Limited reliability of grading scapular notching according to Nerot-Sirveaux on anteroposterior radiographs.

INTRODUCTION: Incidences of scapular notching (SN) in reverse shoulder arthroplasty (RSA) range between 0% and 96%, and controversy remain as to its relevance for patient outcome. We assessed the reliability of scapular notching (SN) grading based on the Sirveaux classification system using anteroposterior radiographs. MATERIALS AND METHODS: 206 RSA procedures with 5-year postoperative anteroposterior shoulder radiographs were classified independently by seven assessors according to Sirveaux (session 1). After a review meeting, three assessors re-classified the radiographs along with quality criteria (session 2). SN grading by the majority of assessors was taken as the reference. Classification interobserver reliability was analyzed using Kappa statistics. RESULTS: The incidence of SN was estimated at 53% and 37% at the first and second sessions, respectively. Interobserver reliability Kappa coefficients resulting from the first and second sessions were 0.27 and 0.43, respectively. Case selection based on radiographic quality criteria did not improve SN grading reliability in the second session. CONCLUSION: Agreement between individual surgeons was low when grading SN in RSA according to Sirveaux using anteroposterior radiographs. Consensus among several assessors may increase reliability in research settings.

Changing lifestyle habits as secondary prophylaxis after coronary artery bypass grafting.

BACKGROUND: Many studies have investigated the effect on mortality and morbidity of modified risk factors after coronary artery bypass grafting (CABG). We performed a retrospective survey to evaluate changing lifestyle habits after CABG during 1990-2003, focusing on the correlation between lifestyle habits and freedom from symptoms and regained exercise tolerances. METHODS: We reviewed data from 2269 patients who had undergone CABG in the year 1990, 1993, 1998, 2000, 2001, 2002, or 2003. Data were collected with a questionnaire that addressed lifestyle modifications and their outcomes with regard to quality of life for up to 5 years after surgery. RESULTS: We observed significant decreases in changing dietary habits after surgery in patients who had surgery in 2000-2003 compared with patients who had surgery in 1990-1998 (15.9% +/- 1.6% vs 24.7% +/- 2.6%; P < .001). In addition, the desire for nutritional counselling decreased steadily over time (35.1% +/- 7.9% vs 26.6% +/- 1.4%; P <.0001). Notably, among patients 50-59 years old, fewer men than women followed a strict diet (males 20.0% vs females 41.5%; P = .001). Patients suffering from recurrent angina consulted nutritionists more often than patients without angina (36.6% vs 29.8%; P = .016). The more the patients were restricted in terms of physical fitness, as determined by the New York Heart Association (NYHA) class, the more likely they were to adhere to a healthy diet (NYHA III 22.2% vs NYHA II 14.6% vs NYHA I 10.2%; P <.001). Among patients 60-79 years old, men exercised more often than women (72.4% +/- 2.4% vs 51.1% +/- 4.9%; P <.001) and suffered less frequently from recurrent angina (13.4% +/- 4.0% vs 28.8% +/- 10.8%; P = .002). CONCLUSIONS: Despite knowledge of hypercholesterolemia or obesity as agents contributing to advancing coronary heart disease, attention to nutrition tends to significantly decrease over time in patients who have undergone CABG. Thus patients who have undergone CABG, especially male patients older than 50, years would benefit from dietary education. Similarly, female patients older than 60 years would benefit from increased physical activity. Patients obviously tend to delay lifestyle modification until symptoms occur. Hence they must be reminded of the importance of healthy nutrition and adequate physical activity.

Myocardial bridging: depiction rate and morphology at CT coronary angiography--comparison with conventional coronary angiography.

PURPOSE: To prospectively assess the depiction rate and morphologic features of myocardial bridging (MB) of coronary arteries with 64-section computed tomographic (CT) coronary angiography in comparison to conventional coronary angiography. MATERIALS AND METHODS: Patients were simultaneously enrolled in a prospective study comparing CT and conventional coronary angiography, for which ethics committee approval and informed consent were obtained. One hundred patients (38 women, 62 men; mean age, 63.8 years +/- 11.6 [standard deviation]) underwent 64-section CT and conventional coronary angiography. Fifty additional patients (19 women, 31 men; mean age, 59.2 years +/- 13.2) who underwent CT only were also included. CT images were analyzed for the direct signs length, depth, and degree of systolic compression, while conventional angiograms were analyzed for the indirect signs step down-step up phenomenon, milking effect, and systolic compression of the tunneled segment. Statistical analysis was performed with Pearson correlation analysis, the Wilcoxon two-sample test, and Fisher exact tests. RESULTS: MB was detected with CT in 26 (26%) of 100 patients and with conventional angiography in 12 patients (12%). Mean tunneled segment length and depth at CT (n = 150) were 24.3 mm +/- 10.0 and 2.6 mm +/- 0.8, respectively. Systolic compression in the 12 patients was 31.3% +/- 11.0 at CT and 28.2% +/- 10.5 at conventional angiography (r = 0.72, P < .001). With CT, a significant correlation was not found between systolic compression and length (r = 0.16, P = .25, n = 150) but was found with depth (r = 0.65, P < .01, n = 150) of the tunneled segment. In 14 patients in whom MB was found at CT but not at conventional angiography, length, depth, and systolic compression were significantly lower than in patients in whom both modalities depicted the anomaly (P < .001, P < .01, and P < .001, respectively). CONCLUSION: The depiction rate of MB is greater with 64-section CT coronary angiography than with conventional coronary angiography. The degree of systolic compression of MB significantly correlates with tunneled segment depth but not length.

Accuracy of 64-slice computed tomography for the preoperative detection of coronary artery disease in patients with chronic aortic regurgitation.

We studied the diagnostic accuracy of 64-slice computed tomography for the diagnosis of significant coronary artery disease (CAD) compared with conventional coronary angiography (CA) in patients with chronic aortic regurgitation (AR) referred for elective aortic valve surgery. Fifty consecutive patients with chronic AR (38 men, mean age 54 +/- 14 years) scheduled for valve surgery underwent 64-slice computed tomographic (CT) coronary angiography and CA. Significant stenosis was defined as a luminal diameter decrease >50%. Mean heart rate during CT scanning was 65.5 +/- 7.4 beats/min. Mean Agatston score was 136 +/- 278 (range 0 to 1207); prevalence of significant CAD in the study population was 26% (13 of 50 patients). Thirteen of 742 segments (1.8%) in 3 patients were considered nondiagnostic with computed tomography because of motion artifacts (n = 9) or calcium (n = 4). In a patient-based analysis taking nonevaluative segments as falsely positive, sensitivity, specificity, and positive and negative predictive values of computed tomography were 100%, 95%, 87%, and 100%, respectively. Preoperative CA could have been avoided in 70% of patients (35 of 50), CA would have been performed to confirm the CT diagnosis in 26% (13 of 50), and unnecessary CA would have been performed in 4% (2 of 50) on the basis of false-positive CT ratings. In conclusion, 64-slice CT coronary angiography provides high diagnostic accuracy for diagnosing significant CAD in patients with chronic AR and may be used as a filter test before valve surgery to decide whether CA should be performed.

Aortic regurgitation: assessment with 64-section CT.

PURPOSE: To prospectively evaluate diagnostic accuracy of 64-section computed tomography (CT) for evaluation of aortic regurgitation (AR), with transthoracic echocardiography (TTE) as reference. MATERIALS AND METHODS: The institutional review board approved this study; written informed consent was obtained. Thirty patients (23 men, seven women; mean age, 56.6 years) with AR underwent TTE and retrospective electrocardiographically gated 64-section CT. CT data sets were reconstructed in 5% steps from 40% to 90% of R-R interval for analysis. Maximum regurgitant orifice area (ROA) in diastole was planimetrically measured with CT, and measurements were compared with semiquantitative classification with TTE (Spearman rank order correlation coefficients). Receiver operating characteristic (ROC) curves were calculated for differentiation between degrees of AR with ROA measurements. Dimensions of the aortic root and left ventricular parameters were compared (Pearson correlation analysis). RESULTS: A significant correlation was observed between CT planimetric size of ROA (mean, 62 mm2+/-63 [standard deviation]; range, 6-224 mm2) and TTE classification of mild, moderate, and severe AR (r=0.84, P<.001). With ROC analysis, discrimination between degrees of AR with CT was highly accurate when cutoff ROAs (25 mm2 and 75 mm2) were used. A significant correlation was observed between methods in dimensions of aortic annulus (mean, 29.0 mm+/-4.6), sinus of Valsalva (mean, 38.3 mm+/-8.6), and ascending aorta (mean, 37.2 mm+/-8.0); mean values were 27.4 mm+/-4.9 (r=0.76, P<.001), 37.7 mm+/-8.6 (r=0.94, P<.001), and 38.2 mm+/-7.9 (r=0.96, P<.001), respectively. Mean end-systolic volume (67 mL+/-38), end-diastolic volume (149 mL+/-48), and ejection fraction (57%+/-13) at CT correlated well with mean results at TTE (65 mL+/-36 [r=0.96, P<.001], 140 mL+/-48 [r=0.91, P<.001], 56%+/-13 [r=0.98, P<.001], respectively). CONCLUSION: Results of assessment of AR with 64-section CT are similar to those with TTE.

New transverse plate fixation system for complicated sternal wound infection after median sternotomy.

Wire fixation after median sternotomy is a safe procedure, but it is still associated with potential wound infection including bony dehiscence. In case of infection and dehiscence the sternum is re-fixated with steel wires. If this is insufficient, then flap reconstruction would be another option. We describe an alternative way for complicated sternal closure by using a rigid sternal fixation system that is feasible for cardiac surgeons. Three patients suffering from sternal instability and infection were operated on with the new titanium plates. The procedures were uneventful and short-term follow-up showed stable sternal conditions. In this report the technical concept has been described in detail in 1 patient. This new sternal fixation technique is safe and easy to handle and broadens the spectrum for closure of complicated sternal wound infections or dehiscence.

Accuracy of dual-source CT coronary angiography: First experience in a high pre-test probability population without heart rate control.

The aim of this study was to assess the diagnostic accuracy of dual-source computed tomography (DSCT) for evaluation of coronary artery disease (CAD) in a population with extensive coronary calcifications without heart rate control. Thirty patients (24 male, 6 female, mean age 63.1+/-11.3 years) with a high pre-test probability of CAD underwent DSCT coronary angiography and invasive coronary angiography (ICA) within 14+/-9 days. No beta-blockers were administered prior to the scan. Two readers independently assessed image quality of all coronary segments with a diameter > or =1.5 mm using a four-point score (1: excellent to 4: not assessable) and qualitatively assessed significant stenoses as narrowing of the luminal diameter >50%. Causes of false-positive (FP) and false-negative (FN) ratings were assigned to calcifications or motion artifacts. ICA was considered the standard of reference. Mean body mass index was 28.3+/-3.9 kg/m2 (range 22.4-36.3 kg/m2), mean heart rate during CT was 70.3+/-14.2 bpm (range 47-102 bpm), and mean Agatston score was 821+/-904 (range 0-3,110). Image quality was diagnostic (scores 1-3) in 98.6% (414/420) of segments (mean image quality score 1.68+/-0.75); six segments in three patients were considered not assessable (1.4%). DSCT correctly identified 54 of 56 significant coronary stenoses. Severe calcifications accounted for false ratings in nine segments (eight FP/one FN) and motion artifacts in two segments (one FP/one FN). Overall sensitivity, specificity, positive and negative predictive value for evaluating CAD were 96.4, 97.5, 85.7, and 99.4%, respectively. First experience indicates that DSCT coronary angiography provides high diagnostic accuracy for assessment of CAD in a high pre-test probability population with extensive coronary calcifications and without heart rate control.

Myocardial gene transfer by selective pressure-regulated retroinfusion of coronary veins: comparison with surgical and percutaneous intramyocardial gene delivery.

OBJECTIVES: We sought to study adenoviral gene delivery using percutaneous selective pressure-regulated retroinfusion and to compare it directly with surgical and percutaneous intramyocardial delivery (PIMD) for the first time. BACKGROUND: Intramyocardial delivery (IMD) has been recommended to be the preferred gene delivery strategy so far. However, surgical and percutaneous intramyocardial injection lead to incomplete retention of the injected viral vectors and to limited spatial myocardial distribution. Percutaneous selective pressure-regulated retroinfusion of the coronary veins was developed recently to provide an effective and more homogenous regional myocardial gene transfer. METHODS: In 15 pigs, adenoviral vectors (Ad2-CMV beta-galactosidase [beta-gal] 5 x 10(9) pfu) were applied via surgical IMD (n = 5), PIMD (n = 5), and selective pressure-regulated retroinfusion (n = 5). Seven days after gene transfer, myocardial beta-gal expression was measured by ELISA. RESULTS: Selective retroinfusion into the anterior cardiac vein substantially increased reporter gene expression (1,039 +/- 79 pg beta-gal/mg protein) in the targeted left anterior descending coronary artery territory when compared with surgical (448 +/- 127, p < 0.05) and PIMD (842 +/- 145, p < 0.05). Both IMD approaches showed an inhomogenous beta-gal expression, particularly along the injection sites, while retroinfusion resulted in a more homogenous transmural gene expression. CONCLUSIONS: Percutaneous selective pressure-regulated retroinfusion compares favorably with surgical and percutaneous intramyocardial injection techniques by providing a more homogenous and even more efficient adenoviral gene delivery.

VEGF165 transfection decreases postischemic NF-kappa B-dependent myocardial reperfusion injury in vivo: role of eNOS phosphorylation.

Endothelial nitric oxide synthase (eNOS) phosphorylation increases nitric oxide formation, for example, after VEGF stimulation. We investigated whether nitric oxide formed after overexpression of VEGF or of phosphomimetic eNOS (S1177D) affects PMN-induced myocardial detriment after ischemia and reperfusion. Pigs (n=8 per group) were subjected to percutaneous liposome-based gene transfer by retroinfusion of the anterior interventricular vein 48 h before LAD occlusion (60 min) and reperfusion (24 h). Thereafter, regional myocardial function was assessed as subendocardial segment shortening (SES), and infarct size was determined. Tissue from the infarct region, the noninfarcted area at risk, and a control region was analyzed for NF-kappaB activation (EMSA), tumor necrosis factor (TNF)-alpha, and E-selectin mRNA and infiltration of polymorphonuclear neutrophils (PMN). L-NAME was applied in one group of VEGF-transfected animals. NF-kappaB activition, PMN infiltration in the infarct region, and AAR were reduced after transfection of VEGF or eNOS S1177D, but not after VEGF+L-NAME coapplication. Infarct size decreased, whereas SES improved after either VEGF or eNOS S1177D transfection, an effect inhibited by L-NAME coapplication. Retroinfusion of liposomal VEGF cDNA reduces NF-kappaB-dependent postischemic inflammation and subsequent myocardial reperfusion injury, an effect mediated at least in part by enhanced eNOS phosphorylation.