Left ventricular mass regression after aortic valve replacement: Sex differences or effect of different methods of indexation?

BACKGROUND: The influence of sex on regression of left ventricular (LV) hypertrophy (LVH) after aortic valve replacement (AVR) for aortic stenosis (AS) remains elusive. The lack of consensus on how to correct LV mass (LVM) for body size, and different normalcy values, contribute to inconclusive results. METHODS: In 164 consecutive patients (mean age 80 ± 4 years, 59% females) with AS, we analyzed LVM (Devereux formula) before and 1 year after AVR (St.Jude Trifecta bio-prosthesis). LVM was indexed to BSA (Du Bois and Gehan formulas), to height1.7 and height2.7 . Limits of normalcy were (women and men, respectively): <95 and <115 g/m², BSA-indexed LVM; <60 and <81 g/m, LVM/height1.7 ; <44 and <48 g/m, LVM/height2.7 . RESULTS: Women had smaller BSA, but not body mass index, than men. AS severity and incidence of hypertension did not differ. LVM indexed to height2.7 was greater in women. LVH incidence was similar in males and females. Independently of the indexation method, LVH reduced significantly (P < 0.0001). LVM reduction was greater in women (P < 0.05 for all methods). At follow-up, nearly half the patients, irrespective of sex, showed residual LVH, and diastolic dysfunction. CONCLUSIONS: We tested different methods of LVM indexation in AS patients. LVM was similar between men and women. Indexation to height2.7 gives higher LVM in women because of their shorter stature. LVH prevalence is independent of sex. Irrespective of the indexation method, LVM reduction is greater in females, whereas LVM normalization occurs in equal proportion. Persistent LVH and diastolic dysfunction suggest earlier AVR in elderly.

Age as a Prognostic Factor in Patients with Acute Coronary Syndrome undergoing Urgent/Emergency Cardiac Surgery.

BACKGROUND: Patients presenting with acute coronary syndrome (ACS) who require urgent/emergency coronary artery bypass grafting (CABG) are increasing, as is the complexity of their clinical characteristics, one of which is advanced age. We evaluated the prognostic role of age in patients undergoing urgent/emergency cardiac surgery for ACS. METHODS: From January to December 2013, 452 consecutive patients underwent CABG at our institution. Among these, 213 presented with ACS, were enrolled in the study and divided into tertiles of age: First: 40-65 years old (n=73), Second: 66-74 (n=70), Third: 75-89 (n=70). Patients were followed post-operatively for 30 days. RESULTS: No differences between tertiles were found for baseline clinical and angiographic characteristics. Off-pump interventions were 67.6%. Older patients more frequently required an associate intervention to CABG for a mechanical complication of ACS. Overall 30-day all-cause mortality was 4.7% (n=10); 0.6% (n=1) in patients undergoing isolated CABG (n=168, 78.9%). The STEMI diagnosis was an independent risk factor for 30-day mortality, and age was not. CONCLUSIONS: The 30-day mortality rate of older ACS patients who undergo urgent/emergency CABG is comparable to that of younger ones. Pre-operative risk assessment should rely on evaluation of the clinical complexity of each patient independent of their chronological age, to customise the therapeutic strategy.

Surgical repair of post-infarction ventricular septal defect: 19 years of experience.

OBJECTIVES: To review our experience of surgical repair of post-infarction ventricular septal defect (VSD). METHODS: In the period 1983-2002, 50 patients underwent repair of VSD. Mean age was 66 years, male sex 52%. Infarct location was anterior in 60% and posterior in 40% of cases. Median interval between rupture and surgery was 2 days. Preoperative intra-aortic balloon counterpulsation was employed in 56%; a coronary angiogram was performed in 98% of cases. A patch repair technique was used in 90% of cases. Coronary bypass grafting was associated in 50% of patients. RESULTS: Mean aortic clamp time was 101+/-31 min. Global operative mortality was 36%, respectively 26.7% in anterior and 50% in posterior location (p=ns). Emergency operation and interval from rupture to surgery less than 3 days were univariate predictor of early mortality. Five years survival excluding operative deaths was 76%. CONCLUSIONS: The surgical repair of post-infarction VSD entails a high operative mortality; different techniques were employed with similar results. Emergency operation is associated with a worse short-term prognosis; long-term survival is acceptable.

19-year patency of a coronary-coronary venous bypass graft.

No data are available on the long-term outcome of coronary-coronary venous bypass grafting. We describe a case in which we successfully stented a discrete, critical stenosis of a coronary-coronary venous graft that had been placed 19 years earlier to minimize manipulation of a severely calcified ascending aorta. Coronary-coronary bypass grafting should be considered in cases involving severe aortic calcification, in situ grafts of inadequate length, and stenosed or occluded subclavian arteries. Such a bypass can be performed with either saphenous vein or arterial conduits, and it provides a flow rate similar to that of aortocoronary bypass. This option could be borne in mind as a 2nd-choice technique for the durable restoration of coronary blood flow in selected cases.

Long-term results of the surgical treatment of chronic ischemic mitral regurgitation: comparison of repair and prosthetic replacement.

BACKGROUND AND AIM OF THE STUDY: The optimal management of chronic ischemic mitral regurgitation (CIMR) remains controversial. Herein, the authors reviewed the past 10 years of their experience to compare the long-term results of mitral valve repair with prosthetic replacement. METHODS: Between January 1993 and January 2003, 102 patients (mean age 67.8 years; range: 51-80 years) with a preoperative diagnosis of CIMR, underwent mitral valve repair (n = 61; 59.8%) or prosthetic replacement (n = 41; 40.2%), along with myocardial revascularization (2.5 +/- 1.0 distal anastomoses per patients, internal thoracic artery used in 78.5%). A Carpentier Classic ring was always used in the repair procedures. The two groups were homogeneous for preoperative characteristics and comorbidities. RESULTS: Total operative mortality was 7.8% (repair 8.2%; prosthesis 7.3%; p = NS). The five-year actuarial survival (operative mortality included) was 66.6 +/- 7.4% for repair and 73.4 +/- 8.7% for prosthesis (p = NS). Cox multivariate analysis showed as independent risk factor for late survival a preoperative left ventricular ejection fraction (LVEF) < or = 30% (RR 3.91; 95% CI = 1.47-10.38) and a preoperative pulmonary artery pressure (PAP) > or = 35 mumHg (RR 2.74; 95% CI = 1.07-7.02), while the type of mitral procedure was not significant. Patients with annular dilation as a mechanism of regurgitation were significant more likely to undergo repair rather than receive a prosthesis. Their preoperative LVEF and PAP were significantly worse than patients who had altered leaflet motion as a regurgitation mechanism. CONCLUSION: Prosthetic mitral replacement and valve repair offer very similar results for CIMR. When a perfect repair is not easily feasible, cardiac surgeons should not hesitate to perform mitral valve replacement, as it is an excellent alternative therapy, though long-term outcome is mainly dependent on preoperative condition.

[Left ventricular thrombus in a patient with antiphospholipid antibody syndrome and hyperhomocysteinemia]. / Trombo endoventricolare sinistro in paziente affetto da sindrome da anticorpi antifosfolipidi e da iperomocisteinemia.

This report describes the case of a 39-year-old man, admitted for the occasional finding of left ventricular, irregular and pedicled mass. Because of the elevated risk of thromboembolism, cardiac surgery was performed with complete removal of the mass. Histologic examination showed it to be composed entirely of thrombotic material. Additional laboratory data revealed the simultaneous presence of two thrombophilic disorders: antiphospholipid syndrome and hyperhomocysteinemia. Screening laboratory evaluation for hypercoagulable states is recommended in similar cases.

[Giant aneurysm of a saphenous vein graft with fistulization into the right atrium: differential diagnosis and treatment]. / Aneurisma gigante di un graft venoso aortocoronarico con fistolizzazione in atrio destro: diagnosi differenziale e trattamento.

The aneurysm of an aortocoronary saphenous vein graft is a rare but potentially fatal complication of coronary artery bypass grafting. This case came to our observation after a single episode of hypotension, followed by dyspnea in a man previously operated on for coronary artery bypass grafting. A para-hilar mass was found on routine roentgenogram. The spiral computed tomographic scan was suggestive for aortic pseudoaneurysm. The correct diagnosis was obtained by cardiac catheterization showing a giant graft aneurysm determining compression and fistulous communication into the right atrium. The difficult diagnosis and the surgical treatment are discussed.

[Acute aortic syndromes: an assessment]. / Il punto sulle sindromi aortiche acute.

The term "acute aortic syndrome" describes a range of severe, painful, potentially life-threatening abnormalities of the aorta. This review discusses the pathophysiology and risk factors, classification schemes, epidemiology, clinical presentations, diagnostic modalities, management options, and outcomes of various aortic conditions, including acute aortic dissection (AD) and its variants intramural hematoma and penetrating atherosclerotic ulcer. The common denominator of acute aortic syndromes is disruption of the media layer of the aorta, with bleeding within the layers (intramural hematoma), along the aortic media resulting in separation of the layers (AD), or transmurally through the wall in the case of ruptured penetrating atherosclerotic ulcer or trauma. The incidence of AD ranges from 2 to 3.5 cases per 100 000 person-years; hypertension and a variety of genetic disorders with altered connective tissues are the most prevalent risk conditions. Recent advances in imaging techniques have helped in understanding the natural history and dynamics of this condition. Prognosis is clearly related to undelayed diagnosis and appropriate surgical repair in case of proximal involvement of the aorta; the advent of endovascular treatment has opened new perspectives in the management of acute aortic syndromes affecting the descending aorta, since this can modify its natural history and improve prognosis.

Asymptomatic cardiac papillary fibroelastoma: diagnostic assessment and therapy.

Papillary fibroelastoma is a rare benign cardiac tumor with elevated risk for embolization. This report describes the case of a 65-year-old man, admitted for the occasional finding of a round, pedunculate mass adherent to the chordae of the anterior mitral valve leaflet, mimicking an endocarditic mass. Appropriate diagnostic evaluations lead to the suspect of a papillary fibroelastoma. Because of the elevated risk of thromboembolism, surgery was emergently performed with complete removal of the mass and preservation of the integrity of the mitral valve. Histologic evaluation confirmed the diagnosis. Papillary fibroelastoma should be always considered in the differential diagnosis of intracardiac masses.