Latest Advances in Annuloplasty Protheses for Valvular Reconstructive Surgery.

This is the third and final part of our update on the latest advances in cardiac valvular replacement. Part 1 was dedicated to cardiac valvular replacement, and Part 2 focused on transcatheter cardiac valvular treatment. This part concerns annuloplasty prostheses for valvular reconstructive surgery. The number of patients undergoing surgical heart valve repair has been increasing, particularly in high-volume centers. Annuloplasty is now considered the gold standard in mitral valve regurgitation repair secondary to degenerative, ischemic and idiopathic dilated cardiomyopathy disease. The techniques of mitral valve reconstruction have been well established, but controversies remain regarding the type of annuloplasty ring to be used. The available annuloplasty rings include rigid, flexible, complete, partial, and semi-rigid/flexible. The choice of annuloplasty ring has been the focus of extensive investigation and debate, but to date it still largely remains a matter of "surgeon's preference" rather than an evidence-based selection. Functional tricuspid regurgitation was traditionally treated by the classic De Vega annuloplasty, but has since evolved after the development of prosthetic tricuspid annuloplasty. Head-to-head comparisons have demonstrated superior long-term outcomes with device-based annuloplasty compared to suture-based surgery, but the type of ring to be used (flexible versus rigid) has recently been questioned, without reaching definitive conclusions. In contrast to mitral and tricuspid valve repair, aortic repair is more difficult with respect to specific valve features. Annuloplasty is considered to play a key role in controlling aortic regurgitation and preventing recurrence after valve repair. Various modifications of annuloplasty have been advocated (internal/external, with/without ring (suture), rigid/flexible ring). but none of them has become a de facto standard. This paper describes the various rings that are available to help orient surgeons and to serve as a reference for students.

Prognostic relevance of masked hypertension in subjects with prehypertension.

BACKGROUND: The prognostic impact of masked hypertension is not yet completely clear. The aim of this study was to evaluate the prognostic relevance of masked hypertension in subjects with prehypertension. METHODS: The occurrence of fatal and nonfatal cardiovascular events was evaluated in 591 subjects with prehypertension defined as clinic blood pressure (BP) in the range of 120-139 mm Hg for systolic BP and 80-89 mm Hg for diastolic BP. Among them, 471 were classified as having true prehypertension (clinic BP <140/90 mm Hg and daytime BP <135/85 mm Hg) and 120 as having masked hypertension (clinic BP <140/90 mm Hg and daytime BP > or =135 or 85 mm Hg). RESULTS: During the follow-up (6.6 +/- 4.3 years, range 0.5-15.5 years), 29 cardiovascular events occurred. In subjects with true prehypertension and masked hypertension the event-rates per 100 patient-years were 0.57 and 1.51, respectively. Event-free survival was significantly different between the groups (P < 0.005). After adjustment for other covariates, including clinic BP (forced into the model), Cox regression analysis showed that cardiovascular risk was significantly higher in masked hypertension than in true prehypertension (masked vs. true prehypertension, relative risk 2.65, 95% confidence interval 1.18-5.98, P = 0.018). CONCLUSIONS: Among subjects with prehypertension, those with masked hypertension are at higher cardiovascular risk than those with true prehypertension. Out-of-office BP should be known in individuals with prehypertension, preferably by ambulatory BP monitoring or alternatively by home BP measurement, to obtain a better prognostic stratification.

Ambulatory blood pressure monitoring in prehypertensive subjects.

BACKGROUND: Although treatment of prehypertensives is feasible and effective, it is unclear how to define those who may benefit. We hypothesized that ambulatory blood pressure monitoring (ABPM) might be a tool for selecting prehypertensive subjects, classified according to the JNC 7, who later develop drug-treated hypertension. METHODS: Prehypertensives (n=107; 62 M, 45 F; age 50 ± 14 years) with or without cardiovascular risk factors were assessed for drug-treated hypertension development. They underwent ABPM at entry examination and were clinically followed-up for an average of 99 ± 42 months. Thereafter, subjects were divided into 2 groups according to the development of drug-treated hypertension. Stepwise logistic regression (LR) analysis was performed to assess the role of factors contributing independent prediction of outcome (i.e. drug-treated hypertension onset). RESULTS: In LR analysis body mass index [odds ratio (OR)=1.29, confidence intervals (CI)95% 1.03-1.62], female gender (OR=11.10, CI95% 2.66-46.30), total cholesterol (OR=1.03, CI95% 1.01-1.05), smoking (OR=3.90, CI95% 0.94-16.20), daytime SBP (OR=1.10, CI95% 1.01-1.19) and 24h DBP (OR=1.23, CI95% 1.08-1.41) predicted the development of hypertension. The criteria combining BP and clinical variables were superior to BP or clinical criteria alone in the correct classification of true positives and true negatives. Altogether there was an improvement of 14.02% (p < 0.01) in comparison to only clinical criteria. CONCLUSIONS: In the setting of global cardiovascular risk assessment, ABPM, in the early diagnosis of hypertension in prehypertensive individuals, appears as a useful tool, both diagnostically and prognostically, to index subjects who are suspected to be masked hypertensives.

Fluoxetine blocks myotonic runs and reverts abnormal surface electromyogram pattern in patients with myotonic dystrophy type 1.

OBJECTIVES: To verify the effects of a muscular injection of fluoxetine both on needle electromyogram (EMG) "myotonic runs" and on the surface EMG pattern in patients affected by myotonic dystrophy type 1. METHODS: Needle EMG recording: We performed needle EMG recordings on the tibialis anterior or opponent thumb muscle in 3 patients. The resting electrical activity and the myotonic discharge were detected before and after the local injection of 100 microL of fluoxetine. Surface EMG recording: A motor point stimulation protocol was carried out on the tibialis anterior of 3 patients. Stimulation consisted of 10-second, 15-Hz pulse train, 0.1 ms in duration. A supramaximal stimulation was applied, and the surface myoelectric signal was recorded. The averaged rectified value (ARV) of the amplitude was evaluated before and after the intramuscular injection of 300 microL of fluoxetine. RESULTS: Needle EMG: The injection of fluoxetine induced a clear-cut reduction of the basal electrical activity and made it impossible to evoke "myotonic runs" in all the patients tested. The reversibility of the effect of the drug was checked in 2 patients who exhibited a partial recovery of myotonic EMG activity 40 minutes after the administration. Surface EMG: The patients showed the typical decreasing ARV pattern before the drug administration; the fluoxetine injection consistently provoked a clear and complete recovery of the normal increasing ARV curve. CONCLUSIONS: We showed, for the first time, that the local application of fluoxetine produces functional modifications in myotonic dystrophy type 1 muscle electrical properties. The relevance of this study consists in the introduction of fluoxetine, a well-known and largely used drug, as a tool for investigating further therapeutical approaches in this disease.

Assessment of swallowing by oropharyngoesophageal scintigraphy in patients with amyotrophic lateral sclerosis.

Amyotrophic lateral sclerosis (ALS) is the most common degenerative motor neuron disease in adults, and dysphagia is one of its most frequent and disabling symptoms. Oropharyngoesophageal scintigraphy (OPES) permits a functional and semiquantitative study of the various stages of swallowing. We studied 28 ALS patients (12 females and 16 males; mean age = 63.57 +/- 10.39 yr SD), who were clinically rated against the ALSFRS scale (Amyotrophic Lateral Sclerosis Functioning Rating Scale) and underwent OPES with (99m)Tc-nanocolloid using either a liquid or a semisolid bolus. The semiquantitative parameters we analyzed were Oral Transit Time (OTT), Pharyngeal Transit Time (PTT), Esophageal Transit Time (ETT), Retention Index (RI), and Esophageal Emptying Rate (EER(10s)). Hence, the OPES performed with a semisolid bolus produced a higher proportion of pathologic values for the swallowing variables than when liquid bolus was used. Analyzed by grouping the patients into classes according to their bulbar ALSFRS scores, we found a significant increase in the OTT (p < 0.005), PTT (p < 0.02), and Oropharyngeal Retention Index (OPRI) (p < 0.0004) variables in ALS patients with more severe bulbar involvement. OPES has turned out to be a very important examination for detecting tracheal-bronchial inhalation and it also offers the possibility of acquiring a semiquantitative evaluation of the amount of food inhaled. In our experience, OPES in patients with ALS has been easy to use, economic, well tolerated, and capable of supplying precise indications with regard to the extent of the swallowing disorder, which permits a better clinical definition of the ALS patient.