Glutathione sodium salt as a novel adjunctive treatment for acute myocardial infarction.

Timely recanalization of infarct related artery along with effective myocardial cell reperfusion represents a major challenge in the management of STEMI. The reperfusion of coronary arteries can induce further cardiomyocyte death by generating oxidative stress, which itself can mediate myocardial damage through a number of different mechanisms. Based on experimental and clinical studies, interventions to treat reperfusion injury by antioxidants were considered to be an appropriate therapeutic option. We emphasize the hypothesis that glutathione sodium salt, a physiologic antioxidant, may be of value when administered to STEMI patients both at an early stage of myocardial reperfusion by primary angioplasty and for up to three days after the procedure, in addition to standard treatment.

Eccentric atherosclerotic plaques with positive remodelling have a pericardial distribution: a permissive role of epicardial fat? A three-dimensional intravascular ultrasound study of left anterior descending artery lesions.

AIMS: The transversal distribution of coronary atherosclerotic plaques (AP) (myocardial vs pericardial) affects vessel remodelling. The aim of this study was to define the impact of transversal lesion distribution on vessel remodelling in proximal and distal coronary segments using a 3D intravascular ultrasound (IVUS) reconstruction. METHODS: The study group included 70 lesions located in the left anterior descending artery within 5mm of the septal take-off, and imaged using 3D-IVUS. The take-off of the septal branch was used to divide the plaque into a myocardial and pericardial surface. The IVUS index of vessel remodelling was calculated as: [narrowest external elastic membrane (EEM) site cross-sectional area (CSA)-reference EEM CSA)/reference EEM CSAx100]. The lesions with an intermediate vessel remodelling index (between -25% and +15%) were excluded from analysis. RESULTS: Of the 38 APs with a pericardial distribution, 34 (89%) showed positive remodelling (P<0.001). The distal lesions had a positive vessel remodelling index regardless of transversal plaque distribution. At multivariate analysis, pericardial distribution and the distal location of AP were the only independent variables predictive of positive remodelling. CONCLUSIONS: The transversal distribution of atherosclerotic plaque affects vessel remodelling in left anterior descending coronary lesions, probably because of an extravascular splinting effect. Distal lesions usually show positive remodelling regardless of transversal plaque distribution.

Acute and mid-term results of phosphorylcholine-coated stents in primary coronary stenting for acute myocardial infarction.

The aim of this pilot study was to evaluate the safety and efficacy of the BiodivYsio phosphorylcholine-coated stent in the primary treatment of acute myocardial infarction. The BiodivYsio stent (Biocompatible) is a balloon-expandable stent, laser etched from a 316 L stainless steel tube. This device is coated with phosphorylcholine, a synthetic, hemocompatible phospholipid polymer that has been shown in experimental studies to reduce platelet and protein adhesion to the surface of the metal. One hundred consecutive patients within 24 hr of symptoms of onset of acute MI, treated with primary PTCA, were enrolled. After PTCA, stenting was attempted in all eligible lesions (reference diameter > or = 2.5 mm; no bend lesion > 45 degrees ). Poststenting regimens contained ticlopidine (500 mg/day) and aspirin (325 mg/day) and 6-12 hr of heparin infusion. Procedural success (TIMI > or = II and residual stenosis < 30%) was obtained in 70/74 cases (95%). TIMI grade III was restored in 90% of cases. In the patient group with procedural success (70 cases), 70 BiodivYsio stents were placed. After stenting, diameter stenosis decreased from 96% +/- 11% to 22% +/- 12% (P < 0.01) and minimal luminal diameter increased from 0.13 +/- 0.29 to 2.47 +/- 0.43 (P < 0.01). Nominal stent diameter was between 3.0 and 4.0 mm (mean, 3.5 +/- 0.4 mm). Stent length was between 11 and 28 mm (mean, 17 +/- 4.5 mm). Clinical follow-up was obtained in all patients; angiographic follow-up was performed in 65/70 (93%). No acute or subacute thrombosis was reported. Two in-hospital major adverse cardiac events (MACE) were reported due to a nontreated left main disease that required coronary artery bypass graft (CABG) surgery. At follow-up, MACE were found in 9 of 68 patients (13%), target lesion revascularization (TLR) in 6%, and CABG in the remaining 6%. Primary stenting with phosphorylcholine-coated stent leads to excellent short- and mid-term clinical outcomes and is associated with a restenosis rate of 12%.

Correlation between high frequency intravascular ultrasound and histomorphology in human coronary arteries.

OBJECTIVE: To test the efficacy of high frequency intravascular ultrasound (IVUS) transducers in identifying lipid/necrotic pools in atherosclerotic plaques. METHODS: 40 MHz transducers were used for in vitro IVUS assessment of 12 arterial segments (10 coronary and two carotid arteries, dissected from five different necropsy cases). IVUS acquisition was performed at 0.5 mm/s after ligature of the branching points to generate a closed system. Lipid/necrotic areas were defined by IVUS as large echolucent intraplaque areas surrounded by tissue with higher echodensity. To obtain histopathological sections corresponding to IVUS cross sections, vessels were divided into consecutive 3 mm long segments using the most distal recorded IVUS image as the starting reference. Samples were then fixed with 10% buffered formalin, processed for histopathological study, serially cut, and stained using the Movat pentacrome method. RESULTS: 122 sections were analysed. Lipid pools were observed by histology in 30 sections (25%). IVUS revealed the presence of lipid pools in 19 of these sections (16%; sensitivity 65%, specificity 95%). CONCLUSIONS: In vitro assessment of lipid/necrotic pools with high frequency transducers was achieved with good accuracy. This opens new perspectives for future IVUS characterisation of atherosclerotic plaques.

Intravascular ultrasound insights into plaque composition.

UNLABELLED: Previous studies correlating histomorphology with 20-30 MHz-derived intravascular ultrasound (IVUS) images showed that IVUS provides to some extent qualitative information on plaque composition. IVUS imaging proved to define calcifications with high sensitivity and specificity but was found to be less accurate in the assessment of soft components. Nevertheless previous studies on atherosclerotic plaque characterization were limited by use of low-frequency transducers that did not define accurately soft components. Our goal was to test the effectiveness of high frequency IVUS transducers in the identification of lipid/necrotic pools in atherosclerotic plaques. METHODS: Forty MHz transducers were used for in vitro IVUS assessment of 12 arterial segments (10 coronary arteries and 2 carotid arteries dissected from 5 different autopsy cases). IVUS acquisition was performed at a 0.5 mm/s speed after ligature of the branching points to generate a closed system. Lipid necrotic areas were defined by IVUS as large echolucent intraplaque areas surrounded by tissue with higher echodensity. To obtain histopathologic sections corresponding to IVUS cross sections, vessels were divided into consecutive 3 mm-long segments using the most distal recorded IVUS image as the starting reference. Then, samples were fixed with 10% buffered formalin, processed for histopathologic study, serially cut, and stained with the Movat penthacrome method. RESULTS: One hundred twenty-two sections were analyzed. Lipid pools were observed by histology in 30 cross sections (25%). IVUS revealed the presence of lipid pools in 19 of 122 cross sections with a sensitivity and specificity of 67% and 94%, respectively. CONCLUSIONS: High frequency transducers accurately identify lipid/necrotic pools and open new perspectives on future IVUS characterization of atherosclerotic plaques.

Recovery of LV contractility in man is enhanced by preischemic administration of enflurane.

BACKGROUND: Volatile anesthetics enhance postischemic functional recovery in animal models; this effect has not been investigated in man. METHODS: Twenty-two patients undergoing coronary surgery were randomized to enflurane administration (0.5% to 2%) for 5 minutes to reduce systolic blood pressure by 20% to 25% immediately before cardioplegic arrest. Left ventricular contractility was assessed by pressure-area relations using echocardiographic automated border detection during inflow occlusion before and after cardiopulmonary bypass. Linear regression analysis in 16 patients with paired data sets assessed changes in contractility. RESULTS: The relation was highly linear (r = 0.95+/-0.02). A change of slope versus the change in x intercept was detected in controls (mean difference, 16.1 mm Hg/cm2, 95% confidence limits, 5.9 to 26.3; 2.2 cm2, 95% confidence limits, -1.1 to 5.5; p = 0.007), which was different from those of treated patients (mean difference, 0.7 mm Hg/cm2, 95% confidence limits, -2.2 to 3.7; -0.06 cm2, 95% confidence limits, -1.6 to 1.5; p > 0.2). Analysis of covariance in the overall group confirmed a significant effect of treatment (p = 0.002). CONCLUSIONS: Enflurane enhances postischemic functional recovery, possibly through pharmacologic preconditioning of myocardium.

Residual aortic valve regurgitation after aortic root remodeling without a direct annuloplasty.

BACKGROUND: Aortic insufficiency secondary to degenerative aneurysms of the ascending aorta can be surgically treated with replacement of the valve or with remodeling of the aortic root. METHODS: In 15 patients who underwent aortic root remodeling from January 1994 to December 1996, we evaluated the postoperative aortic regurgitation and correlated it with several anatomic and functional variables. Operative success was defined as a residual aortic regurgitation less than or equal to 1 on a scale of 0 to 4. RESULTS: Root dimensions and aortic incompetence decreased significantly after the operation (p < 0.0001). The difference between preoperative and postoperative root diameters (p = 0.0006) and the presence of Marfan's syndrome (p < 0.0001) were independently predictive of persisting significant aortic insufficiency. Operative success was obtained in patients with a difference between preoperative and postoperative root diameters smaller than 30 mm. CONCLUSIONS: Aortic root remodeling is effective in reducing aortic regurgitation. Severe aortic root dilatation may result in excessive geometric alteration, leading to suboptimal results. The choice of a larger graft contributes to avoiding excessive geometric constraint of a profoundly diseased aortic root. Indication to undergo root remodeling should be evaluated cautiously in patients with Marfan's syndrome.

Regression of left ventricular hypertrophy after aortic valve replacement for aortic stenosis with different valve substitutes.

OBJECTIVE: Stentless biologic aortic valves are less obstructive than stented biologic or mechanical valves. Their superior hemodynamic performances are expected to reflect in better regression of left ventricular hypertrophy. We compared the regression of left ventricular hypertrophy in 3 groups of patients undergoing aortic valve replacement for severe aortic stenosis. Group I (10 patients) received stentless biologic aortic valves, group II (10 patients) received stented biologic aortic valves, and group III (10 patients) received bileaflet mechanical aortic valves. METHODS: Echocardiographic evaluations were performed before the operation and after 1 year, and the results were compared with those of a control group. Left ventricular diameters and function, left ventricular wall thickness, and left ventricular mass were assessed by echocardiography. RESULTS: Group I patients had a significantly lower maximum and mean transprosthetic gradient than the other valve groups (P = .001). One year after operation there was a significant reduction in left ventricular mass for all patient groups (P < .01), but mass did not reach normal values (P = .05). Although the rate of regression in the interventricular septum and posterior wall thickness differed slightly among groups, their values at follow-up were comparable and still higher than control values (P = .002). The ratio between interventricular septum and posterior wall and the ratio between wall thickness and chamber radius did not change significantly at follow-up. CONCLUSIONS: Because the number of patients was relatively small, we could not use left ventricular mass regression after I year to distinguish among patients undergoing aortic valve replacement for aortic stenosis by means of valve prostheses with different hemodynamic performances.

Extent and pattern of regression of left ventricular hypertrophy in patients with small size CarboMedics aortic valves.

OBJECTIVE: To assess the extent and pattern of regression of left ventricular hypertrophy after valve replacement for aortic stenosis, we studied 26 patients receiving either 19 or 21 mm CarboMedics valves (group I, 13 patients) or either 23 or 25 mm CarboMedics valves (group II, 13 patients). The studies were done before the operation and after 3 years, and results were compared with those of 10 control patients. METHODS: Left ventricular end-diastolic and end-systolic diameters and volumes, ejection fraction and fractional shortening, and interventricular septum and posterior wall thickness were measured. The ratio between interventricular septum and posterior wall thickness, the ratio between left ventricular wall thickness and left ventricular chamber radius, and the left ventricular mass were then calculated. RESULTS: At follow-up there was a significant reduction in the left ventricular mass, interventricular septum, and posterior wall thickness for both patient groups (p < 0.01). However, only the posterior wall thickness reached normal values; the interventricular septum and the left ventricular mass indices were still significantly greater than in the control group (p < 0.01). Because of the incomplete regression of interventricular septal hypertrophy, the ratio between interventricular septum and posterior wall thickness was similar between both patient groups but it was significantly higher than in control subjects (p < 0.01). The ratio between wall thickness and chamber radius did not decrease significantly in group II patients, in whom it remained above the control values. CONCLUSION: Having a bileaflet aortic prosthesis of one size larger did not seem to significantly influence the pattern and the extent of regression of left ventricular hypertrophy after an intermediate period of follow-up.

Hemodynamic performances of small diameter carbomedics and St. Jude valves.

BACKGROUND AND AIMS OF THE STUDY: Optimal hemodynamic performances are of paramount importance when implanting a mechanical valve in patients with a small aortic annulus. A Doppler echocardiographic study was performed to compare the hemodynamic performances of small CarboMedics and St. Jude valves. MATERIALS AND METHODS: Twenty-nine patients receiving either a 19 mm (n = 10) or a 21 mm (n = 10) CarboMedics valve or a 19 mm (n = 9) St. Jude Med HP valve were evaluated. A Doppler echocardiographic study was performed at rest and two minutes after treadmill exercise with the Bruce protocol. Peak and mean gradients across the valve were estimated; effective orifice area, performance index and discharge coefficient were calculated. Heart rate, blood pressure and cardiac output were all significantly increased with exercise. RESULTS: Peak and mean gradients at rest were significantly higher (p < 0.05) in the 19 mm CarboMedics valve (40.2 +/- 15 mmHg and 22.6 +/- 9 mmHg, respectively) when compared either with 21 mm CarboMedics valve (27.6 +/- 6.8 mmHg and 14.2 +/- 3.4 mmHg, respectively) or with the 19 mm St. Jude HP valve (23.6 +/- 10.4 mmHg and 13.6 +/- 5 mmHg, respectively). Peak and mean gradients were not modified with exercise for the 19 mm CarboMedics valve and significantly increased for the 21 mm CarboMedics and the 19 mm St. Jude HP valves. Although these values were still higher in the 19 mm CarboMedics valve, they did not reach the level of statistical significance when compared with the other two valve groups. CONCLUSIONS: The 19 mm St. Jude HP valve shows hemodynamic performances at rest that are similar to those of the 21 mm CarboMedics valve and superior to those of the 19 mm CarboMedics valve. With exercise both sizes of the CarboMedics valve show an in vivo discharge coefficient close to one, testifying to a full utilization of the internal orifice area.

Doppler echocardiography evaluation of the CarboMedics valve in patients with small aortic anulus and valve prosthesis-body surface area mismatch.

A Doppler echocardiographic study was performed to evaluate the hemodynamic performances of small diameter CarboMedics aortic valves (CarboMedics, Inc., Austin, Tex.) in patients with a mismatch between the prosthetic valve and body surface area. Fourteen patients receiving either a 19 mm (n = 7) or a 21 mm valve (n = 7) prosthesis were studied. Only patients with a body surface area greater than 1.65 m2 were included in the study. Pulsed and continuous wave Doppler echocardiography was performed at rest and 2 minutes after treadmill exercise with the Bruce protocol. Peak and mean gradients across the valve prosthesis were estimated; effective orifice area, performance index, and discharge coefficient of the valve prosthesis were calculated. All patients achieved a significant increase in heart rate, systolic blood pressure, and cardiac output with exercise. Mean gradients +/- standard deviation of the mean at rest and 2 minutes after exercise were 20.1 +/- 7.1 mm Hg and 21.8 +/- 9 mm Hg for the 19 mm prosthesis and 12.3 +/- 3.4 mm Hg and 15.9 +/- 3.9 mm Hg for the 21 mm prosthesis. The 19 mm valve prosthesis significantly increased the effective orifice area with exercise (1.02 +/- 0.2 versus 1.20 +/- 0.3; p < 0.05), whereas it was almost unmodified for the 21 mm valve (1.38 +/- 0.2 versus 1.39 +/- 0.3; p = not significant). Therefore, despite a similar increase in cardiac output with exercise, only the 21 mm valve prosthesis showed a significant increase in peak (25.4 +/- 5.2 versus 34.9 +/- 8.1 mm Hg) and mean gradient (p < 0.01). We conclude that small diameter CarboMedics valves have satisfactory hemodynamic performances even after strenuous exercise in patients with large body surface areas. The hemodynamic performances of the 19 mm valve prosthesis seem to be optimized with exercise.

Right coronary artery cirsoid with fistulous connection to the coronary sinus.

A 61-yr-old woman was referred to our hospital for evaluation of a suspected right atrial myxoma. The transesophageal echocardiogram suggested the presence of an anomalous right coronary artery with fistulous connection to the coronary sinus. At cardiac catheterization, an oxygen step-up in the right atrium indicated a 1.3:1.0 left-to-right shunt. Aortic root angiography showed a large and calcified right coronary artery cirsoid draining to the coronary sinus, which appeared remarkably dilated. In this rare anomaly, cardiac catheterization is necessary, not only to quantify the magnitude of the left-to-right shunt, which is an important requirement for the indication to surgical treatment, but also to confirm the echocardiographic diagnosis.

Improvement of cardiac function in patients with severe congestive heart failure and coronary artery disease by dual chamber pacing with shortened AV delay.

Medical therapy often fails to control symptoms of severe heart failure. The possibility of modifying to some degree the global ventricular performance with the implantation of a physiological dual chamber pacemaker, set with a short atrioventricular delay (100 msec), has been adopted in two patients with severe heart failure due to coronary artery disease. The baseline clinical condition of both patients was characterized by leg edema, ascites, dyspnea at rest, or even orthopnea with a functional New York Heart Association (NYHA) class III-IV. Acute measurements of hemodynamic and echocardiographic parameters during stepwise shortening of AV interval guided the pacemaker implantation and setting of AV delay in the chronic phase. Within a few days after pacemaker implantation, both patients considerably improved their clinical status as well as their functional NYHA class, improving to class II in one patient and to class II-III in the other patient. In addition, modification of systolic and diastolic parameters paralleled these improvements functional class and clinical condition. Pacemaker therapy in severe heart failure refractory to medical therapy can be of considerable benefit in patients whose quality-of-life is severely compromised when pharmacological therapy is no longer effective. Acute hemodynamic and echocardiographic testing is useful in assessing the most appropriate AV delay and pacing mode.

Long-term follow-up of cardiac myxomas (7-31 years).

Between 1961 and 1985, 14 patients (9 males, 5 females; mean age 42.3 +/- 7.26 years) underwent surgery for excision of cardiac myxoma. Origin of the neoplasm was left atrium in all patients. In the last 7 cases diagnosis was obtained by echocardiographic examination. The clinical manifestations were dyspnea in 8 cases, palpitation in 5 and neurological symptoms in 3. One patient with concomitant mitral and aortic incompetence died on the 13th postoperative day because of low-output syndrome. All 13 operative survivors are alive and well without echocardiographic evidence of neoplastic recurrence at a follow-up ranging from 7 to 31 years. These results indicate a low incidence of recurrence with a complete tumor excision even without its extension to the normal atrial endocardium.

Cardiac myxoma arising from the inferior vena cava.

A cardiac myxoma that arises from the inferior vena cava (an extremely rare finding) may interfere with caval cannulation. In such cases venous cannulation for cardiopulmonary bypass has been performed directly into the inferior vena cava or through the femoral vein. We present a case in which routine cannulation through the right atrium proved safe and gave good exposure for complete resection of the tumoral mass.