Heart surgery for immigrants in Italy: burden of cardiovascular disease, adherence to treatment and outcomes.

AIM: Italy is a country with high rates of immigration and the knowledge of immigrant health is very fragmentary. We provide a current picture of cardiovascular disease causes and clinical outcomes following heart surgery. METHODS: A clinical and echocardiographic survey was conducted on 154 consecutive immigrants referred for heart surgery to San Raffaele Hospital in Milan between 2003 and 2011. RESULTS: Major causes of heart disease were rheumatic heart disease (RHD) (n = 64, 41%), nonrheumatic valvulopathies (n = 41, 27%), ischemic heart disease (IHD) (n = 25, 16%), congenital heart disease (n = 13, 9%) and miscellaneous (n = 11, 7%). Median age was 49 years [interquartile range (IQR) 7-81]; 55% of patients were male. Among valvulopathies, rheumatic mitral disease was predominant (n = 56, 53%) as both single and multivalvular disease (n = 46, 73%); myxomatous prolapse emerged as the second main pattern of mitral disease (n = 30, 33%). Among patients with IHD, 72% had a high cardiovascular risk. Surgery was scheduled in 138 patients (90%). Clinical follow-up was available in 96 patients (62%) [median time 62 months (IQR 15-123)], among whom 92 (96%) were alive, four patients (4%) had died and 58 (38%) were lost. CONCLUSION: Cardiovascular diseases represent a major health topic among immigrants in developed countries. RHD still is the predominant cause of hospitalization for heart surgery, nonrheumatic valvulopathies and IHD emerging as second and third causes, respectively. Data underline the need of reinforcement of prevention and care strategies in the matter of immigrant health and warrant the urgent attention of the international public health and research communities.

Cardiac surgery for patients with heart failure due to structural heart disease in Uganda: access to surgery and outcomes.

OBJECTIVE: Few data are available on heart failure (HF) in sub-Saharan Africa. We aimed to provide a current picture of HF aetiologies in urban Uganda, access to heart surgery, and outcomes. METHODS: We prospectively collected clinical and echocardiographic data from 272 consecutive patients referred for suspected heart disease to a tertiary hospital in Kampala during seven non-governmental organisation (NGO) missions from 2009 to 2013. We focused the analysis on 140 patients who fulfilled standardised criteria of HF by echocardiography. RESULTS: Rheumatic heart disease (RHD) was the leading cause of HF in 44 (31%) patients. Among the 50 children included (age ≤ 16 years), congenital heart disease (CHD) was the first cause of HF (30 patients, 60%), followed by RHD (16 patients, 32%). RHD was the main cause of HF (30%) among the 90 adults. All 85 patients with RHD and CHD presented with an indication for heart surgery, of which 74 patients were deemed fit for intervention. Surgery was scheduled in 38 patients with RHD [86%, median age 19 years (IQR: 12-31)] and in 36 patients with CHD [88%, median age 4 years (IQR 1-5)]. Twenty-seven candidates (32%) were operated on after a median waiting time of 10 months (IQR 6-21). Sixteen (19%) had died after a median of 38 months (IQR 5-52); 19 (22%) were lost to follow up. CONCLUSION: RHD still represents the leading cause of HF in Uganda, in spite of cost-efficient prevention strategies. The majority of surgical candidates, albeit young, do not have access to treatment and present high mortality rates.

Clinical outcome and quality of life in octogenarians following transcatheter aortic valve implantation (TAVI) for symptomatic aortic stenosis.

OBJECTIVE: TAVI is the alternative option in pts with AS deemed ineligible for surgery. Although mortality and morbidity are measures to assess the effectiveness of treatments, quality of life (QOL) should be an additional target. We assessed clinical outcome and QOL in octogenarians following TAVI. DESIGN: All octogenarians with a risk profile considered by the Heart Team to be unacceptable for surgery entered in this registry. QOL was assessed by questionnaires concerning physical and psychic performance. PATIENTS: A hundred forty-five octogenarians (age: 84.7 ± 3.4 years; male: 48.3%) underwent TAVI for AS (97.2%) or isolated AR (2.8%). NYHA class: 2.8 ± 0.6; Logistic EuroScore: 26.1 ± 16.7; STS score: 9.2 ± 7.7.Echocardiographic assessments included AVA (0.77 ± 0.21 cm2), mean/peak gradients (54.5 ± 12.2/88 ± 19.5 mm Hg), LVEF (21%=EF ≤ 40%), sPAP (43.1 ± 11.6 mmHg). INTERVENTIONS: All pts underwent successful TAVI using Edward-SAPIEN valve (71.2%) or Medtronic CoreValve (28.8%). MAIN OUTCOME MEASURES: Rates of mortality at 30 days, 6 months and 1 year were 2.8%, 11.2% and 17.5%. RESULTS: At 16-month follow up, 85.5% survived showing improved NYHA class (2.8 ± 0.6 vs 1.5 ± 0.7; p<0.001), decreased sPAP (43.1 ± 11.6 mm Hg vs 37.1 ± 7.7 mm Hg; p<0.001) and increased LVEF in those with EF ≤ 40% (34.9 ± 6% vs 43.5 ± 14.4%; p=0.006). Concerning QOL, 49% walked unassisted, 79% (39.5% among pts ≥ 85 years) reported self-awareness improvement; QOL was reported as "good" in 58% (31.4% among pts ≥ 85 years), "acceptable according to age" in 34% (16% among pts ≥ 85 years) and "bad" in 8%. CONCLUSION: TAVI procedures improve clinical outcome and subjective health-related QOL in very elderly patients with symptomatic AS.

Calcified left ventricular endomyocardial fibrosis.

Endomyocardial fibrosis (EMF) is a rare condition, but in certain tropical countries it is a major cause of illness and death. Moreover, the etiology of the disease is unknown, it has no specific treatment, and it carries a poor prognosis. As both the heart and the peritoneum may be affected by the inflammation and deposition of fibrous tissue, even left ventricular EMF may present with gross ascites mimicking right-heart failure. Notwithstanding attempts to standardize the diagnostic criteria, the clinical presentation may still be challenging. The case is described of calcified left ventricular EMF presenting with right-heart failure in the absence of right ventricular fibrosis.

Surgical outcome of partial Shone complex.

Partial forms of Shone complex are rare. Surgical outcomes of the complete forms have generally been poor, whereas there is a lack of data on long-term follow-up of surgically treated adult partial complex. Between 2001 and 2011, nine patients (age: 38 ± 8 years; six males, 67%) were referred for valvular heart disease. Transthoracic and transoesophageal echocardiography was performed. Data were confirmed by intra-operative findings and reports. Patients were diagnosed as partial Shone complex and presented with mitral stenosis (MS) (45%) or mitral regurgitation (22%) or aortic regurgitation (22%). All but one patient (89%) reported previous surgery: coarctation of the aorta repair (87.5%) and aortic valvulotomy (12.5%). Redo intervention included: mitral valve replacement (25%), mitral repair (25%), aortic valve replacement (37.5%) and subvalvular aortic ridge resection (25%). One patient refused surgery. Patients surgically treated before the age of 5 (87.5%) showed favourable outcome (survival rate: 100%) and a 23.6 (± 4.6)-year follow-up free from events. The patient who underwent first intervention at the age of 50 and the patient with MS who refused surgery showed a 45 (± 7)-year follow-up free from major morbidity. Patients with partial Shone complex, properly diagnosed and treated, show favourable surgical outcome free from major clinical events.

Echocardiographic patterns of incomplete Shone's syndrome in adults.

BACKGROUND AND AIM OF THE STUDY: Whilst several cases of complete Shone's complex have been reported in children, the incomplete form--characterized by two or three components--has rarely been described in adults. Because of the wide spectrum of severity of each pattern, the correct diagnosis may be challenging. Moreover, as the hemodynamic interdependence between defects is thought to be a major determinant of clinical outcome and long-term follow up, it is crucial to consider the lesions as part of the same Shone's syndrome. METHODS: Between May 2005 and December 2009, six male patients (mean age 38 +/- 8 years) were referred to the authors' institute with progressive worsening of heart failure symptoms related to valvular disease. All patients had a clinical history of surgery for coarctation of the aorta (CoA), and all but one had a bicuspid aortic valve. Standard transthoracic and transesophageal echocardiographies were performed in all patients to identify the valvular heart disease responsible for clinical deterioration. RESULTS: Unexpected findings of dysplastic mitral valvular apparatus compatible with parachute deformity of the mitral valve (PMV) or 'PMV-like' morphology were disclosed in all patients. The association with major anatomic abnormalities (bicuspid aortic valve, subaortic ridge, and previous CoA surgical repair) was highly suggestive of adult incomplete Shone's syndrome. CONCLUSION: The findings of the present case series emphasized the need for a greater awareness regarding the rare incomplete Shone's syndrome in adulthood, as it occurs far more frequently than might be expected following a random diagnosis. The findings also highlight the additional value of a carefully performed step-by-step echocardiographic study to support the clinical decision-making in this array of left heart anomalies.

Tracking antigen-experienced effector T cells in vitro and in vivo.

The TCR complex is a multisubunit complex, comprising at least eight transmembrane units. The clonotypic TCR alpha and beta chains are responsible for antigen recognition, whilst the invariant chains of the CD3 complex (delta, epsilon and gamma) and two zeta (zeta) polypeptides couple antigen recognition to downstream signal transduction pathways. TCRzeta (CD247) functions as an amplification module in the TCR signalling cascade and is also essential for the assembly and surface expression of the TCR/CD3 complex. Loss of TCRzeta expression is common in chronic infectious and inflammatory diseases, as well as in cancer. Previous work has indicated that TCRzeta(low)-expressing cells phenotypically resemble antigen-experienced effector T cells. Here, we describe the derivation of a flow cytometry-based TCRzeta expression index for the purpose of more precisely defining TCRzeta expression, in addition to utilising a simple transmigration assay in the demonstration that TCRzeta(dim) T cells have intrinsic migratory properties that may explain their accumulation at sites of inflammation.

TCRzetadim lymphocytes define populations of circulating effector cells that migrate to inflamed tissues.

The T-cell receptor zeta (TCRzeta) chain is a master sensor and regulator of lymphocyte responses. Loss of TCRzeta expression has been documented in infectious, inflammatory, and malignant diseases, suggesting that it may serve to limit T-cell reactivity and effector responses at sites of tissue damage. These observations prompted us to explore the relationship between TCRzeta expression and effector function in T cells. We report here that TCRzeta(dim) lymphocytes are enriched for antigen-experienced cells refractory to TCR-induced proliferation. Compared to their TCRzeta(bright) counterparts, TCRzeta(dim) cells share characteristics of differentiated effector T cells but use accessory pathways for transducing signals for inflammatory cytokine gene expression and cell contact-dependent pathways to activate monocytes. TCRzeta(dim) T cells accumulate in inflamed tissues in vivo and have intrinsic migratory activity in vitro. Whilst blocking leukocyte trafficking with anti-TNF therapy in vivo is associated with the accumulation of TCRzeta(dim) T cells in peripheral blood, this T-cell subset retains the capacity to migrate in vitro. Taken together, the functional properties of TCRzeta(dim) T cells make them promising cellular targets for the treatment of chronic inflammatory disease.