Experimental Devices Versus Hand-Sewn Anastomosis of the Aorta: A Systematic Review and Meta-Analysis.

BACKGROUND: To minimize complications associated with the construction of the hand-sewn aortic anastomosis, alternative experimental methods have been pursued. This study aimed to evaluate the efficacy of experimental anastomotic devices in relation to time and point of rupture of the anastomosis in comparison to the conventional technique. MATERIALS AND METHODS: An electronic search was performed using MEDLINE, Scopus, Science Direct, and Cochrane Library databases by two independent authors. Our exclusion criteria referred to studies reporting results solely from end-to-side anastomosis, results on vessels other than the aorta, studies that did not involve animal experiments, and non-English publications. The last search date was January 1, 2020. RESULTS: The meta-analysis included 22 studies with 34 anastomosis samples and a total of 316 animals. The pooled mean automated anastomosis time was 10.38 min, and the mean point of rupture was 32.7 N. In the subgroup analysis of automated anastomosis time by device category, the anastomotic stenting technique reported significantly lower anastomosis time but also showed significantly lower point of rupture. Comparing the efficacy of experimental devices and the hand-sewn technique, our pooled analysis showed that automated devices significantly decrease the time needed to perform the anastomosis (weighted mean difference -7.24 min). On the other hand, the automated anastomosis is also associated with decreased tensile strength (weighted mean difference -20.68 N). CONCLUSIONS: Although experimental devices seem to offer a faster anastomosis, they lack endurance when compared with the hand-sewn technique. Further research is needed for the development of an "ideal" anastomotic technique.

Triglycerides are related to left ventricular mass in hypertensive patients independently of other cardiometabolic risk factors: the effect of gender.

Given the inconsistent results on the prognostic significance of triglycerides (TGs), the purpose of the present study was to investigate the association of plasma TGs with left ventricular mass (LVM) in hypertensive patients. We studied 760 never treated, non diabetic, hypertensive patients. Τransthoracic echocardiography was performed and LVMI was calculated according to the Devereux formula, adjusted to body surface area. Triglycerides were associated with LVMI after adjustment for age, gender, systolic blood pressure (SBP), smoking and fasting glucose (b = 0.08, p = 0.009). This relationship remained significant even after adjustment for BMI, LDL-C and ApoB/ApoA1 ratio (b = 0.07, p = 0.04). Gender-stratified analysis indicated that TGs were related to LVMI in men (p = 0.001) but not in women (p = NS). In addition, TGs were related with LV hypertrophy (LVH) in men, increasing the odds by 7% to present LVMI over 115 g/m2 (OR = 1.07 per 10 mg/dl increase in TGs, p = 0.01). In conclusion, TGs are associated with LVMI in hypertensive patients, independently of other risk factors, including LDL-C. Given the prognostic significance of LVH, it might be suggested that TGs may serve as a useful marker for indentifying hypertensive patients at high risk. The gender discrepancy may suggest a possible gender-specific modulatory effect of TGs on LV structure.

External Validation of the PREMISE Score in the Athens Stroke Registry.

BACKGROUND: A simple score was proposed recently for Predicting Early Mortality from Ischemic Stroke (PREMISE) derived from the Austrian Stroke Unit Registry. This score could be useful in clinical practice and research. However, its generalizability is uncertain, as it was validated internally only. AIMS: We aimed to validate the PREMISE score externally. METHODS: The analysis was performed in the Athens Stroke Registry. The PREMISE score was calculated as described in the original publication. The outcome was death within 7 days after stroke. Logistic regression analysis was used to estimate the relative death risk in different strata of the PREMISE score using the lowest values of the score (ie, 0-4) as the reference category. We assessed the score's calibration by the Hosmer-Lemeshow goodness-of-fit test and its discriminatory power by calculating the area under the receiver operating characteristics curve (AUC). RESULTS: In 2608 consecutive patients (median age 71 years, 38.8% women) with acute ischemic stroke treated in the stroke unit, mortality increased with increasing PREMISE score from .1% (95% confidence intervals [95% CI]: 0%-.2%) in patients with a score of 0-4 to 28.2% (95% CI: 14.1%-42.3%) in patients with a score of ≥10. The risk for death was more than 6 times higher in patients with a PREMISE score of ≥10 compared to patients with 0-4 points (odds ratio [OR]:6.21, 95% CI:4.13-8.29). Τhe PREMISE score showed excellent calibration (Hosmer-Lemeshow χ2: .01, P= .99) and good discriminatory power (AUC .873, 95% CI: .844-.901). CONCLUSIONS: The present study confirms the prognostic accuracy of the PREMISE score in an independent cohort of patients with acute ischemic stroke treated in the stroke unit.

Α systematic review and meta-analysis of the efficacy of aortic anastomotic devices.

OBJECTIVE: One of the factors contributing to complications related to open repair of the aorta is the construction of a hand-sewn anastomosis. Aortic anastomotic devices (AADs), such as the intraluminal ringed graft (IRG), and the anastomotic stenting technique have been developed to perform a sutureless and less complicated anastomosis. This study performed a systematic review and meta-analysis of the literature reporting clinical use of AADs and aimed to assess, primarily, the effect of each device on 30-day overall and operation-related mortality and aortic cross-clamping time and, secondarily, the rate of successful two-sided application of the IRG device and the operation-related morbidity for each device. METHODS: An electronic search was performed using MEDLINE, Scopus, ScienceDirect, and Cochrane Library by two independent authors. Our exclusion criteria included studies incorporating fewer than three patients and studies reporting results solely from animals or in vitro testing, results solely from end-to-side anastomosis, and results solely from endarterectomy procedures. The last search date was February 1, 2018. RESULTS: A total of 41 studies were identified that reported outcomes for the use of three different device types: IRG, anastomotic stenting technique, and surgical staplers. The last two types were classified together as the non-IRG group. The meta-analysis included 27 studies with 50 cohorts incorporating 1260 patients. The median age of the incorporated patients was 61.4 years (range, 51-73 years), and 68.9% were male. The operations were performed for the treatment of acute aortic dissection in 82.3%. The pooled overall 30-day mortality rate varied by device type; IRG devices had a mean rate of all-cause mortality of 9.71%, whereas non-IRG devices were associated with a significantly (I2 = 15.78%; P for Cochrane Q test < .19) lower rate of death (1.47%). The pooled mean aortic cross-clamping time was 35.83 minutes. Metaregression showed that the performance of two-sided anastomosis with the IRG device significantly decreased the aortic cross-clamping time. However, a successful two-sided ringed anastomosis was performed in approximately half of the cases. CONCLUSIONS: Taking into account that the majority of operations were performed for the treatment of acute aortic dissection, AADs had a relatively low rate of 30-day mortality. Despite the observed heterogeneity in study protocols and the small sample size in the non-IRG group, the non-IRG group presented with the lowest 30-day mortality rate. Specific device-related complications between the different device types need further investigation.

Early vascular damage from smoking and alcohol in teenage years: the ALSPAC study.

Aims: To determine the impact of smoking and alcohol exposure during adolescence on arterial stiffness at 17 years. Methods and results: Smoking and alcohol use were assessed by questionnaires at 13, 15, and 17 years in 1266 participants (425 males and 841 females) from the ALSPAC study. Smoking status (smokers and non-smoker) and intensity ('high' ≥100, 'moderate' 20-99, and 'low or never' <20 cigarettes in lifetime) were ascertained. Participants were classified by frequency (low or high) and intensity of drinking [light (LI <2), medium (MI 3-9), and heavy (HI >10 drinks on a typical drinking day)]. Carotid to femoral pulse wave velocity (PWV) was assessed at 17 years [mean ± standard deviation and/or mean difference (95% confidence intervals)]. Current smokers had higher PWV compared with non-smokers (P = 0.003). Higher smoking exposure was associated with higher PWV compared with non-smokers [5.81 ± 0.725 vs. 5.71 ± 0.677 m/s, mean adjusted difference 0.211 (0.087-0.334) m/s, P = 0.001]. Participants who stopped smoking had similar PWV to never smokers (P = 0.160). High-intensity drinkers had increased PWV [HI 5.85 ± 0.8 vs. LI 5.67 ± 0.604 m/s, mean adjusted difference 0.266 (0.055-0.476) m/s, P = 0.013]. There was an additive effect of smoking intensity and alcohol intensity, so that 'high' smokers who were also HI drinkers had higher PWV compared with never-smokers and LI drinkers [mean adjusted increase 0.603 (0.229-0.978) m/s, P = 0.002]. Conclusion: Smoking exposure even at low levels and intensity of alcohol use were associated individually and together with increased arterial stiffness. Public health strategies need to prevent adoption of these habits in adolescence to preserve or restore arterial health.

Brain Natriuretic Peptide mediates the prognostic role of renal function toward 10-year cardiovascular mortality in patients with Acute Coronary Syndrome: the HHF study (2006-2016).

BACKGROUND/INTRODUCTION: Risk stratification in chronic heart failure (HF) remains a challenge. Renal function and B-natriuretic peptide (BNP) might confer predictive value towards long-term mortality in HF patients after an acute coronary syndrome (ACS). METHODS: From May 2006 to March 2009, 1,000 consecutive patients who were hospitalized with ACS diagnosis were enrolled in the study. In 2016, the 10-year follow-up (2006 -2016) was performed in 745 participants. GFR was evaluated through the MDRD formula. HF phenotype was defined according to baseline ejection fraction (EF); HF with reduced EF (i.e. <40%) (HFrEF), preserved EF (i.e. ≥50%) (HFpEF) and mid-range EF (i.e. 40 -49%) (HFmrEF). RESULTS: 10-year mortality was 21%. Deceased patients presented significantly lower GFR and higher BNP values at the baseline, compared with their alive counterparts (p <0.001 for both). By multivariable logistic regression analysis, GFR independently predicted all-cause mortality (OR = 0.98, p = 0.04). After adjusting for baseline BNP, GFR lost its predictive role while BNP was independently associated with 10-year mortality (OR = 1.39 for a 2-fold increase, p = 0.001). A significant interaction was observed between EF and BNP levels on the tested outcome (p for interaction < 0.001). In stratified analysis, BNP predicted all cause death only in HFmrEF (OR=1.43, p = 0.04) and in HFpEF (OR=1.80, p = 0.01). CONCLUSION: BNP mediates the predictive role of GFR towards long-term mortality in ACS-induced HF patients with retained systolic performance of the left ventricle (HFmrEF and HFpEF).

Total arterial compliance, estimated by a novel method, is better related to left ventricular mass compared to aortic pulse wave velocity: The SAFAR study.

AIM: The investigation of the association between total arterial compliance (CT)-estimated by a novel technique-with left ventricular mass (LVM) and hypertrophy (LVH). Our hypothesis was that CT may be better related to LVM compared to the gold-standard regional aortic stiffness. Within the frame of the ongoing cross-sectional study "SAFAR," 226 subjects with established hypertension or with suspected hypertension underwent blood pressure (BP) assessment, carotid-to-femoral pulse wave velocity (cf-PWV), and echocardiographic measurement of LVM. LVM index (LVMI) was calculated by the ratio of LVM to body surface area. CT was estimated by a previously proposed and validated formula: CT = 36.7 /cf-PWV2 [ml/mmHg]. LVMI was related to age (r = 0.207, p = 0.002), systolic BP (r = 0.248, p < 0.001), diastolic BP (r = 0.139, p = 0.04), mean BP (r = 0.212, p = 0.002), pulse pressure (r = 0.212, p = 0.002), heart rate (r = -0.172, p = 0.011), cf-PWV (r = 0.268, p < 0.001), and CT (r = -0.317, p < 0.001). The highest correlation was observed for CT that was significantly stronger than the respective correlation of cf-PWV (p < 0.001). In multivariate analysis, CT was a stronger determinant, compared to cf-PWV, of LVMI and LVH. It remains to be further explored whether CT has also a superior prognostic value beyond and above local or regional (segmental) estimates of pulse wave velocity.

Vitamins in Heart Failure: Friend or Enemy?

BACKGROUND: The failing heart is characterized by a depleted metabolic energy reserve and the upregulation of several molecular mechanisms leading to cardiac hypertrophy, inflammation, fibrosis, angiogenesis, and apoptosis. Dietary or non-dietary supplementation of vitamins could potentially benefit energy balance. OBJECTIVE: The objective of the present study was to evaluate all available information on vitamins supplementation in patients with chronic HF for possible beneficial effect on metabolic, inotropic, chronotropic and hemodynamic indices. METHOD: We searched MEDLINE via Pubmed by using the following terms: "chronic heart failure" OR "cardiomyopathy" AND "vitamins", "vitamin A", "B complex vitamins", "vitamin C", "ascorbic acid", "vitamin D", "retinol", "vitamin E", "thiamine", "riboflavin", "niacin", "pyridoxine", "cobalamin", "folate", "pantothenic acid", "biotin", "tocopherol" and combinations of them. RESULTS: Data regarding supplementation of micronutrients in HF for most vitamins were sparse, and the inference about cardiovascular outcomes was obscured by the heterogeneity of studies, high inherent morbidity, and mortality of this group of high-risk patients, limited sample sizes in certain studies, unclear design and lack of head to head comparisons. Most vitamins in human trials failed to offer survival, or robust beneficial effect. Mostly indirect favorable evidence is derived from patients with deficiencies of certain micronutrients rather than their ad hoc supplementation. CONCLUSION: While vitamins and micronutrients are promising compounds for optimizing myocardial metabolism and homeostasis in HF, additional randomized clinical trials of larger scale are warranted to demonstrate the benefits of their supplementation in this high risk group of patients.

Comparison of prognostic risk scores after successful primary percutaneous coronary intervention.

BACKGROUND: The aim of this study was to compare the predictive ability of clinical risk scores (ACEF, EuroSCORE and EuroSCORE II) to angiographic (SYNTAX score) and combined risk scores (Global Risk Score and Clinical SXscore) towards cardiovascular death and/or major adverse cardiac events (MACE) in patients with ST-segment elevation acute myocardial infarction (STEMI) managed with primary percutaneous coronary intervention (pPCI). METHODS: A total of 685 patients successfully treated with pPCI were evaluated and the risk scores were calculated. The primary endpoint was the 2-year incidence of fatal cardiac events. Secondary end points were target lesion failure (TLF), repeat revascularization (RR) and MACE. RESULTS: Patients distributed in the highest tertile of EuroSCORE II presented increased rates of CV death (CVD), all-cause mortality and MACE (p<0.001 for all). EuroSCORE II was associated with increased C-statistics (0.873, 95% CIs: 0.784-0.962 and 0.825, 95% CIs: 0.752-0.898 respectively) for predicting CVD and MACE over competing risk scores (p<0.05). EuroSCORE II conferred incremental discrimination (Harrell's C, p<0.05 for all, apart from CSS for predicting CVD) and reclassification value (Net Reclassification Index, p<0.05 for all, apart from CSS for reclassifying MACE) over alternative risk scores for study's main endpoints. EuroSCORE II independently predicted CVD (HR=1.06, 95% CIs: 1.03-1.09, p<0.001) and MACE (HR=1.07, 95% CIs: 1.04-1.10, p<0.001). CONCLUSION: EuroSCORE II has the best predictive ability of CVD and/or MACE after successful pPCI for the treatment of STEMI.

Cryoballoon ablation of atrial fibrillation: a practical and effective approach.

Medical management of atrial fibrillation (AF), the most common arrhythmia in the general population, has had modest efficacy in controlling symptoms and restoring and maintaining sinus rhythm. Since the seminal observation in 1998 that pulmonary veins host the triggers of AF in the majority of cases, electrical isolation of all pulmonary veins constitutes the cornerstone of ablation in patients with symptomatic AF. However, due to the elaborate and tedious technique of the conventional point-by-point method with radiofrequency ablation guided by electroanatomical mapping, newer, more versatile single-shot techniques, such as cryoballoon ablation, have been sought and developed over recent years and are progressively prevailing. Cryoballoon ablation appears to be the most promising practical and effective approach, and we review it here by presenting all available relevant data from the literature as well as from our own experience in an attempt to apprise colleagues of the significant progress made over the last several years in this important field of electrophysiology.

Effect of left ventricular pacing mode and site on hemodynamic, torsional and strain indices.

INTRODUCTION: Several reports have indicated that left ventricular (LV) lead placement at an optimal pacing site is an important determinant of short- and long-term outcome. This study investigated the effect of pacing mode (atrioventricular [AV] or ventricular) and site (LV apical or lateral) outside the ischemic region on the LV hemodynamic, torsional and strain indices in the ischemic myocardium. METHODS: Experiments were conducted in anesthetized open-chest pigs (n = 15) 30 min after LAD ligation to investigate the hemodynamic effects of temporary epicardial AV and ventricular LV pacing at the LV apical (outside the ischemic region) or lateral wall. LV hemodynamic data were recorded (ejection fraction, stroke volume, dP/dtmax, systolic pressure, cardiac output and e/e΄ ratio) and torsional (twist, rotation), as well as deformation (radial and circumferential strain), indices of LV function were assessed using two-dimensional speckle tracking imaging. RESULTS: The LV function was highly dependent on the pacing mode and site. LV dP/dtmax, systolic pressure and twist decreased significantly during LV pacing in comparison to sinus rhythm (p = 0.004, p<0.001, p = 0.002, respectively). Torsion in sinus rhythm decreased significantly during AV-pacing at the lateral wall (0.11±0.04°/mm vs. 0.06±0.02°/mm, p = 0.005) but did not change significantly during AV-pacing at the apex (0.07±0.05°/mm). CONCLUSIONS: LV pacing at the apical or lateral wall, in the ischemic myocardium, leads to a suboptimal response in comparison to sinus rhythm. LV pacing at the apex outside the ischemic area exhibits a better response than pacing at the lateral wall, possibly because pacing from this site leads to a more physiological propagation of electrical conduction.

Environment and cardiovascular disease: rationale of the Corinthia study.

Environmental factors constitute an important but underappreciated risk factor towards the development and progression of cardiovascular disease (CVD). Environmental exposure to variable pollutants is implicated in the derangement or propagation of adverse pathophysiological processes linked with atherosclerosis, including genetic, hemodynamic, metabolic, oxidative and inflammation parameters. However, no data exist on environmental pollution in rural or semi-rural areas. Therefore, the purpose of the "Corinthia" study is to examine the impact of environmental pollution in indices of cardiovascular morbidity and mortality in a cross-sectional and longitudinal design. The Corinthia study began in October 2015 and is planned to recruit 1,500 individuals from different regions of Corinthia country with different environmental exposures to pollutants and different patterns of soil/ground and/or air pollution until December 2016. Baseline measurements will include lifestyle measurements, anthropometric characteristics and a comprehensive cardiovascular examination. The follow-up is planned to extend prospectively up to 10 years and this study is anticipated to provide valuable data on the distinct impact of soil and air pollution on early markers of atherosclerosis and cardiovascular disease and on the overall impact of environment pollution to cardiovascular morbidity and mortality.

Short term omega-3 polyunsaturated fatty acid supplementation induces favorable changes in right ventricle function and diastolic filling pressure in patients with chronic heart failure; A randomized clinical trial.

INTRODUCTION: Omega-3 polyunsaturated fatty acids (omega 3-PUFAs) seem to favorably affect cardiac hemodynamics and may benefit the clinical course of heart failure patients. The role of omega 3-PUFAs supplementation on the left and right ventricular function of patients with chronic compensated systolic heart failure, under optimal treatment, was studied. METHODS: 205 consecutive patients with chronic compensated heart failure, due to ischemic (IHF) or dilated cardiomyopathy (DCM)-NYHA classification I-III, under optimal medical treatment, were enrolled. Participants were 1-to-1 randomized on 1000 mg omega 3-PUFA supplementation or no supplementation, in a non-blinded fashion. Echocardiographic assessment was performed at first visit and 6 months after. Plasma BNP and serum creatinine levels were also measured. RESULTS: As compared with the control group, BNP levels in omega 3-PUFA intervention group were 34.6% lower (p=0.001); end-diastolic and end-systolic left ventricle dimensions were decreased by 2.5% (p=0.047) and 3.7% (p=0.01), maximum diameter of left atrium was decreased by 8.4% (p=0.004), left atrium ejection fraction was ameliorated by 6.03% (p=0.021) and as regards tissue Doppler parameters, TDI_Etv/Atv was decreased in omega 3-PUFA intervention group by 6.3% (p=0.038). Moreover, improvement in diastolic indices was more prominent in subjects with DCM as compared to IHF patients. CONCLUSION: Omega 3-PUFA supplementation was associated with improved left diastolic function and decreased BNP levels in patients with chronic heart failure. These findings suggest a beneficial role of omega 3-PUFAs on the hemodynamic course of patients with systolic heart failure.

Metabolic syndrome, independent of its components, affects adversely cardiovascular morbidity in essential hypertensives.

BACKGROUND: The metabolic syndrome (MS) is widespread among hypertensive patients. However, the net impact of MS on major atherosclerotic events beyond the cardiovascular risk imposed by its individual components remains controversial in this group. We sought to assess both the independent and incremental prognostic role of MS for unfavorable cardiovascular events in a cohort of essential hypertensives. METHODS: We followed up 2176 essential hypertensives free of cardiovascular disease for a median period of 40 months. All subjects had at least one annual visit. MS was defined according to the updated NCEP III criteria. Endpoint of interest was the incidence of stroke, coronary artery disease (CAD) and their composite. RESULTS: MS was present at baseline in 819 hypertensives (37.6%). MS group presented increased prevalence of resistant hypertension in comparison to MS free group (18.4% versus 10.6%, p < 0.001). The incidence of the composite end-point was 3.1% (69 events) across the follow-up period. Patients with MS were more likely to experience major adverse cardiovascular events (MACE) in comparison to reference category (3.7% versus 1.9%, log rank p = 0.024). While MS was an independent predictor for MACE, none of the individual components of the syndrome was associated independently with the endpoint. MS provided incremental discriminative value (Harrell's c, p < 0.05 for all) over individual risk factors for the incidence of MACE. CONCLUSIONS: MS predicts adverse cardiovascular events in hypertensives incrementally of its individual components. Early identification of MS in this population may enable more accurate prediction of future cardiovascular risk and could implement more efficient strategies in terms of primary prevention.