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BACKGROUND: Hybrid-convergent radiofrequency (RF) ablation targeting pulmonary veins (PVs) and left atrial posterior wall (LAPW) has shown better arrhythmic outcomes than an endocardial-only RF strategy, despite higher rates of complications. Comparisons with extensive pulsed field ablation (PFA) are currently lacking. OBJECTIVES: This study aimed to compare the efficacy and safety of the hybrid-convergent RF vs PFA of PVs and LAPW in long-standing persistent atrial fibrillation (LSPAF). METHODS: Ninety-three consecutive LSPAF patients, treated with 2-step hybrid-convergent RF ablation (hybrid group, n = 49) or with PFA of PVs and LAPW (PFA group, n = 44) were enrolled. Primary efficacy endpoint was defined as any atrial tachyarrhythmias (ATA) recurrence after the 3-month blanking period, over a follow-up time of 12 months. Periprocedural adverse events and late complications during follow-up were deemed primary safety outcomes. RESULTS: The hybrid and PFA groups had similar baseline characteristics; mean age was hybrid 63.8 ± 10.6 years vs PFA 66.0 ± 7.4 years; P = 0.105. PV and LAPW ablation were acutely successful in all patients. Step 1 hybrid-epicardial procedures were longer than PFA (166 [Q1-Q3: 140-205] minutes vs 107.5 [Q1-Q3: 82.5-12] minutes; P < 0.01). At 12-month follow-up, there was no difference in ATA recurrences between groups (hybrid 36.7% vs PFA 40.9%; P = 0.680; log-rank at survival analysis P = 0.539). After adjusting for confounders, a larger left atrial volume and recurrences during the blanking-period were predictors of ATA recurrences after ablation, regardless of procedural technique employed. PFA showed a better safety profile with a lower rate of major periprocedural complications compared with hybrid ablation (12% vs 0%; P = 0.028). CONCLUSIONS: Hybrid-convergent and PFA share comparable arrhythmic outcomes in LSPAF, but hybrid-convergent ablation carries higher periprocedural risks.
Assuntos
Fibrilação Atrial , Ablação por Cateter , Veias Pulmonares , Humanos , Fibrilação Atrial/cirurgia , Masculino , Pessoa de Meia-Idade , Feminino , Idoso , Ablação por Cateter/métodos , Ablação por Cateter/efeitos adversos , Veias Pulmonares/cirurgia , Resultado do Tratamento , Recidiva , Átrios do Coração/cirurgia , Átrios do Coração/fisiopatologiaRESUMO
AIMS: Patients with coronary heart disease (CHD) are at very high risk of recurrent events. A strategy to reduce excess risk might be to deliver structured secondary prevention programmes, but their efficacy has been mostly evaluated in the short term and in experimental settings. This is a retrospective case-control study aimed at assessing, in the real world, the efficacy of a secondary prevention programme in reducing long-term coronary event recurrences after coronary artery bypass surgery (CABG). METHODS AND RESULTS: Programme participants (henceforth 'cases') were men and women aged <75 years subjected to CABG between 2002 and 2014, living within 100 km of the hospital. Key programme actions included optimization of treatments according to the most updated European preventive guidelines, surveillance of therapy adherence, and customized lifestyle counselling. Controls were analogous patients not involved in the programme because living farther than 100 km away, matched 1:1 with cases for gender, age at CABG, and year of CABG. Both groups (n = 1248) underwent usual periodic cardiology follow-up at our centre. Data on symptomatic or silent CHD recurrences were obtained from the hospital electronic health records. Cox analysis (adjusted for baseline differences between groups) shows that programme participation was associated with a significantly lower incidence throughout 5 years post-CABG of symptomatic [hazard ratio (95% confidence interval): 0.59 (0.38-0.94)] and silent [0.53 (0.31-0.89)] coronary recurrences. CONCLUSION: In a real-world setting, taking part in a structured longstanding secondary prevention programme, in addition to usual cardiology care, meaningfully lowers the risk of coronary recurrences.
Assuntos
Doenças Cardiovasculares , Doença da Artéria Coronariana , Doenças Cardiovasculares/etiologia , Estudos de Casos e Controles , Ponte de Artéria Coronária/efeitos adversos , Doença da Artéria Coronariana/etiologia , Doença da Artéria Coronariana/cirurgia , Feminino , Humanos , Masculino , Recidiva , Estudos Retrospectivos , Prevenção Secundária , Resultado do TratamentoRESUMO
BACKGROUND: The Ozaki procedure is an innovative surgical technique aiming at the reconstruction of the aortic valve with autologous pericardium to overcome the limitations of commercially available prostheses. METHODS: We retrospectively analyzed 71 patients who underwent the Ozaki operation at our center between October 2014 and February 2020. RESULTS: No in-hospital death occurred. Freedom from major adverse valve-related events was 97%. The aortic gradients and transvalvular velocity were significantly lower at the 3-month echocardiographic control than at the predischarge echocardiography (10.93 ± 5.38, P < .01 vs 16.24 ± 7.67, P < .01, respectively). The median follow-up period was 20.7 months (range, 2 to 47). Four patients showed mild/moderate aortic insufficiency (5.6%), and none showed severe aortic valve insufficiency. No patients underwent reoperation. CONCLUSIONS: Midterm outcome follow-up of the Ozaki procedure showed optimal results in terms of mortality, transaortic valve gradients, freedom from major adverse valve-related events, and recurrence of aortic valve insufficiency.
Assuntos
Valvopatia Aórtica/cirurgia , Implante de Prótese de Valva Cardíaca/métodos , Pericárdio/transplante , Adulto , Idoso , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo , Transplante Autólogo , Resultado do TratamentoRESUMO
BACKGROUND: The Ozaki procedure is an innovative surgical technique aiming at the reconstruction of the aortic valve with autologous pericardium to overcome the limitations of commercially available prostheses. METHODS: We retrospectively analysed 71 patients who underwent Ozaki operation at our centre between October 2014 and February 2020. RESULTS: No in-hospital death occurred. Freedom from major adverse valve-related events (MAVRE) was 97%. The aortic gradients and transvalvular velocity are significantly lower at the 3-months echocardiographic control than at the pre-discharged echocardiography (10.93 ± 5.38, p= 0,0003 vs 16.24 ± 7.67 p= 0,0004 respectively). The median follow-up period was 20.7 months (range 2 to 47 months). Four patients showed mild/moderate aortic insufficiency (5.6%) and none showed severe aortic valve insufficiency. No patients underwent reoperation. CONCLUSIONS: Mid-term outcome follow-up of Ozaki procedure showed optimal results in term of mortality, transaortic valve gradients, freedom from MAVRE and recurrence of aortic valve insufficiency.
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Swan-Ganz catheter entrapment in the heart, vena cava, or pulmonary artery is rare but may lead to life-threatening events. We report a case of severe tricuspid regurgitation resulting from papillary muscle rupture during percutaneous removal of a Swan-Ganz catheter (SCG) caught by a surgical suture. We performed urgent tricuspid valve repair by suturing the ruptured papillary muscle. This report highlights preventive measures to avoid suture-related entrapment and raises a word of caution regarding percutaneous removal of accidentally entrapped SCGs.
Assuntos
Cateterismo de Swan-Ganz/efeitos adversos , Cateterismo de Swan-Ganz/instrumentação , Remoção de Dispositivo , Suturas/efeitos adversos , Insuficiência da Valva Tricúspide/etiologia , Insuficiência da Valva Tricúspide/cirurgia , Idoso , Feminino , Humanos , Músculos Papilares/cirurgia , Insuficiência da Valva Tricúspide/diagnósticoRESUMO
Saphenous vein (SV) graft disease represents an unresolved problem in coronary artery bypass grafting (CABG). After CABG, a progressive remodelling of the SV wall occurs, possibly leading to occlusion of the lumen, a process termed 'intima hyperplasia' (IH). The investigation of cellular and molecular aspects of IH progression is a primary end-point toward the generation of occlusion-free vessels that may be used as 'life-long' grafts. While animal transplantation models have clarified some of the remodelling factors, the pathology of human SV is far from being understood. This is also due to the lack of devices able to reproduce the altered mechanical load encountered by the SV after CABG. This article describes the design of a novel ex vivo vein culture system (EVCS) capable of replicating the altered pressure pattern experienced by SV after CABG, and reports the results of a preliminary biomechanical conditioning experimental campaign on SV segments. The EVCS applied a CAGB-like pressure (80-120 mmHg) or a venous-like perfusion (3 ml/min, 5 mmHg) conditioning to the SVs, keeping the segments viable in a sterile environment during 7 day culture experiments. After CABG-like pressure conditioning, SVs exhibited a decay of the wall thickness, an enlargement of the luminal perimeter, a rearrangement of the muscle fibres and partial denudation of the endothelium. Considering these preliminary results, the EVCS is a suitable system to study the mechanical attributes of SV graft disease, and its use, combined with a well-designed biological protocol, may be of help in elucidating the cellular and molecular mechanisms involved in SV graft disease.
Assuntos
Pressão , Veia Safena/fisiologia , Técnicas de Cultura de Tecidos/instrumentação , Técnicas de Cultura de Tecidos/métodos , Idoso , Automação , Imunofluorescência , Humanos , Técnicas In Vitro , Reprodutibilidade dos TestesRESUMO
Saphenous vein graft disease is a timely problem in coronary artery bypass grafting. Indeed, after exposure of the vein to arterial blood flow, a progressive modification in the wall begins, due to proliferation of smooth muscle cells in the intima. As a consequence, the graft progressively occludes and this leads to recurrent ischemia. In the present study we employed a novel ex vivo culture system to assess the biological effects of arterial-like pressure on the human saphenous vein structure and physiology, and to compare the results to those achieved in the presence of a constant low pressure and flow mimicking the physiologic vein perfusion. While under both conditions we found an activation of Matrix Metallo-Proteases 2/9 and of microRNAs-21/146a/221, a specific effect of the arterial-like pressure was observed. This consisted in a marked geometrical remodeling, in the suppression of Tissue Inhibitor of Metallo-Protease-1, in the enhanced expression of TGF-ß1 and BMP-2 mRNAs and, finally, in the upregulation of microRNAs-138/200b/200c. In addition, the veins exposed to arterial-like pressure showed an increase in the density of the adventitial vasa vasorum and of cells co-expressing NG2, CD44 and SM22α markers in the adventitia. Cells with nuclear expression of Sox-10, a transcription factor characterizing multipotent vascular stem cells, were finally found in adventitial vessels. Our findings suggest, for the first time, a role of arterial-like wall strain in the activation of pro-pathologic pathways resulting in adventitial vessels growth, activation of vasa vasorum cells, and upregulation of specific gene products associated to vascular remodeling and inflammation.
Assuntos
Túnica Adventícia/crescimento & desenvolvimento , Ponte de Artéria Coronária/efeitos adversos , Veia Safena/citologia , Veia Safena/crescimento & desenvolvimento , Células-Tronco/citologia , Estresse Mecânico , Fenômenos Biomecânicos , Circulação Sanguínea , Células Cultivadas , Constrição Patológica/etiologia , Regulação da Expressão Gênica , Humanos , MicroRNAs/genética , Complicações Pós-Operatórias/genética , Complicações Pós-Operatórias/patologia , Complicações Pós-Operatórias/fisiopatologia , RNA Mensageiro/genética , RNA Mensageiro/metabolismo , Veia Safena/metabolismo , Veia Safena/fisiologiaAssuntos
Ponte de Artéria Coronária/métodos , Artérias Torácicas/transplante , Adulto , Idoso , Angiografia Coronária , Ponte de Artéria Coronária/instrumentação , Reutilização de Equipamento , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Reoperação , Grau de Desobstrução VascularRESUMO
BACKGROUND: This study was undertaken to compare the in vitro effects of 17beta-estradiol on human epicardial coronary arteries, resistance coronary arteries and on arterial vessels usually employed as grafts in surgical myocardial revascularization. METHODS: Coronary artery rings (descending coronary artery, right coronary artery, circumflex coronary artery, first septal branch) and arterial graft rings (internal thoracic artery, gastro-epiploic artery) obtained from human heart donors with heart not suitable to cardiac transplantation were connected to force transducer for isometric force recording. Precontracted specimens with and without endothelium were exposed to increasing concentration of 17beta-estradiol (3-30-300-3000 nmol/l) and to vehicle (0.1% v/v ethanol). We also evaluated the effects of 17beta-estradiol on vessels before and 20 minutes after exposure to L-monomethyl-arginine and indomethacin. RESULTS: 17beta-estradiol induced a significant relaxation in all precontracted vessels (mean maximum effect: 78,6% +/- 8,5). This effect was not different among the different rings and was not related to the presence of endothelium. N-monomethyl-L-arginine and indomethacin did not modify 17beta-estradiol relaxant effect. CONCLUSION: The vasodilator action of the 17beta-estradiol is similar on coronary arteries, resistance coronary arteries and arterial vessels usually employed as grafts in myocardial revascularization.
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BACKGROUND: Reduction ascending aortoplasty is an alternative procedure to the replacement of the ascending aorta in case of ascending aorta aneurysm without aortic root involvement. This study was designed to evaluate the midterm follow-up of aortoplasty and to determine predictors of redilatation. METHODS: From January 1, 1998, to April 30, 2005, 68 patients with dilatation of the ascending aorta underwent unsupported reduction aortoplasty in combination with other cardiac procedures. All patients underwent associated surgical procedures. Sixty patients (88.2%) underwent associated aortic valve replacement. Cumulative follow-up time was 191.4 patient-years and was 100% complete. Median follow-up time was 2.5 years, and mean follow-up time was 2.9 +/- 1.7 years (range, 0.4 to 6.3 years). RESULTS: The overall perioperative mortality rate was 1.5%. Overall survival estimates at 3 and 6 years were 93.3% +/- 4.5% and 89.3% +/- 5.9%, respectively. The actuarial freedom from cardiac-related death at 3 and 6 years was 100% and 95.7% +/- 4.3%, respectively. Ascending aorta redilatation occurred in 5 patients (7.5%). The actuarial freedom from redilatation at 3 and 6 years was 97.7% +/- 2.3% and 79.8% +/- 8.4%, respectively. The actuarial freedom from reoperation at 3 and 6 years was 100% and 86.3% +/- 7.5%, respectively. Only preoperative diameter was a significant predictor of redilatation using multivariate stepwise logistic regression analysis. CONCLUSIONS: Unsupported reduction aortoplasty is a safe and effective technique with low mortality, low morbidity, and rare late complications for selected chronic aneurysm of the ascending aorta with diameter less than 55 mm.