Surgical repair of postinfarction ventricular septal rupture: current state of the art.

The incidence of postacute myocardial infarction ventricular septal rupture (post-AMI VSR) has decreased over the past two decades. Nevertheless, individuals who suffer from post-AMI VSR continue to represent a subgroup of patients with high morbidity and mortality. The care for these patients is complex and requires a multidisciplinary approach. However, because of the small number of reports that exist to guide clinical practice, there is a significant variability in care among centers. This review summarizes information on post-AMI VSR diagnosis and outline contemporary best management and practice consideration.

Optimal timing of discontinuation of clopidogrel and risk of blood transfusion after coronary surgery. Propensity score analysis.

BACKGROUND: The optimal time delay between last clopidogrel dose and surgery is controversial. The aim of the present study was to analyze the impact of preoperative clopidogrel on the need for blood transfusions with reference to the proper timing of discontinuation. METHODS AND RESULTS: Between January 2005 and December 2010, 1,947 consecutive patients undergoing coronary surgery were enrolled. Of these, 255 patients receiving preoperative clopidogrel were matched to a control group by propensity score analysis. Clopidogrel discontinuation interval before surgery was examined in 1-day increments from 0 to 5 days and >5 days. Patients who discontinued clopidogrel within 5 days of surgery accounted for 91% (211/255). Clopidogrel stop within 5 days before surgery was independently associated with transfusion requirement (P=0.001). Preoperative clopidogrel was not associated with an increased risk of hemorrhagic complications (P=0.696). No differences were observed between patients taking clopidogrel and those not taking clopidogrel with regard to hospital resource utilization and mortality. Patients receiving clopidogrel in association with aspirin did not have an additive risk for transfusion or hemorrhagic complications compared with those on clopidogrel alone (odds ratio [OR], 1.25; 95% confidence interval [CI]: 0.77-2.03; OR, 1.02; 95%CI: 0.38-2.79, respectively). CONCLUSIONS: Clopidogrel administration in the 5 days preceding coronary surgery was an independent predictor for increased transfusion requirements, supporting the discontinuation of clopidogrel >5 days before surgery.

Papillary fibroelastoma: insight to a primary cardiac valve tumor.

Papillary fibroelastomas are rare benign cardiac tumors. Although they have minimal hemodynamic effects, their propensity for embolization can result in serious morbidity. The pathophysiology and management of these tumors is the subject of this review.

Atrial fibrillation after isolated coronary surgery affects late survival.

BACKGROUND: Atrial fibrillation (AF) after coronary artery bypass graft surgery is a difficult problem and a continuing source of morbidity and mortality. However, the prognostic implications of postoperative AF are still in dispute. Our aim was to ascertain the impact of AF after coronary artery bypass graft on postoperative survival and to assess its prognostic role in cause-specific mortality. METHODS AND RESULTS: We conducted a prospective observational study of 1832 patients undergoing isolated coronary artery bypass graft between January 2000 and December 2005 at 2 cardiac surgery centers in northern Italy. Patients affected by postoperative AF were identified and followed up until death or study end (April 30, 2007). A total of 570 patients (31%) developed AF after coronary surgery. Patients affected by postoperative AF experienced a longer hospital stay (7 days [25th to 75th percentile, 7 to 10 days] versus 7 days [25th to 75th percentile, 6 to 8 days]; P<0.001). Hospital mortality also was higher in AF patients (3.3% versus 0.5%; P<0.001). On discharge, 1806 patients were alive; 143 were lost to follow-up. The remaining 1663 were followed up for a median of 51 months (25th to 75th percentile, 41 to 63 months); 126 of them died after a median of 14 months (25th to 75th percentile, 5 to 32 months). Long-term mortality rates were significantly higher for patients with postoperative AF (2.99 per 100 person-years; 95% confidence interval, 2.33 to 3.84; 61 deaths) compared with those without the arrhythmia (1.34 per 100 person-years; 95% confidence interval, 1.05 to 1.71; 65 deaths), with an adjusted hazard ratio of 2.13 (P<0.001) and 2.56 (P=0.001) when also accounting for the prescription of warfarin at discharge. With Cox regression, patients with AF were shown to be at higher risk of dying from embolism (adjusted hazard ratio, 4.33; 95% confidence interval, 1.78 to 10.52) but not from other causes. CONCLUSIONS: Postoperative AF affects early and late mortality after isolated coronary artery bypass graft surgery. Patients affected by AF are at higher risk of fatal embolic events. Careful postoperative surveillance with a specific antiarrhythmic and antithrombotic prophylaxis, aimed at reducing AF and its complications, is recommended.

Comparison of human skeletal myoblasts and bone marrow-derived CD133+ progenitors for the repair of infarcted myocardium.

OBJECTIVES: The present study was designed as a face-to-face functional comparison of human skeletal myoblasts (SMs) and CD133(+) bone marrow-derived hematopoietic progenitors in an animal model of semichronic myocardial infarction. BACKGROUND: Compared with SMs, bone marrow-derived cells have the advantage of plasticity and might more effectively regenerate ischemic cardiac tissue. However, few data exist on the comparative efficacy of these two cell types in semichronic infarcts. METHODS: A myocardial infarction was created by coronary ligation in 32 nude rats. Ten days later, rats received in-scar injections of human SMs, CD133(+) progenitors, or culture medium. Left ventricular function was assessed before and one month after transplantation by echocardiography and pressure-volume loops. Immunofluorescence, polymerase chain reaction, and in situ hybridization were used to detect cells grafted in the hearts. RESULTS: One month after transplantation, left ventricular ejection fraction decreased by 8 +/- 4% in controls, whereas it increased by 7 +/- 3% in CD133(+)-grafted hearts (p = 0.0015 vs. controls) and further by 15 +/- 5% in SM-treated hearts (p = 0.008 vs. controls). Systolic indices yielded by pressure-volume loops paralleled these data. Engrafted myotubes were identified in all SM-treated hearts by immunofluorescence, whereas in CD133(+)-grafted hearts, few human cells were only detected by polymerase chain reaction. CONCLUSIONS: In the setting of postinfarction scars, the transplantation of bone marrow-derived CD133(+) progenitors improves cardiac function, but this benefit is not superior to that afforded by myogenic cells.

St. Jude Medical Trifecta aortic valve: results from a prospective regional multicentre registry.

BACKGROUND: The Trifecta aortic bioprosthesis (St. Jude Medical, Inc., St. Paul, MN, USA) is a stented pericardial heart valve with excellent preliminary results. Aim of the study was to evaluate its early clinical and hemodynamic performances in a multicenter regional registry. METHODS: Between January 2011 and June 2012, 178 consecutive patients undergoing aortic valve replacement with the Trifecta bioprosthesis were prospectively enrolled at 9 Italian centers. Clinical and echocardiographic data were collectedat discharge, 6-months and at 1-year postoperatively. RESULTS: The average age was 75.4 ± 7.7 years,and 95 (53 %) were men. Indication for valve replacement included stenosis in 123 patients (69 %), mixed lesions in 25 (14 %), and regurgitation in 30 (17 %). Ninety-three (52 %) patients were in NYHA functional class III/ IV. Hospital mortality accounted for 5 (2.8 %) patients. No valve-related perioperative complications were encountered. Median follow-up was 20.5 months (range: 1-34). Early (≤6 months) complications included one thromboembolic event, one major bleeding, and 3 endocarditis (2 explants). Two late (>6 months) thromboembolic events and two endocarditis (1 explant) were registered. No valve thrombosis or structural deterioration were observed after discharge. At 30-months, freedom from all-cause mortality was 87 %, freedom from valve-related mortality 99.4 %, freedom from endocarditis 97.5 %, and freedom from valve explants 98 %. At 1-year, mean gradients ranged from 8 to 16 mmHg, and effective orifice area indexes from 1.0 to 1.2 cm(2)/m(2) for valve sizes from 19 to 27 mm, respectively. No patients had severe prosthesis-patient mismatch. CONCLUSIONS: Trifecta bioprosthesis provided favourable clinical and hemodynamic results over time.

The effect of timing of cardiac catheterization on acute kidney injury after cardiac surgery is influenced by the type of operation.

BACKGROUND: Acute kidney injury (AKI) is a vexing complication of cardiac surgery. Since exposure to contrast agents is a relevant contributing factor in the development of postoperative AKI, the optimal timing between cardiac catheterization and surgery is decisive. METHODS: A total of 2504 consecutive nonemergent patients undergoing isolated coronary artery bypass grafting (CABG), valve surgery (with or without concomitant CABG), and proximal aortic procedures were enrolled. AKI was defined by consensus RIFLE (Risk, Injury, Failure, Loss of function, End-stage renal disease) criteria. The association of postoperative AKI and time between cardiac catheterization and operation was evaluated using multivariable logistic regression modeling and propensity-matched analysis. RESULTS: Postoperative AKI occurred in 230 (9%) patients. The median number of days from cardiac catheterization to operation was 5 (25th to 75th percentile: 2 to 10). The incidence of AKI was significantly higher in patients operated on ≤1 day after cardiac catheterization compared to those operated on >1 day after (13% vs. 8%, p=0.004). The time interval between cardiac catheterization and surgery (tested both as a continuous and a categorical variable) was not an independent AKI predictor in the propensity-matched population or the pre-matched one. Contrast exposure≤1 day before surgery was independently associated with postoperative AKI in patients undergoing valve surgery with concomitant CABG only (post-matched: OR 3.68, 95%CI 1.30 to 10.39, p=0.014). CONCLUSIONS: Delaying cardiac surgery beyond 24h of exposure to contrast agents seems to be justified only in patients undergoing valve surgery with concomitant CABG.

Preoperative n-3 polyunsatured fatty acids are associated with a decrease in the incidence of early atrial fibrillation following cardiac surgery.

BACKGROUND: Atrial fibrillation (AF) after cardiac surgery is associated with increased mortality, morbidity, and expenditure. Controversial data exist on possible preventive effects of n-3 polyunsatured fatty acids (PUFAs) against postoperative AF. We investigated whether preoperative PUFA therapy is effective in reducing AF after cardiac surgery during the surgical hospitalization and/or the cardiac rehabilitation period. METHODS: Over a 4-year period, 530 patients (363 men, 68.5%) with a mean age of 66.4 +/- 10.9 years, undergoing cardiac surgery were monitored for ''early AF'' and ''late AF'' defined as AF documented in the surgical department or during the rehabilitation program, respectively. RESULTS: The overall incidence of early AF in the whole study sample was 44.7%, whereas late AF occurred in 14.7% patients. Patients with AF had a longer length of hospital and rehabilitation stay (10.4 +/- 9.8 vs 9.5 +/- 9.2 days, P = .025 and 24.2 +/- 15.3 vs 21.1 +/- 8.3 days, P = .008, respectively). Early AF occurred in 31.0% of the patients with preoperative PUFAs compared with 47.3% of those without them (P = .006). Conversely, late AF was not influenced by preoperative PUFA regimen (11.9% vs 15.2%, P = .43). Preoperative PUFAs were independently associated with a 46% reduction in risk of early AF development (OR 0.54, 95% CI 0.31-0.92), after propensity score analysis. CONCLUSION: Preoperative PUFA therapy is associated with a decreased incidence of early AF after cardiac surgery but not late AF. Patients undergoing cardiac surgery may benefit from a preventive PUFA approach.

Asymptomatic cardiac papillary fibroelastoma: diagnostic assessment and therapy.

Papillary fibroelastoma is a rare benign cardiac tumor with elevated risk for embolization. This report describes the case of a 65-year-old man, admitted for the occasional finding of a round, pedunculate mass adherent to the chordae of the anterior mitral valve leaflet, mimicking an endocarditic mass. Appropriate diagnostic evaluations lead to the suspect of a papillary fibroelastoma. Because of the elevated risk of thromboembolism, surgery was emergently performed with complete removal of the mass and preservation of the integrity of the mitral valve. Histologic evaluation confirmed the diagnosis. Papillary fibroelastoma should be always considered in the differential diagnosis of intracardiac masses.