Intravenous Levosimendan versus Inhalational Milrinone in the Management of Pulmonary Hypertension during Adult Cardiac Surgery: A Randomized Clinical Trial.

Introduction: The perioperative management of patients with pulmonary hypertension (PH) undergoing cardiac surgery is challenging, mainly due to the potential risk of right ventricular failure (RVF). Levosimendan is a calcium-sensitizing agent that has primarily been used in the treatment of decompensated heart failure. However, recently levosimendan has been shown to be an effective and safe therapeutic strategy for patients with pulmonary arterial hypertension and PH associated with left heart disease. The aim of this study was to investigate the potential utility of the preemptive administration of levosimendan in cardiac surgical patients with preexisting PH and to compare its effectiveness with milrinone, which represents an already established therapeutic option in the management of PH during cardiac surgery. Materials and Methods: In this study, 40 adult cardiac surgical patients with PH were randomly assigned to receive either levosimendan intravenously or milrinone via inhalation in a double-blind fashion prior to a cardiopulmonary bypass (CPB). Hemodynamic and echocardiographic parameters were recorded and evaluated before and after the administration of the drugs. Results and Conclusions: The results of this study demonstrated that both levosimendan and milrinone administered before CPB in cardiac surgical patients with PH may offer protective benefits, reducing pulmonary artery pressure and preventing the exacerbation of PH and RVF. Pulmonary vasodilation attributed to levosimendan is of longer duration and greater magnitude compared to pulmonary vasodilation afforded by milrinone.

Long-term quality of life improvement after transcatheter aortic valve implantation.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is a novel therapeutic option for severe aortic stenosis in old patients with high surgical risk. The aim of this study was to assess changes in quality of life (QoL) along with functional status and late survival after this procedure. METHODS: Thirty-six consecutive patients (80.5 ± 5.9 years, 21 men and 15 women) with a logistic Euroscore of 29.7 ± 13.7 underwent TAVI using the 18-Fr CoreValve prosthesis. Aortic valve prosthesis was inserted retrograde using a femoral or a subclavian arterial approach. QoL was evaluated by administering the Short Form 36 (SF-36) tool and the shorter SF-12 version 2 (SF-12v2) questionnaires before and 1-year after TAVI. RESULTS: TAVI was successfully performed in all patients. The estimated 1-year overall survival rate using Kaplan-Meier method was 68%. One-year follow-up also showed a marked improvement in echocardiographic parameters (peak gradient 76.2 ± 26.1 vs 15.4 ± 7.8 mm Hg, P < .001; aortic valve area 0.7 ± 0.1 vs 2.6 ± 2.7 cm(2), P < .001) with a significant change in New York Heart Association class (3 ± 0.7 vs 1.2 ± 0.4, P < .001). Both preprocedural summary SF-36 and SF-12v12 physical and mental scores showed a significant improvement 1 year after TAVI (21.6 vs 46.7, P < .001; 42.9 vs 55.2, P < .001; 22 vs 48.9, P < .001; 43.3 vs 52.2, P < .001, respectively). CONCLUSIONS: Our results show a marked 1-year clinical benefit in functional status and physical and mental health in patients who underwent TAVI.

The predictive value and evolution of N-terminal pro-B-type natriuretic peptide levels following transcutaneous aortic valve implantation.

AIMS: We sought to define the predictive value and evolution of N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels following transcutaneous aortic valve implantation (TAVI). METHODS AND RESULTS: We investigated 91 consecutive patients who underwent TAVI (59 transfemoral [TF], 32 transapical [TA]) in our institution. The balloon-expandable valve was implanted in 75 and the self-expanding in 16 patients. The baseline (within 48 hours prior to procedure), early (24-74 hours), and late (3-12 months) postprocedural NT-proBNP levels were determined. The mortality status of all patients was ascertained as of September 2010. The 30-day and 1.3(mean)-year mortality was 3% and 12% (2%, 9% in the TF and 6%, 19% in the TA group). Increased baseline (χ(2) = 5.9, P = 0.016) and early (χ(2) = 4.9, P = 0.028) NT-proBNP levels were predictive of mortality. All decrements of the NT-proBNP levels in the TF patients were significant (baseline 4,984 ± 8,106 vs. early 3,912 ± 6,551 pg/mL, P = 0.016; late 633 ± 606 pg/mL, P = 0.003). In contrast, there was a trend for the early levels to increase in the TA patients (6,423 ± 8,897 vs. 8,100 ± 10,178 pg/mL, P = 0.090), and a significant decline in the late levels as compared to baseline (1,704 ± 3,417 pg/mL, P = 0.005). CONCLUSION: NT-proBNP levels are predictive of mortality following TAVI. There is a differential early evolution of their levels between the TF and TA patients and a significant decline later in both groups.

NT-proBNP in the mitral valve surgery.

BACKGROUND: Prognosis and severity of mitral valve disease in patients are reflected in their natriuretic peptide levels. Patients in the upper margin of this range with severe mitral valve dysfunction also present with a range of myocardial dysfunction and symptomatic progression. We investigated whether serial pre- and immediate postoperative measurements of N-terminal probrain natriuretic peptide (NT-proBNP) can serve as surrogate markers of these surgical patients' severity status and predictors of their immediate postoperative progress. METHODS: Clinical characteristics, echocardiographic indices, and preoperative and postoperative day 1, 5, 7 values of NT-proBNP were retrospectively recorded in a cohort of 75 patients who underwent mitral valve surgery. They were analyzed as a whole and separately for those suffering from severe mitral regurgitation. Correlations, multiple linear regression, logistic regression, and nonparametric receiver operating characteristic curve analyses were implemented. RESULTS: The patients' preoperative New York Heart Association class, presence of atrial fibrillation, and left ventricular function were strongly correlated with the preoperative NT-proBNP level. Specifically for those with severe mitral regurgitation, preoperative NT-proBNP was also correlated to their left ventricular end-diastolic diameter. NT-proBNP values increased respectively postoperatively in all patients and were related to the preoperative values, the patients' preoperative characteristics, and the operative times. Logistic regression analysis identified preoperative NT-proBNP as a predictor of postoperative optimal clinical outcome (P < 0.001). CONCLUSIONS: NT-proBNP is a valuable biomarker of the clinical presentation and immediate postoperative outcome in patients undergoing mitral valve surgery. The preoperative measurement of NT-proBNP can be used to predict an optimal postoperative clinical outcome.

Percutaneous aortic valve implantation of the Medtronic CoreValve self-expanding valve prosthesis via left subclavian artery access: the first case report in Greece.

This case report describes a percutaneous aortic valve implantation with the Medtronic CoreValve selfexpanding valve prosthesis in a patient with severe aortic stenosis. The approach was made via the left subclavian artery because of the lack of femoral vessel access. The patient was a 78-year-old female with breathlessness on minimal effort, a recent hospitalisation due to pulmonary oedema, and frequent episodes of pre-syncope; surgical valve replacement had been ruled out. The prosthetic valve was successfully implanted with mild paravalvular aortic regurgitation. At 30 days, the patient's clinical condition had significantly improved, with excellent functioning of the aortic valve prosthesis.

Transcatheter aortic valve implantation: first Greek experience.

INTRODUCTION: Percutaneous aortic valve replacement represents an alternative to conventional open-heart surgery for selected high-risk patients without the need for sternotomy, aortotomy, or cardiopulmonary bypass. We present the first Greek series of transcatheter prosthetic aortic valve implantation procedures, performed in our centre. METHODS: All 12 patients (age 81 +/- 5 years) had severe, symptomatic, calcific aortic stenosis and were judged not to have a reasonable surgical option by a medical team including experienced cardiac surgeons. The patients' mean logistic EuroSCORE was 34 +/- 15% (min 11%, max 61%). Eight (8) of them underwent transfemoral (SAPIEN, Edwards 23 mm valve in 7 and 26 mm in 1 patient) and 4 transapical (26 mm in 2 and 23 mm in 2 patients) prosthetic aortic valve implantation, all in the cardiac catheterisation laboratory under general anaesthesia. RESULTS: The procedural, in-hospital and 2-month (mean follow up 50 days, min 17, max 122 days) mortality was 0%. The length of hospital stay was 8 +/- 2 days (min 5, max 12 days). The aortic valve area increased from 0.64 +/- 0.14 cm2 to 1.83 +/- 0.14 cm2 and the mean pressure gradient decreased from 57 +/- 23 mmHg to 10 +/- 3 mmHg post-implantation (p<0.001 for both). The patients' mean NYHA functional status improved from 2.8 +/- 0.7 to 1.3 +/- 0.5 at follow-up (p<0.001). CONCLUSIONS: Our initial experience with transcatheter prosthetic aortic valve implantation demonstrates that it can be performed safely and with excellent short and mid-term clinical outcomes.