Metal pollutants and cardiovascular disease: mechanisms and consequences of exposure.

INTRODUCTION: There is epidemiological evidence that metal contaminants may play a role in the development of atherosclerosis and its complications. Moreover, a recent clinical trial of a metal chelator had a surprisingly positive result in reducing cardiovascular events in a secondary prevention population, strengthening the link between metal exposure and cardiovascular disease (CVD). This is, therefore, an opportune moment to review evidence that exposure to metal pollutants, such as arsenic, lead, cadmium, and mercury, is a significant risk factor for CVD. METHODS: We reviewed the English-speaking medical literature to assess and present the epidemiological evidence that 4 metals having no role in the human body (xenobiotic), mercury, lead, cadmium, and arsenic, have epidemiologic and mechanistic links to atherosclerosis and CVD. Moreover, we briefly review how the results of the Trial to Assess Chelation Therapy (TACT) strengthen the link between atherosclerosis and xenobiotic metal contamination in humans. CONCLUSIONS: There is strong evidence that xenobiotic metal contamination is linked to atherosclerotic disease and is a modifiable risk factor.

Minimally invasive papillary muscle sling placement during mitral valve repair in patients with functional mitral regurgitation.

BACKGROUND: We evaluated the safety and feasibility of minimally invasive mitral valve repair with papillary muscle sling placement via a right anterior thoracotomy approach in patients with severe functional mitral regurgitation (MR). METHODS: We retrospectively reviewed all minimally invasive mitral valve repairs with papillary muscle sling placement in patients with severe functional MR performed at our institution between October 2011 and September 2012. The operative times, lengths of stay, postoperative complications, and mortality were analyzed. RESULTS: We identified a total of 19 consecutive patients. There were 12 men (63%); the mean age was 60 ± 13 years. The mean ± SD left ventricular ejection fraction was 23% ± 5.5%, and 4 (21%) of the patients underwent previous coronary artery bypass graft surgery. The median aortic cross-clamp and cardiopulmonary bypass times were 106 (interquartile range [IQR], 76-120) and 163 (IQR, 119-170) minutes, respectively. The median intensive care unit length of stay was 64 (IQR, 43-75) hours, and the median postoperative length of stay was 7 (IQR, 5-7.5) days. Postoperatively, 2 patients developed acute kidney injury. There were no reoperations for bleeding or any cerebrovascular accidents. The 30-day mortality was 0. A follow-up echocardiogram, obtained at a median of 3 (IQR, 1-7.5) months, demonstrated none to trivial MR in all patients. CONCLUSIONS: Minimally invasive mitral repair with papillary muscle sling placement for severe functional MR is safe and effective in the short-term. Long-term data are needed to evaluate the effects on left ventricular remodeling and to assess the durability of the repair.

The new era of cardiac surgery: hybrid therapy for cardiovascular disease.

Surgical therapy for cardiovascular disease carries excellent long-term outcomes but it is relatively invasive. With the development of new devices and techniques, modern cardiovascular surgery is trending toward less invasive approaches, especially for patients at high risk for traditional open heart surgery. A hybrid strategy combines traditional surgical treatments performed in the operating room with treatments traditionally available only in the catheterization laboratory with the goal of offering patients the best available therapy for any set of cardiovascular diseases. Examples of hybrid procedures include hybrid coronary artery bypass grafting, hybrid valve surgery and percutaneous coronary intervention, hybrid endocardial and epicardial atrial fibrillation procedures, and hybrid coronary artery bypass grafting/carotid artery stenting. This multidisciplinary approach requires strong collaboration between cardiac surgeons, vascular surgeons, and interventional cardiologists to obtain optimal patient outcomes.