MRI-based strain measurements reflect morphological changes following myocardial infarction: A study on the UK Biobank cohort.

In a porcine experimental model of myocardial infarction, a localised, layer-specific, circumferential left ventricular strain metric has been shown to indicate chronic changes in ventricular function post-infarction more strongly than ejection fraction. This novel strain metric might therefore provide useful prognostic information clinically. In this study, existing clinical volume indices, global strains, and the novel, layer-specific strain were calculated for a large human cohort to assess variations in ventricular function and morphology with age, sex, and health status. Imaging and health data from the UK Biobank were obtained, including healthy volunteers and those with a history of cardiovascular illness. In total, 710 individuals were analysed and stratified by age, sex and health. Significant differences in all strain metrics were found between healthy and unhealthy populations, as well as between males and females. Significant differences in basal circumferential strain and global circumferential strain were found between healthy males and females, with males having smaller absolute values for both (all p ≤ 0.001). There were significant differences in the functional variables left ventricular ejection fraction, end-systolic volume, end-systolic volume index and mid-ventricular circumferential strain between healthy and unhealthy male cohorts aged 65-74 (all p ≤ 0.001). These results suggest that whilst regional circumferential strains may be useful clinically for assessing cardiovascular health, care must be taken to ensure critical values are indexed correctly to age and sex, due to the differences in these values observed here.

Cardiopulmonary exercise testing augments watchful waiting in asymptomatic severe primary mitral regurgitation.

INTRODUCTION: Our aim is to describe the use of cardiopulmonary exercise testing in watchful waiting for asymptomatic severe primary mitral regurgitation. METHODS: Between October 2016 and October 2017, ten patients with asymptomatic severe primary mitral regurgitation underwent watchful waiting in a single centre. Baseline assessment included history, physical examination, transthoracic echocardiogram and cardiopulmonary exercise testing. Patients were re-evaluated every 6 months with history, physical examination and transthoracic echocardiogram; and at 12 months with cardiopulmonary exercise testing. RESULTS: At 1 year follow up, five patients remained asymptomatic with no significant change in left ventricular ejection fraction (p = 0.18). This was associated with no significant change in cardiopulmonary exercise testing parameters. However, five patients developed early new symptoms or changes in echocardiographic parameters with a significant fall in left ventricular ejection fraction (p < 0.01). This was associated with a significant fall in anaerobic threshold (p = 0.04) and four of the five patients having an abnormal percentage predicted peak VO2 at 1 year follow up. CONCLUSIONS: Changes in symptomatic status or echocardiographic parameters during a watchful waiting approach for asymptomatic severe primary mitral regurgitation is associated with a significant reduction in cardiopulmonary exercise testing parameters.

Detachable Aortic Clamp for Minimally Invasive Cardiac Surgery.

Since its first implementation, minimally invasive cardiac surgery has become more and more popular among surgeons. By avoiding a complete opening of the sternum, this surgery is traditionally associated with a faster recovery, less surgical pain and less postoperative bleeding and transfusions. With its growing popularity, the need for specifically designed surgical instrumentation is evident. Since 2008, the detachable-branch Glauber clamp (Cardiovision-Trytech, Tokyo, Japan) has been used to facilitate aortic cross-clamp during minimally invasive cardiac surgery, to optimize the intraoperative visualization field without the need for adjunctive incisions of the thorax. It has been specifically developed for limited single-access minimally invasive valve surgery. The clamp is introduced through the main access incision (mini-sternotomy or mini thoracotomy) by means of a specifically designed delivery system, which is subsequently removed, leaving inside the thorax only the detachable closed branches on the aorta. Since its first implementation, the clamp has been used in numerous patients at several cardiac surgery centers worldwide. Over the years, attempts have been made to improve its ergonomics and enhance its performance. The G2 detachable-branch Glauber clamp (USB Medical, Hatboro, PA, USA) occupies a smaller space inside the thorax, has a simplified gripping mechanism and comes with detachable arms that enhance versatility with up to 10 possible clamp configurations. This article describes the characteristics of detachable-branch aortic clamps and compares them to other aortic cross-clamps that are currently available for minimally invasive cardiac surgery.

A novel small diameter nanotextile arterial graft is associated with surgical feasibility and safety and increased transmural endothelial ingrowth in pig.

Globally, millions of patients are affected by myocardial infarction or lower limb gangrene/amputation due to atherosclerosis. Available surgical treatment based on vein and synthetic grafts provides sub-optimal benefits. We engineered a highly flexible and mechanically robust nanotextile-based vascular graft (NanoGraft) by interweaving nanofibrous threads of poly-L-lactic acid to address the unmet need. The NanoGrafts were rendered impervious with selective fibrin deposition in the micropores by pre-clotting. The pre-clotted NanoGrafts (4 mm diameter) and ePTFE were implanted in a porcine carotid artery replacement model. The fibrin-laden porous milieu facilitated rapid endothelization by the transmural angiogenesis in the NanoGraft. In-vivo patency of NanoGrafts was 100% at 2- and 4-weeks, with no changes over time in lumen size, flow velocities, and minimal foreign-body inflammatory reaction. However, the patency of ePTFE at 2-week was 66% and showed marked infiltration, neointimal thickening, and poor host tissue integration. The study demonstrates the in-vivo feasibility and safety of a thin-layered vascular prosthesis, viz., NanoGraft, and its potential superiority over the commercial ePTFE.

Surgical transcatheter valve implantation: The more pathways, the better.

Transcatheter aortic valve implantation (TAVI) is rapidly spreading across the world with the endorsement of the cardiological community and the supporting results of randomized controlled trials. However, TAVI-related complications like aortic dissection, aortic valvular rupture, or left ventricle perforation are still potentially catastrophic.

Surgical treatment of a giant right coronary aneurysm following coronary stent fracture.

BACKGROUND: Coronary artery aneurysm represents a challenging and potentially fatal disease. AIM AND MATERIAL METHODS: We present the case of a giant right coronary artery aneurysm treated surgically after percutaneous intervention and fracture of the stent. RESULTS AND DISCUSSION: The aneurism was opened and the coronary ligated proximally and distally. It was not possible to re-established continuity of the coronary artery or perform a bypass graft. An early surgical strategy would have re-established blood flow in the involved coronary artery and avoided chronic ischemia of the supplied myocardial territory.

Blood lactate predicts mortality after surgical repair of type A acute aortic dissection.

BACKGROUND: Ischemia and malperfusion are strong predictors of poor postoperative outcomes in type A acute aortic dissection (TAAAD). Serum lactate is an accurate surrogate point-of-care marker of malperfusion. The aim of this study is to investigate the correlation between lactate, in-hospital outcomes, and 1-year survival following TAAAD repair. METHODS: One hundred and thirty-two patients underwent operative repair of TAAAD over a 4-year period at our institution 128 patients had serum lactate measurements at three stages peri-operatively-preoperatively, at the end of cardiopulmonary bypass (post-CPB) and 6 h postintensive care unit (ICU) admission. The primary outcomes were in-hospital mortality and 1-year survival. The secondary outcomes were the incidences of in-hospital morbidities. RESULTS: Patients were divided into two groups: 88 (68.8%) with normal lactate and 40 (31.2%) with elevated lactate (>2.2 mmol/L). Lactate measured preoperatively (odds ratio 1.52, 95% confidence interval 1.17-2.07, p < .01), post-CPB (1.34, 1.14-1.64, p < .01) and 6 h post-ICU admission (1.29, 1.08-1.55, p < .01) was an independent predictor of in-hospital mortality. Following adjustment for the Penn Classification, lactate continued to have a significant correlation with in-hospital mortality at all three timepoints. There was a higher incidence of complications in the elevated lactate group and especially hemofiltration (20% vs. 9.1%, p = .08). 1-year survival was similar in both groups (p = .23). CONCLUSIONS: There is a direct correlation between elevated serum lactate and postoperative mortality after TAAAD repair, which is independent of the Penn Classification status on admission.

Frozen elephant trunk procedure for complex aortic arch surgery: The Salerno experience with Thoraflex hybrid.

BACKGROUND AND AIM OF THE STUDY: To report early clinical outcomes of the frozen elephant trunk (FET) technique for the treatment of complex aortic diseases after transition from conventional elephant trunk. METHODS: A single-center, retrospective study of patients who underwent hybrid aortic arch and FET repair for aortic arch and/or proximal descending aortic aneurysms, acute and chronic Stanford type A aortic dissection with arch and/or proximal descending involvement, Stanford type B acute and chronic aortic dissections with retrograde aortic arch involvement. RESULTS: Between December 2017 and May 2020, 70 consecutive patients (62.7 ± 10.6 years, 59 male) were treated: 41 (58.6%) for emergent conditions and 29 (41.4%) for elective. Technical success was 100%. In-hospital mortality was 14.2% (n = 12, 17.1% emergent vs. 10.3% elective, P = NS); 2 (2.9%) major strokes; 1 (1.4%) spinal cord injury. Mean follow-up was 12.5 months (interquartile range, 3.7-22.3). Overall survival at 3, 6, 12, and 24 months was 90% (95% confidence interval [CI], 83.2-97.3), 85.6% (95% CI, 77.7-94.3), 79.1% (95% CI, 69.9-89.5), 75.6% (95% CI, 65.8-86.9) and 73.5% (95% CI, 63.3-85.3). There were no aortic re-interventions and no distal stent graft-induced new entry (dSINE); 5 patients with residual type B dissection underwent TEVAR completion. CONCLUSIONS: In a real-world setting, FET with Thoraflex Hybrid demonstrated feasibility and good clinical outcomes, even in emergent setting. Our implant technique optimize cerebral perfusion reporting good results in terms of neurological complications. Techniques to perfect the procedure and to reduce remaining risks, and consensus on considerations such as standardized cerebral protection need to be reported.

Development and Preliminary Testing of Porcine Blood-Derived Endothelial-like Cells for Vascular Tissue Engineering Applications: Protocol Optimisation and Seeding of Decellularised Human Saphenous Veins.

Functional endothelial cells (EC) are a critical interface between blood vessels and the thrombogenic flowing blood. Disruption of this layer can lead to early thrombosis, inflammation, vessel restenosis, and, following coronary (CABG) or peripheral (PABG) artery bypass graft surgery, vein graft failure. Blood-derived ECs have shown potential for vascular tissue engineering applications. Here, we show the development and preliminary testing of a method for deriving porcine endothelial-like cells from blood obtained under clinical conditions for use in translational research. The derived cells show cobblestone morphology and expression of EC markers, similar to those seen in isolated porcine aortic ECs (PAEC), and when exposed to increasing shear stress, they remain viable and show mRNA expression of EC markers similar to PAEC. In addition, we confirm the feasibility of seeding endothelial-like cells onto a decellularised human vein scaffold with approximately 90% lumen coverage at lower passages, and show that increasing cell passage results in reduced endothelial coverage.

Acute coronary occlusion after surgical replacement of the aortic valve treated with emergency off-pump coronary artery bypass grafting.

Acute coronary occlusion after surgical replacement of the aortic valve is a rare but potentially fatal event. Due to its rarity, there is no univocal treatment with the percutaneous approach being the most commonly used for its promptness and ease of use. Only a few cases have been treated with coronary artery bypass grafting (CABG) and, to the best of our knowledge, none has been reported with the use of off-pump CABG (OPCABG). Here we describe the case of acute coronary occlusion of the circumflex artery immediately after surgical replacement of the aortic valve in a 79-year-old patient. The occlusion was promptly diagnosed and treated with interval emergency balloon angioplasty followed by OPCABG of the circumflex artery. The patient made a full recovery and was discharged home 12 days after the surgery.

The impact of patient-prosthesis mismatch on early and long-term survival after aortic replacement with the Edwards Perimount valve: A propensity score-matched analysis.

BACKGROUND: To investigate the impact of severe patient-prosthesis mismatch (PPM) related to the Edwards Lifesciences Perimount (EP) bioprosthesis in the aortic position on early in-hospital outcomes and long-term survival. METHODS: A total of 5964 consecutive patients underwent aortic valve replacement at the Bristol Heart Institute between 1998 and 2014, 2667 representing the cohort of this study received EP. PPM was defined severe as EOAi < 0.65 cm2 /m2 . To minimize bias, propensity score matching was conducted and two groups A and B (without and with severe PPM) of 320 patients with similar preoperative characteristics were matched. We assessed early in-hospital outcomes including CVA, re-exploration for bleeding, low cardiac output, wound infection, acute renal injury, length of hospital stay, and long-term survival for both groups in unmatched and matched populations. RESULTS: In the unmatched analysis, 18.3% of patients had severe PPM. Severe PPM was not associated with increased in-hospital mortality (4.5% vs. 2.9%, respectively, p = .09) or any other early adverse outcomes except increased length of hospital stay (10.57 ± 8.2 vs. 11.7 ± 9.4, respectively, p = .01). Long-term survival differed significantly between groups at 2 and 8 years (91.8% vs. 91.4% and 60.5% vs. 55.7%, respectively, p = .02). Matched analysis showed no differences between the groups in early health outcomes and overall survival at 2 and 8 years was also similar (89.7% vs. 91% and 57.3% vs. 58%, group A vs. B, respectively p = .9). CONCLUSION: Presence of PPM does not seem to affect early in-hospital outcomes or late survival when using EP in patients undergoing aortic valve replacement.

Benefits of mitral valve repair over replacement in the elderly: a systematic review and meta-analysis.

OBJECTIVES: Mitral valve (MV) repair has demonstrated excellent short- and long-term outcomes, however, its merit in the elderly population is still debated. We conducted a meta-analysis of studies that have compared the MV repair to replacement in the elderly population. METHODS: A systematic literature search was conducted for any study published on MV surgery on elderly patients (≥75 years old). A pooled risk-ratio meta-analysis was done to evaluate short-term mortality, postoperative complications, surgical timings, and long-term survival rates. RESULTS: A total of nine retrospective observational studies were included in the quantitative meta-analysis. Pooled meta-analysis showed a reduced risk of short-term mortality for the MV repair group (risk ratio [RR] = 0.41 [0.24-0.71], p-value = .005). Postoperative neurological complications were in favor of repair, although not significantly (RR = 0.49 [0.21-1.11], p-value = .07). Operative timings (cardiopulmonary bypass and crossclamp time) were not different between the groups although no data were available on the complexity of the repairs. Long-term survival rates were in favor of the repairs (pooled treatment effect of -0.47 [-0.64; -0.29], p = .005). CONCLUSIONS: MV surgery is a safe and effective procedure for the elderly. MV repair demonstrated better short-term outcomes compared to replacement. Long-term survival rates are significantly better after repair.

Frozen Elephant Trunk Technique in Acute Type A Aortic Dissection: Is It for All?

Acute type A aortic dissection (ATAAD) is an indisputable emergency with very poor outcomes without surgical treatment. Although the aortic arch is often involved in the aortic dissection, its optimal management during surgical therapy remains uncertain. A conservative tear-oriented approach has traditionally been adopted, limiting the procedure to the ascending aorta (or hemiarch) replacement. However, dilation of the residual dissected aorta and subsequent rupture may occur, requiring further intervention in the future. In the last two decades, the frozen elephant trunk (FET) technique has become a valid and attractive option to treat aortic disease when the arch and the thoracic aorta are involved, both in elective and in emergency settings. Here, we report a review of the contemporary literature regarding the short- and long-term outcomes of the FET technique in ATAAD repair.

Saphenous vein graft disease, pathophysiology, prevention, and treatment. A review of the literature.

BACKGROUND: The saphenous vein remains the most frequently used conduit for coronary artery bypass grafting, despite reported unsatisfactory long-term patency rates. Understanding the pathophysiology of vein graft failure and attempting to improve its longevity has been a significant area of research for more than three decades. This article aims to review the current understanding of the pathophysiology and potential new intervention strategies. METHODS: A search of three databases: MEDLINE, Web of Science, and Cochrane Library, was undertaken for the terms "pathophysiology," "prevention," and "treatment" plus the term "vein graft failure." RESULTS: Saphenous graft failure is commonly the consequence of four different pathophysiological mechanisms, early acute thrombosis, vascular inflammation, intimal hyperplasia, and late accelerated atherosclerosis. Different methods have been proposed to inhibit or attenuate these pathological processes including modified surgical technique, topical pretreatment, external graft support, and postoperative pharmacological interventions. Once graft failure occurs, the available treatments are either surgical reintervention, angioplasty, or conservative medical management reserved for patients not eligible for either procedure. CONCLUSION: Despite the extensive amount of research performed, the pathophysiology of saphenous vein graft is still not completely understood. Surgical and pharmacological interventions have improved early patency and different strategies for prevention seem to offer some hope in improving long-term patency.

Impact of Body Mass Index on Short- and Long-Term Outcomes After Isolated First-Time Surgical Aortic Valve Replacement for Aortic Stenosis.

OBJECTIVE: To ascertain whether body mass index (BMI) has a clinical effect on short- and long-term postoperative outcomes after surgical aortic valve replacement in patients with severe aortic stenosis. DESIGN: Single-center, retrospective study. SETTING: Tertiary referral hospital. PARTICIPANTS: The study comprised 1,561 patients who underwent isolated first-time aortic valve replacement between 2005 and 2012. INTERVENTIONS: Fourteen underweight patients were removed from the analysis. The remaining patients were divided into the following 4 groups according to their BMI: 418 as normal weight (≥18.5 to <25 kg/m2), 629 as overweight (≥25 to <30 kg/m2), 342 as obese (≥30 to <35 kg/m2), and 158 as very obese (≥35 kg/m2). Early mortality and postoperative complications were compared, and long-term survival rates were investigated. MEASUREMENT AND MAIN RESULTS: Thirty-day mortality was higher in the normal weight group but did not reach statistical significance (p = 0.054), and the incidence of postoperative complications was not different for cerebrovascular accident (p = 0.70), re-sternotomy for bleeding (p = 0.17), sternal wound infection (p = 0.07), and dialysis (p = 0.07). With a mean follow-up time of 4.92 ± 2.82 years, survival rate was better in the overweight group. A Cox proportional hazard model found BMI inversely correlated with long-term mortality when analyzed in a univariable fashion (hazard ratio 0.95; p = 0.009), but this apparent protective effect disappeared when adjusted for preoperative covariates (hazard ratio 0.98, 95% confidence interval 0.96-1.004; p = 0.12). CONCLUSION: Once adjusted for preoperative characteristics, obesity does not represent an independent predictor for long-term survival rates. There was a higher incidence of 30-day mortality in the normal weight group compared with the overweight and very obese groups. The incidence of deep sternal wound infection was higher in very obese patients.

[The Integrated Environmental Health Impact of emissions from a steel plant in Taranto and from a power plant in Brindisi, (Apulia Region, Southern Italy)]. / L'impatto ambientale e sanitario delle emissioni dell'impianto siderurgico di Taranto e della centrale termoelettrica di Brindisi.

OBJECTIVES: to estimate the environmental and health impact attributable to PM2.5 emissions from the ex-ILVA steel plant in Taranto and the ENEL power plant in Brindisi (Apulia Region, Southern Italy). DESIGN: a SPRAY Lagrangian dispersion model was used to estimate PM2.5 concentrations and population weighted exposures following the requirements of the Integrated Environmental Authorization (IEA) of the two plants under study. Available concentration-response functions (OMS/HRAPIE and updates) were used to estimate the number of attributable premature deaths. SETTING AND PARTICIPANTS: residents in the 40 municipalities of the domains of the VDS (assessment of health damage, according to the Regional Law n. 21/2012) of Brindisi (source: Italian National Institute of Statistics 2011 Census) and residents in Taranto, Statte, and Massafra (source: cohort study). MAIN OUTCOME MEASURES: mortality from natural causes, cardiovascular and respiratory diseases, and lung cancer attributable to PM2.5. Incremental lifetime cumulative risks (ILCRs) for lung cancer associated to PM2.5 exposure. RESULTS: there was a reduction of the estimated impacts from the pre to the post IEA-scenarios in both Taranto and Brindisi. In Taranto, ILCRs greater than 1x10-4; were estimated in 2010 and 2012; the ILCR was greater than 1x10-4; in the district of Tamburi (near the plant) also for the 2015 scenario. ILCRs estimated for Brindisi were between 1x10-6; and 4x10-5;. CONCLUSIONS: the Integrated Environmental Health Impact Assessment confirmed the results of the VDS conducted according to the toxicological risk assessment approach. An unacceptable risk was estimated for Tamburi also for the 2015 scenario, characterized by a production of 4.7 million tons of steel, about half compared to one foreseen by the IEA (8 mt.).

Effectiveness and Safety of Aprotinin Use in Thoracic Aortic Surgery.

OBJECTIVE: To determine the effectiveness and safety of aprotinin use in adult patients undergoing thoracic aortic surgery. DESIGN: Single-center, retrospective study. SETTING: All cases performed at a single university hospital. PARTICIPANTS: Between January 2004 and December 2014, 846 adult patients underwent thoracic aortic surgery. Due to missing or duplicated data on primary outcomes, 314 patients were excluded. The final sample of 532 patients underwent surgery on the thoracic aorta. INTERVENTIONS: The patients were divided in the following 2 groups: 107 patients (20.1%) received aprotinin during the surgery, which represented the study group, whereas the remaining 425 patients (79.9%) underwent surgery without the use of aprotinin. MEASUREMENTS AND MAIN RESULTS: To adjust for patient selection and preoperative characteristics, a propensity score-matched analysis was conducted. Mean total blood loss at 12 hours after surgery was similar between the 2 groups. The blood product transfusion rates did not differ in the 2 groups, except for the rate of fresh frozen plasma transfusion being significantly higher in the aprotinin group. Re-exploration for bleeding and the incidence of a major postoperative bleeding event were similar between the groups. Rates of in-hospital mortality, renal failure, and cerebrovascular accidents did not show any statistically significant difference. Aprotinin did not represent a risk factor for mortality over the long term (hazard ratio 1.14, 95% confidence interval 0.62-2.08, p = 0.66). CONCLUSIONS: The use of aprotinin demonstrated a limited effect in reducing postoperative bleeding and prevention of major bleeding events. Aprotinin did not adversely affect early outcomes and long-term survival.

Safety and mid-term outcome of catheter ablation of ventricular tachycardia in octogenarians.

AIMS: Radiofrequency (RF) catheter ablation (CA) is superior to standard medical therapy in controlling recurrent ventricular tachycardia (VT). The majority of procedures have been performed in a middle-aged population. The outcome of VT ablation in the elderly has not been described. METHODS AND RESULTS: We retrospectively studied the outcome and safety of CA of VT in octogenarians performed in four European centres. The population consisted of patients presenting with recurrent VT refractory to medical therapy. Patients aged over 80 years were compared with younger patients undergoing CA. Clinical characteristics, procedural data, complications, and outcomes were examined. Implantable cardioverter-defibrillator (ICD) therapy data were collected. A total of 54 consecutive octogenarian patients underwent RF CA of VT and represented the study group (42 males, age 82.8 ± 2.7 years) compared with a control group of 104 younger patients (85 males, age 66.7 ± 8.9 years). Mean follow-up was 33 ± 48 months. Implantable cardioverter-defibrillators were present in 81 and 86% of patients, respectively (P = 0.93). Left ventricular ejection fraction was 29% ± 8.2 in octogenarians vs. 34% ± 10.2 in the younger group (P < 0.01). More major complications occurred in octogenarians (18 vs. 2%, P < 0.01). During follow-up, there were more ICD shocks in the octogenarians (28 vs. 15%, P < 0.01). The Kaplan-Meier curve of survival after VT ablation confirms comparable survival rates at 1 year, but the elderly have poor survival in the mid-term. Survival in the elderly post VT ablation is comparable with that in an age-matched cohort with ICDs but no VT storm. CONCLUSION: Octogenarians undergoing CA of VT have more risk factors, higher risk of complications and ICD shocks, but demonstrate comparable short-term survival rates.