Long-term Follow up of Patients with Acute Aortic Syndromes: Relevance of both Aortic and Non-aortic Events.

BACKGROUND: The aim was to assess the long-term outcome of patients diagnosed with type A and type B acute aortic syndromes (AAS) and the mortality risk predictors. METHODS: A single centre retrospective observational study was performed on consecutive patients diagnosed with AAS and discharged between 2000 and 2016: 242 surgically treated type A, 87 uncomplicated, medically treated type B, and 80 complicated type B who received endovascular/surgical/hybrid treatment. Follow up of discharged patients (5 ± 3.9 years) was almost complete by the end of the study (December 2017). RESULTS: The mean age was 65.3 ± 12.5 years, and 70.2% were men. Long-term all cause mortality was 5.4 per 100 patients per year in surgically treated type A AAS patients and 6.7 per 100 patients per year in type B AAS patients (p = .236). The rates of major aorta related events were 6.1 per 100 patients per year and 13.4 per 100 patients per year, respectively (p < .001). Non-aorta related events during long-term follow up occurred in 18.2 per 100 patients per year in type A and 13.8 per 100 patients per year in type B (p = .055). At the end of follow up 279/409 (68.2%) patients (165/242 type A and 114/167 type B) experienced at least one event. CONCLUSIONS: Among patients with either type A or type B AAS surviving the acute phase, the risk of adverse aorta and non-aorta related events, including death, persists during follow up, so that eventually two thirds of patients will experience at least one event. Notably, all cause mortality after type B AAS exceeds that of type A AAS after three years.

Clinical outcomes with percutaneous coronary revascularization vs coronary artery bypass grafting surgery in patients with unprotected left main coronary artery disease: A meta-analysis of 6 randomized trials and 4,686 patients.

Some but not all randomized controlled trials (RCT) have suggested that percutaneous coronary intervention (PCI) with drug-eluting stents may be an acceptable alternative to coronary artery bypass grafting (CABG) surgery for the treatment of unprotected left main coronary artery disease (ULMCAD). We therefore aimed to compare the risk of all-cause mortality between PCI and CABG in patients with ULMCAD in a pairwise meta-analysis of RCT. METHODS: Randomized controlled trials comparing PCI vs CABG for the treatment of ULMCAD were searched through MEDLINE, EMBASE, Cochrane databases, and proceedings of international meetings. RESULTS: Six trials including 4,686 randomized patients were identified. After a median follow-up of 39 months, there were no significant differences between PCI vs CABG in the risk of all-cause mortality (hazard ratio [HR] 0.99, 95% CI 0.76-1.30) or cardiac mortality. However, a significant interaction for cardiac mortality (Pinteraction= .03) was apparent between randomization arm and SYNTAX score, such that the relative risk for mortality tended to be lower with PCI compared with CABG among patients in the lower SYNTAX score tertile, similar in the intermediate tertile, and higher in the upper SYNTAX score tertile. Percutaneous coronary intervention compared with CABG was associated with a similar long-term composite risk of death, myocardial infarction, or stroke (HR 1.06, 95% CI 0.82-1.37), with fewer events within 30 days after PCI offset by fewer events after 30 days with CABG (Pinteraction < .0001). Percutaneous coronary intervention was associated with greater rates of unplanned revascularization compared with CABG (HR 1.74, 95% CI 1.47-2.07). CONCLUSIONS: In patients undergoing revascularization for ULMCAD, PCI was associated with similar rates of mortality compared with CABG at a median follow-up of 39 months, but with an interaction effect suggesting relatively lower mortality with PCI in patients with low SYNTAX score and relatively lower mortality with CABG in patients with high SYNTAX score. Both procedures resulted in similar long-term composite rates of death, myocardial infarction, or stroke, with PCI offering an early safety advantage and CABG demonstrating greater durability.

Spleen stiffness measurement can predict clinical complications in compensated HCV-related cirrhosis: a prospective study.

BACKGROUND & AIMS: Hepatic venous pressure gradient (HVPG) measurement represents the best predictor of clinical decompensation (CD) in cirrhotic patients. Recently data show that measurement of spleen stiffness (SS) has an excellent correlation with HVPG levels. Aim of the present prospective study was to assess SS predictive value for CD compared to HVPG, liver stiffness (LS), and other non-invasive tests for portal hypertension in a cohort of patients with HCV-related compensated cirrhosis. METHODS: From an initial cohort of 124 patients, 92 underwent baseline LS, SS, HVPG measurements and upper gastrointestinal endoscopy at enrolment and then followed-up for 2 years or until the occurrence of the first CD. Univariate and multivariate logistic regression models were used for determining judgement criteria associated parameters. Accuracy of predictive factors was evaluated using c statistic. The final model was internally validated using the bootstrap method. RESULTS: During follow-up, 30 out 92 (32.6%) patients developed CD. At univariate analysis varices at enrolment, all non-invasive parameters, HVPG, and model for end-stage liver disease (MELD) resulted clinical predictors of CD. At multivariate analysis only SS (p=0.0001) and MELD (p=0.014) resulted as predictive factors. A decision algorithm based on the results of a predictive model was proposed to detect patients with low risk of decompensation. CONCLUSIONS: This study shows that in compensated cirrhotic patients a SS and MELD predictive model represents an accurate predictor of CD with accuracy at least equivalent to that of HVPG. If confirmed by further studies, SS and MELD could represent valid alternatives to HVPG as prognostic indicator of CD in HCV-related cirrhosis.

Total aortic arch replacement with frozen elephant trunk technique: Results from two European institutes.

OBJECTIVE: We report on a large series of patients treated at the S. Orsola Hospital, University of Bologna (Bologna, Italy) and Hannover Medical School (Hannover, Germany), with the aim to evaluate the early and midterm results. METHODS: Between January 2007 and March 2017, 437 patients underwent total aortic arch replacement with the frozen elephant trunk technique. The frozen elephant trunk prostheses used were the custom-made Chavan-Haverich (Hanover, Germany) (n = 27, 6%), Jotec E-vita open (Jotec Inc, Hechingen, Germany) (n = 192, 44%), and Vascutek Thoraflex-Hybrid (Vascutek, Inchinnan, Scotland) (n = 218, 50%). The main indications were thoracic aortic aneurysm (n = 135, 31%), chronic aortic dissection (n = 182, 41.6%), and acute aortic dissection (n = 120, 27.5%). RESULTS: Overall in-hospital mortality was 14.9%, and permanent neurologic deficit and spinal cord injury were 10.8% and 5.5%, respectively. Patients with chronic aortic dissection presented a better in-hospital mortality rate than the thoracic aortic aneurysm and acute aortic dissection groups. Independent risk factors for mortality in the overall population were prolonged cardiopulmonary bypass time, age, urgent/emergency surgery, and Marfan syndrome. The median (p25, p75) follow-up time was 2.6 (1.4-4.4) years, and the mortality rate was 7.01 (95% confidence interval, 5.7-8.7) per 100 patient-years. A total of 86 patients (23.1%) required an additional procedure during the follow-up; 61 (16.3%) required endovascular extensions, and 25 (6.7%) required aortic surgery. CONCLUSIONS: The frozen elephant trunk technique is a treatment option for all complex pathologies of the thoracic aorta. Patients with thoracic aortic aneurysms presented a higher mortality rate, and in patients with acute aortic dissection, the malperfusion syndrome still remains a catastrophic complication. The midterm follow-up showed satisfactory results in terms of survival and freedom from reintervention.

The influence of the trocar choice on post-operative acute pain after thoracoscopy.

BACKGROUND: Acute post-operative pain following thoracic surgery procedures is still an unresolved problem despite the introduction of minimally invasive procedures such as video assisted surgery. Until now it is never investigated if different surgical instruments could influence post-operative pain. The aim of our study is to investigate the role of different type of trocar on post-operative pain in minimally invasive thoracic surgery. METHODS: This was a prospective randomized single center study. We identified 53 patients randomized into three groups underwent single port thoracoscopy for malignant pleural effusion with drainage of the fluid and talc poudrage. The three groups differ for the trocar type, rigid, flexible and wound protector. RESULTS: We compared the postoperative pain between the three groups in which there was no statistical difference. Rigid trocar seems to give a more stable level of pain during the days, flexible trocar gains more pain in the first few hours, however the pain at discharge decreases significantly, reaching the similar values, in all the three groups. The association between pain at discharge and operative time or days of drainage was analyzed by means of linear regression, no statistically significant difference was found. CONCLUSIONS: Our study showed that different type of trocars during video assisted thoracic surgery (VATS) produces similar level of acute postoperative pain. In future, further randomized study with a great number of patients enrolled needs to confirm our results.

Redefining the histopathologic profile of acute aortic syndromes: Clinical and prognostic implications.

OBJECTIVES: The study objectives were to describe the aortic histopathologic substrates in patients with type A surgically treated acute aortic syndromes, to provide clinico-pathological correlations, and to identify the possible prognostic role of histology. METHODS: We assessed the aortic wall degenerative or inflammatory alterations of 158 patients according to the histopathologic consensus documents. Moreover, we correlated these histologic patterns with the patients' clinical data and long-term follow-up for mortality, major aorta-related events, and nonaorta-related events (including cardiovascular ones). RESULTS: We identified 2 histopathologic patterns: 122 patients (77%) with degenerative alterations and 36 patients (23%) with mixed degenerative-atherosclerotic lesions. Patients with mixed alterations were older (mean 69.6 ± 8.7 years vs 62.2 ± 12.4 years, P = .001) and more hypercholesterolemic (33.3% vs 13.9%, P = .017). The degenerative subgroup showed more intralamellar-mucoid extracellular matrix accumulation (86% vs 66.7%, P = .017) and a lower prevalence of translamellar collagen increase (9.8% vs 50%, P < .001). Patients with mixed degenerative-atherosclerotic abnormalities more frequently had long-term nonaorta-related events compared with those with degenerative abnormalities alone (P = .046); no differences were found between the groups with respect to mortality, major aorta-related events, and cardiovascular nonaorta-related events. CONCLUSIONS: Although degenerative lesions of the medial layer were present in all specimens, substantial atherosclerosis coexisted in approximately one quarter of cases. Patients with mixed degenerative-atherosclerotic abnormalities had a coherent clinical risk profile, a clinical presentation frequently mimicking acute coronary syndrome, and a higher incidence of nonaorta-related events during follow-up. Histopathologic characterization may improve the long-term prognostic stratification of patients after surgical treatment.

Treatment of cystoid macular edema in retinitis pigmentosa with intravitreal triamcinolone.

OBJECTIVE: To evaluate the results of treatment with intravitreal triamcinolone acetonide injection in patients with cystoid macular edema secondary to retinitis pigmentosa. METHODS: This prospective, nonrandomized comparative trial included 20 eyes of 20 patients with cystoid macular edema secondary to retinitis pigmentosa (group A) and 20 eyes of 20 control individuals (group B) with the same characteristics who declined treatment. All treated eyes received an intravitreal injection of 0.1 mL of triamcinolone acetonide (4 mg). The total follow-up was 12 months. The main outcome measures were best-corrected visual acuity, central macular thickness measured by optical coherence tomography, and intraocular pressure. RESULTS: No statistically significant changes were observed in best-corrected visual acuity. Central macular thickness showed statistical differences between the 2 groups. Intraocular pressure showed a statistically significant increase after the first day, at 1 month, and at 3 months in both groups but no significant increase afterward. CONCLUSIONS: Intravitreal triamcinolone administration may be useful for select cases of cystoid macular edema in patients with retinitis pigmentosa but its efficacy seems to be limited over time. Therefore, to obtain a good anatomical result and an improvement of best-corrected visual acuity, further treatment would be necessary after 6 months.

Preoperative C-reactive protein levels predict 9-month mortality after coronary artery bypass grafting surgery for the treatment of left main coronary artery stenosis.

OBJECTIVE: Preprocedural levels of C-reactive protein predict mid-term mortality after percutaneous coronary intervention for the treatment of unprotected left main coronary artery stenosis. However, there are no data regarding the impact of C-reactive protein on mid-term mortality in patients with unprotected left main coronary artery stenosis treated with coronary artery bypass graft. METHODS: The predictive value of preoperative C-reactive protein levels, leukocyte counts, and fibrinogen levels were evaluated in a series of 108 patients who underwent coronary artery bypass graft surgery at our Institution from 1st January 2002 to 31st April 2005. Patients were divided in two groups: Group 1 included patients with C-reactive protein levels in quartiles IV (C-reactive protein levels > or =1.22mg/dl) and Group 2 included patients with C-reactive protein levels in quartiles I+II+III. RESULTS: At 9-month follow-up the rate of mortality was 25.9% in Group 1 and 4.9% in Group 2 (hazard ratio=5.86, 95% confidence intervals=1.71-20.03; p=0.005). In all patients who had cardiac mortality, C-reactive protein levels were >0.5mg/dl. In the multivariate analysis age >75 years, peripheral vascular disease and C-reactive protein quartiles were the only independent predictors of mortality. CONCLUSIONS: Elevated preoperative levels of C-reactive protein indicate an increased risk of death after coronary artery bypass graft surgery for the treatment of unprotected left main coronary artery stenosis. Inflammatory risk assessment in patients with unprotected left main coronary artery stenosis provides incremental prognostic value for adequate preoperative patient stratification.

Utility of stress perfusion-cardiac magnetic resonance in follow-up of patients undergoing percutaneous coronary interventions of the left main coronary artery.

To assess the accuracy of cardiac magnetic resonance (CMR) for the diagnosis of angiographic stenosis after percutaneous coronary intervention (PCI) of left main coronary artery (LMCA). Patients undergone in the last year PCI of unprotected LMCA and scheduled for conventional X-ray coronary angiography (CXA) were evaluated with stress perfusion CMR within 2 weeks before CXA. Main contraindications to CMR were exclusion criteria. Stress perfusion CMR was performed to follow a bolus of contrast Gadobutrol after 3 min of adenosine infusion. Between the 50 patients enrolled, only 1 did not finish the CMR protocol and 49 patients with median age 71 (65-75) years (38 male, 11 female) were analyzed. Between 784 coronary angiographic segments evaluated we found 75 stenosis or occlusions (prevalence 9.5%), but only 13 stenosis or occlusions in proximal segments (prevalence 6.6%). Patients with coronary stenosis (n = 12, 24%) showed a significantly (p = 0.002) higher prevalence of diabetes (7 of 12, 58%). At CMR examination, late gadolinium enhancement was present in 25 (51%), reversible perfusion defects in 12 (24%), and fixed perfusion defects in 6 subjects (12%). The only patient with LMCA restenosis resulted positive at perfusion CMR. The accuracy of stress perfusion CMR in diagnosis of coronary stenosis was higher when the analysis was performed only in proximal coronary arteries (95%, CI 86-99) compared to overall vessels (84%, CI 70-92). Stress perfusion CMR could strongly reduce the need for elective CXA in follow up of LMCA PCI and should be validated in further multicenter prospective studies.

Comparison of ventricular long-axis function in patients with cardiac amyloidosis versus idiopathic restrictive cardiomyopathy.

To investigate ventricular long-axis function in cardiac amyloidosis (CA) and idiopathic restrictive cardiomyopathy (IRC), 16 patients with CA and 14 with IRC were studied. Left ventricular (LV) long-axis function was depressed in all patients with CA compared with only 36% of patients with IRC. Impairment in longitudinal function was clearly evident, even if fractional shortening and LV filling were normal. Ventricular long-axis function may be used as a sensitive marker of early systolic dysfunction. CA and IRC have quite distinct pathophysiologic profiles, raising some concerns about the appropriateness of considering them as 2 subtypes of a single nosographic entity.

Safety and efficacy of two types of influenza vaccination in heart transplant recipients: a prospective randomised controlled study.

BACKGROUND: Influenza may cause severe disease in immunosuppressed patients. Different vaccines have been proved to be efficacious to prevent influenza in tranplant recipients. Since the last five years the addition of adjuvants to improve the immune response to vaccine preparations has been proposed and evaluated. In this study, two antigenically identical vaccines, but different for the presence of adjuvants were randomised among a cohort of heart transplant recipients to evaluate their safety and immunogenicity. METHODS: 58 patients, receiving an heart transplant more than 6 months before, were randomised to receive one shoot vaccination with Fluad (containing the MF59 adjuvant) or Agrippal (no adjuvant added) or to enter the control, not-vaccinated, group. The immune response to influenza was evaluated separately for type A and type B viruses and for the IgG and the IgM antibodies. Patients were clinically evaluated at least monthly up to 6 months. RESULTS: Influenza symptoms were reported by 33% of patients receiving Fluad, 29% of the Agrippal and 63% of the control group. 4 episodes of acute myocardial rejection >/=3A were identified without difference between the three groups. CONCLUSIONS: The superior efficacy of vaccines containing adjuvants was not found and the data clearly confirmed that vaccination against influenza is safe and effective in heart transplant recipients. The use of vaccine containing adjuvant substances do not ameliorate the clinical performance of the immunisation suggesting that less expensive influenza vaccine preparation without adjuvant substances could be equally useful to protect heart transplant recipients.

Non-invasive detection of coronary artery stenosis: a comparison among power-Doppler contrast echo, 99Tc-Sestamibi SPECT and echo wall-motion analysis.

BACKGROUND: Power-Doppler imaging is a recently developed method for myocardial contrast echocardiography (MCE). It can selectively evaluate the signal coming from an ultrasound contrast agent, allowing myocardial perfusion studies. OBJECTIVE: To compare the ability of power-Doppler MCE with stress-echo wall-motion and nuclear scan imaging (SPECT) to assess myocardial ischaemia during pharmacological stress, using coronary angiography as reference. METHODS: In 25 patients the three non-invasive imaging modalities were acquired during a single dipyridamole stress test (so as to avoid stress variations). Power-Doppler MCE was acquired using continuous intravenous infusion of Levovist. Echo wall-motion was acquired too. At peak stress 99Tc-Sestamibi was injected; stress SPECT images were acquired 30 min after injection. RESULTS: Power-Doppler MCE and SPECT showed 84% concordance (21 of 25 patients; kappa=0.67) for detection of ischaemia. Concordance based on coronary artery territories for normal perfusion versus fixed defects versus reversible defects was 92% (69 of 75; kappa=0.81), with 100% for left anterior descending, 92% for right coronary artery and 84% for circumflex. Power-Doppler MCE had lower sensitivity than SPECT (89 versus 100%) but higher specificity (100 versus 88%) for identification of stenotic (> or = 70%) coronary arteries as assessed by angiography. Echo wall-motion analysis showed the lowest sensitivity (68%) with 100% specificity. Accuracy was 94% for both power-Doppler MCE and SPECT, and 83% for wall-motion analysis. CONCLUSION: Power-Doppler MCE is a sensitive and specific method for identification of myocardial perfusion during pharmacological stress. Accuracy of power-Doppler MCE for stenotic coronary arteries appears to be slightly higher than stress-echo wall-motion and similar to SPECT.

Long-term alpha interferon and lamivudine combination therapy in non-responder patients with anti-HBe-positive chronic hepatitis B: results of an open, controlled trial.

AIM: To investigate the safety and efficacy of long-term combination therapy with alpha interferon and lamivudine in non-responsive patients with anti-HBe-positive chronic hepatitis B. METHODS: 34 patients received combination treatment (1 month lamivudine, 12 month lamivudine+interferon, 6 month lamivudine), 24 received lamivudine (12 months), 24 received interferon (12 months). Interferon was administered at 6 MU tiw and lamivudine at 100 mg orally once daily. Patients were followed up for 6 months after treatment. RESULTS: At the end of treatment, HBV DNA negativity rates were 88 % with lamivudine+interferon, 99 % with lamivudine and 55 % with interferon, (P=0.004, combination therapy vs. interferon, and P=0.001 lamivudine vs. interferon), and serum transaminase normalization rates were 84 %, 91 % and 53 % (P=0.01 combination therapy vs. interferon, and P=0.012 lamivudine vs. interferon). Six months later, HBV DNA negativity rates were 44 % with lamivudine+interferon, 33 % with lamivudine and 25 % with interferon, and serum transaminase normalization rates were 61 %, 42 % and 45 %, respectively, without statistical significance. No YMDD variants were observed with lamivudine+interferon (vs. 12 % with lamivudine). The combination therapy appeared to be safe. CONCLUSION: Although viral clearance and transaminase normalization are slower with long-term lamivudine+interferon than that with lamivudine alone, the combination regimen seems to provide more lasting benefits and to protect against the appearance of YMDD variants. Studies with other regimens regarding sequence and duration are needed.

Impact of gene polymorphisms, platelet reactivity, and the SYNTAX score on 1-year clinical outcomes in patients with non-ST-segment elevation acute coronary syndrome undergoing percutaneous coronary intervention: the GEPRESS study.

OBJECTIVES: The aim of this study was to investigate the association between high on-treatment platelet reactivity (HPR) and the SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score (SS) for risk prediction of major adverse cardiovascular events (MACE) in patients with non-ST-segment elevation acute coronary syndrome (NSTEACS) undergoing percutaneous coronary intervention (PCI). BACKGROUND: Platelet function testing may be used to optimize antiplatelet therapy in high-risk patients, but identification of this category of patients remains challenging. METHODS: The GEPRESS (Gene Polymorphism, Platelet Reactivity, and the Syntax Score) study was a prospective, multicenter, observational study enrolling 1,053 patients with NSTEACS undergoing PCI and treated with clopidogrel. The platelet reactivity index (PRI) was measured at 3 time points: before PCI, at hospital discharge, and 1 month after PCI. Genetic variants of clopidogrel metabolism were determined in 750 patients. Patients were stratified by the presence of HPR (PRI >50%) and by tertile of the SS (upper SS tertile ≥15). The primary objective of this study was the risk of MACE in the period between 1 month and 1 year. RESULTS: Between 1 month and 1 year, 1-month HPR was an independent predictor of MACE in patients with an SS ≥15, but not in those with an SS <15, displaying a 5-fold increase in event rates (10.4% vs. 2.5%; p < 0.0001). CYP2C19*2 was the only single nucleotide polymorphism associated with HPR, but it was not associated with MACE. Although there was a significant variability in the PRI across the 1-month period, predischarge HPR and SS effectively stratified the risk of subsequent MACE up to 1-year follow-up. CONCLUSIONS: In clopidogrel-treated patients with NSTEACS undergoing PCI, HPR was independently associated with an increased risk of MACE only in the presence of a high SS.

Risk of stroke with coronary artery bypass graft surgery compared with percutaneous coronary intervention.

OBJECTIVES: This study sought to determine whether coronary artery bypass graft (CABG) surgery is associated with an increased risk of stroke compared with percutaneous coronary intervention (PCI). BACKGROUND: Some, but not all, randomized trials have reported increased rates of stroke with CABG compared with PCI. However, all these studies were powered insufficiently to examine differences in the risk of stroke reliably. METHODS: We performed a meta-analysis of 19 trials in which 10,944 patients were randomized to CABG versus PCI. The primary end point was the 30-day rate of stroke. We also determined the rate of stroke at the midterm follow-up and investigated whether there was an interaction between revascularization type and the extent of coronary artery disease on the relative risk of stroke. RESULTS: The 30-day rate of stroke was 1.20% after CABG compared with 0.34% after PCI (odds ratio: 2.94, 95% confidence interval: 1.69 to 5.09, p < 0.0001). Similar results were observed after a median follow-up of 12.1 months (1.83% vs. 0.99%, odds ratio: 1.67, 95% confidence interval: 1.09 to 2.56, p = 0.02). The extent of coronary artery disease (single vessel vs. multivessel vs. left main) did not affect the relative increase in the risk of stroke observed with CABG compared with PCI at either 30 days (p = 0.57 for interaction) or midterm follow-up (p = 0.08 for interaction). Similar results were observed when the outcomes in 33,980 patients from 27 observational studies were analyzed. CONCLUSIONS: Coronary revascularization by CABG compared with PCI is associated with an increased risk of stroke at 30 days and at the mid-term follow-up.

Is time on cardiopulmonary bypass during cardiac surgery associated with acute kidney injury requiring dialysis?

It is commonly accepted that the longer the time on extracorporeal cardiopulmonary bypass (CPB), the higher is the likelihood of developing acute renal failure requiring dialysis (ARF-D). Nonetheless, previous works elicited conflicting evidence. We investigated the relationship between CPB duration and ARF-D occurrence. Data were extracted from a large observational study. All factors independently associated with ARF-D were detected. Overall, 11,092 case record forms were analyzed. At the univariate analyses, time on CBP was associated with an increase in the ARF-D risk (odds ratio of fifth vs. first quintile of CBP time: 3.84; 95% confidence interval: 2.58-5.7; P < 0.001). However, after adjusting for confounders, the association between time on CBP and ARF-D lost its statistical significance. In this large dataset, CBP time did not predict ARF-D occurrence. These results might suggest that an accurate risk assessment might be more important than time on CPB in determining ARF-D occurrence.

Role of (99m)Tc-DPD scintigraphy in diagnosis and prognosis of hereditary transthyretin-related cardiac amyloidosis.

OBJECTIVES: In a cohort of patients with hereditary transthyretin-related amyloidosis (ATTR), we aimed to assess the role of (99m)Tc-3,3-diphosphono-1,2-propanodicarboxylic acid ((99m)Tc-DPD) in detecting myocardial amyloid infiltration across a wide spectrum of cardiac involvement and in predicting major adverse cardiac events (MACE). BACKGROUND: Hereditary transthyretin-related amyloidosis is a challenging and underdiagnosed condition where both early diagnosis and prognosis remain problematic. METHODS: We evaluated 63 patients with ATTR: 40 with and 23 without echocardiographically diagnosed amyloidotic cardiomyopathy (AC). Myocardial uptake of (99m)Tc-DPD scintigraphy was semiquantitatively and visually assessed at 5 min and 3 h. RESULTS: All patients with AC showed moderate-to-severe myocardial tracer uptake (i.e., visual score ≥2). Within the subgroup without AC, only 4 patients (with Ala36Pro, Gly47Ala, Thr49Ala, and Glu89Gln transthyretin mutations) showed myocardial tracer uptake and abnormal heart/whole body retention (H/WB) values: in all these cases endomyocardial biopsies showed amyloidotic infiltration. The H/WB was positively correlated with left ventricular (LV) mean wall thickness (Pearson's r=0.695, p<0.001) and negatively with LV ejection fraction (r=-0.368, p=0.004). The H/WB was an unfavorable predictor of MACE-free survival at Cox univariate analysis and contributed to the multivariate model. Notably, LV wall thickness >12 mm in combination with H/WB >7.5 was associated with the highest event rate. CONCLUSIONS: In ATTR, (99m)Tc-DPD scintigraphy can identify myocardial infiltration across a wide spectrum of morphologic/functional cardiac involvement, allowing an early diagnosis of the disease (even before the appearance of echocardiographic abnormalities). The (99m)Tc-DPD myocardial uptake is a prognostic determinant of "cardiac" outcome in ATTR, either alone or in combination with LV wall thickness.

A randomised study comparing the antiplatelet and antiinflammatory effect of clopidogrel 150 mg/day versus 75 mg/day in patients with ST-segment elevation acute myocardial infarction and poor responsiveness to clopidogrel: results from the DOUBLE study.

INTRODUCTION: The antiplatelet effect of standard or increased clopidogrel doses in patients with ST- segment elevation acute myocardial infarction (STEMI) has never been studied. In this study we compared the antiplatelet effect of a 75 mg daily maintenance dose of clopidogrel with 150 mg in patients with STEMI undergoing primary percutaneous coronary intervention (PCI). MATERIALS AND METHODS: Fifty-four patients with STEMI undergoing PCI were randomly allocated to receive either 75 mg/day clopidogrel (group 1) or 150 mg/day (group 2) for 1 month. Platelet function, measured by 5 different assays, was determined at 3 time points: 38+/-8 hours after the procedure, 1 week and 1 month after randomization. RESULTS: In group 1, mean +/- SD platelet reactivity index (PRI) measured with the VASP assay was 57.7+/-15.7% and 46.9+/-15.7% at 1 week and 1 month, respectively, compared to 38.8+/-15.7% and 34.9+/-12.6% in group 2 (p=0.0001). Same results were observed for light transmittance aggregometry, whole blood aggregometry and VerifyNow, but not for thromboelastometry. In contrast to what may be expected, the 75 mg daily maintenance dose took longer than 1-week to provide the full clopidogrel antiplatelet effect. Furthermore, patients in group 2 had a nearly 50% reduction in C-reactive protein levels both at 1 week and 1 month. CONCLUSION: In patients with STEMI and poor responsiveness to clopidogrel a 150 mg daily maintenance dose of clopidogrel is associated with a significant reduction of platelet aggregation and a trend towards reduced inflammation.

Early and late outcomes of acute type A aortic dissection: analysis of risk factors in 487 consecutive patients.

AIMS: The purpose of this retrospective study was to assess the risk factors for the early and late outcome of the surgical treatment of acute type A aortic dissection, in terms of mortality and morbidity. METHODS AND RESULTS: From 1976 to 2003, 487 patients with acute type A aortic dissection treated surgically were enrolled. Twenty-five pre-operative and intra-operative variables were analysed to identify conditions influencing early and late morbidity and early mortality. The in-hospital mortality rate including operative death was 22% (107 patients). Multivariable analysis indicated that pre-existing cardiac disease (RR=3.7, 95% CI=1.8-7.4) and cardiopulmonary resuscitation (RR=6.8, 95% CI=2.3-20.2) were independent predictors of in-hospital death. The causes of in-hospital mortality were low cardiac output in 32 patients (6.6%), major brain damage in 24 patients (5.9%), haemorrhage in 11 patients (2.2%), sepsis in nine patients (1.8%), visceral ischaemia in eight patients (1.6%), multiple organ failure in seven patients (1.4%), rupture of the thoracic aorta in six patients (1.2%), respiratory failure in six patients (1.2%), and four intra-operative deaths. The follow-up was 100% complete. The actuarial survival was 94.9+/-1.2% and 88.1+/-2.6%, at 5 and 10 years, respectively. CONCLUSIONS: Patients' pre-operative co-morbidities and dissection-related complications significantly affect early and late survival and morbidity after surgical treatment of acute type A aortic dissection.