Minimally Invasive Extracorporeal Bypass in Minimally Invasive Heart Valve Operations: A Prospective Randomized Trial.

BACKGROUND: Minimally invasive extracorporeal circulation (MECC) is predominantly used in coronary operations. Data supporting the benefits of MECC in minimally invasive valve operations are still absent. METHODS: Patients undergoing either isolated minimally invasive mitral or aortic valve procedures were prospectively randomized to a minimally invasive group (MECC; n = 101) or a conventional extracorporeal circulation group (CECC; n = 99). The procedural and postoperative outcomes were compared, including the levels of inflammation factors (procalcitonin, interleukin [IL]-6, IL-8, and IL-10), tumor necrosis factor-α [TNF-α], and interferon-gamma [IFN-γ]). RESULTS: The demographics were comparable between the groups regarding age (MECC versus CECC, 70.5 ± 10.2 years versus 73.1 ± 8.9 years; P = 0.086), left ventricular function (59.2% ± 13.4% versus 62.1% ± 14.0%; p = 0.302), EuroSCORE (7.4% ± 7.9% versus 6.8% ± 4.0%; p = 0.256), and other comorbidities. Hospital mortality (n = 1 versus n = 3; p = 0.339) and other complications were similar. However, hemoglobin level (111.9 ± 19.0 g/L versus 103.8 ± 14.6 g/L; p = 0.001), the number of packed red blood cells (PRBCs) (1.1 ± 1.9 versus 1.7 ± 1.8; p = 0.003), the levels of ILs (IL-6, 194.0 ± 131.8 pg/mL versus 289.2 ± 62.5 pg/mL; p = 0.020; IL-8, 38.1 ± 27.3 pg/mL versus 45.8 ± 43.4 pg/mL; p = 0.012; IL-10, 29.0 ± 123.9 pg/mL versus 49.9 ± 85.6 pg/mL; p = 0.012), TNF-α (3.8 ± 6.7 ng/mL versus 10.8 ± 47.7 ng/mL; p = 0.049), and IFN-γ (1.9 ± 1.9 pg/mL versus 4.5 ± 2.7 pg/mL; p = 0.027) were in favor of patients in the MECC group. Additionally, those patients had shorter postoperative ventilation time (7.7 ± 8.4 hours versus 9.3 ± 12.9 hours; p = 0.010) and intensive care unit (ICU) stay (1.2 ± 1.2 days versus 2.2 ± 3.8 days; p = 0.047). CONCLUSIONS: The intraprocedural data were excellent and comparable in the groups, but postoperative outcomes were better in the MECC group. Thus MECC is preferable to CECC even for minimally invasive valve procedures. These findings strongly support a combined strategy of minimally invasive valve operations and minimally invasive extracorporeal circulation.

Acetylcholine-induced coronary spasm in patients with unobstructed coronary arteries is associated with elevated concentrations of soluble CD40 ligand and high-sensitivity C-reactive protein.

OBJECTIVES: To assess whether epicardial and microvascular coronary artery spasm in response to acetylcholine (ACH) is associated with markers of inflammation, platelet stimulation, and endothelial activation in patients with angina and unobstructed coronary arteries. BACKGROUND: Patients with angina pectoris despite angiographically normal coronary arteries represent a diagnostic and therapeutic challenge. Both impaired coronary microvascular dilatory responses as well as diffuse distal epicardial and microvascular coronary artery spasm have been described as possible pathogenic mechanisms. Although inflammation has been proposed to play a pathogenic role in angina, an association between ACH-induced coronary vasospasm and inflammation in Caucasians has not been reported previously in this context. PATIENTS AND METHODS: We assessed 62 consecutive patients (26 men, age 60±10 years) with chest pain despite angiographically unobstructed coronary arteries (<50% stenosis) who underwent intracoronary ACH testing for the diagnosis of coronary artery spasm. High-sensitivity C-reactive protein (hs-CRP), e-selectin, neopterin, and sCD40L concentrations were measured in all patients before ACH testing. The ACH test was considered to be 'positive' in the presence of (a) angina and at least 75% coronary diameter reduction (epicardial coronary artery spasm) or (b) ischemic ST-shifts and angina in the absence of epicardial spasm (microvascular spasm). Eight patients without angina pectoris served as a control group. RESULTS: The ACH test was positive in 48 patients (77%). Twenty-seven patients had epicardial spasm (56%) and 21 patients had microvascular spasm (44%). Epicardial spasm was diffuse in 26 patients (96%) and focal in one patient (4%). Elevated hs-CRP, e-selectin, and sCD40 ligand concentrations were significantly (P≤0.05) associated with a positive ACH-test response. Hs-CRP (odds ratio 1.54, confidence interval 1.02-2.33, P=0.04) and sCD40 ligand (odds ratio 1.001, confidence interval 1.00-1.001, P=0.003) were predictors for a positive ACH test on multivariate analysis. None of the patients in the control group developed epicardial or microvascular spasm during ACH testing. CONCLUSION: Epicardial and microvascular coronary spasm in response to ACH correlate significantly with hs-CRP and sCD40 ligand concentrations in patients with angina pectoris and angiographically unobstructed coronary arteries. These results suggest that an association exists between inflammation and coronary artery spasm in patients with angina pectoris despite unobstructed coronary arteries and studies are needed to explore the mechanisms underlying this association.

Severe hyperphosphatemia in a patient with chronic kidney disease and multiple myeloma-to strengthen the case toward renal replacement therapy?

KEY CLINICAL MESSAGE: We report a patient with multiple myeloma and chronic kidney disease who presented with severe hyperphosphatemia in the outpatient clinic without any related symptoms. Initial differential diagnosis: Tumor lysis syndrome or chronic kidney disease. Further work-up revealed pseudohyperphosphatemia. In general, treatment is not necessary if the true phosphate level is within the reference range and the patient is asymptomatic.

Caucasian patients suffering from coronary vasospastic angina have an intact peripheral endothelium-dependent vasoreactivity.

We sought to evaluate whether Caucasian patients suffering from vasospastic angina have a decreased brachial artery flow-mediated dilation (FMD) like their Japanese counterparts and whether certain serum factors known to be associated with impaired vasomotility or endothelial dysfunction are abnormal. In this prospectively conducted study, 33 subjects presenting with resting angina were identified to suffer from coronary vasospastic angina (coronary spasm group). A control group of 19 subjects with matched cardiovascular risk profiles was defined out of patients admitted to our hospital for evaluation of atypical chest pain. Intracoronary acetylcholine(ACh)-testing for vasospasm was performed in all patients after coronary artery disease (CAD) had been ruled out. Brachial artery FMD was measured using high-resolution ultrasound. There was no significant difference in brachial artery FMD between the coronary spasm and the control group (7.05+/-2.24% vs. 7.12+/-2.50%; p=0.93). The endothelium-independent vasodilator response of the brachial artery to sublingual nitroglycerin did not differ either between the two groups (21.88+/-6.13% vs. 21.48+/-7.38%; p=0.84). Simple and multiple linear regression analysis revealed that only baseline brachial artery diameter was a significant determinant of FMD (p<0.0001). No relationship could be detected between impaired coronary vasomotility and peripheral endothelium-dependent or independent vasodilation in Caucasian patients suffering from coronary vasospastic angina illustrating a further clue for racial differences in the pathophysiology of vasospastic angina.