Six-Month Performance of a 3-Dimensional Annuloplasty Ring for Repair of Functional Tricuspid Regurgitation.

BACKGROUND: Functional tricuspid regurgitation (FTR) secondary to left-sided heart disease may lead to poor quality of life and reduced long-term survival. This study evaluated clinical and functional outcomes of patients undergoing tricuspid valve (TV) repair using a rigid three-dimensional ring (Contour 3D, Medtronic) concomitant with another procedure. METHODS: From September 2011 to July 2015, 112 patients (mean age 70.9 ± 9.0 years) were enrolled at 10 centers in Europe, Israel, and the United States. Inclusion criteria were FTR ≥ moderate and/or tricuspid annular diameter (TAD) ≥ 40 mm. Echocardiography was planned before surgery and at discharge with echocardiographic and clinical follow-ups performed 6 months postoperatively. RESULTS: Three fourths (74.4%) of patients had higher than moderate TR. Mean TAD was 41.0 ± 7.3 mm; 61.7% of patients were in the New York Heart Association (NYHA) class III/IV. The most common concomitant procedure was mitral valve repair (57 patients, 53.3%). The 30-day mortality rate was 0.9% (n = 1). The mean EuroSCORE II was 8.9 ± 8.4% (median: 5.9%; interquartile range: 3.5-11.5%). The observed to expected ratio (O/E) based on the median was 0.1. Six deaths occurred during follow-up (three cardiac related). Mean implanted ring size was 30.3 ± 2.7. At 6 months, 94.4% of patients showed ≤ mild TR, and 92.0% were in NYHA class I/II (p < 0.001 vs baseline for both). Mean pressure gradient across the TV was 2.0 ± 1.1 mm Hg; leaflet coaptation length was 7.5 ± 3.3 mm. CONCLUSION: The Contour 3D annuloplasty ring used for treatment of FTR substantially reduced TR for up to 6 postoperative months with low mean pressure gradients across the TV and significant improvement in NYHA class. REGISTRATION: www.ClinicalTrials.gov, NCT01532921.

Local prolonged release of antibiotic for prevention of sternal wound infections postcardiac surgery-A novel technology.

INTRODUCTION: Sternal wound infection (SWI) is a devastating postcardiac surgical complication. D-PLEX100 (D-PLEX) is a localized prolonged release compound applied as a prophylactic at the completion of surgery to prevent SWI. The D-PLEX technology platform is built as a matrix of alternating layers of polymers and lipids, entrapping an antibiotic (doxycycline). The objective of this study was to assess the safety profile and pharmacokinetics of D-PLEX in reducing SWI rates postcardiac surgery. METHOD: Eighty-one patients were enrolled in a prospective single-blind randomized controlled multicenter study. Sixty patients were treated with both D-PLEX and standard of care (SOC) and 21 with SOC alone. Both groups were followed 6 months for safety endpoints. SWI was assessed at 90 days. RESULTS: No SWI-related serious adverse events (SAEs) occurred in either group. The mean plasma Cmax in patients treated with D-PLEX was about 10 times lower than the value detected following the oral administration of doxycycline hyclate with an equivalent overall dose, and followed by a very low plasma concentration over the next 30 days. There were no sternal infections in the D-PLEX group (0/60) while there was one patient with a sternal infection in the control group (1/21, 4.8%). CONCLUSION: D-PLEX was found to be safe for use in cardiac surgery patients. By providing localized prophylactic prolonged release of broad-spectrum antibiotics, D-PLEX has the potential to prevent SWI postcardiac surgery and long-term postoperative hospitalization, reducing high-treatment costs, morbidity, and mortality.

Postoperative Atrial Fibrillation Following Coronary Artery Bypass Graft Surgery Predicts Long-Term Atrial Fibrillation and Stroke.

BACKGROUND: Atrial fibrillation (AF) is a common complication of coronary artery bypass graft (CABG) surgery, occurring in 20%-40% of patients, mostly during the first week after surgery. It is associated with increased morbidity and mortality, but data are limited. OBJECTIVES: To assess the correlation between new-onset in-hospital AF following CABG and long-term AF, cerebrovascular accident (CVA), or death. METHODS: We conducted an analysis of 161 consecutive patients who underwent isolated CABG surgery in a tertiary center during the period 2002-2003. RESULTS: Patients' mean age was 72 years, and the majority were males (77%). Approximately half of the patients experienced prior myocardial infarction, and 14% had left ventricular ejection fraction < 40%. Postoperative AF (POAF) occurred in 27% of the patients. Patients were older and had larger left atrium diameter. POAF was strongly correlated with late AF (OR 4.34, 95%CI 1.44-13.1, P = 0.01) during a mean follow-up of 8.5 years. It was also correlated with long-term stroke but was not associated with long-term mortality. CONCLUSIONS: POAF is a common complication of CABG surgery, which is correlated with late AF and stroke. Patients with POAF should be closely monitored to facilitate early administration of anticoagulant therapy in a high risk population upon recurrence of AF.

Penetrating pulmonary vein laceration following blunt chest trauma.

Flail chest is a common injury in blunt trauma which is usually treated with analgesia, oxygen, and other conservative measures. In more severe cases mechanical ventilation and surgical stabilization of rib fractures (SSRF) may be warranted. Penetrating injury to the heart or great vessels due to rib fractures however, is much less common. Here we present a 33 year old male that was admitted to the Emergency department (ED) after a horse riding accident, demonstrating severe shock. Emergency computerized tomography scan showed multiple bilateral displaced rib fractures, Left hemothorax and possibly a penetrating injury to the left side of the heart by one of the ribs. Notably, no significant pericardial effusion was demonstrated. In addition, a grade V splenic injury was diagnosed. A Joined thoracic and abdominal emergent surgical treatment was successfully carried out and the patient survived and fully recovered.

Heart Team/Guidelines Discordance Is Associated With Increased Mortality: Data From a National Survey of Revascularization in Patients With Complex Coronary Artery Disease.

BACKGROUND: Practice guidelines emphasize the role of the SYNTAX score (SS; Synergy Between PCI With TAXUS and Cardiac Surgery) in choosing between percutaneous coronary intervention and coronary artery bypass graft surgery in cases of complex coronary artery disease. There is paucity of data on the implementation of these recommendations in daily practice, and on the consequences of guideline discordant revascularization. METHODS: This was a retrospective analysis of a prospective national survey of consecutive real world patients undergoing coronary revascularization for complex coronary artery disease according to decisions of local heart team at each center. SS was calculated at a dedicated CoreLab, and patients were classified as heart team/guidelines agreement/discordant. RESULTS: Nine hundred seventy-nine patients (571 percutaneous coronary intervention and 408 coronary artery bypass graft) were included. Mean age was 65 years and the mean SS was 22. Heart team/guidelines discordance occurred in 170 (17.3%) patients. Independent predictors of heart team/guidelines discordance were age, admission to a center with no cardiac surgery service, SS, and previous percutaneous coronary intervention/myocardial infarction. A multivariate model based on these characteristics had a C statistic of 0.83. Thirty-day outcomes were similar in the agreement/discordance groups, however, heart team/guidelines discordance was associated with a significant increase in 3 year mortality (17.6% versus 8.4%; hazard ratio, 2.05; P=0.002) after multivariate adjustment. CONCLUSIONS: Heart team/guidelines discordance is not infrequent in real world patients with complex coronary artery disease undergoing revascularization. This is more likely to occur in elderly patients, those with more complex coronary disease (as determined by the SS), and those treated at centers with no cardiac surgery service. These patients have a higher risk for mid-term mortality.

Association between mitral and aortic valve calcification and preferential left or right coronary artery disease.

BACKGROUND AND AIM OF THE STUDY: Mitral annular calcification (MAC) and aortic valve calcification (AVC) are predictive of coronary artery disease (CAD). However, no data exist concerning the association between preferential CAD side localization to the left or right coronary arteries and MAC or AVC. METHODS: A cohort analysis was performed of 1,000 consecutive coronary angiographies recorded in patients with CAD. The angiographies were divided according to the distribution of CAD to the isolated right coronary tree disease, left coronary tree disease, or both. The echocardiograms were reviewed for MAC, AVC or combined valvular calcification (CVC). RESULTS: Significant CAD (lumenal stenosis > 70%) was observed in 688 patients, among whom 167 had isolated (right or left) CAD and 521 double-sided coronary tree disease. Valvular calcification (VC) was observed in 70 (42%) of the isolated CAD patients; of these, 41 had isolated left CAD and 29 isolated right CAD. Among the isolated left CAD patients with VC, 13 (32%) had AVC, 22 (53%) had CVC, and only six (15%) had MAC (p < 0.01). Among the isolated right CAD patients with VC, 18 (62%) had MAC, nine (31%) had CVC, and only two (7%) had AVC (p < 0.01). VC was observed in 266 patients (51%) with mixed CAD; of these, 152 (57%) had CVC, 103 (39%) had AVC, and 11 (4%) had MAC (p < 0.01). CONCLUSION: Isolated left CAD is associated with AVC or CVC more frequently than with MAC. In contrast, isolated right CAD is associated with MAC or CVC, but rarely with AVC.

Revascularization Strategies and Survival in Patients With Multivessel Coronary Artery Disease.

BACKGROUND: We sought to assess real-world implementation of the guidelines in patients with multivessel coronary artery disease (CAD) using a prospective national registry in Israel. METHODS: All consecutive patients with left main or 2- to 3-vessel CAD involving the proximal or mid left anterior descending artery were enrolled in a dedicated multicenter registry. Patients were managed at the discretion of the treating team at each hospital and were followed for 30 months. RESULTS: This registry included 1,064 patients, 55% treated with percutaneous coronary intervention (PCI) and 45% with coronary artery bypass surgery (CABG). Multivariate logistic regression analysis showed that chronic renal failure (odds ratio [OR], 2.43; p = 0.001) and prior myocardial infarction (OR, 1.7; p = 0.024) were associated with referral to PCI versus CABG, whereas male gender (OR, 2.27; p < 0.001), prior aspirin treatment (OR, 1.72; p = 0.005), diabetes mellitus (OR, 1.51; p = 0.007), 3-vessel CAD (OR, 3.45; p < 0.001) and SYNTAX score (SS) greater than 32 (OR, 10.0; p < 0.001) were associated with referral to CABG versus PCI. Each point increment in the SS was independently associated with a 9% greater likelihood of referral to CABG (p < 0.001). Survival analysis showed that mortality risk was lower among PCI patients less than 8 months after the procedure, and CABG was associated with a significant survival benefit thereafter. CONCLUSIONS: We found good agreement with current guidelines regarding revascularization strategies in real-world patients with multivessel CAD. The SS was the main independent predictor associated with the choice of revascularization strategy. The time-dependent association between revascularization strategy and long-term survival should be incorporated in the risk assessment of this population.

Correlation between atrial ZnT-1 expression and atrial fibrillation in humans: a pilot study.

BACKGROUND: Until recently, the membrane protein ZnT-1 was studied mainly in the context of zinc homeostasis. However, new findings indicate that it acts as an inhibitor of L-type calcium channels. We recently found that acute rapid pacing of the rat atria in vivo augments the expression of ZnT-1, while knockdown of ZnT-1 in culture can oppose the inhibition of L-type calcium channels following rapid pacing. This pilot study, the first to assess cardiac ZnT-1 in humans, was designed to look for possible correlation between the atrial expression of ZnT-1 and atrial fibrillation. METHODS: Right atrial appendage tissue was collected from 39 patients (27 with sinus rhythm and 12 with atrial fibrillation; 6-permanent, 6- paroxysmal or persistent) undergoing open-heart surgery. The expression of ZnT-1 was analyzed by Western blot utilizing beta-actin as an internal loading control and a standard rat heart sample (STD) for inter-blot comparison. RESULTS: Overall atrial fibrillation patients (n = 12) had median ZnT-1/beta-actin of 1.80 STD (inter-quartile range 1.26 to 2.85) versus 0.73 STD (0.24 to 1.64) in the sinus rhythm group (P = 0.002). No association was found between ZnT-1 level and most other clinical parameters tested. Multivariate analysis determined that atrial fibrillation and increased body mass index were the only independent variables clearly associated with higher ZnT-1 levels (Standardized coefficients Beta = 0.62, 0.31; P = 0.002, P = 0.04, respectively). CONCLUSIONS: This pilot study provides evidence for increased ZnT-1 expression in the atria of patients with atrial fibrillation.

In-situ left-sided bilateral internal thoracic artery: elevated hemidiaphragm.

Background Procurement of the internal thoracic artery risks ipsilateral phrenic nerve injury and elevated hemidiaphragm. Anatomical variations increase the risk on the right side. Patients receiving left-sided in-situ right internal thoracic artery configurations appear to be at greatest risk. Methods From 2014 to 2016, 432 patients undergoing left-sided in-situ bilateral internal thoracic artery grafting were grouped according to right internal thoracic artery configuration: retroaortic via transverse sinus (77%) or ante-aortic (23%); targets were the circumflex and left anterior descending artery territories, respectively. Elevated hemidiaphragm was assessed by serial chest radiographs and categorized by side, complete (≥2 intercostal spaces) versus partial, and permanent versus transient. Results Right elevated hemidiaphragm occurred in 4.2% of patients. The incidence of radiological complete right elevated hemidiaphragm was 2.8% (12/432); 8 cases were transient with recovery in 3.5 ± 0.3 weeks. Permanent right elevated hemidiaphragm occurred in 0.9% (retroaortic group only). Permanent left elevated hemidiaphragm occurred in 0.9% and was significantly higher in the ante-aortic group (3/99 vs. 1/333, p = 0.039). No bilateral hemidiaphragm elevation was documented. Partial right elevated hemidiaphragm occurred in 1.4% and was not associated with adverse early or late respiratory outcomes. Conclusions Despite susceptible right phrenic nerve-internal thoracic artery anatomy, the incidence of permanent right elevated hemidiaphragm is low and no higher than left-sided in prone bilateral internal thoracic artery subsets. This reflects skeletonized internal thoracic artery procurement. Although statistical significance was not achieved, a retroaortic right internal thoracic artery configuration may constitute a higher risk of right phrenic nerve injury.

Telomere dynamics in arteries and mononuclear cells of diabetic patients: effect of diabetes and of glycemic control.

Telomeres serve as a mitotic clock and biological marker of senescence. Diabetes mellitus (DM) is associated with damage to target organs and premature aging. We assessed the effect of glycemic control on telomere dynamics in arterial cells of 58 patients undergoing coronary artery bypass and in mononuclear blood cells of other diabetic (32 type I and 47 type II) patients comparing well controlled to uncontrolled patients. All were compared to age-dependent curve of healthy controls. Telomeres were significantly shorter in the arteries of diabetic versus non-diabetic patients (p=0.049) and in mononuclear cells of both type I and type II diabetes. In all study groups good glycemic control attenuated shortening of the telomeres. In arterial cells good glycemic control attenuated, but not abolished, the telomere shortening. In type II DM the mononuclear telomere attrition was completely prevented by adequate glycemic control. Telomere shortening in mononuclear cells of type I diabetic patients was attenuated but not prevented by good glycemic control. Results of this study suggest that diabetes is associated with premature cellular senescence which can be prevented by good glycemic control in type II DM and reduced in type I DM.

The impact of intraoperative transesophageal echocardiography in infective endocarditis.

BACKGROUND: [corrected] The use of intraoperative transesophageal echocardiogram in patients with infective endocarditis is usually reserved for cases of inadequate preoperative testing or suspected extension to perivalvular tissue. OBJECTIVES: To explore the impact of routine intraoperative TEE in patients with infective endocarditis. METHODS: The impact of intraoperative TEE on the operative plan, anatomic-physiologic results, and hemodynamic assessment or de-airing was analyzed in 59 patients (38 males, 21 females, mean age 57.7 +/- 16.8 years, range 20-82) operated for active infective endocarditis over 56 months. RESULTS: Immediate pre-pump echocardiography was available in 52 operations (86.7%), and changed the operative plan in 6 of them (11.5%). Immediate post-pump study was available in 59 patients (98.3%) and accounted for second pump-run in 6 (10.2%): perivalvular leak (3 cases), and immobilized leaflet, significant mitral regurgitation following vegetectomy, and failing right ventricle requiring addition of vein graft (1 case each). Prolonged de-airing was necessary in 6 patients (10.2%). In 5 patients (8.5%) the postoperative study aided in the evaluation and treatment of difficult weaning from the cardiopulmonary bypass pump. In 21 patients (35.6%) the application of intraoperative TEE affected at least one of the four pre-specified parameters. CONCLUSIONS: Intraoperative TEE has an important role in surgery for infective endocarditis and should be routinely implemented.

[Criteria for the acceptable heart donor: maximizing the use of hearts recovered from potential donors in Israel].

The shortage of available donor hearts limits the number of cardiac transplantations worldwide and in Israel as well. This organ shortage results in 15%-20% annual mortality of heart transplant candidates. For the sub-group of hospitalized decompensated heart failure patients depending on continuous inotropic support (Status I), the annual mortality is over 50%. Suboptimal utilization of donor hearts has been one of the reasons for the organ shortage. In 2004, only 42% of the potential donor hearts in Israel were eventually transplanted. The objective of this report is to define guidelines regarding the suitability of potential cardiac donors allowing more liberal criteria for accepting borderline donor hearts. Implementing the new guidelines will permit the utilization of organs that otherwise would have been discarded.

Blood-Brain Barrier Disruption After Cardiopulmonary Bypass: Diagnosis and Correlation to Cognition.

BACKGROUND: Cardiopulmonary bypass (CPB) elicits a systemic inflammatory response that may impair blood-brain barrier (BBB) integrity. BBB disruption can currently be detected by dynamic contrast enhancement magnetic resonance imaging (MRI), reflected by an increase in the permeability constant (Ktrans). We aimed to determine (1) whether CPB induces BBB disruption, (2) duration until BBB disruption resolution, and (3) the obtainable correlation between BBB injury (location and intensity) and neurocognitive dysfunction. METHODS: Seven patients undergoing CPB with coronary artery bypass grafting (CABG) were assigned to serial cerebral designated MRI evaluations, preoperatively and on postoperative day (POD) 1 and 5. Examinations were analyzed for BBB disruption and microemboli using dynamic contrast enhancement MRI and diffusion-weighted imaging methods, respectively. Neuropsychologic tests were performed 1 day preoperatively and on POD 5. RESULTS: A significant local Ktrans increase (0.03 min-1 vs 0.07 min-1, p = 0.033) compatible with BBB disruption was evident in 5 patients (71%) on POD 1. Resolution was observed by POD 5 (mean, 0.012 min-1). The location of the disruption was most prominent in the frontal lobes (400% vs 150% Ktrans levels upsurge, p = 0.05). MRI evidence of microembolization was demonstrated in only 1 patient (14%). The postoperative global cognitive score was reduced in all patients (98.2 ± 12 vs 95.1 ± 11, p = 0.032), predominantly in executive and attention (frontal lobe-related) functions (91.8 ± 13 vs 86.9 ± 12, p = 0.042). The intensity of the dynamic contrast enhancement MRI BBB impairment correlated with the magnitude of cognition reduction (r = 0.69, p = 0.04). CONCLUSIONS: BBB disruption was evident in most patients, primarily in the frontal lobes. The location and intensity of the BBB disruption, rather than the microembolic load, correlated with postoperative neurocognitive dysfunction.

Development of malignancy following lung transplantation.

BACKGROUND: A substantial excess risk of certain malignancies has been demonstrated after organ transplantation. Immunosuppressive treatment to prevent allograft rejection is probably the main cause. METHODS: We reviewed retrospectively all medical records of the 121 patients that underwent lung and heart-lung transplantation from 1992 until December 2004. We compared our results to the International Society for Heart and Lung Transplantation (ISHLT) registry data and previous reports concerning lung transplantation. RESULTS: 102 of the 121 patients survived for 3 months to 12 years. Malignancies developed in 16 patients, as follows: lymphoproliferative disorder in 3, Kaposi's sarcoma in 3, other nonmelanoma skin cancers in 7, urinary bladder transitional cel carcinoma in 3, and colon cancer in 1. Patients with malignancy were older at transplantation than those without (mean +/- SD, 54.1+/-7.8 vs. 49.5+/-14.2 years; P=0.03). Fourteen had smoked in the past. Four died of bronchiolitis obliterans. In comparison with the ISHLT, we observed more skin cancer and transitional cell carcinoma (12.8% vs. 0.7% and 3.8% vs. 0.03%, respectively) and a similar frequency of posttransplant lymphoproliferative disease. CONCLUSIONS: We conclude that malignancy is a common complication after lung transplantation. In Israel, which is sunny most of the year, skin cancers and transitional cell carcinoma of bladder are more common. Modification of the immunosuppression late posttransplantation may reduce the risk of cancer. Patients should also be counseled to avoid sun exposure and ensure adequate hydration.

Lung transplantation in patients with cystic fibrosis: the Israeli experience.

BACKGROUND: Lung transplantation is a well-established therapeutic option for end-stage lung disease in cystic fibrosis. Although it confers a clear survival advantage, outcome differs among centers according to local experience, patient selection, transplantation procedure, and postoperative care. OBJECTIVES: To evaluate the national Israeli experience with lung transplantation in patients with CF. METHODS: We reviewed the medical charts of all CF patients who underwent lung transplantation between January 1996 and June 2005 at the two Israeli centers that perform this procedure. RESULTS: Eighteen transplantations were performed in 17 patients. Mean patient age at transplantation was 25.3 +/- 9.1 years, and mean duration of follow-up in survivors (n=14) was 37.2 months (range 1-113 months). The actuarial survival rate was 88% at 1 year and 74% at 5 years. Pulmonary function, expressed as percent of predicted normal forced expiratory volume in 1 sec, improved from 22.4 +/- 8.1% to 76 +/- 16.8% at one year after transplantation. Bronchiolitis obliterans syndrome was diagnosed in 5 patients (29%), of whom 2 died and 2 are currently candidates for retransplantation. Median time to onset of BOS was 34.2 months (range 17-64 months). CONCLUSION: In Israel, the early and intermediate-term results of lung transplantation for cystic fibrosis are encouraging. BOS remains a major complication that threatens long-term outcome.

Cardiothoracic surgery training in Israel: A critical look at the past, aiming for a better future.

Training the next generation of cardiothoracic surgeons is a global persistent challenge. Major issues, including length of training, decreasing volume of cases, shift toward high-risk, complex, and less-invasive procedures, increased specialization, and uncertainty with regard to future employment, are relevant and affect residency training programs in the United States, Europe, and other parts of the world. To produce high-quality, mature, and qualified surgeons, these challenges mandate an ongoing effort by our specialty leadership aimed at identifying creative solutions and adapting the current residency training curricula and methodology to the dynamic changes in our field. The current situation in Israel is discussed with the hope that sharing our experience might be useful and lead to adoption of some of our solutions by other countries.

Comparison of diameter of ascending aorta in patients with severe aortic stenosis secondary to congenital versus degenerative versus rheumatic etiologies.

Aortic root dilation has been previously reported to be associated with aortic stenosis (AS), but data to support this statement are scarce. The dimensions of the aortic root were measured at 4 levels (annulus, sinuses, sinotubular junction, and ascending aorta) in 88 patients (mean age 71.2+/-9.7 years; 56% men) with severe AS who underwent intraoperative transesophageal echocardiography immediately before aortic valve replacement. These patients were compared with 76 gender- and age-matched patients without AS who underwent transesophageal echocardiography for various indications. The etiology of aortic valve stenosis was degenerative in 62 (70.5%), bicuspid aortic valve (BAV) in 15 (17.0%), and rheumatic in 11 (12.5%). The ascending aorta was significantly wider in AS with various etiologies (BAV, rheumatic, degenerative) than in the controls (39+/-6.9, 35.0+/-4.2, 33.1+/-4.1, and 31.3+/-3.7 mm, respectively; p<0.001). The dimensions of the sinuses and sinotubular junction were significantly less in those with AS of degenerative etiology than in the controls (29.5+/-4.0 vs 32.5+/-4.3 mm and 23.6+/-3.0 vs 26.8+/-3.0 mm, respectively, p<0.001). The prevalence of a dilated aorta (>37 mm) was 3.9%, 13.1%, 36.4%, and 60% in the control group and AS patients with degenerative, rheumatic, and BAV etiology, respectively (p<0.0001). In conclusion, patients with severe AS due to BAV had significant dilation of the aortic root. Patients with degenerative and rheumatic etiology had less remarkable dilation compared with control group, and most values were within the normal range.

Is routine coronary angiography and revascularization indicated among patients undergoing evaluation for lung transplantation?

OBJECTIVES: To review coronary artery disease (CAD) prevalence among lung transplantation (LTx) candidates, the time interval from coronary angiography (CA) to LTx/death, and post-revascularization outcomes. BACKGROUND: CA is advised for LTx candidates because significant CAD is a contraindication for LTx. METHODS: We monitored all LTx candidates from 1997 who underwent CA. Significant CAD was defined as stenosis > or = 70% in diameter. RESULTS: Of 118 candidates > 40 years old (68.3% men; median age, 58 years; 25 to 75th interquartiles, 53 to 61 years), 59 patients underwent LTx, 56 patients were eligible for LTx, and 3 patients were excluded due to CAD. Significant CAD was detected in 21 patients (17.8%), nonsignificant CAD was found in 21 patients (17.8%), and no CAD was found in 76 patients (64.4%), without significant differences in the demographic/clinical profile among patients with or without significant CAD. Among 21 patients with significant CAD, 12 patients (57.1%) underwent successful percutaneous coronary intervention (PCI), 1 patient had failed to respond to PCI, and 8 patients (38.1%) had no intervention. After PCI, one patient had periprocedural infarction, one patient had stent thrombosis, and one patient had symptomatic restenosis. The median time interval CA to LTx/death/last visit among the 115 candidates was 166 days (interquartiles, 48 to 410 days). Death occurred before LTx in 30 patients (53.5%) during a follow-up of 312 days (interquartiles, 46 to 664 days) and after LTx in 14 patients (23.7%) during a follow-up of 142 days (interquartiles, 73 to 304 days), without any difference in outcome based on severity of CAD in the two groups (p = 0.7 and p = 0.6, respectively). CONCLUSIONS: CAD prevalence among LTx candidates is low and cannot be accurately predicted by risk factors. Revascularization may be associated with complications, and the time interval between revascularization and LTx may be long. Conversely, certain patients with significant CAD underwent LTx without complications. The practice of routine CA and revascularization prior to LTx should be reconsidered, and perhaps reserved for selected patients with high-risk features.

Atherosclerosis of the aorta is common in patients with severe aortic stenosis: an intraoperative transesophageal echocardiographic study.

OBJECTIVE: Several studies have recently reported an association between aortic valve calcification and atherosclerosis of the cardiovascular system, suggesting that aortic valve calcification might represent an atherosclerosis-like process. Hence the aim of the present study was to determine whether there is a similar association between aortic stenosis and aortic atheromas. METHODS: We evaluated the records and echocardiographic videotapes of 91 consecutive patients with severe aortic stenosis who underwent intraoperative transesophageal echocardiography before aortic valve replacement to measure the presence and characteristics of aortic atheromas. There were 50 men (55%) and 41 women (45%). The mean age was 71.9 +/- 9.4 years (range, 34-91 years). These patients were compared with 91 sex-and age-matched patients without aortic stenosis who underwent transesophageal echocardiography for various indications. Aortic atheroma was defined as localized intimal thickening of 3 mm or larger. A lesion was considered complex if there was a plaque extending 5 mm or more into the aortic lumen; if the lesion was protruding, mobile, or ulcerated; or both. RESULTS: The aortic stenosis group had significantly higher rates of aortic atheromas (85% vs 37%, P < .001) and complex atheromas (47% vs 9%, P < .001) compared with the control group. In the vast majority of patients in the aortic stenosis group, the aortic atheromas were localized in the aortic arch (60 [66%] patients, with 50% being complex aortic atheromas) and in the descending aorta (70 [77%] patients, with 45.7% being complex aortic atheromas); in only 4 (4.4%) patients, the aortic atheromas were localized in the ascending aorta (50% complex aortic atheromas). CONCLUSIONS: There is a strong association between the presence of severe aortic stenosis and the presence and severity of aortic atheromas, suggesting that aortic stenosis might be a manifestation of the atherosclerotic process. These findings imply that (1) aggressive atherosclerotic risk-factor modification for patients with aortic stenosis might be advisable and (2) consideration of evaluation of the aorta by means of transesophageal echocardiography before aortic valve replacement in selected patients might be helpful.