Status of coronary disease and results from early endovascular aneurysm repair after preventive percutaneous coronary revascularization.

BACKGROUND: The incidence of coronary artery disease (CAD) is high in patients with an aortic aneurysm but preoperative routine coronary angiography and preventive coronary revascularization are not recommended to reduce cardiac events in patients with severe CAD. AIM: This study evaluated the safeness and efficacy of preventive percutaneous coronary intervention (PCI) in patients with severe CAD scheduled for endovascular aneurysm repair (EVAR). METHODS: All patients with descending thoracic aneurysm (DTA) or abdominal aortic aneurysm (AAA) scheduled for EVAR underwent preliminary coronary angiography. Based on coronary angiography results, 917 patients (40.7%) had significant CAD and were treated by percutaneous coronary intervention (PCI; CAD group) and 1337 patients (59.3%) were without or with mild/moderate CAD and were considered as controls (no-CAD group). To evaluate the safeness and efficacy of preventive PCI in patients with severe CAD undergoing EVAR, groups were compared for hospital and 12-month cardiac adverse events. RESULTS: CAD was present in 1210 patients (53.6%): significant in 917 patients (38%) and mild to moderate in 293 patients (5.3%). Hospital and 12-month cardiac events occurred in 15 (1.6%) and 13 (1.4%) CAD group patients and in 9 (0.7%) and 8 (0.4%) no-CAD group patients (p = .05 and p = .08), respectively. Hospital and 12-month cardiac deaths occurred in 3 (0.3%) and 2 (0.2%) CAD group patients and in 3 (0.2%) and 2 (0.2%) no-CAD group patients (p = .9 and p = .9), respectively. CONCLUSION: The strategy to treat severe CAD preoperatively by PCI and early subsequent EVAR brings a similar outcome to that in patients without or with mild/moderate CAD.

Impact of different values of prosthesis-patient mismatch on outcome in male patients with aortic valve replacement.

AIMS: Mortality and left ventricular mass (LVM) recovery/regression after aortic valve replacement in patients with prosthesis-patient mismatch (PPM) is controversial. This study evaluated the impact of different values of indexed effective orifice area (EOAi) in male patients on mortality and indexed LVM (ILVM) recovery/regression. METHOD: The study recruited 376 male patients with and without PPM after aortic valve replacement with different EOAi cut-off values. RESULTS: At EOAi 0.85 cm/m or less, 295 patients had PPM (78.5%). ILVM recovery occurred in 60.5% of no-PPM patients versus 46.1% of patients with PPM (P = 0.003), and ILVM regression was 35 versus 25% (P < 0.001). Time for ILVM regression was shorter in no-PPM group. At EOAi 0.75 cm/m or less, 201 patients had PPM (53.4%). ILVM recovery occurred in 55.4% of no-PPM patients versus 45.2% of patients with PPM (P = 0.06), regression was 32 versus 29% (P = 0.09). Time for ILVM regression was similar between groups. Regardless the cut-off value for PPM definition, mortality was similar. CONCLUSION: LVM recovery/regression, but not mortality, was different at different EOAi. The cut-off value at EOAi 0.75 cm/m or less guaranteed a more balanced patient distribution between groups and the best compromise between specificity and sensitivity.

Severe prosthesis-patient mismatch after aortic valve replacement for aortic stenosis: Analysis of risk factors for early and long-term mortality.

BACKGROUND: Severe prosthesis-patient mismatch (PPM) is considered to further decrease survival compared to moderate PPM. This study aimed to assess the impact of severe PPM on survival after aortic valve replacement (AVR). METHODS: We retrospectively studied 2404 consecutive patients with PPM who underwent first-time AVR for pure stenosis between January 2003 and December 2014. Mismatch was moderate for indexed effective valve orifice >0.65 to <0.85cm2/m2 and severe for indexed effective valve orifice ≤0.65cm2/m2. Moderate mismatch occurred in 2165 patients (89%), and severe in 239 (11%) patients. Logistic multiple regression with bootstrapping and propensity score analyses were performed using 29 clinical and demographic data to assess the risk-adjusted impact of severe mismatch on mortality. The Cox proportional hazards model was constructed to process the long-term outcome. RESULTS: Early mortality was 2.3% (51/2165) in moderate mismatch group and 3.7% (9/239) in severe mismatch group (p=0.2). Mortality at 5 and 10 years, was 218/1470 (14.8%) and 252/585 (43.1%) for moderate mismatch and 43/198 (21.7%) and 61/105 (58.1%) for severe mismatch (p=0.02 and p=0.006). Multivariable predictors of late mortality were as follows: age ≥70 years, left ventricular ejection fraction ≤40%, indexed left ventricular mass >220g/m2 and concomitant coronary artery revascularization. After propensity score matching, conditional logistic regression analysis demonstrated no relationship between severe mismatch and increased mortality at 5 postoperative years (HR, 0.9; 95% CI, 0.7-1.6; p=0.06), whereas it was significant at 10 postoperative years (HR, 1.9; 95% CI, 1.2-2.5; p=0.03). During the follow-up, severe mismatch was associated with more frequent hospital readmissions for cardiac events (0.12 vs. 0.08 events/patient/year, p=0.007). CONCLUSIONS: Patients with severe mismatch had lower long-term survival and higher incidence of hospital readmissions for cardiac events. However, the effect of severe mismatch on outcome appeared mainly related to the preoperative risk profile of each patient.

Central venous catheter related bloodstream infections in adult patients on home parenteral nutrition: Prevalence, predictive factors, therapeutic outcome.

BACKGROUND: The prevalence of central venous catheter (CVC)-related blood-stream infections (CRBSI), infecting agents and the effectiveness of antibiotic therapy were evaluated in 172 adult patients on Home Parenteral Nutrition (HPN) at the Clinical Nutrition Outpatient Unit of Federico II University Hospital in Naples, Italy. MATERIALS AND METHODS: The study population consisted of 127 oncological (74%) and 45 (26%) non-oncological patients, for a total of 53,818 (median 104; range 14-1080) CVC days. RESULTS: Ninety-four CRBSIs were diagnosed on 238 CVC (infection rate 1.74/1000 CVC days). Coagulase negative (CoNs) Staphylococci were the most frequently infecting agents (52.8% as single agent) with 17.1% Staphylococcus epidermidis infections. Eighty-three percent S. epidermidis were beta-lattamase producer (BLACT), 66.6% methicillin-resistant (MR) and 55.5% had a MIC for Vancomicin ≥1. Gram-negative bacteria represented 18.6% infections, fungi 7.1%, finally 15% infections were polymicrobial. Previous catheterizations and the presence of an enterocutaneous stoma were significantly related with a higher infection risk (p < 0.0001 in both cases). CONCLUSIONS: CRBSI and antibiotic resistance of infecting agents remain an important challenge in adult patients on HPN; an active research on strategies to counteract the phenomena is required.

Comparison of Left Ventricular Myocardial Structure and Function in Patients with Aortic Stenosis and Those with Pure Aortic Regurgitation.

OBJECTIVE: We aimed to support the structural and functional distinction between aortic stenosis (AS) and aortic regurgitation (AR). METHODS: Biopsy specimens taken from 70 selected patients (35 with AS and 35 with AR) undergoing aortic valve replacement (AVR) were analyzed for their cardiomyocyte dimensions and structure, interstitial fibrosis and contractile function. To determine normal values of contractile function, 10 donor hearts were analyzed. RESULTS: Cardiomyocyte diameter was higher in AS than in AR (22.7 ± 2.2 vs. 13.2 ± 0.7 µm, p < 0.001). Length was higher in AR (121.2 ± 9.4 vs. 95.6 ± 3.7 µm, p < 0.001). Collagen volume fraction was increased in both AS and AR, but was lower in the AS specimens (7.7 ± 2.3 vs. 8.9 ± 2.3, p = 0.01). Myofibril density was reduced in AR (38 ± 4 vs. 48 ± 5%, p < 0.001). Cardiomyocyte diameter and length were closely linked to the relative left ventricular (LV) wall thickness (R2 = 0.85, p < 0.001 and R2 = 0.68, p = 0.003). The cardiomyocytes of AS patients had higher Fpassive (6.6 ± 0.3 vs. 4.6 ± 0.2 kN/m2, p < 0.001), but their total force was comparable. Fpassive was also significantly higher in AS patients with restrictive rather than pseudo-normal LV filling (7.3 ± 0.5 vs. 6.7 ± 0.6, p = 0.004). In AS patients, but not in AR patients, Fpassive showed a significant association with the cardiomyocyte diameter (R2 = 0.88, p < 0.001 vs. R2 = 0.31, p = 0.6). CONCLUSIONS: LV myocardial structure and function differ in AS and AR, allowing for compensative adjustment of the diastolic/systolic properties of the myocardium. © 2015 S. Karger AG, Basel.

Multiple composite grafts (k, π or double-Y) in coronary artery surgery: a choice or a necessity?

OBJECTIVES: Composite grafts allow complete arterial revascularization with minimal aortic manipulations. The Y-T configuration supplies all distal branches adequately, whereas it is unclear whether complex composite configurations (K, Π or double-Y) are equally at rest or when challenged by maximal requirements. METHODS: Forty-seven patients who underwent off-pump coronary artery revascularization by multiple arterial composite grafts (K, Π or double-Y) were retrospectively evaluated. Indication for this surgical option was porcelain aorta or conduit unavailability. Composite systems were evaluated by intraoperative flow measurements and perioperative transthoracic Doppler ultrasonography, 12 months later also by exercise test, sestamibi scintigraphy at rest and during induced hyperaemia and by 64-slice multidetector CT angiography. RESULTS: A total of 141 distal anastomoses were implanted as composite grafts. Perioperative flow measurements and 12-month Doppler ultrasonography were adequate at rest. At stress test, chest pain and/or induced ECG evidence of ischaemia are found in 16 patients (39%). During dipyridamole-induced hyperaemia, single-photon emission computed tomography image revealed that mean summed stress score was 7.2 ± 5.7, summed difference score 5.3 ± 4.2 and coronary flow reserve 1.7 ± 0.2. CONCLUSIONS: Multiple composite grafts, albeit adequate at rest, were unable to meet flow requirements during maximal hyperaemia. In daily practice, their use must be not a choice but rather a necessity in those patients without alternative options.

Y grafts with the left internal mammary artery and radial artery. Mid-term functional and angiographic results. Cohort study.

BACKGROUND: This retrospective cohort study investigated the functional and haemodynamic mid-term results over 3-years follow up of the left internal mammary artery (LIMA) conduit in composite Y-graft configuration with radial artery (RA) in a population of patients who underwent off-pump coronary artery bypass grafting (CABG). METHODS: 148 patients who underwent off-pump CABG with composite Y-graft, were evaluated over 3-year follow up. Two-day dipyridamole induced maximal hyperaemia/rest 99mTc-sestamibi was scheduled preoperatively and 36 months after surgery for functional evaluation. Morphological evaluation was performed by 64 slice multidetector computed tomography (CT) 36 months after surgery. RESULTS: Clinical adverse events were rare within 3 years follow up. Minimal to severe scintigraphic evidence of stress induced ischaemia occurred in 24 patients. Left ventricular (LV) hypertrophy (HR 3.1; 95% CI, 1.5-9.3; p = 0.01) and poor coronary run off (HR 4.1; 95% CI, 2.1-10.8; p = 0.005) were significant multivariate predictors of reversible stress induced ischaemia. 64 slice multidetector CT showed that the main stem of Y composite grafts was patent in all patients, while distal LIMA or RA was stenosed or occluded in 9 patients. CONCLUSION: Composite Y-graft was adequate to meet the flow requirements of target coronary artery either at rest or during maximal hyperaemia. The use of Y-graft should be carefully evaluated in patients with LV hypertrophy and/or poor coronary run-off.

Continuative statin therapy after percutaneous coronary intervention improves outcome in coronary bypass surgery: a propensity score analysis of 2501 patients.

OBJECTIVES: A history of percutaneous coronary intervention increases the risk of death and complications of coronary artery bypass grafting. This retrospective multicenter study evaluated the impact of continuative use of statin on postoperative outcomes when subsequent elective coronary artery bypass grafting is required after percutaneous coronary intervention. METHODS: Among 14,575 patients who underwent isolated first-time coronary artery bypass grafting between January 2000 and December 2010, 2501 who had previous percutaneous coronary intervention with stenting and fulfilled inclusion criteria were enrolled. Continuative statin therapy was used in 1528 patients and not used in 973 patients. Logistic multiple regression and propensity score analyses were used to assess the risk-adjusted impact of statin therapy on in-hospital mortality and major adverse cardiac events. The Cox proportional hazards model was constructed to assess the effect of continuative statin therapy on 24-month outcome. RESULTS: At multivariate analysis, age more than 70 years, 3-vessel or 2-vessel plus left main coronary disease, multivessel percutaneous coronary intervention, ejection fraction 0.40 or less, diabetes mellitus, and logistic European System for Cardiac Operative Risk Evaluation 5 or greater were independent predictors of hospital mortality and major adverse cardiac events. After propensity score matching, conditional logistic regression analysis demonstrated that continuative statin therapy before coronary artery bypass grafting reduced the risk for hospital and 2-year mortality (odds ratio [OR], 0.27; 95% confidence interval [CI], 0.12-0. 57; P=.004 and OR, 0.6; 95% CI, 0.36-0.96; P=.04, respectively) and major adverse cardiac events (OR, 0.31; 95% CI, 0.18-0.78; P=.003 and OR, 0.5; 95% CI, 0.34-0.76; P=.006, respectively). CONCLUSIONS: Long-term statin treatment after percutaneous coronary intervention improves early and midterm outcome when surgical revascularization will be required.

Treatment of a rapidly expanding thoracoabdominal aortic aneurysm after endovascular repair of descending thoracic aortic aneurysm in an old patient.

BACKGROUND: Aortic pathology progression and/or procedure related complications following endovascular repair should always be considered mostly in older patients. We herein describe a hybrid procedure for treatment of rapidly expanding thoracoabdominal aneurysm following endovascular treatment of a descending thoracic aortic aneurysm in an older patient. CASE PRESENTATION: A 82-year-old man at 18 months after endovascular surgery for a contained rupture of descending thoracic aortic aneurysm revealed a type IV thoracoabdominal aneurysm with significant increase of the aortic diameters at superior mesenteric and renal artery levels. A hybrid approach consisting of preventive visceral vessel revascularization and endovascular repair of entire abdominal aorta was performed. Under general anaesthesia and by xyphopubic laparotomy, the infrarenal aneurysmatic aorta and common iliac arteries were replaced by a bifurcated woven prosthetic graf. From each of the prosthetic branches two reverse 14 x 7 mm bifurcated PTFE prosthetic grafts were anastomized to both renal arteries and to the celiac axis and superior mesenteric artery, respectively. Vessel ischemia was restricted to the time required for anastomosis. Three 10 cm Gore endovascular stent-grafts for a total length of 15 cm, were used. The overlapping of the stent-grafts was carried out from the bottom upwards, starting from the aorto-iliac prosthetic body up to the healthy segment of thoracic aorta, 40 mm from the previous stent-grafts.The patient was discharged on the 9th postoperative day. CONCLUSION: This technique offers the advantage of a less invasive treatment, reducing the risk of paraplegia, visceral ischaemia and pulmonary complications, mostly in older patients.

Left ventricular-assisted myocardial revascularization favorably affects levels of circulating adhesion molecules and lung function.

BACKGROUND: We investigated whether the use of left ventricular-assisted (LVA) technique in beating heart myocardial revascularization would exert less impact on patients adhesion molecules and oxygenation index as compared with conventional cardiopulmonary bypass (CPB). METHODS: Sixty-six consecutive patients undergoing myocardial revascularization were randomly assigned either to LVA (group A, 34 patients) or CPB (group B, 32 patients). Adhesion molecules and oxygenation indexes were measured at baseline and at various time points postoperatively. RESULTS: Pre-operative clinical and demographic data did not differ between the 2 groups. The 2 groups were also similar with respect to mortality, number of grafts performed, duration of extracorporeal circulation, and need for inotropes. However, postoperatively patients treated with LVA had a reduced levels of adhesion molecules compared with patients treated with CPB, as indicated by a significant difference in endothelial leukocyte adhesion molecule-1 (P = .002), intercellullar adhesion molecule-1 (P = .0001), and vascular cell adhesion molecule-1 (P = .004). The oxygenation index at 1 (P = .04) and 3 hours (P = .03) postoperatively was better in the LVA group than in the CPB group. CONCLUSION: Patients undergoing beating heart myocardial revascularization with LVA show reduced levels of adhesion molecules and better oxygenation index than patients treated with CPB.

Major complications following endovascular surgery of descending thoracic aorta.

We evaluated the impact of major complications on clinical outcome in a series of patients undergoing endovascular repair (EVAR) of descending thoracic aorta. From March 2001 to June 2005, 51 patients underwent EVAR for descending aortic diseases. Thirty-five were treated in emergency (60.7%) and 41 (80.4%) were in III-IV ASA class. There were no deaths, surgical conversion or paraplegia. A neurologic complication occurred in one patient (1.9%). Eleven major systemic complications occurred in 5 patients. One patient showed a primary type I endoleak at discharge, resolved spontaneously after 9 months. Three (5.9%) vascular injuries occurred during the endovascular procedure, requiring an emergency rescue iliac-femoral artery bypass. At follow-up (29+/-14 months), there was an overall mortality rate of 5.1% (3/51); 2 deaths (3.9%) were procedure related. Two secondary EVARs (3.9%) were successfully performed, one for a late type I endoleak six months after EVAR in a traumatic patient, and a second for a late rupture distally to the stent-graft implanted 36 months before in an acute type-B dissected patient. EVAR for descending aortic diseases is associated with decreased mortality and complications, however, long-term follow-up and additional studies are mandatory to detect late failure and to confirm clinical safety of this procedure.

A single-stage procedure for carotid endarterectomy and myocardial revascularization: early and late results.

Cardiac events are some of the most frequent postoperative complications of carotid endarterectomy, while cerebrovascular accidents frequently occur in patients who have undergone coronary artery bypass grafting. The strategy for treatment of combined carotid and coronary artery disease is still controversial. We report our experience with a single-stage procedure for carotid endarterectomy and myocardial revascularization during cardiopulmonary bypass; then we evaluate our early and late results. From January 1994 through December 2001, 73 patients underwent combined myocardial revascularization and carotid endarterectomy in a single-stage procedure. Three patients (4.1%) died during the early postoperative period. Five patients (6.8%) showed temporary neurologic complications, while 1 patient (1.4%) had cerebrovascular accidents with late permanent neurologic deficit. At 5.5 +/- 2.1 years' follow-up (range: 2.6-10.4 years), 9 of the 70 surviving patients had died: 5 (71%) of cardiac-related events, 2 (2.9%) of cerebrovascular-related causes, and 2 (2.9%) of noncerebral or noncardiac causes. During the late postoperative period, 6 patients experienced cerebrovascular accidents, with a linearized rate of 2.3%/pt-yr (70% confidence interval: 1.5% to 3.2%/pt-yr), and 8 patients experienced cardiac-related events, with a linearized rate of 3.8%/pt-yr (70% confidence interval: 2.8% to 4.9%/pt-yr). A single-stage procedure for carotid endarterectomy and myocardial revascularization during cardiopulmonary bypass can be considered safe and effective when it incorporates systemic heparinization, hemodilution, and moderate hypothermia with pulsatile flow and normal blood pressure, which helps to preserve normal cerebrovascular autoregulatory mechanisms.