Cardiac surgery in adults with high-surgical complexity CHD: results of a network collaborative programme.

BACKGROUND: Adults with CHD often exhibit complex cardiac abnormalities, whose management requires specific clinical and surgical expertise. To enable easier access of these patients to highly specialised care, we implemented a collaborative programme that incorporates medical and surgical specialists belonging to both paediatric and adult cardiovascular institutions. OBJECTIVES: The objective of this study was to review the experience gained and to analyse the surgical outcome of major cardiac surgery. METHODS: We retrospectively reviewed all consecutive patients admitted for major cardiac surgery using our network between January, 2010 and December, 2013. Analysis of surgical outcome was performed in patients selected for major cardiac surgery with cardiopulmonary bypass. Early and late outcomes were evaluated. RESULTS: Out of a total of 433 inward patients, 86 were selected for surgery. The median age was 25.5 years, -64 patients (74.4%) had previously undergone heart surgery, and -55 patients (64%) had been subjected to at least one sternotomy. Abnormalities of the left ventricular and right ventricular outflow tract were the most frequent (37.2% and 30.2%, respectively), and despite high-surgical complexity only one death occurred (in-hospital mortality 1.1%). On a median follow-up time of 4 years no deaths and no heart-failure events have occurred; one patient underwent further cardiac surgery programmed at the time of discharge. CONCLUSIONS: Low mortality and morbidity rates can be obtained in high-surgical complexity adults with CHD populations when paediatric and adult cardiac specialists operate in the same multidisciplinary environment.

Assessment of residual viability by enoximone echocardiography in patients with previous myocardial infarction correlation with positron emission tomographic studies and functional follow-up.

BACKGROUND: The aim of this study was to evaluate enoximone echocardiography (EE) for the identification of residual myocardial viability in postinfarction patients. Findings obtained during EE were compared with those acquired by myocardial uptake of fluorine-18 fluorodeoxyglucose ((18)F-FDG) positron emission tomography (PET) and functional follow-up results. METHODS: Twenty-five patients underwent EE and PET (18)F-FDG studies. An asynergic segment was considered as having contractile enhancement when the wall motion score decreased by > or = 1 grade during EE and was defined as viable if (18)F-FDG uptake score was > or = 2 grade on PET. RESULTS: Of 293 dysfunctional segments at baseline, 139 (47%) were viable by PET criteria; 117 (40%) had contractile enhancement induced by enoximone (P = 0.07). Agreement between EE and PET was found in 75% of involved segments (K = 0.46, P < 0.001). The majority of discrepancies (65%, P < 0.01) were mainly due to discordant segments in which PET revealed evidence of (18)F-FDG uptake but EE showed no change in wall motion. In 179 revascularized segments, negative predictive value for functional recovery of both tests reached the same value (89% for both), whereas positive predictive value was 82% for EE and 68% for PET, respectively (P < 0.05). Sensitivity was 85% for EE and 88% for PET (P = ns); specificity was 87% and 70%, respectively (P < 0.01). CONCLUSIONS: EE yields a fair concordance with PET study. Compared with PET, despite a similar negative accuracy, EE shows a greater specificity for prediction of function recovery after revascularization. (Echocardiography 2010;27:544-551).

Early recovery of pulmonary vein conduction after cryoballoon ablation for paroxysmal atrial fibrillation: a prospective study.

AIMS: To assess the incidence of early pulmonary vein (PV) reconnection, characterize the anatomic features of the reconducting veins, and analyse the time course of their recovery in a series of consecutive patients with paroxysmal atrial fibrillation (AF) undergoing ablation with the Arctic Front Cryoballoon. METHODS AND RESULTS: We prospectively enrolled 26 patients (20 males; age 55.4 +/- 4.1) for circumferential PV cryoballoon isolation for highly symptomatic paroxysmal AF. Following isolation of all veins, we analysed PV potentials in each vein after 30 and 60 min with a circular mapping catheter. After successful electrical isolation of all 104 PV's, recurrence was observed only in three veins (2.8%) after 30 min. Two further cryoballoon applications in each of these veins lead to their isolation. These veins were still electrically disconnected at 60 min. No PV reconnection was observed in any of the other 101 veins (97.1%) at 30 and 60 min. CONCLUSION: Cryoballoon ablation of the PV's ostia is a very effective technique to achieve electrical isolation, with a very low rate of early reconnection.

Comparison of two antiplatelet regimens (aspirin alone versus aspirin + ticlopidine or clopidogrel) after intracoronary implantation of a carbofilm-coated stent.

Stent thrombosis (ST) is an infrequent (0.5% to 1.5%) complication of intracoronary stenting, with severe clinical consequences. This multicenter, randomized study evaluated the clinical outcome in 479 patients (598 lesions treated) who underwent elective coronary stenting with a Carbofilm-coated stent (CarboStent) who met prespecified eligibility criteria and were randomly assigned to receive aspirin alone (n = 235) or aspirin plus a thienopyridine antiplatelet regimen (n = 244). Clinical, angiographic, and procedural characteristics were similar between groups. The primary end point was the incidence of 30-day ST; secondary end points included major vascular or bleeding complications within 30 days and death, acute myocardial infarction, and target vessel revascularization at 6 months. ST occurred in 4 patients (1.4%) in the aspirin-only group and in 1 patient (0.3%) in the aspirin-plus-thienopyridine group (relative risk 0.23, 95% confidence interval 0.03 to 2.08, p = NS). After careful review of cases, 89 patients (19%) with protocol deviations were identified. When they were excluded from the analysis, no ST was observed in either group. Secondary end points were reached by 4% of the aspirin-alone group and 8% of the aspirin-plus-thienopyridine group (relative risk 2.35, 95% confidence interval 0.94 to 5.85, p = NS). In conclusion, after optimal intracoronary implantation of the CarboStent, antiplatelet therapy with aspirin alone was safe and provided efficacy comparable to aspirin plus a thienopyridine in the prevention of ST.

Minimally invasive mitral valve repair in osteogenesis imperfecta.

Osteogenesis imperfecta is a disorder of the connective tissue that affects several structures including heart valves. However, cardiac surgery is associated with high mortality and morbidity rates. In a 48-year-old man with osteogenesis imperfecta and mitral valve prolapse, we performed the first successful mitral valve repair by right anterior mini-thoracotomy. At the 1-year follow-up, he was asymptomatic and echocardiography confirmed the initial success.

Distal protection with a filter device during coronary stenting in patients with stable and unstable angina.

BACKGROUND: Filter protection after percutaneous coronary intervention (PCI) is now available to prevent distal embolization. The aims of this study were (1) to evaluate the microembolization phenomenon during procedures of stent implantation in native coronary arteries of patients with stable and unstable angina, (2) to assess the amount and characteristics of the debris captured by the Angioguard, and (3) to investigate the relation between clinical and angiographic variables and pathological data. METHODS AND RESULTS: Elective coronary stenting with the use of a protective filter was attempted in 39 consecutive coronary artery lesions with >60% stenosis (mean, 67.6+/-8.79%). Debris was present in 75.6% of the filters. Particle size ranged from 47.16 to 2503.48 microm (mean, 518.83+/-319.61 microm) in the major axis. Particles >300 microm were found in 24 of 28 filters with debris (85.7%), and particles >1000 microm were present in 10 of 28 filters (35.7%). Patients with unstable angina had greater particles (mean maximum longitudinal diameter, 1098.33+/-714.3 microm) than those with stable angina (412.91+/-453 microm; P<0.001). The presence of unstable angina (OR, 65; CI, 1.2 to 3420; P=0.03) and age >67 years (OR, 42; CI, 1 to 1698; P=0.04) were found to be the only independent predictors of embolic particle size. CONCLUSIONS: By limiting embolization, protective devices may prevent a number of potentially unfavorable events, thereby improving outcome. Our data support the use of these devices, especially in lesions with higher embolic potential, such as those occurring in older patients and in those with unstable angina.

Acute intravenous L-arginine infusion decreases endothelin-1 levels and improves endothelial function in patients with angina pectoris and normal coronary arteriograms: correlation with asymmetric dimethylarginine levels.

BACKGROUND: We tested the hypothesis that asymmetric dimethylarginine (ADMA) levels could be elevated and influence endothelin-1 and nitric oxide release and action in patients with cardiac syndrome X (CSX). In addition, we evaluated whether an intravenous infusion of L-arginine would improve endothelial function in these subjects. METHODS AND RESULTS: Nine patients with CSX and 14 control subjects underwent a continuous infusion of L-arginine (0.125 g/min) or saline for 120 minutes. Sixty minutes after L-arginine or saline infusions, an intravenous insulin bolus (0.1 U/kg) combined with a euglycemic clamp was performed. Basal ADMA and endothelin-1 levels were higher in patients with CSX than in controls. At the end of the first hour of infusion, compared with saline, L-arginine infusion increased basal forearm blood flow, nitrite and nitrate (NOx), and forearm cGMP release and decreased endothelin-1. After insulin bolus, during saline, insulin-induced NOx, endothelin-1, and forearm cGMP release was almost abolished. Conversely, L-arginine restored a physiological profile of all endothelial variables compared with control subjects. In control subjects, compared with saline infusion, L-arginine infusion did not modify any parameter. ADMA levels were positively correlated with basal endothelin-1 levels and negatively correlated with insulin-induced incremental levels of NOx and forearm cGMP release. CONCLUSIONS: Plasma ADMA levels are increased in patients with CSX, and they are correlated with increases in endothelin-1 and reductions in insulin-induced increments in plasma NOx and cGMP, effects that are reversed by intravenous L-arginine. These data suggest that increased ADMA levels play a role in the abnormal vascular reactivity that is observed in patients with CSX.

Acute effects of heparin administration on the ischemic threshold of patients with coronary artery disease: evaluation of the protective role of the metabolic modulator trimetazidine.

OBJECTIVES: We sought to assess the effects of heparin and the potential protective effects of trimetazidine (TMZ) on exercise performance, plasma nitric oxide (NO), endothelin-1 (ET-1) and free fatty acid (FFA) release in patients with stable coronary artery disease (CAD). BACKGROUND: Heparin has been shown to reduce the ischemic threshold in patients with CAD. Trimetazidine may affect myocardial substrate utilization by shifting energy production from FFA to glucose oxidation. METHODS: In four consecutive days, nine patients with CAD each received one of the following four regimens: 1) one tablet of placebo the evening before and at 8 AM and 4 PM on the day of the study, 10 ml of saline in a bolus 10 min before exercise, followed by an infusion of the same preparation; 2) placebo at the same times as in the first regimen, 5,000 IU of heparin 10 min before exercise, followed by 1,000 IU/h; 3) 20 mg TMZ at the same times as in the first regimen, 5,000 IU of heparin 10 min before exercise, followed by 1,000 IU/h; or 4) TMZ at the same times as in the first regimen, 10 ml of saline 10 min before exercise, followed by an infusion of the same preparation. RESULTS: During placebo (test 2), heparin reduced the time to 1-mm ST-segment depression and prolonged the recovery time, as compared with the results of test 1. When heparin was administered after TMZ (test 3), the time to 1-mm ST-segment depression and the recovery time were similar to those recorded during saline (test 1). Finally, compared with all study phases, TMZ during saline (test 4) prolonged the time to 1 mm. No changes in NO release were found, whereas ET-1 was decreased at peak exercise and during recovery, when the patients were receiving TMZ (tests 3 and 4). Free fatty acids increased after heparin, both with placebo and TMZ. CONCLUSIONS: In patients with CAD, heparin reduces the ischemic threshold. Trimetazidine reduces the effects of heparin, probably by inhibiting FFA oxidation and enhancing glucose metabolism. The concomitant novel observation of reduced ET-1 release is likely to be also dependent on TMZ-induced improvement of endothelial metabolism or reduction of myocardial ischemia.

Non-ST-elevation acute coronary syndrome in the elderly: treatment strategies and 30-day outcome.

BACKGROUND: The purpose of this study was to assess the current care of elderly patients with non-ST-elevation acute coronary syndrome (ACS), with particular regard to the rate of use of antiplatelet drugs and the type of strategy, aggressive or conservative, in a population of consecutive patients admitted to 76 Coronary Care Units in Italy. METHODS: Prospective registry of patients admitted to Coronary Care Units with a diagnosis of non-ST-elevation ACS during a 2-month period. Thirty-day follow-up was available in all patients. RESULTS: Of 1581 patients enrolled in the registry, 564 were 75 years or older. As compared with the 1017 younger patients, elderly patients had a greater prevalence of female sex (42% vs 27%, P <.001), hypertension (70% vs 59%, P <.001), prior myocardial infarction (MI) (41% vs 29%, P <.001), prior angina (18% vs 13%, P <.01), prior use of aspirin (49% vs 39%, P <.001), ST-segment depression (54% vs 43%, P <.001), and troponin positivity (66% vs 59%, P <.05). The higher-risk profile of elderly patients was confirmed by the greater number of patients with a high TIMI risk score (37% vs 22%, P <.001). GPIIb/IIIa inhibitors were less frequently used in elderly patients (P <.05). An aggressive strategy (coronary arteriography within 4 days of admission, followed by revascularization, if feasible) was adopted in 39% elderly patients and in 56% younger patients (P <.001). An interventional procedure within 30 days was performed in 30% of elderly patients and 48% of younger patients (P <.001). Elderly patients had a more unfavorable 30-day outcome compared with younger ones, as shown by the higher rates of death (6.4% vs 1.7%), acute myocardial infarction (7.1% vs 5%), and stroke (1.3% vs 0.5%). Multivariate analysis of the elderly group identified a conservative strategy (OR, 2.31; 95% CI, 1.20 to 4.48) and a diagnosis of non-Q-wave MI (OR, 2.27; 95% CI, 1.32 to 3.93) as independent predictors of 30-day events. CONCLUSIONS: The elderly represent a very high-risk subgroup among patients with non-ST-elevation ACS, with a nearly 4-fold as high 30-day death rate as that of younger patients. These data call for a greater attention to such population, both in terms of an improved representation in clinical research and of the assessment of the outcome of different strategies in appropriately designed randomized trials.

Effect of oral L-arginine on blood pressure and symptoms and endothelial function in patients with systemic hypertension, positive exercise tests, and normal coronary arteries.

Thirteen hypertensive patients with microvascular angina were studied before and after receiving oral L-arginine (4 weeks, 2 g, 3 times daily). L-arginine significantly improved angina class, systolic blood pressure at rest, and quality of life. Maximal forearm blood flow, plasma L-arginine, L-arginine:asymmetric dimethyl arginine ratio, and cyclic guanylate monophosphate increased significantly after treatment. In medically treated hypertensive patients with micro-vascular angina, oral L-arginine may represent a useful therapeutic option.

Modifications of minimal luminal diameter during the 24 hours following percutaneous treatment of in-stent restenosis.

The early renarrowing after percutaneous coronary interventions (PCI) for in-stent restenosis (ISR) is a phenomenon that has received little investigation. Therefore, we assessed the angiographic minimal luminal diameter (MLD) before, immediately after, and 24 hours after the procedure in 30 ISR's treated with balloon angioplasty (BA) or rotational atherectomy (RA). The MLD was 0.68+/-0.48 mm at baseline, 2.42+/-0.38 mm after the procedure, and 2.25+/-0.39 mm at 24 hours (p < 0.0001 for all comparisons). Therefore, a small but significant decrease in MLD between post-procedure and 24 hours, corresponding to an early loss of 0.18+/-0.16 mm, was evident. The early loss was not significantly different in ISR's treated with BA or RA (0.15+/-0.16 mm and 0.20+/-0.16 mm, respectively). No significant correlation between early loss and lesion length, diameter stenosis, reference diameter, and acute gain was found. However, no increase of the 24-hour diameter stenosis to more than 50% was observed. We conclude that the magnitude of early luminal loss after PCI of ISR is small and therefore does not generally constitute a clinical problem.

Cell transplantation: a novel perspective in the treatment of heart failure.

Stem cell transplantation has been proposed as a novel experimental strategy to treat heart diseases, such as acute myocardial infarction and heart failure. The beneficial effects of transplanted cells may include active contribution to contractile function, passive improvement of cardiac mechanics, induction of neoangiogenesis or other indirect influences on the biology of the heart. Several cell types have been used for cardiac transplantation. These include embryonic stem cells, bone marrow stem cells, and skeletal myoblasts. Encouraging results have been obtained in experimental ischemic and non-ischemic heart disease that show sustained cell survival after transplantation, integration into the host myocardium, and functional improvement of diseased hearts. Furthermore, preliminary data, obtained in patients with acute myocardial infarction, suggest that the observation obtained in the experimental animal may be transferred to the clinical arena in the near future. These observations fueled an exciting period of discovery and high expectations followed by controversies that need to be addressed before this strategy can be added to the therapeutic options for patients with heart disease.

Local electrogram assessment of unidirectional isthmus block is sufficient to predict the acute and long-term success of cavo-tricuspid isthmus ablation.

BACKGROUND: This study investigated whether a minimal approach to typical atrial flutter ablation using an 8 mm tip catheter with a 150 W generator with only the documentation of clockwise block by means of local criteria predicts a good long-term outcome. METHODS: Seventy patients underwent typical atrial flutter ablation. A multipolar catheter was inserted into the coronary sinus (CS) and an 8 mm tip ablation catheter was used to ablate and map the isthmus. The ablation line was performed in the posteroseptal region. The clockwise block was confirmed by recording a corridor of double potentials along the line and by counterclockwise activation of the portion of the isthmus just beyond the lesion line as demonstrated by measuring the conduction times during CS pacing. RESULTS: In case of block, the mean distance between the two split atrial electrograms was 129 +/- 31 ms. Acute isthmus block was achieved in all 70 patients. The median of the radiofrequency pulses was 10 (range 1-36). No immediate or late complications were noted. The long-term follow-up (19.5 +/- 4 months) revealed recurrence of typical atrial flutter in 2 cases (2.8%). CONCLUSIONS: Our results demonstrate that the acute success rate following typical atrial flutter isthmus ablation using an 8 mm tip catheter with a 150 W generator is high. No complications occurred. Moreover, the documentation of just the clockwise isthmus block using a minimal approach according to local electrogram criteria is a good predictor of the long-term success.

Short-term and long-term results of cardiac surgery in elderly and very elderly patients.

OBJECTIVE: Cardiac operations in elderly patients are increasingly frequent and imply major clinical, ethical, and economic issues. Operative and 5-year results of cardiac operations in patients aged 79 years or more are known in limited series, and a debate is ongoing on the appropriateness of selection of patients for surgery. METHODS: We retrospectively reviewed our experience in 6802 patients aged 79 years or more who had received a cardiac operation. Surgical candidates were selected according to functional status, crude operative risk, and social context and were managed according to a multimodality protocol. RESULTS: Mean age was 82 years and surgery was nonelective in 1613 cases (23.5%, 31 salvage). Procedures consisted of valve replacement (aortic, 2817; mitral, 532; and tricuspid, 2 cases), valve repair (aortic, 66; mitral, 532; and tricuspid, 232 cases), coronary bypass grafting (12,034 coronary vessels bypassed), and replacement of the thoracic aorta (ascending, 315; arch, 28 cases). Overall operative mortality was 3.4%. Nonelective presentation, need for aortic counterpulsation, cardiopulmonary bypass time, blood transfusion, depressed systolic function, and chronic lung disease predicted operative mortality. Five-year cumulative mortality was 7.5%. Poor systolic function, previous myocardial infarction, and combined coronary/mitral surgery predicted late mortality. The operative risk of nonagenarians operated on electively did not differ from that of risk-matched octogenarians. CONCLUSIONS: Cardiac surgery in elderly and very elderly patients can be performed with acceptable mortality provided that accurate selection and a multifactorial risk evaluation are adopted. Whenever possible, nonelective operations should be avoided and earlier surgery should be encouraged. Five-year survival and functional recovery are good.

Gender differences in the cardiovascular effects of sex hormones.

Over the last decade, compelling evidence supports the idea that the different impact of cardiovascular disease (CVD) and the differences in vascular biology in men and women may be, at least in part, related to the cardiovascular and metabolic effects of sex steroid hormones. Indeed, androgens and oestrogens influence a multitude of vascular biological processes and their cardiovascular effects are multifaceted. While in women the effects of androgens mainly depend upon oestrogens' levels and, ultimately, upon the estradiol/testosterone ratio, the effects of androgens in men mostly relate to their aromatization into oestrogens. Oestrogens exert potential beneficial effects on the cardiovascular system in both sexes. In women, the effect of oestrogens, alone or in association with progestins, has been widely investigated, but data obtained from older patient populations have lead the medical community and the general public to misleading conclusions. Growing evidence supports the 'timing hypothesis', which suggests that oestrogen/hormone replacement therapy may increase CVD risk if started late after menopause, but produce beneficial cardiovascular effects in younger postmenopausal women. Because in men adequate interventional studies with testosterone are lacking, specific investigations should be performed.

Minimally invasive radiofrequency ablation of lone atrial fibrillation by monolateral right minithoracotomy: operative and early follow-up results.

BACKGROUND: Although an increasing number of symptomatic patients with atrial fibrillation (AF) are being treated with percutaneous radiofrequency ablation, the actual long-term success rate of this procedure remains uncertain. The increasing availability of minimally invasive techniques has made surgery progressively more appealing, especially because of its superior capacity to create transmural lesions. METHODS: In a group of 46 patients with paroxysmal or persistent "lone" AF, who were refractory to medical treatment or had arrhythmia recurrences after a transcatheter procedure, we performed epicardial radiofrequency ablation by a minimally invasive, monolateral thoracoscopic approach. Mean operative time was 85 +/- 35 minutes, and intensive care unit and hospital stays were, respectively, 18.7 +/- 5.1 hours and 4.1 +/- 1.4 days. There were no deaths and only 1 serious complication due to severe bleeding requiring conversion to median sternotomy. RESULTS: At the 6-month follow-up (Holter monitoring), 40 patients (87%) were in stable sinus rhythm. Of the 6 recurrences that we observed, 5 occurred in patients with persistent AF and 1 in a patient with paroxysmal AF (p < 0.01). CONCLUSIONS: Minimally invasive monolateral thoracoscopic radiofrequency ablation is safe and apparently effective. If these findings are confirmed on larger populations followed for longer periods, this procedure may become a viable proposal for treating refractory lone AF.

Comparison of exercise electrocardiography, technetium-99m sestamibi single photon emission computed tomography, and dobutamine and dipyridamole echocardiography for detection of coronary artery disease in hypertensive women.

To assess the performance of currently used stress tests for the detection of coronary artery disease (CAD) in a series of female hypertensive patients. We performed exercise electrocardiography (ECG), technetium-99m sestamibi (MIBI) single photon emission computed tomography, dobutamine and dipyridamole echocardiography, and coronary angiography in 76 hypertensive women. Of the 76 study patients, 31 (41%) had significant CAD. The sensitivity of exercise ECG (81%), MIBI scanning (90%), and dobutamine echocardiography (87%) was greater than that of dipyridamole echocardiography (61%). This finding resulted from the lower sensitivity of dipyridamole echocardiography in the detection of single-vessel CAD (47% vs 76%, 88%, and 82% for the other 3 methods). In contrast, the sensitivity of the 4 tests was similar in the detection of multivessel CAD. The specificity of exercise ECG (56%) and MIBI scanning (53%) was less than that of dobutamine (82%, both p <0.01) and dipyridamole (91%, both p <0.001) echocardiography. This finding related to the lower specificity of exercise ECG in patients with either left ventricular hypertrophy or ST-T abnormalities at rest compared to the specificity in patients without these disorders (33% vs 89%, p <0.01). A lower MIBI scan specificity was found only in patients with left ventricular hypertrophy (31% vs 66%, p <0.05). The overall accuracy of dobutamine echocardiography reached 84% compared to exercise ECG (66%, p <0.01), MIBI scan (68%, p <0.05), and dipyridamole echocardiography (79%, p <0.05). In conclusion, dobutamine echocardiography yielded satisfactory diagnostic accuracy for identifying CAD in hypertensive women. Although dipyridamole echocardiography had the greatest specificity, it might be limited in detecting mild CAD. Both exercise ECG and MIBI scanning had fare sensitivity; however, our findings limit the usefulness of these 2 tests in unselected patients.