Attenuation of post-infarction remodeling in rats by sustained myocardial growth hormone administration.

Prevention of left ventricular remodeling is an important therapeutic target post-myocardial infarction. Experimentally, treatment with growth hormone (GH) is beneficial, but sustained local administration has not been thoroughly investigated. We studied 58 rats (322 ± 4 g). GH was administered via a biomaterial-scaffold, following in vitro and in vivo evaluation of degradation and drug-release curves. Treatment consisted of intra-myocardial injection of saline or alginate-hydrogel, with or without GH, 10 min after permanent coronary artery ligation. Echocardiographic and histologic remodeling-indices were examined 3 weeks post-ligation, followed by immunohistochemical evaluation of angiogenesis, collagen, macrophages and myofibroblasts. GH-release completed at 3 days and alginate-degradation at ∼7 days. Alginate + GH consistently improved left ventricular end-diastolic and end-systolic diameters, ventricular sphericity, wall tension index and infarct-thickness. Microvascular-density and myofibroblast-count in the infarct and peri-infarct areas were higher after alginate + GH. Macrophage-count and collagen-content did not differ between groups. Early, sustained GH-administration enhances angiogenesis and myofibroblast-activation and ameliorates post-infarction remodeling.

Repair of aorto-left ventricular and aorto-right ventricular fistulas following prosthetic valve endocarditis.

We report a case of a 77-year-old male who presented with an aorto-left ventricular fistula and an aorto-right ventricular fistula secondary to prosthetic valve endocarditis.

A rare case of Ebstein's anomaly with left ventricular noncompaction.

Ebstein's anomaly is a rare congenital cardiac disease characterized by apical displacement of the tricuspid valve with decreased right ventricular function. Left ventricular noncompaction is a cardiomyopathy characterized by the presence of numerous and prominent trabeculations together with deep intertrabecular recesses in a portion of the ventricular wall, principally at the lateral and apical level. We describe the very rare case of a patient living for 78 years with a benign form of Ebstein's anomaly and left ventricular noncompaction cardiomyopathy with slightly reduced systolic function.

Simultaneous implantation of MitraClip devices in a patient with severe mitral and tricuspid valve regurgitation.

We present a case of an 84-year old patient with severe mitral and tricuspid regurgitation with a lot of cormobidities who underwent a simultaneous transfemoral (one approach) mitral and tricuspid valve repair using the MitraClip system.

An Unusual Case of Arterial Embolism in an Adolescent With a Mitral Valve Repair With a Ring.

We report a case of an adolescent young man who presented with embolism of both lower legs. The patient had undergone mitral valve repair with a Kalangos biodegradable ring (Bioring SA, Lonay, Switzerland) 9 months earlier. Bilateral embolectomy was performed. Histopathologic examination revealed minute fragments of synthetic material within the embolus, which otherwise consisted of recent thrombus.

Effects of central sympathetic activation on repolarization-dispersion during short-term myocardial ischemia in anesthetized rats.

AIMS: Sympathetic activation during myocardial ischemia enhances arrhythmogenesis, but the underlying pathophysiologic mechanisms remain unclear. We investigated the central sympathetic effects on ventricular repolarization during the early-period post-coronary artery occlusion. MAIN METHODS: We studied 12 Wistar rats (254±2 g) for 30 min following left coronary artery ligation, with (n=6) or without (n=6) pretreatment with the central sympatholytic agent clonidine. Mapping of left and right ventricular epicardial electrograms was performed with a 32-electrode array. As an index of sympathetic activation, heart rate variability in the frequency domain was calculated. Heart rate and repolarization duration were measured with a custom-made recording and analysis software, followed by calculation of intra- and inter-ventricular dispersion of repolarization. KEY FINDINGS: Heart rate and heart rate variability indicated lower sympathetic activation in clonidine-treated rats during ischemia. Repolarization duration in the left ventricle prolonged after clonidine at baseline, independently of heart rate, but no differences were present 30 min post-ligation. Dispersion of repolarization in the right ventricle remained stable during ischemia, whereas it increased in the left ventricle, equally in both groups. A similar trend was observed for inter-ventricular dispersion, without differences between groups. SIGNIFICANCE: In addition to intra-ventricular repolarization-dispersion, anterior-wall myocardial ischemia may also increase inter-ventricular repolarization-dispersion. Progressive central sympathetic activation occurs during myocardial ischemia, but it does not affect intra- or inter-ventricular dispersion of ventricular repolarization during the early phase. Further research is warranted on the potential effects during subsequent time-periods.

What is the best approach in a patient with a failed aortic bioprosthetic valve: transcatheter aortic valve replacement or redo aortic valve replacement?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether transcatheter aortic valve-in-valve replacement (viv-TAVR) or redo aortic valve replacement (rAVR) is the best strategy in a patient with a degenerative bioprosthetic aortic valve. Altogether, 162 papers were found using the reported search, of which 12 represented the best evidence to answer the question. The authors, journal, date, country of publication, patient group, study type, outcomes and results of papers are tabulated. The results of the studies provided interesting results. All the studies are retrospective. Four papers reported the results of redo aortic valve replacement in patients with failed aortic bioprosthetic valve, six papers demonstrated their results with transcatheter aortic valve-in-valve replacement for the same indication and two papers reported their propensity-matched analysis of outcomes between viv-TAVR and rAVR in patients with previous cardiac surgery. Thirty-day mortality for rAVR was 2.3-15.5% and 0-17% for viv-TAVR. For rAVR, survival rate at 30 days was 83.6%, 76.1% at 1 year, 70.8% at 3 years, at 51.3-66% at 5 years, 61% at 8 years and 61.5% at 10 years. For viv-TAVR, the overall Kaplan-Meier survival rate at 1 year was 83.2%. After viv-TAVR at 1 year, 86.2% of surviving patients were at New York Heart Association (NYHA) class I/II. The complications after rAVR were stroke (4.6-5.8%), reoperation for bleeding (6.9-9.7%), low-cardiac output syndrome (9.9%) whereas complications after viv-TAVR at 30 days were major stroke (1.7%), aortic regurgitation of at least moderate degree (25%), new permanent pacemaker implantation rate (0-11%), ostial coronary obstruction (2%), need for implantation of a second device (5.7%) and major vascular complications (9.2%). It is noteworthy to mention that there is a valve-in-valve application that provides information to surgeons for choosing the correct size of the TAVR valve. Transcatheter aortic valve-in-valve procedures are clinically effective, at least in the short term, and could be an acceptable approach in selected high-risk patients with degenerative bioprosthetic valves. Redo AVR achieves acceptable medium and long-term results. Both techniques could be seen as complementary approaches for high-risk patients.

Coil embolization of traumatic pseudoaneurysm of right internal thoracic artery.

Traumatic injury to the chest and internal thoracic artery is a perplexing problem that is difficult to diagnose and open to different treatment options. Internal thoracic artery pseudoaneurysms are an extremely rare vascular abnormality. We report the case of a patient with a pseudoaneurysm of the musculophrenic artery, a branch of right internal thoracic artery, caused by a penetrating injury of the chest.

Central Sympathetic Activation and Arrhythmogenesis during Acute Myocardial Infarction: Modulating Effects of Endothelin-B Receptors.

Sympathetic activation during acute myocardial infarction (MI) is an important arrhythmogenic mechanism, but the role of central autonomic inputs and their modulating factors remain unclear. Using the in vivo rat-model, we examined the effects of clonidine, a centrally acting sympatholytic agent, in the presence or absence of myocardial endothelin-B (ETB) receptors. We studied wild-type (n = 20) and ETB-deficient rats (n = 20) after permanent coronary ligation, with or without pretreatment with clonidine. Cardiac rhythm was continuously recorded for 24 h by implantable telemetry devices, coupled by the assessment of autonomic and heart failure indices. Sympathetic activation and arrhythmogenesis were more prominent in ETB-deficient rats during the early phase post-ligation. Clonidine improved these outcomes throughout the observation period in ETB-deficient rats, but only during the delayed phase in wild-type rats. However, this benefit was counterbalanced by atrioventricular conduction abnormalities and by higher incidence of heart failure, the latter particularly evident in ETB-deficient rats. Myocardial ETB-receptors attenuate the arrhythmogenic effects of central sympathetic activation during acute MI. ETB-receptor deficiency potentiates the sympatholytic effects of clonidine and aggravates heart failure. The interaction between endothelin and sympathetic responses during myocardial ischemia/infarction and its impact on arrhythmogenesis and left ventricular dysfunction merits further investigation.

Mitral valve repair of isolated posterior leaflet prolapse: resect or respect?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether it is best in a patient with posterior leaflet prolapse to resect tissue from the posterior leaflet or to preserve the leaflet tissue by only adding neochordal reconstruction. Altogether, 279 papers were found using the reported search, of which 16 represented the best evidence to answer the clinical question. The authors, journal, date, country of publication, patient group, study type, relevant outcomes and results of these papers are tabulated. The results of the reported studies provided interesting results. All the studies identified were retrospective. Seven papers reported their results on mitral valve (MV) repair with neochordae. These papers included study groups of 74 to 662 patients. The spanned operation dates were from 1983 to 2008. The main disease was degenerative valve disease. The authors performed MV repair using neochordae with or without a ring. The 5-year freedom rate from reoperation was from 94.3 to 98.7%, the 10-year freedom rate from reoperation was from 81.7 to 94.7%, the 15-year freedom rate from reoperation was 92%, and the 18-year freedom rate from reoperation was 90.2%. The 5-year survival rate was from 96.6 to 96.9%, the 10-year survival rate was from 88 to 89.3%, the 15-year survival rate was 84%, and the 18-year survival rate was 66.8%. Seven papers reported their results on MV repair with resection techniques. These papers included patient groups of 162 to 3074 patients. Operation dates were from 1970 to 2008. The authors performed MV repair with quadrangular resection, plus or minus a sliding annuloplasty. The 5-year freedom rate from reoperation was from 93.9 to 98%, the 10-year freedom rate from reoperation was from 93 to 98.5%, and the 20-year freedom rate from reoperation was from 88 to 96.9%. The 5-year survival rate was from 86.9 to 96%, the 10-year survival rate was from 79 to 93.5%, the 15-year survival rate was 76%, and the 20-year survival rate was from 46 to 62%. The length of follow-up in neochordal papers was shorter and there were fewer patients. The results in the resection groups seemed to derive from larger cohorts of patients and their findings had been proved over a longer period of time. The results of both techniques are comparable and excellent. The surgeons may decide on either technique based on their own experience, safe in the knowledge that both techniques have excellent reported outcomes.

Is aortic valve repair or replacement with a bioprosthetic valve the best option for a patient with severe aortic regurgitation?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether it is best to repair or replace the aortic valve with a bioprosthesis in young patients with severe aortic regurgitation as the patients do not like to take warfarin for the rest of life. Altogether 74 papers were found using the reported search, of which 10 represented the best evidence to answer the clinical question. The authors, journal, date, country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The results of the reported studies provided interesting results. All the studies identified are retrospective. Three papers reported the results about the Ross operation for aortic valve (AV) disease. Freedom from autograft reoperation at 10 years was from 81 to 84%, at 15 years 92% and at 18 years 51%. Freedom from aortic insufficiency (AI) (moderate to severe) at 15 years was 89.7%. Four papers reported that freedom from AV reoperation after AV repair at 5 years was from 86 to 94% and at 8 years was from 83 to 93%. Freedom from recurrent AI (>2+) at 5 years was from 85 to 94%. One study showed that reoperation-free survival after AV repair for rheumatic valve disease at 160 months was 85%. Two papers compared AV repair with aortic valve replacement (AVR) with a bioprosthetic valve and found that freedom from AV reoperation at 5 years was from 90 to 91% for the repair group and 94 to 98% for AVR. Freedom from AI (moderate or severe) at 5 years was 79% for the repair group and 94% for AVR. Aortic valve repair yielded good early and mid-term results. It is a viable alternative to replacement with a bioprosthesis, especially for young patients who did not like to take warfarin. The Ross operation appeared to be a good choice for selected patients with AV disease.

Simultaneous occurrence of coronary artery disease and lung cancer: what is the best surgical treatment strategy?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether combined surgical procedures in one or two stages are the best surgical treatment strategy in patients with simultaneous coronary artery disease and lung cancer. Altogether, 264 papers were found using the reported search; of which, 15 represented the best evidence to answer the clinical question. The authors, journal, date, country of publication, patient group, study type, outcomes and results of papers are tabulated. The outcomes of the reported studies provided interesting results. All the studies were retrospective. Ten papers reported the results of combined and staged operations. The operative mortality rate of combined procedures was 0-20.8% and of staged procedures was 0-10%. The reoperation rate for bleeding of combined procedures was 0-11% and of staged procedures was 0%. The survival rate of combined procedures at 1 year was 79-100%, at 5 years was 34.9-85% and at 7 years was 61%. The survival rate of staged procedures at 1 year was 72.7% and at 5 years was 53%. Five studies reported the results of off-pump coronary artery bypass grafting (OPCABG) and lung surgery versus on-pump and lung surgery. The operative mortality rate of OPCABG and lung surgery was 0-6.6%. The 2-year survival rate of OPCABG and lung surgery was 47% and the 5-year survival rate was 13-68%. The re-exploration rate for bleeding of OPCABG was 4%. Simultaneous lung surgery and CABG could be safely performed with adequate cancer-free survival in patients with Stage I or II lung cancer. Lung surgery is better performed before institution of cardiopulmonary bypass, avoiding the complications of such a technique. Long-term survival after combined treatment is mostly related to the predicted survival after lung resection. This depends on the T stage and mostly on the patient's nodal status. In certain high-risk groups (if the cardiac procedure is difficult or if the patient is unstable), separate staged procedures (CABG as the first and lung resection as the second procedure) might be the most prudent action (3-6 weeks apart). There is also another option: OPCABG and lung resection, which could be a safe and effective treatment when unstable coronary heart disease and lung cancer coexist.

Right upper lobe partial anomalous pulmonary venous connection.

Partial anomalous pulmonary venous return (PAPVR) is a left-to-right shunt where one or more, but not all, pulmonary veins drain into a systemic vein or the right atrium. We report a case of a 45-year-old male with PAPVR to superior vena cava which was incidentally discovered during a right lower bilobectomy for lung cancer.