The Use of CYFRA 21-1 for the Detection of Breast Cancer Axillary Lymph Node Metastases in Needle Washouts of Fine-Needle Aspiration Biopsies.

BACKGROUND: In the preoperative setting of breast cancer, fine-needle aspiration biopsy (FNAB) guided by ultrasonography can be used to detect axillary lymph node metastases. The aim of the current study was to determine whether measurement in needle washouts of CYFRA 21-1, a soluble fragment of cytokeratin 19 (CK19), can improve the diagnosis of lymph node tumor deposits. MATERIALS AND METHODS: Our prospective study included 329 breast cancer patients eligible for a sentinel node procedure. Eighty-two patients had a ultrasonography-guided FNAB of an abnormal or suspicious axillary node and were included in the current analysis. Samples were processed with smears and cell-block histology; afterwards, needles were washed with saline solution, and the CYFRA 21-1 content in the washouts was measured. The cutoff value for positive samples that expressed CK19, as shown by their immunohistochemistry, was determined by a receiver operating characteristic curve. On the basis of this value, the specificity and the sensitivity, as well as the positive and negative predictive values, were then calculated using cytology results as a reference standard. RESULTS: Of the 82 axillary lymph nodes sampled, 61 were positive on cytology and were metastatic for breast cancer, as confirmed by surgery. The median CYFRA 21-1 concentration of positive samples was 88.94 ng/mL, whereas in the 21 negative nodes, its median concentration was 1.02 ng/mL (P<0.0001). A CYFRA 21-1 cutoff value of 1.98 ng/mL, obtained by the receiver operating characteristic curve, was able to clearly separate negative from positive samples and gave the test a sensitivity of 0.98 and a specificity of 1.00. Positive and negative predictive values were 1.00 and 0.95, respectively. CONCLUSIONS: The measurement of CYFRA 21-1 levels in needle washouts after axillary lymph node FNABs represents an accurate, sensitive, and highly predictive procedure in detecting metastatic deposits of breast cancer and is fit to complement cytology and CK19 immunohistochemistry as a diagnostic tool.

Long-Term Outcomes and Complications of Intracardiac Echocardiography-Assisted Patent Foramen Ovale Closure in 1,000 Consecutive Patients.

BACKGROUNDS: Long-term fate of patients submitted to patent foramen ovale (PFO) closure is still unclear. The aim of the study was to evaluate the incidence of atrial fibrillation (AF), aortic or atrial free wall erosion, device thrombosis (DT), new onset or worsening of mitral valve regurgitation (MVR), and recurrent cerebral ischemic events in the long-term follow up after intracardiac echocardiography (ICE)-aided PFO closure in a large population. METHODS: We reviewed the medical and instrumental data of 1,000 consecutive patients (mean age 47.3 ± 17.1 years, females) prospectively enrolled in 2 centres over a 13 years period (February 1999-February 2012) for R-to-L shunt ICE-aided catheter-based closure using different devices. RESULTS: Immediate success was 99.8%. Implanted devices were Amplatzer PFO Occluder in 463 patients (46.3%), Amplatzer ASD Cribriform Occluder in 420 patients (42.0%), Premere Occlusion System in 95 patients (9.5%), and Biostar Occluder in 22 patients (2.2%). On a mean follow-up of 12.3 ± 0.6 years (minimum 4- maximum 17 years), permanent AF occurred in 0.5%, DT was apparent in 0.5%, new onset or worsening of MVR was observed in 0.2%, whereas recurrent cerebral ischemic events were 0.8%. Occlusion rate was 93.8%. No aortic or atrial free wall erosion has been observed. CONCLUSION: ICE-aided closure of PFO using different devices, appeared very safe and effective on very long-term follow up with low incidence of erosion, DT, recurrent ischemic events, MVR new onset or worsening, and permanent AF.

Echocardiographic guidance of percutaneous patent foramen ovale closure: head-to-head comparison of transesophageal versus rotational intracardiac echocardiography.

BACKGROUND: Transesophageal (TEE) and intracardiac (ICE) echocardiography are commonly used to guide percutaneous patent foramen ovale (PFO) closure. The study aim was to perform a head-to-head comparison between TEE and rotational ICE echocardiography in the measurement of the fossa ovalis and device selection. METHODS: In 45 patients with cryptogenic stroke or peripheral embolism and PFO with large right-to-left shunt, fossa ovalis dimensions were assessed preoperatively by TEE and intraoperatively by rotational ICE. The Amplatzer devices, deployed on the basis of ICE, were compared with those that would have been selected by TEE. RESULTS: A good correlation between TEE and rotational ICE was observed for both longitudinal and transverse fossa ovalis dimensions (TEE four-chamber vs. ICE four-chamber: r = 0.75; TEE bicaval vs. ICE four-chamber: r = 0.77; TEE aorta vs. ICE aorta: r = 0.59; P < 0.001 for all). However, no such correlation was found in 13 patients with atrial septal aneurysm (ASA) (TEE four-chamber vs. ICE four-chamber: r = 0.33; TEE bicaval vs. ICE four-chamber: r = 0.49; TEE aorta vs. ICE aorta: r = 0.05; P = NS for all). At Bland-Altman analysis, slight systematic differences with wide limits of agreement for each comparison were observed, particularly in patients with ASA, suggesting that the two imaging modalities cannot be used interchangeably. As regards device selection, a moderate agreement was found between TEE- and ICE-guided device size (72%, κ = 0.53, P < 0.001), except in patients with ASA (36%, κ = 0.02, P = NS). CONCLUSIONS: Our study suggests a significant disagreement between TEE and rotational ICE in measuring fossa ovalis and selecting the device for PFO closure, particularly in patients with ASA.

Funnel technique for EVAR: "a way out" for abdominal aortic aneurysms with ectatic proximal necks.

BACKGROUND: To describe an endovascular technique for proximal stent-graft fixation in patients with an abdominal aortic aneurysm and an ectatic aortic neck. METHODS: We describe a method in which using currently available devices in a hybrid assembly offers another option for circumventing the limitations of problematic proximal fixation. CONCLUSIONS: Through four examples, we illustrate the feasibility of placing a straight endograft as proximal extension of a bifurcated or aorto-uni-iliac graft in patients with a dilated proximal aortic neck. It appears secure and effective, with no type I endoleak or migration over a midterm follow-up.

[Is obesity still a coronary risk factor?]. / L'obesità è ancora un fattore di rischio coronarico?

Although obesity and, in particular, abdominal obesity is clearly a risk factor for developing coronary artery disease, once coronary artery disease has been established, the correlation of obesity with total mortality, cardiovascular mortality, myocardial infarction, and revascularization is unclear and still remains a matter of debate. The relationship between obesity and mortality in patients with coronary artery disease has so far only been investigated by posthoc analysis of cohort studies, which have produced contradictory results. When a higher percentage body fat has been found to be a strong independent predictor of event-free survival, the phenomenon has been described as an 'obesity paradox' or 'reverse epidemiology'. A recent meta-analysis, appearing in the August 19 issue of Lancet on 250,152 patients with documented coronary artery disease, suggests that after grouping 40 cohort studies with adjusted risks, overweight patients were consistently associated with a better survival and lower cardiovascular events than patients with a low body mass index, whereas obesity was associated with a higher total mortality only in patients with history of coronary artery bypass graft, and severe obesity was associated with a significantly higher cardiovascular mortality but not with an increased risk for total mortality. Far from proving that obesity is harmless, these findings suggest that alternative methods might be required to better characterize individuals who truly have excess body fat and that additional studies with different methods are needed. Moreover, still unknown is the unique contribution of higher muscle-to-fat ratio, which may be merely a surrogate of increased physical fitness. Future research is needed to assess the link between high muscle mass, high body fat and clinical outcomes.

Hyperhomocysteinemia is inversely related with left ventricular ejection fraction and predicts cardiovascular mortality in high-risk coronary artery disease hypertensives.

OBJECTIVE: The purpose of this study was to investigate the relationship of plasma homocysteine (tHcy) levels with coronary artery disease (CAD) and left ventricular ejection fraction (LVEF) in high-risk patients undergoing coronary angiography for suspected CAD. METHODS AND RESULTS: In 936 consecutive patients, we measured LVEF, tHcy, folate levels, and quantified CAD with a modified Duke Index score. We also genotyped patients at the methylen-tetrahydrofolate-reductase 677C-->T polymorphism. Hyperhomocysteinemia (HHcy) was defined as tHcy levels > or =15.46 micromol/L; total and cardiovascular mortality was assessed at follow-up that lasted 43 months (median). CAD was confirmed in 75% of patients and ruled out in the rest (non-CAD group). No relationship of HHcy with either arterial hypertension or the CAD score was found. In contrast, there was a significant inverse relationship of tHcy with LVEF in arterial hypertensive but not in normotensive patients, regardless of previous myocardial infarction. At logistic regression, HHcy was the strongest predictor (P=0.001) of a low (<40%) LVEF, followed by type 2 diabetes mellitus and cigarette smoking. At follow-up, HHcy significantly predicted cardiovascular mortality but only in the arterial hypertension subgroup. CONCLUSIONS: In arterial hypertensive but not in normotensive patients, HHcy predicts cardiovascular mortality and a low LVEF, independent of CAD and history of myocardial infarction.

Pseudo-lesion of internal mammary artery graft and left anterior descending artery during percutaneous transluminal angioplasty--a case report.

New lesions appearing during coronary angioplasty may be due to spasms, dissection, and thrombosis. Straightening of the tortuous vessels by guidewire may produce transient angiographic pseudo-lesions, which mimic severe artery damage. An additional case is reported, in which simultaneous artifactual lesions involved the internal mammary artery and the left anterior descending coronary artery, mimicking thrombosis and dissection. Recognition of this entity is essential to avoid unnecessary interventions and potentially harmful complications.

Role of intracardiac echocardiography in atrial septal abnormalities.

The purpose of this review is to outline the feasibility of performing a comprehensive atrial septal examination from the internal confine of the right atrium and to evaluate the advantages resulting by intracardiac echocardiography (ICE) evaluation of atrial septal morphology as well as pathophysiology. In this setting, ICE indications have not yet been established because ICE is a relatively new technique that is still evolving. Notwithstanding, during catheter-based secundum atrial septal defect and patent foramen ovale closure, ICE seems useful for diagnosing cardiac abnormalities instantly, guiding and monitoring all stages of the procedures, and assessing proper selection and optimal device placement. Moreover, ICE provides solid anatomical criteria to diagnose fenestrated atrial septal aneurysm, interatrial communications such as ostium primum and sinus venosus defects, partial anomalous pulmonary venous connection, and lipomatous hypertrophy of atrial septum.

The T-786C endothelial nitric oxide synthase genotype is a novel risk factor for coronary artery disease in Caucasian patients of the GENICA study.

OBJECTIVES: We investigated the association of polymorphisms in the promoter region and exon 7 endothelial nitric oxide synthase (eNOS) gene with coronary artery disease (CAD). BACKGROUND: Endothelial dysfunction foretells cardiovascular events and can be genetically determined. METHODS: We genotyped for the promoter (T(-786)C) and exon 7 (Glu298Asp, G(894)T) polymorphisms in 1,225 subjects; 1,106 were consecutive patients undergoing coronary angiography and 119 control subjects without any cardiovascular risk factors. Genotyping was performed with melting curve analysis of polymerase chain reaction products from allele-specific acceptor and donor probes that were 5'- and 3'-end labeled with LCRed640 and fluorescein, respectively; CAD was assessed by quantitative coronary angiography. We performed multiple logistic regression analysis for the effect of the T(-786)C, the missense Glu298Asp variant, and other coronary risk factors on two- and three-vessel CAD. RESULTS: The overall genotype distribution of T(-786)C (CC = 17.7%, CT = 40.4%, and TT = 41.9%) and Glu298Asp (GG = 43.3%, GT = 37.0%, and TT = 19.7%) was consistent with the Hardy-Weinberg equilibrium. The regression analysis showed that the T(-786)C, but not the missense Glu298Asp variant, significantly predicted CAD, independent of other risk factors. Compared with TT homozygous, subjects carrying the C allele had a significant (p = 0.002) increase in the odds ratio of harboring two- or three-vessel CAD of 1.672 (95% confidence interval, 1.062 to 2.527). A subgroup analysis confirmed this effect of the T(-786)C polymorphism in men (p = 0.007), cigarette smokers (p = 0.001), subjects older than 60 years of age (p = 0.007), with hypercholesterolemia (p = 0.011), low high-density lipoprotein cholesterol (p = 0.006), and overweight or with obesity (p = 0.041). CONCLUSIONS: The C allele at the T(-786)C endothelial nitric oxide synthase polymorphism is associated with a higher risk of multivessel CAD in Caucasians.

Activity-rest stimulation protocol improves cardiac assistance in dynamic cardiomyoplasty.

OBJECTIVE: No data have ever been published regarding cardiac assistance in demand dynamic cardiomyoplasty (DDCMP). We tested the efficacy of the Doppler flow wire in measuring beat-to-beat aortic flow velocity and evaluating cardiac assistance in demand cardiomyoplasty patients. METHODS: The technique was tested in seven patients (M/F=6/1; age=57.1+/-6.2 years; atrial fibrillation/sinus rhythm=1/6; NYHA=1.4+/-0.5). Measurements were done using a 0.018inch peripheral Doppler flow wire advanced through a 5F arterial femoral sheath. Three 1-min periods with the stimulator off and three 1-min periods with clinical stimulation were recorded. We measured peak aortic flow velocity in all beats. Latissimus dorsi (LD) mechanogram was simultaneously recorded. RESULTS: Comparison between pre-operative and follow-up data showed significantly higher values of tetanic fusion frequency (TFF) and ejection fraction at follow-up, whereas mean NYHA class was significantly lower. Statistical analysis showed an increase in aortic flow velocity not only in assisted versus rest period, but also in assisted versus unassisted beats (8.42+/-6.98% and 7.55+/-3.07%). A linear correlation was found between the increase in flow velocity and LD wrap TFF (r(2)=0.53). CONCLUSIONS: In DDCMP, systolic assistance is significant and correlated to LD speed of contraction; demand stimulation protocol maintains muscle properties and increases muscle performance.