Comparative Analysis of Immediate Postoperative Complications Following Total Gastrectomy.

INTRODUCTION: Total gastrectomy (TG), despite disrupting the continuity of the alimentary tract and accounting for significant postoperative complications, is the procedure of choice for curative resection of gastric carcinoma. The objectives of this study were to report the rate of postoperative complications following TG, to analyze adverse postoperative outcomes, and to determine which of the two techniques - the Roux-en-Y esophagojejunostomy and Omega-Braun TG, is safer. MATERIALS AND METHODS: A retrospective, observational study was conducted among patients diagnosed with gastric carcinoma who underwent TG between January 1st, 2010 and December 31st, 2012 in the Surgery Department of the Bucharest Clinical Emergency Hospital. Descriptive and analytical statistical analysis with parametric and non-parametric tests was carried out using GraphPad, with statistical significance set at p <0.05. RESULTS: Seventy-seven patients, aged 37-91 years (average age 64.1 ± 11.59 years), were enrolled in this study. A total of 84 immediate postoperative complications were encountered in 35 patients (47.5%), classified into local (n=21, 25%) and general complications (n=63, 75%). Reoperation was necessary in five cases (6.2%), all after Roux-en-Y end-side esophagojejunostomy. Two deaths (n=2, 2.5%), one after Roux-en-Y and one after Omega-Braun TG, were reported. DISCUSSION: The Roux-en-Y technique had a higher number of complications, both local and general. Omega-Braun TG was associated with a lower number of local complications; however, it was associated with life-threatening complications including hemodynamic instability and multisystem organ failure. CONCLUSION: The study deemed Roux-en-Y Esophagojejunostomy the overall safer procedure. A statistically significant correlation between manual anastomosis and mortality was observed. Total Gastrectomy is a complex procedure with numerous potential complications which calls for an improved surgical technique to reduce postoperative risk.

Quantifying subtle changes in cardiovascular mechanics in acromegaly: a Doppler myocardial imaging study.

AIM OF THE STUDY: To describe morphological and functional cardiovascular changes in acromegaly (ACM) patients, as well as to investigate the ability of Doppler-based myocardial deformation imaging (DMI) to characterize subtle dysfunction in ACM. METHODS: 69 patients (pts) with ACM (mean age 47 ± 10 years, 27 men) and 31 controls (mean age 43 ± 16 years, matched for age and gender) were recruited. Standard echocardiography and DMI data were obtained for all patients. Peak systolic longitudinal strain values (S) were determined for the left and right ventricles. Radial S was measured at the level of the mid inferolateral segment. Using a high-resolution echo-tracking system, the main indices of arterial stiffness were measured. RESULTS: Of the ACM subjects, 57 had active disease (group A), and 12 controlled ACM (group B). All pts with ACM presented structural changes: a higher LV indexed mass (112 ± 36, 118 ± 23 vs 74 ± 18 g/m(2), p < 0.001) and a higher relative wall thickness (0.45 ± 0.09, 0.50 ± 0.07 vs 0.40 ± 0.07, p = 0.003) compared to controls. Also, ACM pts had functional changes: reduced LV ejection fraction (57 ± 5, 55 ± 5 vs 64 ± 4%, p < 0.001) and altered diastolic function (E/A 1.0 ± 0.4, 1.1 ± 0.1 vs 1.3 ± 0.3, p = 0.005) compared to controls. Both longitudinal and radial LV S values were lower in ACM compared to controls: -16.5 ± 3.5, -16.8 ± 4.3 vs -21.5 ± 3.8%, p < 0.001 for longitudinal and 38.3 ± 12.3, 35.6 ± 11.8 vs 52.2 ± 11.7%, p = 0.002 for radial strain. CONCLUSIONS: ACM pts present LV concentric hypertrophy and LV systolic and diastolic dysfunction, even in controlled disease. Altered global LV systolic function appears to be due both to longitudinal and radial dysfunction.

Aortic regurgitation due to quadricuspid aortic valve--case report and literature review.

Quadricuspid aortic valve is a rare variant of aortic semilunar valve, often being an unexpected discovery during cardiac surgery. We present the case of a 59 years old patient, who was admitted for dyspnea on light exertion and palpitations. The transthoracic echocardiography revealed severe aortic valve regurgitation due to a quadricuspid aortic valve, the result being confirmed by the transesophageal echo examination. The patient had a first class indication for aortic valve replacement and the surgical intervention was uneventful. The operative technique and case particularities are discussed in view of the literature published so far regarding this uncommon condition.

Structural and functional changes of carotid wall properties in patients with acromegaly are not restored after 1 year of GH/IGF1 normalization.

UNLABELLED: Vascular changes are common in acromegaly (ACM). Current therapies can normalise the levels of both growth hormone (GH) and insulin-like growth factor (IGF1). OBJECTIVE: To establish whether the ACM vascular changes in patients with effectively managed disease are different from those in patients with an active condition. METHODS: 64 ACM patients were tested for serum GH (random and during an oral glucose tolerance test) and IGF1. Ultrasonography of the right common carotid (RCC) explored structural (the carotid diameter and intima-media thickness index (IMT)) and functional (the augmentation index (AIx), elastic modulus (Ep), and local pulse wave velocity (PWV)) arterial parameters in the ACM patients (groups A and B) and an age- and sex-matched control group of 21 patients without acromegaly (group C). RESULTS: The ACM patients were divided into 2 subgroups that had similar cardiovascular risk factor profiles: A (n=10, with controlled ACM), and B (n=54, with active ACM). The AIx was higher in groups A (27.7% [2.2-54.3]) and B (20.0% [ - 38.2-97.1]) than in group C (3.5% [ - 11.3-31.1]), p=0.01 and 0.002, respectively. The group B patients presented with poorer functional carotid wall parameters than the control subjects: Ep-95.5 [33-280] KPa vs. 77.5 [39-146] KPa, p=0.01; and PWV-6 [3.6-10.4] m/s vs. 5.4 [3.9-7.2] m/s, p=0.03.The ACM patients had greater RCC diameters (6.4 ± 0.6 mm vs. 5.7 ± 0.6 mm, p<0.001) and IMT values (0.72 ± 0.13 mm vs. 0.58 ± 0.08 mm, p<0.001) than the subjects in group C. CONCLUSIONS: Both the controlled and active ACM patients showed structural arterial changes. After 1 year of disease control, the patients with controlled ACM showed improvements in the functional, but not the structural, arterial parameters compared with the patients with an active condition.

Coarctation of the aorta in adults: what is the best treatment? Case report and literature review.

Coarctation of the aorta is a congenital cardiac malformation that can go undiagnosed until old age with only hypertension as a marker of its presence because clinical signs can be subtle and overlooked if a complete physical exam is not performed. We report the case of a 45 year-old women, diagnosed with severe coarctation of the aorta just distal to the left subclavian artery, with poststenotic dilatation of the descending aorta and difficult control of blood pressure values. The patient was successfully treated interventionally, by balloon angioplasty with deployment of a covered stent. We review here the different methods employed for the treatment of coarctation of the aorta in adults, including surgical or percutaneous balloon angioplasty with or without stent placement, underlying their complications and the factors that influence the choice of the best coarctation repair method.

Restrictive cardiomyopathy--an outdated concept?

Restrictive cardiomyopathy is probably the least common of all cardiomyopathies, with a nonspecific clinical presentation and a frequently unknown cause. The concept of RCM has changed tremendously over time. Today it includes a large panel of disorders characterized by a non-hypertrophied, non-dilated cardiac phenotype and a restrictive ventricular filling pattern. Several unsuccessful attempts to define and classify cardiomyopathies have been made, but they all proved problematic due to the contradiction in terms and the overlap between classical patterns. Advances in disease pathology, genomics and molecular biology are emerging as the framework of a new revolutionary classification system, focused on the dynamic interaction between genotype and phenotype. In this context, RCM is evolving as a self-contained hemodynamic and pathophysiological concept, although questionable due to its uncertain practical utility.

Changes in plasma levels of MMP-9, MMP-7 and their inhibitors in patients with coronary artery disease.

UNLABELLED: To describe the enzymatic profile of plasma matrix metalloproteinases (MMP-7 and -9) and tissue inhibitors of metalloproteinases (TIMP-1 and -2) in different categories of patients (pts.) with coronary artery disease (CAD), and their relationship with clinical status, left ventricular (LV) function and remodelling. METHODS: Total plasma MMP7, active fraction of MMP9, TIMP1 and TIMP2 were determined in 68 consecutive pts with confirmed CAD (Group A, 56.6 +/- 9 y, 75% men, LVEF 56.4 +/- 11%) and compared with a control group of 23 pts. without cardiovascular disease and normal coronary arteries (Group B, 58.1 +/- 10 y, 56.5% men, LVEF 58.7 +/- 5%). LVEF and wall motion index (WMI) were computed. Diastolic function parameters were evaluated: mitral E/A ratio, E/E'septal ratio. We calculated global longitudinal (L), circumferential (C) and radial (R) strain (S) and strain rate (SR) values as the average of segmental values, by 2D strain analysis. RESULTS: The active form of MMP9 differed significantly between group A and B, as did the MMP9/TIMP1 and MMP9/TIMP2 ratios (8.78 +/- 10.0 ng/ml vs 3.33 +/- 4.0 ng/ml; 5.43 +/- 3.4 vs 0.85 +/- 0.9, and 11.60 +/- 5.2 vs 3.71 +/- 1.0, respectively, p < 0.04 for all). Group A included 35 pts. with acute coronary syndromes (ACS) and 33 pts. with stable angina (SA), with similar profile of LVEF and number of coronary arteries involved. There were no significant differences in plasma MMP9, MMP9/TIMP1 and MMP/TIMP2 ratio between normal and SA group, but only between normal and ACS group (p = 0.02 for MMP9). In group A, only MMP7, TIMP1/MMP7 and TIMP2/MMP7 ratio correlated with markers of systolic function: LVEF, WMI and global LS. CONCLUSION: There were no significant changes in extracellular matrix markers in pts. with chronic stable ischemia vs normals. Only active form of MMP9 and its ratio with TIMP differed significantly in ACS. Total MMP7 and its ratio with TIMP correlated with parameters of LV systolic function even in pts. with normal LVEF.

Doppler flow patterns in the evaluation of pulmonary hypertension.

Pulmonary arterial hypertension is defined as a group of diseases characterised by a progressive increase in pulmonary vascular load, leading to marked increase in pulmonary artery pressure, right ventricular failure and premature death. Given the nonspecific nature of its early symptoms and signs, pulmonary arterial hypertension (PAH) is often diagnosed in its advanced stages. Although clinical assessment is essential when initially evaluating patients with suspected PAH, echocardiography is a key screening tool in the diagnostic algorithm, because, in comparison with invasive measurements, it has the advantages of being safe, portable, and repeatable. Therefore, Doppler echo is the modality most frequently used in pulmonary hypertension patients. Several echocardiographic techniques centered on the Doppler principle (both conventional Doppler parameters and tissue Doppler imaging) used in the assessment of PAH magnitude and its cardiac effects are presented in this paper. They provide important data on the severity, possible causes and consequences of pulmonary hypertension, both initially and during follow-up, therefore having the ability to estimate disease progression, prognosis, or to monitor therapeutic response. Doppler echocardiography allows to noninvasively estimate systolic pulmonary arterial pressure (SPAP), mean and end-diastolic pulmonary arterial pressure, as well as the quantification of right ventricular (RV) function and the evaluation of pulmonary vascular resistance (PVR).

Cardiac involvement in myasthenia gravis--is there a specific pattern?

Myasthenia gravis is an autoimmune neuromuscular disorder characterized by skeletal muscle involvement, causing muscle weakness and fatigue. The prevalence of the disease is approximately 1:7500 with a maximal prevalence during the second and third decade in women and the fifth and sixth decade in men, although it may appear at any age. The disease has a slight female preponderance, with a sex ratio of 3:2. Cardiac involvement in myasthenia gravis may take several forms, ranging from asymptomatic ECG changes to ventricular tachycardia, myocarditis, conduction disorders, heart failure and sudden death. We hereby report two cases of patients with myasthenia gravis who developed signs and symptoms of cardiovascular involvement, requiring admission in a cardiology ward for further investigation and treatment. The particular characteristics of the first case may be summarized by the symptomatic conduction disturbances with frequent episodes of syncope in a patient with myasthenia gravis who necessitated permanent pacing and the difficulties we encountered in the establishment of conduction disturbancies etiology (due to the disease or due to the treatment with acetylcolinesterase inhibitors). The second case shows a different kind of cardiac involvement in myasthenia gravis--the ECG changes (giant diffuse T waves in a patient with cardiovascular risk factors) which needed further investigation and long term surveillance.

The electrocardiographic profile of patients with angina pectoris.

Angina pectoris is a common disabling disorder and a clinical syndrome, caused by myocardial ischemia; an imbalance between myocardial oxygen supply and myocardial oxygen consumption. Thus, ischemia produces a typical series of events such as metabolic and biochemical alterations which lead to impaired ventricular relaxation and diastolic dysfunction, impaired systolic function, and electrocardiographic abnormalities and painful symptoms of angina. Transmembrane ionic currents are responsible for the cardiac potentials that are recorded as the electrocardiogram (ECG). The electrocardiographic profile of patients with angina pectoris is variate. The electrocardiogram provides critical information for both diagnosis and prognosis, particularly when a tracing is obtained during the episodes of pain. A completely normal electrocardiogram does not exclude the possibility of acute coronary syndrome. Serial ECG tracings improve the clinician's ability to diagnose acute and chronic coronary syndromes. The ECG may assist in clarifying the differential diagnosis if taken in the presence of pain. The resting ECG also has an important role in risk stratification. Exercise ECG is more sensitive and specific than the resting ECG as far as myocardial ischemia detection is concerned, and it represents the test of choice which helps identifying inducible ischemia in the majority of patients suspected of stable angina.

Echocardiography in congenital mitral valve regurgitation--the liaison between cardiologist and surgeon.

Congenital heart diseases are broadly defined as those cardiac anomalies that are present at birth. By their very nature, such defects have their origin in embryonic development. Congenital mitral valve regurgitation is a rare disease occurring in infancy or childhood. In up to 60% of cases, congenital anomalies of the mitral valve occur in association with other cardiac lesions, and often more than one component of the mitral apparatus is involved. The true incidence of congenital mitral valve regurgitation (MVR) is difficult to determine accurately (0.21-0.42% from total mitral valve regurgitations); isolated congenital mitral regurgitation is uncommon. The Carpentier classification of congenital mitral valve disease is the most commonly used nomenclature based on a functional analysis of the mitral valve leaflet. The contemporary anatomic classification has the advantage of minimizing observer variability in the diagnosis and it offers a much better liaison between the cardiologist and surgeon.

Calcific aortic valve disease and aortic atherosclerosis--two faces of the same disease?

Calcific (degenerative) aortic valve disease is the most common etiology of acquired aortic valve stenosis. Historically, it was seen as a degenerative, "senile-like" process, resulting from aging--"wearing and tearing"--of the aortic valve. However, several lines of evidence suggest that calcific valve disease is not simply due to age-related degeneration but, rather, it is an active disease process with identifiable initiating factors, clinical and genetic risk factors, and cellular and molecular pathways that mediate disease progression. Histopathologically, the early lesions of aortic valve sclerosis resemble arterial atherosclerotic plaques. Furthermore, atherosclerotic risk factors and clinical atherosclerotic cardiovascular disease are independently associated with aortic sclerosis suggesting that it represents an atherosclerosis-like process involving the aortic valve. Until now, the only established treatment for symptomatic aortic valve stenosis has been valve replacement. Newer therapies that may modify or reduce the likelihood of developing aortic valve disease are highly desirable and are currently under investigation. In this article we tried to review the available data on calcific aortic valve disease, starting from histological and pathogenic aspects and finishing with therapeutic implications, in order to characterize its relationship with the atherosclerotic process.

[New approaches in coronary microcirculation]. / Noi perspective privind microcirculatia coronariana.

The last decades, coronary microcirculation has become a very important territory because of its role in coronary circulation physiology and pathophysiology. Only its implication in coronary artery disease was known at the beginning, but subsequently its role in many others diseases was shown. The nontraditional pathophysiological construct sustains that myocardial microcirculatory dysfunction is the primary event, and the atherosclerotic plaque rupture or erosion is the secondary event. In some instances, the coronary microvascular dysfunction may be an epiphenomena, an important marker of risk or even a cause, thus becoming therapeutic target.

Left atrial remodelling early after mitral valve repair for degenerative mitral regurgitation.

OBJECTIVE: Left atrial (LA) size is an important predictor of outcome after mitral valve replacement in patients with symptomatic chronic mitral regurgitation (MR). Data on LA remodelling after mitral valve repair (MVr) for chronic non-ischaemic MR are scarce. The aim of this study was to assess changes in LA size early after MVr for chronic severe degenerative MR and to identify clinical and echocardiographic correlates of those changes. METHODS: The study analysed 225 consecutive patients who underwent MVr and were echocardiographically evaluated in our hospital within 1 month before and 1-6 months after surgery. Patients with MR aetiology other than degenerative, associated aortic valve replacement, or congenital heart disease were excluded. The remaining 79 patients (aged 60 (SD 12) years, 55 men) with isolated chronic severe degenerative MR formed the study group. LA reverse remodelling was defined as a decrease in LA volume index (LAVi) > or = 15%. RESULTS: LA dimensions significantly decreased after MVr (p<0.001). Mean LAVi reduction was 29% (SD 18%). LA reverse remodelling was observed in 63 patients (80%). Correlates of LAVi reduction were preoperative LAVi (p = 0.008), systolic and diastolic blood pressure (p = 0.032, p = 0.009), postoperative transmitral mean pressure gradient (p = 0.001) and residual MR (p = 0.043). LAVi reduction was lower in patients > 45 years (p = 0.008) and in hypertensive patients (p = 0.031). CONCLUSION: LA reverse remodelling is common early after MVr for chronic severe degenerative MR. Preoperative LAVi, blood pressure, postoperative transmitral mean pressure gradient, residual MR and age > 45 are related to LAVi reduction. The prognostic value of LA reduction in this setting needs further study.

Understanding the genetic causes of inter-patient variability. Clinical relevance with focus on cardiovascular drugs.

There is a large inter-patient variability concerning the response to drug therapy and a great interest for determining the causes of this variability. This review takes into discussion some aspects of cardiovascular drugs metabolism and transport, pointing out the effects of genetic variation. Isoenyzmes belonging to the Cytochrome P450 super family have an important role in cardiovascular drug metabolism, namely CYP 1A2; CYP 3A; CYP 2C19; CYP2C9; CYP 2D6, involved in the oxidative phase and also N-acetyltransferase 2, involved in the conjungative phase of the metabolism. P-glycoprotein is implied in cardiovascular drug transport. Polymorphisms of those enzymes and transport protein result in different phenotypes, that is the case of CYP isoenyzmes with abolished, low or increased activity and in the case of N-acetyltransferase 2, slow, intermediate and rapid acetylator phenotypes. There is hope that, in the future, a more individualized treatment of a certain disease, with minimum adverse effects and a maximum therapeutic effect, will be available, by means of genetic testing.

Cardiac tumors: the experience of a tertiary cardiology center.

UNLABELLED: Cardiac tumors represent a rare condition, often presenting with severe symptoms and having a poor outcome in the absence of early diagnosis and therapy. The aim of this study was to assess the prevalence and type of cardiac tumors, the techniques used for the diagnosis and the therapy used in a tertiary cardiology center. METHODS: During a 2-years period, among the 35004 patients (pts) hospitalized in our Cardiology Department, 24 pts were diagnosed with CTum (0.068% of all hospitalizations). A retrospective study of CTum cases was based on the patient files, with full clinical data, paraclinic investigations and therapy details. RESULTS: In the CTum group (49 +/- 16.2 years, similar between men and women), the main symptoms leading to patients referral were dyspnea (15 pts, 62.5%) and embolic events (coronary, cerebral, peripheral arteries: 7 pts, 29%), while in 4 asymptomatic pts the diagnosis was incidental. Transthoracic echocardiography (TTE) detected the presence of CTum in all cases. In 20 pts (83%), TTE and transesophageal echocardiography (TEE) provided all the data required for preoperative assessment (tumor size, extension, location, insertion site). In 4 pts, additional CT and MRI investigations were necessary, mainly for complex disease (malignant secondary CTum). The imaging techniques suggested a diagnosis of benign tumor in 15 pts (62.5%) and malignant tumor in 5 pts. In 4 pts the tumor type could not be established. Myxoma was the most frequent diagnosis (14 pts, 58% CTum). Among malignant CTum, secondary tumors (melanoma, lung and uterine cancer) were more frequent than primary CTum (4 vs 1 pt). The localization of CTum was intracavitary in 22 pts, 91% mainly in the left atrium (15 pts), intramyocardic in 1 pt and pericardic in 1 pt. Surgery was performed in 18 pts, confirming the preoperative diagnosis in 17 cases (94%). In one case, a myxochondrosarcoma was diagnosed at pathology in a patient with an echocardiography-based preoperative diagnosis of myxoma. CONCLUSIONS: CTum represent a rare condition, accounting for only 0.068% of hospitalizations in a tertiary cardiology center, but with severe clinical presentation. Echocardiography (TTE and TEE) is the essential imaging modality, allowing in most cases the diagnosis, classification and localization of CTum and their insertion site. CT and MRI are useful additional modalities in complex cases (mainly malignant primary and secondary CTum). In the case of benign tumors, surgery must be performed as soon as possible after the diagnosis has been established, whereas for malignant tumors there is still much controversy in what regards the benefits of surgery.

Current challenges of anticoagulant treatment.

Anticoagulant therapy plays an important role in current medical practice. The main types of anticoagulant agents are: heparins, hirudins and vitamin K antagonists. None of the drugs used as anticoagulants meet the criteria of an ideal anticoagulant because they have side effects and they interact with other compounds. The main side effect of anticoagulant therapy is bleeding. The choice of a certain anticoagulant is made by the doctor based on the clinical context and also on the desired effect.