection. The VLR group was compared to a matched control group of patients without rejection. All biopsies were stained for C4d/C3d/CD68 with sera screened for the presence of donor-specific antibodies (DSAs). In addition to cellular infiltrates with myocyte damage, 60% of VLR patients had evidence of intravascular macrophages. C4d and/or C3d-capillary deposition was found in 55% VLR EMB. All cases of VLR associated with microcirculation injury had DSAs (mean DSA(max) -MFI = 1751 ± 583). This entity was absent from the control group (p < 0.0001). Finally, after a similar follow-up postreference EMB of 6.4 ± 1 years, the mean of CAV grade was 0.76 ± 0.18 in the control group compared to 2.06 ± 0.26 in the VLR group respectively, p = 0.001). There was no difference in patient survival between study and control groups. In conclusion, VLR is frequently associated with complement-cascade activation, microvascular injury and DSA, suggesting an antibody-mediated process. VLR is associated with a dramatic progression to severe CAV in long-term follow-up.

Downregulation of remodelling enzymatic activity induced by an angiotensin-converting enzyme inhibitor (perindopril) reduces the degeneration of experimental abdominal aortic aneurysms in a rat model.

AIMS: Angiotensin-converting enzyme (ACE) inhibitors have proven their ability to affect vascular wall remodelling, in addition to their anti-hypertensive effects. The aim of this study was to assess the impact of perindopril on the development of abdominal aortic aneurysm (AAA) in a rat model, and its correlation to enzyme activities involved in vascular wall remodelling. METHODS: The model of the decellularised aortic xenograft in Lewis rat was chosen. Rats were randomised to two groups: group P fed with 3 mg kg(-1) of perindopril daily during 30 days, or control group C (n = 15 per group)). Rats were euthanised at 30 days for analysis. AAA growth and histological changes in the aortic wall were measured by histomorphometry. Proteolytic activities were measured by gelatin zymography of conditioned medium for activematrix metalloproteinase 9/pro-matrix metalloproteinase 9 (MMP9/pro-MMP9) and activeMMP2/pro-MMP2, and by quantitative immunofluorescence tissue for elastase and plasmin. RESULTS: The mean maximal diameter of AAAs at 30 days was significantly lower in the treated group P compared with the control group C (2.5 ± 1.0 vs. 4.9 ± 2.1 mm; P < 0.01). The expansion rate of AAAs after 30 days was significantly reduced in group P compared with group C (36 ± 14% vs. 67 ± 23%; P < 0.01). Pro-MMP9 and MMP9 activities were significantly decreased in relative intensity (RI) in group P compared with group C (0.43 ± 0.64 RI vs. 1.02 ± 0.61 RI, P = 0.01; 0.18 ± 0.57 RI vs. 0.66 ± 1.19 RI, P = 0.004). The activation rate of MMP2 was also significantly lower in group P compared with group C (1.27 ± 0.42 vs. 1.67 ± 0.44; P = 0.002). Elastase and plasmin tissue activities were significantly lower in group P compared with group C, respectively (3.9 ± 3.3 vs. 5.8 ± 3.7 IF min(-1) g(-1),and 25.9 ± 23.9 vs. 49.1 ± 38.7 IF min(-1) g(-1); P < 0.05). CONCLUSION: After 30 days of treatment by perindopril, a significant decrease in aneurysmal degeneration of the decellularised aortic xenograft AAA model was observed. This phenomenon appears to be induced by a downregulation of enzymes involved in the aortic wall remodelling during aneurysmal degeneration.

[Superior vena cava thrombosis or stricture secondary to implanted central venous access: Six cases of endovascular and direct surgical treatment in cancer patients]. / Thromboses ou sténoses de la veine cave supérieure sur chambres implantables. Six cas traités par voie endovasculaire ou chirurgie directe dans un contexte de cancer.

Superior vena cava (SVC) stenosis or thrombosis is a well-known complication of central venous catheterization for endocavitary treatments, hemodialysis, or chemotherapy. In cancer patients, these SVC lesions are often symptomatic due to intimal damage and chemotherapy toxicity. We report our experience with six patients treated between 2007 and 2012 via an endovascular approach (n=5) or a direct surgical approach (n=1). All patients had SVC syndrome with facial edema, headache and upper limb edema. In three cases, the catheter was in place when the clinical symptoms occurred. Duplex Doppler and computed tomography (CT)-angiography identified the following lesions: isolated SVC stenosis (n=2); SVC stenosis with right Pirogoff confluence stenosis (n=1); SVC stenosis associated with left innominate vein thrombosis and right Pirogoff confluence stenosis (n=1); SVC thrombosis affecting azygos flow (n=2). In one patient, the thrombus extended into the right atrium. Five patients underwent endovascular repair via a right jugular approach (n=2) or a double jugular approach (n=3). Treatment involved: SVC angioplasty with stent (n=2); right Pirogoff angioplasty and SVC stent (n=1); kissing angioplasty of both innominate trunks with a SVC stent (n=1); and SVC angioplasty without stent because of an incomplete result with a residual lumen less than 8mm (n=1). One patient had a complete SVC occlusion with extension of thrombus into the right atrium. She was treated via a median sternotomy for open surgical control of both innominate trunks and lateral clamping of the right atrium. A long cavotomy prolonged on the right atrium allowed thrombo-intimectomy and pericardial patch angioplasty. Postoperative follow-up was uneventful in five cases. However, postoperative hemorrhage required pericardial drainage in one patient. The CT scan showed a good morphological aspect in five patients and an incomplete result in one case. Patients have been followed up annually with a duplex scan from two to six years. One patient had a restenosis at 7 months treated by a new angioplasty via a femoral approach. A new catheter was positioned via a cervical approach. Two patients died of metastatic diffusion at 8 and 32 months. The other four patients have remained asymptomatic, with a satisfactory duplex scan. In conclusion, VCS lesions after implanted central access for chemotherapy can often be treated endovascularly. Conventional surgery still has indications when lesions extend into the right atrium.

[Systolic anterior motion (SAM): a rare cause of late failure in mitral valve repair]. / Le SAM: une cause exceptionnelle d'echec tardif de plastie mitrale.

Systolic anterior motion (SAM) of the mitral valve is a rare complication of mitral valve repair. The treatment of the large majority of cases is purely medical. Nevertheless, an early degradation may require reoperation (revision of the repair or valve replacement). The authors report two cases of post-repair SAM with a poor outcome with medical therapy which required reoperation after several years. In both cases, an excess of bivalvular tissue with respect to the size of the mitral orifice was observed. A second repair was possible (sliding valvuloplasty associated with an oval resection of the anterior leaflet) with satisfactory long-term results. The identification of the risk factors and careful analysis of the lesions in cases of SAM after mitral valve repair may lead to a repeat repair and the avoidance of mitral valve replacement.

Dynamics of Parascaris and Strongylus spp. parasites in untreated juvenile horses.

Parasite control in foals is of utmost importance due to the high susceptibility to parasitic infection and disease in this age group. Foals are commonly co-infected with strongyle and ascarid parasites, which complicate parasite control strategies. The present study retrospectively investigated necropsy records of foals born into a university herd kept without anthelmintic treatment since 1979. The aims were to statistically analyze the relationship between fecal egg counts, worm burdens, foal age, sex, and season with specific focus on Parascaris and Strongylus spp. A total of 83 foals born between 1999 and 2015 were included. Foals were born between January and September within the given year and age at necropsy ranged between 27 and 563 days of age with a mean and median of 202 and 204 days, respectively. One set of multivariate mixed linear models was constructed analyzing strongyle and ascarid fecal egg counts as outcome variables, and another set of analyses investigated the following worm counts as outcome variables: Intestinal Parascaris spp. counts (immatures and adults), S. vulgaris (migrating and intestinal stages), S. edentatus (migrating and intestinal stages). Both ascarid and strongyle egg counts were influenced significantly by differences between study years (p<0.05). In addition, total ascarid egg counts were statistically influenced by age (p=0.020) exhibiting a peak at four months of age and fillies had significantly higher ascarid worm burdens (p=0.043). Foal age had significant influences on intestinal counts of immature Parascaris spp. (p=0.034) and adult S. edentatus counts (p=0.028). Larval counts of S. edentatus were significantly associated with birth month (p=0.023), whereas counts of migrating S. vulgaris larvae were not statistically associated with any of the investigated covariates. This study provides novel information on the dynamics of important parasites in naturally infected foals.

Long-term (29 years) results of reconstructive surgery in rheumatic mitral valve insufficiency.

BACKGROUND: Results of conservative surgery are well established in degenerative mitral valve (MV) insufficiency. However, there are controversies in rheumatic disease. This study is the evaluation of one center for rheumatic MV insufficiency based on a functional approach. METHODS AND RESULTS: From 1970 to 1994, 951 patients with rheumatic MV insufficiency were operated on with the reconstructive techniques elaborated by Alain Carpentier. Aortic valve diseases were excluded. Mean age was 25.8 years (4 to 75), and sinus rhythm was present in 63%. The functional classification used was type I, normal leaflet motion, 71 patients (7%); type II, prolapsed leaflet, 311 patients (33%); and type III, restricted leaflet motion, 345 patients (36%). The combined lesion of prolapse of the anterior leaflet and restriction of the posterior was present in 224 patients (24%). Surgical techniques used were implantation of a prosthetic ring in 95%, shortening of the chords and leaflet enlargement with autologous pericardium, and commissurotomy. Hospital mortality rate was 2%. The mean follow-up was 12 years (maximum, 29 years): 8618 patients per year. Actuarial survival was 89+/-19% at 10 years and 82+/-18% at 20 years. The rate of thromboembolic events was 0.4% patients per year (33 events), with 3 deaths. Freedom from reoperation was 82+/-19% at 10 years and 55+/-25% at 20 years. The main cause (83%) of reoperation was progressive fibrosis of the MV. The actuarial rate of reoperation was 2% patients per year and was correlated to the degree of preoperative fibrosis. CONCLUSIONS: Conservative surgery of rheumatic MV insufficiency has a low hospital mortality rate and an acceptable rate of reoperation. The results are excellent regarding the minimal risk of thromboembolic events.

Effect of chronic treatment with the inducible nitric oxide synthase inhibitor N-iminoethyl-L-lysine or with L-arginine on progression of coronary and aortic atherosclerosis in hypercholesterolemic rabbits.

BACKGROUND: We examined the implications of iNOS in atherosclerosis progression using the selective inducible NO synthase (iNOS) inhibitor N:-iminoethyl-L-lysine (L-NIL) in hypercholesterolemic rabbits. METHODS AND RESULTS: Nine rabbits were fed a 0.3% cholesterol diet for 24 weeks (Baseline group); 25 animals were maintained on the diet and treated for 12 extra weeks with L-NIL (5 mg x kg(-1) x d(-1), L-NIL group, n=8), vehicle (Saline group, n=9), or L-arginine (2.25%, L-Arg group, n=8). In abdominal aortas of Saline rabbits, the lesions (53.7+/-5.7%, Baseline) increased to 75.0+/-5.0% (P:<0.05) but remained unaltered in the L-NIL group (63. 4+/-6.6%). Similar results were obtained for the intima/media ratio in thoracic aortas. In coronary arteries, the intima/media ratio was comparable in Baseline (0.68+/-0.18) and Saline (0.96+/-0.19) rabbits but decreased to 0.34+/-0.19 (P:<0.05) in L-NIL rabbits. L-Arginine had beneficial effects only in abdominal aortas. An increased thoracic aorta collagen content was found in Saline and L-Arg but not in L-NIL rabbits. In thoracic aortas of the Saline group, acetylcholine caused modest relaxations that slightly increased by L-arginine but not by L-NIL. Relaxations to nitroglycerin were ameliorated by L-NIL. CONCLUSIONS: This is the first study showing that chronic treatment with an iNOS inhibitor, L-NIL, limits progression of preexisting atherosclerosis in hypercholesterolemic rabbits. Increased intimal collagen accumulation may participate in iNOS-induced atherosclerosis progression.

Very long-term results (more than 20 years) of valve repair with carpentier's techniques in nonrheumatic mitral valve insufficiency.

BACKGROUND: Mitral valve repair is considered the gold standard in surgery of degenerative mitral valve insufficiency (MVI), but the long-term results (>20 years) are unknown. METHODS AND RESULTS: We reviewed the first 162 consecutive patients who underwent mitral valve repair between 1970 and 1984 for MVI due to nonrheumatic disease. The cause of MVI was degenerative in 146 patients (90%) and bacterial endocarditis in 16 patients (10%). MVI was isolated or, in 18 cases, associated with tricuspid insufficiency. The mean age of the 162 patients (104 men and 58 women) was 56+/-10 years (age range 22 to 77 years). New York Heart Association functional class was I, II, III, and IV in 2%, 39%, 52%, and 7% of patients, respectively. The mean cardiothoracic ratio was 0.58+/-0.07 (0.4 to 0.8), and 72 (45%) patients had atrial fibrillation. Valve analysis showed that the main mechanism of MVI was type II Carpentier's functional classification in 152 patients. The leaflet prolapse involved the posterior leaflet in 93 patients, the anterior leaflet in 28 patients, and both leaflets in 31 patients. Surgical technique included a Carpentier's ring annuloplasty in all cases, a valve resection in 126 patients, and shortening or transposition of chordae in 49 patients. During the first postoperative month, there were 3 deaths (1.9%) and 3 reoperations (2 valve replacements and 1 repeat repair [1.9%]). Six patients were lost to follow-up. The remaining 151 patients with mitral valve repair were followed during a median of 17 years (range 1 to 29 years; 2273 patient-years). The 20-year Kaplan-Meier survival rate was 48% (95% CI 40% to 57%), which is similar to the survival rate for a normal population with the same age structure. The 20-year rates were 19.3% (95% CI 11% to 27%) for cardiac death and 26% (95% CI 17% to 35%) for cardiac morbidity/mortality (including death from a cardiac cause, stroke, and reoperation). During the 20 years of follow-up, 7 patients were underwent surgery at 3, 7, 7, 8, 8, 10, or 12 years after the initial operation. Valve replacement was carried out in 5 patients, and repeat repair was carried out in 2 patients. At the end of the study, 65 patients remained alive (median follow-up 19 years). Their median age was 76 years (age range 41 to 95 years). All except 1 were in New York Heart Association functional class I/II. CONCLUSIONS: Mitral valve repair using Carpentier's technique in patients with nonrheumatic MVI provides excellent long-term results with a mortality rate similar to that of the general population and a very low incidence of reoperation.

[Prevention and treatment of atrial fibrillation after cardiac surgery]. / Prevention et traitement de la fibrillation atriale après chirurgie cardiaque.

The incidence of postoperative atrial fibrillation in cardiac surgery is still high despite major advances in anesthetic, pharmacological and surgical techniques. Its precise mechanism is still totally unknown. Postoperative atrial fibrillation increases length of stay as well as hospital costs. Rate of postoperative atrial fibrillation spontaneous conversion is high. Several protocols have been developed for prevention and/or treatment of postoperative atrial fibrillation. Beta-blockers, amiodarone and atrial pacing reduce.atrial fibrillation incidence as compared to placebo. On the other hand, amiodarone and propafenone achieve a high conversion rate of installed postoperative atrial fibrillation. However, among many pharmacological options, the best treatment is still to be defined.

[Five years experience with non-pulsatile flow]. / Enseignement de 5 années d'expérience avec les assistances circulatoires à flux non pulsé.

Mechanical circulatory assistances now belong to the therapeutic stock in case of advanced heart failure. Their mainspring lays on the substitution of the failing left and/or right ventricle function with a pump. The goal being to maintain or restore the system main functions. Their main indication is a bridge to transplant mechanical circulatory assistance, allowing the patient to await transplantation. However, indications for definitive implantation appear in case of transplantation counter indication, mechanical circulatory assistances already emerging as a possible alternative to transplantation. For over 10 years, we have used pulsatile flow assistances, either with pneumatic ventricles or electro-mechanic implantable left ventricles. We henceforth observe the development of a new generation of implantable assistance providing a non-pulsatile flow. These are axial pumps. We evaluated the first model, the DeBakey axial pump which became the most used axial pump worldwide. We now observe the development of other axial pumps as well as the development of new implantable centrifugal pumps.

Myocardial neutrophil sequestration and activation related to the reperfusion of human heart during coronary artery surgery.

OBJECTIVE: The aim was to determine if neutrophils are activated and sequestered as they pass through postischaemic human myocardium. METHODS: The occurrence of neutrophil activation during the reperfusion of the ischaemic myocardium was investigated in 16 selected patients undergoing coronary artery bypass surgery. Neutrophils were counted and elastase and lactoferrin released into the plasma were measured simultaneously in myocardial venous blood and in peripheral venous blood, before aortic cross clamping (T0), and two (T1), 10 (T2), and 20 (T3) min after unclamping. RESULTS: At T0, no statistically significant difference was noted between peripheral and myocardial blood with respect to the three variables studied. Reperfusion was associated with a significantly lower neutrophil count in myocardial blood compared to peripheral blood (p < 0.001), suggesting that neutrophils were trapped within the myocardium during reperfusion. In addition, levels of elastase (T1, T2, and T3), and lactoferrin (T1) were significantly higher in myocardial blood as compared to peripheral blood (p < 0.001), suggesting that activated neutrophils released their granular content into the plasma milieu. CONCLUSION: We provide evidence consistent with local neutrophil activation during myocardial reperfusion in patients undergoing coronary artery bypass surgery, in addition to the well described systemic activation related to cardiopulmonary bypass.

Plasma from patients exposed to ischemia reperfusion contains clastogenic factors and stimulates the chemiluminescence response of normal leukocytes.

Clastogenic factors (CFs) are released by cells exposed to superoxide radicals and are found in various situations of oxidative stress. Certain of their components stimulate further superoxide production by competent cells, as shown with cytochrome c assay in previous work. In the present study, we report CF formation after ischemia reperfusion in patients undergoing coronary bypass surgery. Plasma ultrafiltrates, collected 20 min after reperfusion, had clastogenic properties in contrast to those collected before ischemia. We also show that the luminol-enhanced chemiluminescence response of neutrophils from healthy persons is increased when these cells are exposed to CF-containing postreperfusion samples from patients. Light emission was reduced to control values in the presence of superoxide dismutase. The burst of oxyradicals upon reperfusion is probably the initiating event of CF formation, which in turn leads to further oxyradical generation. This amplification process may explain why detectable levels of CF need a delay of at least 10 min. The activated state of neutrophils in ischemia reperfusion is at once a consequence and a source of CFs. Individual variation in the persistence of this clastogenic and leukocyte-activating material was observed. Therefore, antioxidants for prevention of ischemia reperfusion injury should be continued during the postoperative course.

Distribution and prevalence of inducible nitric oxide synthase in atherosclerotic vessels of long-term cholesterol-fed rabbits.

The expression of inducible nitric oxide synthase (iNOS) as well as its functional activity has recently been reported in atherosclerotic lesions. The aim of the present study was to evaluate the expression of iNOS in various arteries of rabbits fed a long-term but low-level cholesterol-enriched diet which promotes different types of atherosclerotic lesions resembling human diseased vessels. No iNOS expression was revealed in arteries from control rabbits and in fatty streaks found in carotid and femoral arteries from hypercholesterolemic rabbits. In transitional lesions from the thoracic and abdominal aortas, the coronary and pulmonary arteries, a punctiform iNOS staining was detected in the intima. When lesions were more advanced, iNOS expression was found more intense and diffuse and localized in the subendothelial layer as well as in the media. Smooth muscle cell accumulation in intimal layers of the arteries is a marker of the degree of evolution of the atherosclerotic lesion; since we found a correlation between the smooth muscle cell infiltration in the intima and the iNOS expression in the intima and the subendothelial layer, our results suggest a link between the severity of the lesion and the iNOS expression.

Ambulatory blood pressure profile after carotid endarterectomy in patients with ischaemic arterial disease.

OBJECTIVE: To assess the circadian blood pressure profile observed 3 months after endarterectomy. DESIGN: Twenty-five patients undergoing unilateral or bilateral carotid endarterectomy were compared with a control population of 20 patients, matched for age, sex, weight and drug therapy. Casual mean blood pressure measured by mercury sphygmomanometry was similar in both groups. RESULTS: Non-invasive ambulatory blood pressure monitoring showed that, whereas mean arterial pressure was identical in both groups, the group undergoing surgery had a significant increase in pulse pressure and its variability over 24 h. Such abnormalities predominated during the nocturnal period, in which the reduction in systolic blood pressure was less pronounced in the operated group than in controls. For all parameters there was no significant difference between subjects with unilateral or bilateral endarterectomy. CONCLUSION: This study provides evidence that patients with carotid endarterectomy were characterized in the long term by an increase in the pulsatile component of blood pressure and its variability, in association with a disturbance in the physiological circadian rhythm. Such findings were not identified using casual blood pressure measurements.

Superiority of controlled surgical reperfusion versus percutaneous transluminal coronary angioplasty in acute coronary occlusion.

Although percutaneous transluminal coronary angioplasty is successful in more than 90% of patients after acute coronary occlusion, overall mortality remains approximately 10% with higher subgroup mortality (i.e., occlusion of the left anterior descending coronary artery, multivessel disease, age older than 70 years, cardiogenic shock) and early recovery of regional wall motion is marginal. This multicenter report shows that controlled surgical reperfusion in patients with acute coronary occlusion reduces overall and subgroup mortality and restores substantial early contractility. In a survey from six institutions, 156 consecutive patients with acute coronary occlusion documented by angiography underwent surgical revascularization with controlled reperfusion using amino acid-enriched blood cardioplegic solution on total vented bypass. Ventricular wall motion was studied by echocardiography or multiple gated acquisition scan on postoperative days 5 to 7 and scored independently (0 = normal, 1 = mild hypokinesia, 2 = severe hypokinesia, 3 = akinesia, 4 = dyskinesia). Results are compared with results in 1203 patients with acute coronary occlusion treated by angioplasty in five reported medical series. Surgically treated patients were revascularized at longer ischemic intervals (6.3 versus 3.9 hours, p < 0.05) and had a greater incidence of left anterior descending occlusion (61% versus 43%, p < 0.05), multivessel disease (42% versus 22%, p < 0.05), and cardiogenic shock (41% versus 10%, p < 0.05), with 12 patients undergoing cardiopulmonary resuscitation en route to the operating room. Surgical results were superior in all categories, with overall mortality reduced from 8.7% after angioplasty to 3.9% after coronary bypass (p < 0.05). All surgical deaths occurred in patients with preoperative cardiogenic shock. Regional wall motion recovered significantly (score < 2) in 131 of 150 (87%) surgically treated patients with an average score of 0.9 +/- 0.8 (normal to mild hypokinesia) despite longer ischemic times.