Flurbiprofen in the subglottic space to prevent postoperative sore throat after cardiac surgery: A randomized double-blind study.

STUDY OBJECTIVE: Postoperative sore throat (POST) and hoarseness are common complications of tracheal intubation. This study aims to evaluate the efficacy of flurbiprofen administered through the subglottic port of tracheal tubes to prevent POST after cardiac surgery. DESIGN: Single-center, prospective, randomized, double-blind, placebo-controlled trial. SETTING: Tertiary Care Referral University Hospital (Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome). PATIENTS: Included 71 patients undergoing for elective cardiac surgery. Inclusion criteria were (a) age between 50 and 75 years, (b) NYHA class I or II, (c) surgery for myocardial revascularization or valve repair or replacement under cardiopulmonary bypass. INTERVENTION: Patients were double blind randomized to receive flurbiprofen or saline in the subglottic port of the endotracheal tube (groups F and P). The solution was injected ten minutes after tracheal tube placement, ten minutes after ICU admission and ten minutes before tracheal tube removal. MEASUREMENTS: The primary outcome was to assess the effect of topical flurbiprofen administered through the subglottic port of the tracheal tube to prevent post-operative sore throat (POST). The secondary outcomes were the presence of hoarseness safety and patient's subjective satisfaction with their recovery. We did not report any exploratory outcomes. MAIN RESULTS: We analyzed 68 patients, 34 patients in each group. In group F, two patients complained of POST and hoarseness (5.9%), while all controls did. The two groups significantly differed in the severity scores (VAS and TPS for sore throat and HOAR for hoarseness) at all time points. In group P, patients reported mild to moderate symptoms that significantly improved or disappeared 36 h after tracheal tube removal. According to the multivariable model, hoarseness affected women less than men, in the control group (p = 0.002). None of the patients in either group reported any adverse effects. CONCLUSIONS: Repeated administration of flurbiprofen through the subglottic port of tracheal tubes reduced the incidence of sore throat and hoarseness after cardiac surgery without evidence of complications.

Comparison of De-Kay repair versus De Vega suture for functional tricuspid regurgitation: a preliminary experience.

BACKGROUND: In patients undergoing mitral valve surgery, restrictive suture annuloplasty (De Vega) for less-than-severe functional tricuspid regurgitation has been proven to be safe and effective. The aim of this study is to determine whether the adjunct of the plication of the posterior tricuspid leaflet with the same running suture (bicuspidized De Vega or "De Kay") is equally safe and effective. METHODS: Single center, retrospective study on patients submitted to suture repair of the tricuspid valve during mitral valve surgery, with either conventional or De Kay, between January 2014 and December 2020. Comparison was based on degree of residual tricuspid valve regurgitation and right ventricular assessment at discharge. RESULTS: Over the course of the study period, 255 patients undergoing mitral valve surgery had a dilated (>40 mm or >20 mm/m2) tricuspid valve annulus, with less-than-severe tricuspid regurgitation. Conventional De Vega was employed in 166 patients (65.1%) and De Kay in the remaining 89 (34.9%). At discharge the adjunct of postero-septal commissure plication has similar outcomes to the classic De Vega repair. It seems to preserve right ventricular function. CONCLUSIONS: De Kay repair guarantees the same tricuspidal regurgitation reduction as compared with conventional De Vega early after surgery.

Two innovative aortic bioprostheses evaluated in the real-world setting. First results from a two-center study.

BACKGROUND: The increasing use of biological substitutes for surgical aortic valve replacement (AVR), has led to the development of new bioprostheses with improved hemodynamics and expected durability. METHODS: In this observational retrospective two-center cohort study, two innovative bioprostheses, INSPIRIS Resilia and AVALUS were analyzed. We analyzed early and 2.4-year follow-up results in terms of safety, clinical outcome and hemodynamic performance. RESULTS: From November 2017 to February 2021, 148 patients underwent AVR with INSPIRIS Resilia (N.=74) or AVALUS (N.=74) bioprosthesis. The 30-day and mid-term mortality was comparable (1% vs. 3%, P=0.1 and 7% vs. 4%, P=0.4, respectively). Valve-related mortality was observed in one AVALUS patient. Three (4%) patients of the AVALUS group developed prosthetic endocarditis and two of them died after reoperation. No other cases of prosthetic endocarditis were observed. No cases of structural valve degeneration or significant paravalvular leak were detected at follow-up. Median follow-up peak pressure gradient was 21 vs. 23 mmHg (P=0.4) and the mean pressure gradient was 12 vs. 13 mmHg (P=0.9) for Inspiris and AVALUS, respectively. The effective orifice area (EOA) and indexed EOA were 1.5 cm2 vs. 1.4 cm2 (P=0.4) and 0.8 vs. 0.7 cm2/m2 (P=0.5), respectively. Indexed left ventricular mass regression was -33 vs. -52 g/m2 for the Inspiris and AVALUS groups, respectively, (R2-adjusted =0.14; P<0.01). CONCLUSIONS: INSPIRIS Resilia and AVALUS bioprostheses were reliable with comparable results in safety, clinical outcome and hemodynamic performance. After statistical adjustment, AVALUS was associated with better left ventricular mass reduction. Long-term follow-up would provide definitive comparative results.

Single shot of intravenous iron in cardiac surgery: The ICARUS study.

BACKGROUND: Iron deficiency (ID), with or without anemia, is commonly observed among patients scheduled for cardiac surgery. We investigated if screening ID in the immediate preoperative period and treating ID patients regardless of anemia could reduce perioperative transfusion requirements. METHODS: This is an observational single-center propensity score-matched study including candidates to elective cardiac surgery prospectively and retrospectively enrolled. Prospectively enrolled patients were screened for ID at hospital admission: if ferritin was ≤100 µg/L or ≤ 300 µg/L with transferrin saturation index ≤20% they received intravenous ferric carboxymaltose, B12-vitamin, and folic acid. A retrospective series of patients not screened for ID and matched for gender, type of surgery, BMI, Goudie transfusion risk score, hemoglobin level, and red blood cell (RBC) indices, served as controls. The primary outcome was the proportion of patients requiring ≤1 packed RBC (pRBC) unit within day 7 or discharge The main secondary outcomes were intraoperative and postoperative pRBC transfusions, duration of hospitalization, and cost-effectiveness of ID screening and treatment. RESULTS: We included 479 prospective and 833 retrospective cases: 442 patients screened for ID and 442 matched controls with unknown iron status were analyzed. ID was observed in 196 patients (44.3%) and iron was administered 1 day (IQR 1-2) before surgery. Overall, 76.9% of patients in the prospective group and 69.7% of controls received ≤1 pRBC transfusion (p = 0.014). The risk for multiple transfusions was lower in patients screened for ID (OR 0.689, 95% CI 0.510-0.930). Despite similar Hb levels at day 7, patients in the prospective group received fewer postoperative pRBC transfusions (p < 0.001) and had a shorter hospital length of stay (p < 0.001). Globally, hospitalization costs were lower in patients screened and treated for ID. CONCLUSIONS: Short-term pre-operative iron therapy is associated with a reduction in postoperative transfusions in anemic and non-anemic ID cardiac surgery patients and has a favorable impact on hospitalization costs. CLINICAL TRIAL REGISTRATION: NCT04744181.

Postoperative Intensive Care Management of Aortic Repair.

Vascular surgery patients have multiple comorbidities and are at high risk for perioperative complications. Aortic repair surgery has greatly evolved in recent years, with an increasing predominance of endovascular techniques (EVAR). The incidence of cardiac complications is significantly reduced with endovascular repair, but high-risk patients require postoperative ST-segment monitoring. Open aortic repair may portend a prohibitive risk of respiratory complications that could be a contraindication for surgery. This risk is greatly reduced in the case of an endovascular approach, and general anesthesia should be avoided whenever possible in the case of endovascular repair. Preoperative renal function and postoperative kidney injury are powerful determinants of short- and long-term outcome, so that preoperative risk stratification and secondary prevention are critical tasks. Intraoperative renal protection with selective renal and distal aortic perfusion is essential during open repair. EVAR has lower rates of postoperative renal failure compared to open repair, with approximately half the risk for acute kidney injury (AKI) and one-third of the risk of hemodialysis requirement. Spinal cord ischemia used to be the most distinctive and feared complication of aortic repair. The risk has significantly decreased since the beginning of aortic surgery, with advances in surgical technique and spinal protection protocols, and is lower with endovascular repair. Endovascular repair avoids extensive aortic dissection and aortic cross-clamping and is generally associated with reduced blood loss and less coagulopathy. The intensive care physician must be aware that aortic repair surgery has an impact on every organ system, and the importance of early recognition of organ failure cannot be overemphasized.

Non-invasive follicular neoplasm with papillary-like nuclear features: a challenging and infrequent entity in Argentina.

PURPOSE: Non-invasive encapsulated follicular variant of papillary thyroid cancer was reclassified as non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP). These neoplasms have an extremely low malignant potential. The aim of this study was (1) to assess the prevalence of NIFTP in patients with papillary thyroid carcinoma, (2) to evaluate their outcomes, and (3) to determine their molecular profile. METHODS: Multicenter, descriptive, retrospective study. Patients with papillary thyroid cancer diagnosed from January 2006 to December 2016 from 11 referral centers were included. Diagnosis of NIFTP was based on criteria described by Nikiforov et al. in 2018. At least two pathologists agreed on the diagnosis. Two thousand six hundred and seventy-seven papillary thyroid cancer patients were included; 456 (17%) of them were follicular variant papillary thyroid cancer, and 30 (1.12%) fulfilled diagnostic criteria for NIFTP. RESULTS: Each of the 30 included patients underwent a total thyroidectomy, and 50% were treated with radioiodine (median dose 100 mCi). After a median follow-up of 37 months, 84% of patients had an excellent response, 3% had an indeterminate response and data was missing in the remaining 13%. No metastatic lymph nodes, distant metastases or recurrences were found. RAS mutations were detected in 4 patients (13%). CONCLUSION: The prevalence of NIFTP in our series is amongst the lowest reported. Excellent outcomes of patients underscore their low malignant potential. Molecular findings differ from other series, probably related to environmental or ethnic features of our population and the meticulous criteria for diagnosing NIFTP.

Myocardial fibrosis in asymptomatic patients undergoing surgery for mitral and aortic valve regurgitation.

BACKGROUND: Chronic heart valve regurgitation induces left ventricular (LV) volume overload, leading to the development of hypertrophy and progressive dilatation of the ventricle to maintain physiological cardiac output. In order to prevent potential irreversible LV structural changes, the identification of the best timing for treatment is pivotal. OBJECTIVE: To assess the presence and extent of fibrosis in myocardial tissue in asymptomatic patients with valvular heart disease (VHD) and preserved LV dimensions and function undergoing cardiac surgery. METHODS: Thirty-nine patients were enrolled. Sixteen patients were affected by aortic or mitral regurgitation: they were all asymptomatic, undergoing valve surgery according to VHD European Society of Cardiology guidelines. Twenty-three patients with end-stage nonischemic dilated cardiomyopathy (DCM) and severe LV dysfunction undergoing cardiac surgery for implantation of a durable left ventricular assist device (LVAD) served as controls. During surgery, VHD patients underwent three myocardial biopsies at the level of the septum, the lateral wall and LV apex, while in LVAD patients the coring of the apex of the LV was used. For both groups, the tissue samples were analyzed on one section corresponding to the apical area. All slides were stained with hematoxylin and eosin and Masson's trichrome staining and further digitalized. The degree of fibrosis was then calculated as a percentage of the total area. RESULTS: Of 39 patients, 23 met the inclusion criteria: 12 had mitral or aortic insufficiency with a preserved ejection fraction and 11 had idiopathic dilated cardiomyopathy. Quantitative analysis of apical sections revealed a myocardial fibrosis amount of 10 ±â€Š6% in VHD patients, while in LVAD patients the mean apical myocardial fibrosis rate was 38 ±â€Š9%. In VHD patients, fibrosis was also present in the lateral wall (9 ±â€Š4%) and in the septum (9 ±â€Š6%). CONCLUSION: Our case series study highlights the presence of tissue remodeling with fibrosis in asymptomatic patients with VHD and preserved LV function. According to our results, myocardial fibrosis is present at an early stage of the disease, well before developing detectable LV dysfunction and symptoms. Since the relationship between the progressive magnitude of myocardial fibrosis and potential prognostic implications are not yet defined, further studies on this topic are warranted.

Bleeding Complications in Patients With Perioperative COVID-19 Infection Undergoing Cardiac Surgery: A Single-Center Matched Case-Control Study.

OBJECTIVE: Previous studies reported a poor outcome in patients with coronavirus 2019 (COVID-19) undergoing cardiac surgery. Complications most frequently described were respiratory failure, renal failure, and thromboembolic events. In their recent experience, the authors observed a very high incidence of bleeding complications. The purpose of the study was to investigate a possible significant correlation between perioperative COVID-19 infection and hemorrhagic complications compared to non-COVID-19 patients. DESIGN: Single-center, observational, retrospective, matched case-control (1:2) study involving patients who underwent open-heart cardiac surgery from February 2020 and March 2021 with positive perioperative diagnosis of COVID-19 infection, matched with patients without COVID-19 infection. SETTING: Cardiac surgery unit and intensive care unit of a university tertiary center in a metropolitan area. PARTICIPANTS: In the study period, 773 patients underwent cardiac surgery on cardiopulmonary bypass (CPB). Among them, 23 consecutive patients had perioperative diagnosis of COVID-19 infection (study group). These patients were compared with 46 corresponding controls (control group) that matched for age, sex, body mass index, and Society of Thoracic Surgeons score. INTERVENTIONS: Open-heart cardiac surgery on CPB. MEASUREMENTS AND MAIN RESULTS: In the study group, 2 patients (9%) died in the intensive care unit from severe respiratory failure, shock, and multiple organ failure. In the study group, patients showed a significantly higher incidence of bleeding complications (48% v 2%, p = 0.0001) and cases of surgical reexploration for bleeding (35% v 2%, p = 0.0001), a higher incidence of severe postoperative thrombocytopenia (39% v 6%, p = 0.0007), and a higher need of blood components transfusions (74% v 30%, p = 0.0006). Chest tubes blood loss and surgical hemostasis time were markedly prolonged (p = 0.02 and p = 0.003, respectively). CONCLUSIONS: A worrisome increased risk of early and late bleeding complications in COVID-19 patients was observed, and it should be considered when assessing the operative risk. CPB-related inflammatory reaction could exacerbate the deleterious effect of COVID-19 on the coagulation system and likely deviate it toward a hemorrhagic pattern.

Influence of cardiopulmonary bypass set-up and management on clinical outcomes after minimally invasive aortic valve surgery.

INTRODUCTION: Minimally invasive aortic valve replacement (MIAVR) requires changes in cannulation strategy and cardiopulmonary bypass (CPB) management when compared to the conventional approach (CAVR). We aimed at evaluating if these differences could influence perfusion-related quality parameters and impair postoperative outcomes. METHODS: Overall, 339 consecutive patients underwent MIAVR or CAVR between 2014 and 2020 and were analyzed retrospectively. To account for baseline differences, a propensity-matching analysis was performed, obtaining two groups of 97 patients each. RESULTS: MIAVR group had longer CPB time [107 (95-120) vs 95 (86-105) min, p = .003] than CAVR group. Of note, average pump flow rate index [2.4 (2.2-2.5) vs 2.7 (2.4-2.8) l/min/m2, p = .004] was lower in the MIAVR group. Mean arterial pressure was 73 = 9 mmHg vs 62 = 11 mmHg for the MIAVR and CAVR group, respectively (p < .001). Cell-salvaged blood was most commonly used in the MIAVR group (25.8% vs 11.3%, p = .02). Finally, CPB temperature was 32.8°C (32.1-34.8) for MIAVR group vs 34.9°C (33.2-36.1) for the CAVR group (p = .02). Postoperative complications were similar between groups. CONCLUSIONS: In conclusion, despite differences in CPB parameters in patients undergoing CAVR and MIAVR, the incidences of adverse outcomes were similar. However, compared to CAVR, MIAVR was associated with shorter durations of mechanical ventilation and hospital stay as well as less transfusion of blood products.

Long-term results of tricuspid annuloplasty with 3-dimensional-shaped rings: effective and durable!

OBJECTIVES: 3-Dimensional (3D)-shaped rings are largely adopted for tricuspid annuloplasty, but evidence about their long-term results is scanty. The goal of this study was to analyse the long-term results of tricuspid annuloplasty with 3D-shaped rings. MATERIALS AND METHODS: A retrospective review of our prospectively maintained database was carried out to identify all patients who underwent tricuspid valve repair with 3D-shaped rings between January 2011 and December 2014. Kaplan-Meier methods were used to analyse long-term survival. Cumulative incidence function using death as the competitive outcome was used to estimate cardiac death. RESULTS: A total of 168 patients were identified. The median age was 66 years. Eighty-two patients (49%) were in advanced New York Heart Association functional class III-IV. Atrial fibrillation (AF) was present in 101 (60%); the median ejection fraction was 60%. In 82 (49%) patients, a Medtronic 3D Contour annuloplasty ring was employed; in the remaining 86 (51%) patients, an Edwards MC3 ring was used. Cumulative incidence function of cardiac death, with non-cardiac death as a competing risk, was 1.9 ± 1.1%, 95% confidence interval (CI) (0.51-4.95) at 7 years. The cumulative incidence function of recurrence of tricuspid regurgitation (TR) ≥2+ at 7 years was 14 ± 3.17%, 95% CI (8.49-20.82). Recurrence of TR ≥2+ at 7 years was not significantly different between the Medtronic 3D Contour and the Edwards MC3 rings (P = 0.3). AF was identified as the only independent predictor of recurrence of TR ≥2+. CONCLUSIONS: 3D-shaped rings are effective and durable. TR recurrence was relatively low at 7 years and usually moderate (2+/4+) without a significant difference between the 2 types of rings. The role of AF as a predictor of TR recurrence was confirmed.

Size and shape of the inferior vena cava before and after a fluid challenge: a pilot study.

BACKGROUND: Recent meta-analyses failed to support the reliability of ultrasound assessment of the inferior vena cava (IVC) to predict fluid responsiveness. However, the techniques utilized were heterogeneous. We hypothesized that the variability of the elliptic section and caliber of the IVC along its course may influence ultrasound evaluation. Therefore, we investigated IVC size and shape at four levels, before and after a fluid challenge. METHODS: Twenty mechanically-ventilated adult patients who received a fluid challenge after cardiac surgery were enrolled. They were regarded as responders if the cardiac index increased more than 15%. Before and after the fluid challenge, IVC anteroposterior (AP) and lateral (LA) diameters, the flat ratio, and the distensibility index were assessed by ultrasound just above the iliac veins, at the confluence of the renal veins, before the confluence of the hepatic veins (where blood flow velocity was also measured), and after it. RESULTS: At all levels, IVC section was elliptical, so that IVC diameters varied between a minimum and a maximum according to the measurement angle. Such interval increased in correspondence of the renal veins, where IVC section was more eccentric. The distensibility index was higher when assessed on AP diameters. After the fluid challenge, non-responders showed a diffuse increase of AP diameters, whereas responders showed an increase of blood velocity before the confluence of the hepatic veins. CONCLUSIONS: The elliptic section should be considered when assessing IVC size. AP diameters are shorter and more affected by the respiratory cycle. After a fluid challenge, an increase of blood velocity associated with unchanged AP diameters may suggest fluid responsiveness.

Dynamic right ventricular outflow obstruction: A rare cause of hypotension during anestesia induction.

INTRODUCTION: Dynamic obstruction of right ventricle outflow tract (RVOTO) is a rare condition that may acutely cause severe heart failure. It has been reported in some hypertrophic cardiomyopathies, after lung transplantation, and in some cases of hemodynamic instability after cardiopulmonary bypass. PRESENTATION OF CASE: We report the case of a 71-year-old man who developed severe hypotension during the induction of general anesthesia for surgical coronary revascularization. Hypotension did not respond to the initial treatment with vasoconstrictors and fluids. RVOTO was suspected during pulmonary artery catheterization because of the difficulty of the catheter tip to move from the right ventricle to the pulmonary artery and, successively, because of the finding of a large gradient between the systolic pressure in the right ventricle and in the pulmonary artery. The diagnosis was confirmed by transesophageal echocardiogram (TEE). Hemodynamics recovered after the infusion of cristalloids, 1L, and the suspension of vasoconstrictors and inotropes. DISCUSSION: This is the first case in which RVOTO was observed during the induction of general anesthesia. Although this is a rare condition, the diagnostic suspect is of outmost importance because treatment is mainly based on fluid administration, and drugs with positive inotropic properties (like most vasoconstrictors) are contraindicated. CONCLUSIONS: RVOTO is an unusual, but possible cause of severe arterial hypotension during general anesthesia induction. TEE is useful for the evaluation of severely hypotensive patients who do not respond to routine treatment with fluids and vasoconstrictors.

New findings on type 2 diabetes in first-generation Chinese migrants settled in Italy: Chinese in Prato (CHIP) cross-sectional survey.

BACKGROUND: Chinese people are one of the fastest growing immigrant populations in Europe, and their health has become a key issue to host nations. Although type 2 diabetes (T2DM) is a big burden among migrant populations, data on Chinese immigrants in Europe are limited. METHODS: A cross-sectional survey was performed in 2014, adopting principles of community-based participatory research to investigate T2DM, diagnosed by the American Diabetes Association fasting criteria, in Chinese first-generation migrants aged 16 to 59 years settled in Prato (Italy). Association with different factors was investigated using logistic regression. RESULTS: Of the 1608 participants, 177 had T2DM (11.0%), 119 being newly diagnosed (7.4%). Among subjects with diabetes, 58 (32.8%) were aware of the disease; among subjects with diabetes aware of their condition, 46 (79%) were treated with glucose lowering drugs. Age-standardized (World Health Organization 2001 population) prevalence of T2DM was 9.6% (95% CI 9.1 to 10.2%), being 12.0% (95% CI 11.0 to 12.9%) in men, and 7.8% (95% CI 7.1 to 8.4%) in women. At adjusted logistic regression, diabetes was associated with hypertension, current smoking, adiposity indices (waist circumference, waist-to-hip ratio, waist-to-height ratio, and body mass index), and high triglycerides. T2DM, adiposity indices, and high triglycerides were not associated with duration of stay in Italy. CONCLUSIONS: The high prevalence of T2DM among first-generation Chinese immigrants in Europe stresses the need for specific health programs for T2DM early diagnosis, treatment, and prevention. There is an urgent need for policies to support this group because current policies will produce major social and economic costs. Copyright © 2016 John Wiley & Sons, Ltd.

Sleep History and Hypertension Burden in First-Generation Chinese Migrants Settled in Italy: The CHIinese In Prato Cross-Sectional Survey.

Migration flows from China are largely directed towards the South of Europe, Chinese being now the third largest overseas-born population in Italy. The aim of the study was to investigate hypertension burden and self-reported sleep disorders among 1608 first-generation Chinese migrants aged 16 to 59 years settled in Prato and recruited in a cross-sectional survey. Hypertension was defined as systolic BP ≥ 140  mm Hg and/or diastolic BP ≥ 90  mm Hg or self-reported antihypertensive treatment; potential impact of sleep disorders was analyzed by logistic regression adjusted for age, sex, marital status, education, health insurance, current smoking, parental hypertension, alcohol drinking, overweight or obesity, central obesity, diabetes, high total cholesterol, and high triglycerides. Among the 1608 participants, 21.7% were hypertensive (age-standardized prevalence 19.2%; 95% Cl: 18.5-20.0); 54% of hypertensive subjects were aware of their condition; 70% of aware hypertensive subjects received drugs, and 39% of treated subjects had blood pressure controlled. Self-reported snoring increased the risk of hypertension; when compared with no snoring, the age- and sex-adjusted OR for hypertension of snoring 3 to 6  d/week was 2.11 (95% Cl: 1.48-3.01) and 2.48 (95% Cl: 1.79-3.46) of snoring every day. When compared with a sleep duration ≤ 5  hours, subjects with sleep duration of 7  hours had reduced risk of high triglycerides (adjusted OR: 0.66; 95% Cl: 0.43-0.95).Despite a high level of awareness, low treatment rates for hypertension were observed among Chinese participants, independently of health insurance. Sleep history is to be considered in screening and prevention programs.

Lifestyle interventions in preventing new type 2 diabetes in Asian populations.

The aim of this study was to review current evidence on interventional studies aimed at the prevention of type 2 diabetes in Asian population with lifestyle interventions. Prevalence of type 2 diabetes sharply increased in most Asian countries during the last decades. This issue has now also relevant implication for Europe where different surveys are also consistently revealing an higher prevalence of type 2 diabetes and other and major CVD risk factors among subjects originating from Asian Countries than in the native population. Nutrition and lifestyle transition seem to play a role in disclosing the predisposition for the development of type 2 diabetes and great interest is now shown toward the possibility to intervene with lifestyle intervention on at risk populations. A meta-analysis of Randomized Controlled Trials showed that lifestyle interventions are highly effective also in the Asian population. All studies were, however, conducted with an individual approach based on the identification of high-risk individuals. When ethnic minority groups have to be addressed, an approach directed to the community rather than to the individual might, however, be more effective. This review reinforces the importance for policy-makers to consider the involvement of the whole community of minority immigrant groups with lifestyle intervention programs.

Is commissural closure associated with mitral annuloplasty a durable technique for the treatment of mitral regurgitation? A long-term (≤15 years) clinical and echocardiographic study.

OBJECTIVE: Mitral regurgitation (MR) due to commissural prolapse/flail can be corrected by suturing the margins of the anterior and posterior leaflets in the commissural area (commissural closure). The long-term results of this type of repair are unknown. Our aim was to assess the clinical and echocardiographic outcomes of this technique up to 15 years after surgery. METHODS: From 1997 to 2007, 125 patients (age, 56.8 ± 15.7 years; left ventricular ejection fraction, 58.1% ± 7.1%) with MR due to pure commissural prolapse/flail of 1 or both leaflets underwent commissural closure combined with annuloplasty. The etiology of the disease was degenerative in 88.8% and endocarditis in 11.2%. The commissural region involved was posteromedial in 96 patients (76.8%) and anterolateral in 29 (23.2%). RESULTS: Hospital mortality was 1.6%. At discharge, MR was absent or mild in 120 patients (97.5%) and moderate (2+/4+) in 3 (2.4%). Clinical and echocardiographic follow-up was 98.4% complete (mean length, 7.1 ± 3.0 years; median, 6.7; longest follow-up, 15). At 11 years, the actuarial survival, freedom from cardiac death, and freedom from reoperation was 78.8% ± 6.2%, 95.2% ± 3.3%, and 97.4% ± 1.4%, respectively. At the last echocardiographic examination, MR 3+ or greater was demonstrated in 4 patients (3.3%). Freedom from MR 3+ or greater at 11 years was 96.3% ± 1.7%. No predictors for recurrence of MR 3+ or greater were identified. The mean mitral valve area and gradient was 2.9 ± 0.4 cm(2) and 3.4 ± 1.1 mm Hg, respectively. New York Heart Association class I to II was documented in all cases. CONCLUSIONS: Commissural closure repair combined with annuloplasty provides excellent clinical and echocardiographic long-term results in patients with MR due to commissural lesions.

Can the edge-to-edge technique provide durable results when used to rescue patients with suboptimal conventional mitral repair?

OBJECTIVES: The 'edge-to-edge' technique (EE) can be used as a bailout procedure in case of a suboptimal result of conventional mitral valve (MV) repair. The aim of this study was to assess the long-term outcomes of this technique used as a rescue procedure. METHODS: From 1998 to 2011, of 3861 patients submitted to conventional MV repair for pure mitral regurgitation (MR), 43 (1.1%) underwent a rescue edge-to-edge repair for significant residual MR at the intraoperative hydrodynamic test or at the intraoperative transoesophageal echocardiography. Residual MR was due to residual prolapse in 30 (69.7%) patients, systolic anterior motion in 12 (27.9%) and post-endocarditis leaflet erosion in 1 (2.3%). According to the location of the regurgitant jet, the edge-to-edge suture was performed centrally (60.5%) or in correspondence with the anterior or posterior commissure (39.5%). The original repair was left in place. RESULTS: There were no hospital deaths. Additional cross-clamp time was 15.2 ± 5.6 min. At hospital discharge, all patients showed no or mild MR and no mitral stenosis. Clinical and echocardiographic follow-up was 97.6% complete (median length 5.7 years, up to 14.6 years). At 10 years, actuarial survival was 89 ± 7.4% and freedom from cardiac death 100%. Freedom from reoperation and freedom from MR ≥ 3+ at 10 years were both 96.9 ± 2.9%. At the last echocardiogram, MR was absent or mild in 37 patients (88%), moderate in 4 (9.5%) and severe in 1 (2.4%). No predictors for recurrence of MR ≥ 2+ were identified. The mean MV area and gradient were 2.8 ± 0.6 cm(2) and 2.7 ± 0.9 mmHg. NYHA I-II was documented in all cases. CONCLUSIONS: A 'rescue' EE can be a rapid and effective option in case of suboptimal result of 'conventional' MV repair. Long-term durability of the repair is not compromised.

Undersized annuloplasty for functional mitral regurgitation: is it responsible for clinically relevant mitral stenosis during exercise?

BACKGROUND AND AIM OF THE STUDY: The study aim was to assess if an undersized mitral annuloplasty for functional mitral regurgitation (FMR) in dilated cardiomyopathy can determine a clinically relevant mitral stenosis during exercise. METHODS: Both, rest and stress echocardiography were performed in 12 patients submitted to an undersized ring annuloplasty for FMR in dilated cardiomyopathy. The mean ring size was 27 +/- 1.3 mm. All patients were in NYHA functional classes I-II, were in stable sinus rhythm, and without significant residual mitral regurgitation (grade < or = 2/4). RESULTS: At peak exercise (mean 81 +/- 12 W), the main cardiac performance indices were significantly improved, including systolic blood pressure (121 +/- 5.6 versus 169 +/- 14 mmHg, p < 0.001), stroke volume (63 +/- 15 versus 77 +/- 14 ml, p < 0.001), left ventricular ejection fraction (43 +/- 9% versus 47 +/- 9%, p = 0.001), and systolic right ventricular function (pulsed tissue Doppler index peak systolic velocity: 8.6 +/- 1.7 versus 11.1 +/- 3.2 cm/s, p = 0.004). A mild increase in planimetric mitral valve area was observed at peak exercise (2.12 +/- 0.4 versus 2.17 +/- 0.3 cm2, p = 0.05). Although the transmitral mean gradient was increased from 3.2 +/- 1.2 to 6.3 +/- 2.3 mmHg (p < 0.0001), the systolic pulmonary artery pressure did not change significantly (27 +/- 2.8 versus 30.1 +/- 6.4 mmHg, p = 0.3), thus revealing a preserved cardiac adaptation to exercise. CONCLUSION: In these preliminary data, postoperative clinically relevant mitral stenosis was not observed in patients submitted to mitral repair for FMR. Stress echocardiography represents a valuable tool to assess an appropriate cardiac response to exercise and to detect a significant exercise-induced pulmonary hypertension after undersized annuloplasty ring surgery.

Mid-term results of tricuspid annuloplasty with a three-dimensional remodelling ring.

OBJECTIVE: To assess the results of tricuspid annuloplasty performed with the Edwards MC3 remodeling ring. METHODS: From 2005 to 2007, 140 patients with tricuspid regurgitation (TR) secondary to left-sided valve disease (mean age 63.8 ± 11.6, permanent pacemaker in 7.8%, LVEF 56.4 ± 10.1%, LVEDD 54.1 ± 8 mm, SPAP 52.5 ± 14.4 mmHg) underwent tricuspid annuloplasty using the MC3 ring. Dilatation of the tricuspid annulus was present in all patients. Other concomitant mechanisms of TR (moderate leaflet prolapse, pacemaker wires, leaflets' retraction) were documented in 21 cases (15%). All patients underwent concomitant left-sided valve surgery. Ring size was between 28 and 32 in 84.3% of patients. RESULTS: Hospital mortality was 3.5% and actuarial survival at 3 years 94.8 ± 2.1%. Mean follow-up of the 135 hospital survivors was 22 ± 9.5 months (median 23 months). Echocardiography at hospital discharge documented no or mild TR in 119 patients (87%), moderate TR (2+/4+) in 15 (11%) and moderate-to-severe (3+/4+) in 1 patient (0.7%). At echocardiographic follow-up moderate TR was present in 14 patients (10.3%) and moderate-to-severe TR in 2 (1.4%). At 3 years freedom from TR ≥ 2+ was 88.1 ± 2.78% and freedom from TR ≥ 3+ was 94.3 ± 4.89. Predictors of TR ≥ 2+ at hospital discharge and at follow-up were preoperative LVEF (OR:0.8; p = 0.001 at discharge; HR:0.9; p = 0.003 at follow-up) and the presence of other mechanisms of TR besides annular dilatation (OR:10.8; p = 0.007 at discharge; HR:6.1; p = 0.003 at follow-up). CONCLUSION: Tricuspid annuloplasty with the MC3 ring provides satisfactory early results which remain stable at mid-term follow-up. The presence of other mechanisms besides annular dilatation leads to residual valve insufficiency after ring annuloplasty alone.