Ranolazine enhances the antiarrhythmic activity of amiodarone by accelerating conversion of new-onset atrial fibrillation after cardiac surgery.

Ranolazine is a relatively novel antiischemic/antianginal compound with antiarrhythmic properties. We investigated its ability to shorten the time to conversion of postoperative atrial fibrillation (POAF) when added to amiodarone after coronary artery bypass graft (CABG) surgery. In this prospective, randomized, allocation-concealed, single-blind, single-site clinical trial, we enrolled consecutive eligible patients who developed POAF after elective on-pump CABG surgery. Participants were randomized to receive either ranolazine 375 mg twice daily orally plus intravenous amiodarone (active group) or intravenous amiodarone alone (control group). We enrolled 41 patients; 20 in the active and 21 in the control group. There were no significant differences between the groups in terms of age, procedural duration, extracorporeal circulation time, and aortic cross-clamp time. Mean time of conversion was significantly shorter in the active group (19.9 ± 3.2 vs 37.2 ± 3.9 hours, P < .001), suggesting that compared to amiodarone alone, the ranolazine-amiodarone combination had a superior antiarrhythmic effect against POAF.

Effect of ranolazine in preventing postoperative atrial fibrillation in patients undergoing coronary revascularization surgery.

BACKGROUND/OBJECTIVE: Ranolazine is a new anti-ischemic agent approved for chronic angina with additional electrophysiologic properties. The purpose of the present trial was to investigate its effect in preventing postoperative atrial fibrillation (POAF) after on-pump coronary artery bypass graft (CABG) surgery. METHODS: In the current prospective, randomized, (1 active: 2 control), single-blind (outcome assessors), single-centre clinical trial we recruited consecutive eligible patients scheduled for elective on-pump CABG. Participants were assigned to receive either oral ranolazine 375 mg twice daily for 3 days prior to surgery and until discharge, or to receive usual care. Patients were monitored for the development of POAF. RESULTS: We enrolled 102 patients. Significantly lower incidence of POAF was noted in the ranolazine group compared with the control group (3 out of 34 patients, 8.8%, vs 21 out of 68 patients, 30.8%; p< 0.001). Mean values of left atrial diameter and left ventricular ejection fraction between the control and the ranolazine group were not significantly different. CONCLUSION: Our findings suggest a protective role of oral ranolazine when administered in a moderate dose preoperatively in patients undergoing on-pump CABG surgery. Future studies based on a wider sample of patients will eventually support our conclusions.

Why are thoracic operations postponed?

AIM: To investigate and present the reasons that cause the postponement of thoracic surgical operations. METHODS: We retrospectively included in the study all patients submitted to elective thoracic surgery in our department during the 4-year period 2007-2010 and noted all cases of postponement after official inclusion in the operating schedule. RESULTS: 81 out of a total of 542 patients (14.9%) scheduled for elective thoracic operation had their procedure postponed. The reasons were mainly organisatory (in 42 cases, 51.85%), which in order of significance were: shortage in matching erythrocyte units, shortage in anaesthetic/nursing staff and unavailability in operating rooms. The rest of the cases (39, 48.1%) were postponed due to medical reasons, which in descending order of significance were: respiratory infections and exacerbations of COPD, cardiological problems, misregulation of antiplatelet/antithrombotic drugs and infections from other systems (gastrointestinal, urinary, etc.). Elderly male patients planned for major/oncologic surgery were most possible to have their operation postponed for medical reasons. DISCUSSION-CONCLUSIONS: Thoracic operations are postponed owed to organisatory as well as medical reasons, the latter mainly affecting elderly, morbid patients awaiting for major/oncologic surgery.

Ondasetron versus haloperidol for the treatment of postcardiotomy delirium: a prospective, randomized, double-blinded study.

BACKGROUND: To investigate the controlling efficacy of ondasetron and haloperidol in regard to the postcardiotomy delirium. METHODS: We included in this prospective, randomized, double-blinded study 80 patients who developed delirium after heart surgery with the application of heart lung-machine. The patients were divided into two, equally-sized groups, which on detection of delirium received ondasetron 8 mg iv or haloperidol 5 mg iv respectively. The statistical analysis compared the baseline and demographic characteristics of the two groups (age, gender, comorbidities, years of education, type of surgery etc.). RESULTS: Both ondasetron and haloperidol had very good delirium controlling effects, without statistically significant differences. DISCUSSION-CONCLUSIONS: Ondasetron and haloperidol are efficient agents as far as the treatment of postcardiotomy delirium is concerned. As, in addition, ondasetron bares milder side-effects, we believe this could be the agent of choice in patients developing postcardiotomy delirium in the future.

Classic and non-classic forms of mitral valve prolapse.

OBJECTIVE: To investigate the significance of the established distinction between classic and non-classic forms of mitral valve prolapsed (MVP). METHODS: We included in this prospective study all patients examined in our preventive cardiology outpatient clinics during the biannual period October 2004-October 2006. We examined in total 10.818 patients, 238 of whom (2.2%) were diagnosed for MVP. We noted relevant demographic and clinical data (gender, age of diagnosis, symptoms, need for hospitalization) and performed statistical comparisons between patients with the classic and those with the non-classic form. Follow-up controls were performed three years afterwards. RESULTS: Patients with the classic form had an earlier age of first diagnosis, more prominent symptoms, and more frequently diagnosis for other disorders (atrial septal defect, ventricular septal defect, Marfan syndrome, Ehlers-Danlos syndrome) than the rest of the patients; however, there were no significant differences as far as certain major complications (stroke, death, submission to surgery) were concerned. CONCLUSION: The classic form of mitral valve prolapse is more tightly associated with morbid complications, and a more frequent follow-up control in this group of patients may be useful.

Altered arterial stiffness and subendocardial viability ratio in young healthy light smokers after acute exercise.

BACKGROUND: Studies showed that long-standing smokers have stiffer arteries at rest. However, the effect of smoking on the ability of the vascular system to respond to increased demands (physical stress) has not been studied. The purpose of this study was to estimate the effect of smoking on arterial stiffness and subendocardial viability ratio, at rest and after acute exercise in young healthy individuals. METHODS/RESULTS: Healthy light smokers (n = 24, pack-years = 2.9) and non-smokers (n = 53) underwent pulse wave analysis and carotid-femoral pulse wave velocity measurements at rest, and 2, 5, 10, and 15 minutes following an exercise test to exhaustion. Smokers were tested, 1) after 12h abstinence from smoking (chronic condition) and 2) immediately after smoking one cigarette (acute condition). At rest, chronic smokers had higher augmentation index and lower aortic pulse pressure than non-smokers, while subendocardial viability ratio was not significantly different. Acute smoking increased resting augmentation index and decreased subendocardial viability ratio compared with non-smokers, and decreased subendocardial viability ratio compared with the chronic condition. After exercise, subendocardial viability ratio was lower, and augmentation index and aortic pulse pressure were higher in non-smokers than smokers in the chronic and acute conditions. cfPWV rate of recovery of was greater in non-smokers than chronic smokers after exercise. Non-smokers were also able to achieve higher workloads than smokers in both conditions. CONCLUSION: Chronic and acute smoking appears to diminish the vascular response to physical stress. This can be seen as an impaired 'vascular reserve' or a blunted ability of the blood vessels to accommodate the changes required to achieve higher workloads. These changes were noted before changes in arterial stiffness or subendocardial viability ratio occurred at rest. Even light smoking in young healthy individuals appears to have harmful effects on vascular function, affecting the ability of the vascular bed to respond to increased demands.

How many lobes do you see?

Accessory fissures represent a variation of the normal lung anatomy. Incomplete development or even the absence of the major or minor fissures can lead to confusion in distinguishing adjacent lobes. This report aims to present a rare intraoperative finding of an anatomic malformation of the right lung in a 19-year old male patient with recurrent pneumothorax who underwent a surgical repair. An accessory fissure which was separating the superior segment of the lower lobe from the basal segments gave to the whole lung the unique image of a four-lobed one. A profound knowledge of the accessory fissures, even if they are incidentally discovered, is of pivotal importance for the thoracic surgeon and leads to optimal operative assessment and strategic planning.

Why are heart operations postponed?

AIM: To investigate the reasons that lead to postponement of cardiac operations, in order to elucidate the problem and help patients through modes of prevention. METHODS-DESIGN: We retrospectively included in the study all patients submitted to elective adult heart surgery in our department during the 4-year period 2007-2010 and noted all cases of postponement after official inclusion in the operating schedule. RESULTS: 94 out of a total of 575 patients (16.34%) scheduled for elective cardiac operation had their procedure postponed. The reasons were mainly organisatory (in 49 cases, 52.12%), which in order of significance were: unavailability in operating rooms, shortage in matching erythrocyte units and shortage in anaesthetic/nursing staff. The rest of the cases (45, 47.88%) were postponed due to medical reasons, which in order of significance were: febrile situations, including infections of the respiratory, gastrointestinal and urinary system, problems with the regulation of antiplatelet and antithrombotic drugs, neurological manifestations such as stroke and transient ischaemic attacks, exacerbation of asthma/chronic obstructive pulmonary disease, arrhythmias, renal problems and allergic reactions to drugs. Patients with advanced age and increased Euroscore values were most possible to have their heart operation postponed. CONCLUSIONS: Heart operations are postponed due to organisatory as well as medical reasons, the latter mainly affecting older, morbid patients who therefore require advanced preoperative care.

Double auricles of the right atrium: a unique anatomic deformity.

BACKGROUND: Anatomic deviations, especially those detected during the course of an operation, are medically intriguing, as they raise concerns about their clinical significance and putative complications. CASE PRESENTATION: We present, to our knowledge, for the first time a case of an anatomic deviation in the form of a second right atrial auricle in a 70 year-old, coronary bypass-operated male Caucasian patient of Greek origin. No complications were noted intra-or postoperatively. CONCLUSIONS: A second right atrial auricle was found intraoperatively, without causing any clinical complications, or obstructing the normal course of a surgical procedure.

Poland's syndrome and recurrent pneumothorax: is there a connection?

AIM: To investigate the possible connection of Poland's syndrome with the presence of lung bullae and, thus, with an increased risk for recurrent pneumothorax. PATIENTS-METHODS: Two male patients, aged 19 and 21 years respectively were submitted to our department after their second incident of pneumothorax. Both had Poland's syndrome (unilaterally hypoplastic chest wall with pectoralis major muscle atrophy) and both had multiple bullae to the ipsilateral lung based on CT findings. The patients were treated operatively (bullectomy, lung apicectomy, partial parietal pleurectomy and chemical pleurodesis) due to the recurrent state of their pneumothorax. RESULTS: The patients had good results with total expansion of the affected lung. CONCLUSIONS: Poland's syndrome can be combined with ipsilateral presence of lung bullae, a common cause of pneumothorax. Whether this finding is part or a variation of the syndrome needs to be confirmed by a larger number of similar cases.

Coronary artery surgery in a man with achondroplasia: a case report.

INTRODUCTION: Achondroplasia is a musculoskeletal disorder associated with short stature. Despite an estimated prevalence of 1:25,000 in the general population, there is little literature concerning the diagnostic and treatment challenges faced by doctors dealing with a heart operation on a patient with this condition. CASE PRESENTATION: We present the case of a 41-year-old Caucasian man of Greek ethnicity with achondroplasia, who underwent bypass heart surgery. CONCLUSIONS: The surgery was successful and did not present particular difficulties, showing that heart surgery can be safely performed on people with achondroplasia.

An alternate solution for the treatment of ascending aortic aneurysms: the wrapping technique.

BACKGROUND: The aortic Dacron wrapping technique is a surgical technique used under certain circumstances in cases of ascending aorta dilatation. Herein, we are presenting our experience on the method performed on multimorbid patients who denied major aortic surgery. METHODS: We included in our series 7 patients (5 male-2 female) with mild to moderate ascending aortic dilatation, who were operated with the wrapping technique. One patient was submitted to biological aortic valve replacement during the same procedure. The number of conventionally operated patients during the same period (2 years) was 21. RESULTS: Mortality during the 18-months follow-up control was 0%. One patient had to be operated with biological aortic valve replacement 18 months after the initial wrapping operation, although the diameter of her ascending aorta remained stable. CONCLUSIONS: The Dacron wrapping technique is a method that can alternatively be used in multimorbid patients with mild to moderate ascending aortic dilatation without dissecting elements and has generally good results.

Visual disorders or "eye stroke"after heart surgery: can we prevent it?

The aim of the study was to elucidate the problem of visual disorders after heart surgery, focusing on aetiology, modes of prevention and treatment. Information from a literature search and the authors' personal experience are provide clues as to the modes of development and the means of avoidance and therapy of this category of postoperative, neurosensory complications. Multiple morbid situations, such as preoperative augmented ocular pressure, perioperative bleeding and hypotension, are shown to be predisposing and precipitating factors. Medical treatment seems to be less important than minimisation of risk factors. Prevention rather than treatment is more helpful for heart-operated patients, as far as postoperative visual disorders are concerned.

Association between ankle-brachial index and risk factor profile in patients newly diagnosed with intermittent claudication.

BACKGROUND: The primary objective of the present study was to determine whether there is an association between the ankle-brachial index (ABI) and the risk factor profile in patients with newly diagnosed peripheral arterial disease (PAD). A secondary objective was to identify the risk factor profile of these patients, and evaluate how well these factors are controlled in the primary care setting. METHODS AND RESULTS: In this cross-sectional study, all new consecutive patients referred by primary care to a vascular surgery outpatient clinic, after diagnosis of PAD was confirmed, were subsequently referred to the Risk Factor Modification Clinic for assessment and management of their risk factors. Patients with intermittent claudication (n=170) (age 68.7+/-10.6 years; 118 men; ABI 0.65+/-0.13) were included. In patients not on lipid-lowering drugs, low-density lipoprotein-cholesterol (LDL-C) was inversely correlated with the ABI (r= -0.42, p<0.0001). Also ABI was significantly correlated with serum creatinine (rs= -0.38, p<0.0001) (and estimated glomerular filtration rate), high-sensitivity C-reactive protein (hsCRP) (rs= -0.20, p=0.009) and plasma fibrinogen (rs= -0.18, p=0.018). In stepwise multiple linear regression analysis, hsCRP and creatinine levels and diabetes were independent predictors of ABI (p<0.0001). Only 32.4% of the patients had normal blood pressure and 25.9% had an optimal LDL-C level <2.6 mmol/L (100 mg/dl); 85.3% were ever smokers; 44.1% had diabetes/impaired fasting glucose; 84.7% had hsCRP >3.0 mg/L; 78.8% fibrinogen >3.0 g/L (300 mg/dl); and 68.8% homocysteine >12.0 micromol/L (44.7% >15.0 micromol/L). CONCLUSIONS: For the first time, a significant inverse correlation between ABI and LDL-C was shown in patients not on lipid-lowering drugs, and also between ABI and creatinine, hsCRP and fibrinogen in all patients, supporting a link between the severity of PAD and atherogenic and inflammatory risk factors. HsCRP, creatinine and diabetes were independently associated with the ABI. Despite the increased vascular risk, PAD remains undertreated in the primary care setting. Increased awareness will overcome this barrier to effective secondary prevention of vascular events.

Carotid artery atherosclerosis: what is the evidence for drug action?

Carotid artery disease is a well-established cause of cerebrovascular events. This risk is predicted by the severity of stenosis and other plaque characteristics that can be documented using imaging techniques. Among these techniques, ultrasound is the most widely available. Increased carotid intima-media thickness (IMT) measured ultrasonically is associated with a higher risk for cerebrovascular as well as coronary heart disease. Furthermore, it is increasingly recognized that echolucent and heterogeneous carotid plaques in patients with high-grade carotid stenosis are associated with a greater risk for cerebrovascular events. Several local and systemic factors can influence plaque stability. Identifying the high-risk carotid plaque could improve selection for vascular intervention (surgery/angioplasty) and increase cost-effectiveness. Aggressive medical treatment should always be provided for these high-risk patients. For example, lipid-lowering, anthihypertensive and antiplatelet drugs decrease the carotid IMT, stabilize carotid plaques or reduce the risk of cerebrovascular and systemic events. Continuously evolving technology will lead to more accurate identification of high-risk carotid plaques. A combination of comprehensive non- or minimally-invasive imaging techniques together with measuring clinical and systemic biochemical markers of risk may facilitate the identification of the vulnerable plaque in the vulnerable patient, and help select the best treatment options.