Aortic dilation is an independent predictor of cardiovascular disease. The association between hypertension and aortic dilation is still controversial. Also, most previous research has investigated ...this relationship regarding only the aortic root, and no information is available for the ascending aorta (AscAo).
To assess AscAo dimensions in hypertensive patients, 1,027 patients with hypertension and 1,002 healthy volunteers were prospectively enrolled. Aortic diameters at four levels were measured using the leading edge-to-leading edge convention at end-diastole: the sinuses of Valsalva, sinotubular junction (STJ), AscAo, and aortic arch (AoArch), using two-dimensional echocardiography.
All four diameters were significantly larger in hypertensive patients than in control subjects, with positive correlations with age, body size, and male sex. On multivariate analysis, gender and body surface area were independently associated with aortic diameters. The general linear model showed that after adjusting for age, sex, and body surface area, hypertension was positively associated (P < .01) with higher aortic diameter at every level. Hypertension was associated with increases of 1.7 mm (95% CI, 1.2-2.1 mm) at the sinuses of Valsalva, 4.1 mm (95% CI, 3.6-4.6 mm) at the STJ, 1.6 mm (95% CI, 1.1-2.1 mm) at the AscAo, and 2.2 mm (95% CI, 1.7-2.6 mm) at the AoArch. On the basis of nomograms, an abnormally high prevalence of aortic dilation in hypertensive patients was observed for the STJ (14%) and the AoArch (7%).
Systematic analysis of the AscAo in hypertensive patients showed that, together with age, sex, and body surface area, hypertension is an independent factor associated with increases in all four aortic diameters and that aortic dilation occurred more frequently at the level of the STJ and AoArch.
Abstract Background With age, aortic valve cusps undergo varying degrees of sclerosis which, sometimes, can progress to calcific aortic valve stenosis (AVS). To perform a retrospective ...clinico-pathologic investigation in patients with calcific AVS. Methods We characterized and graded the structural remodeling in 236 aortic valves (200 tricuspid and 36 bicuspid) from patients with calcific AVS (148 males; average 72 years); possible relationships between general/clinical/echocardiographic characteristics and the histopathologic changes were explored. Twenty autopsy aortic valves served as controls. In 40 cases, we also tested the immunohistochemical expression of metalloproteinases and cytokines, and characterized the inflammatory infiltrate. In 5 cases, we cultured cusp stem cells and explored their potential to differentiate into osteoblasts/adipocytes. Results AVS cusps showed structural remodeling as severe fibrosis (100%), calcific nodules (100%), neoangiogenesis (81%), inflammation (71%), bone metaplasia with or without hematopoiesis (6% and 53%, respectively), adipose metaplasia (16%), and cartilaginous metaplasia (7%). At multivariate analysis, AVS degree and interventricular septum thickness were the only predictors of remodeling (barring inflammation). All the tested metalloproteinases (except MMP-13) and cytokines were expressed in AVS cusps. Inflammation mainly consisted of B and T lymphocytes (CD4 +/CD8 + cell ratio 3:1) and plasma cells. AVS changes were mostly different from typical atherosclerosis. Cultured mesenchymal cusp stem cells could differentiate into osteoblasts/adipocytes. Conclusions Structural remodeling in AVS is peculiar and considerable, and is related to the severity of the disease. However, the different newly formed tissues – where “valvular interstitial cells” play a key role – and their well-known slow turnover suggest a reverse structural remodeling improbable.
Background Refractory vascular spasm (RVS) concomitantly involving the entire coronary artery system and grafted conduits after coronary artery bypass grafting (CABG) surgery is a rare, but dreadful ...event. No consensus exists in terms of appropriate management. Methods Between 1986 and 2009, 5,762 patients underwent isolated CABG at our institution, and 7 patients experienced RVS involving the coronary arteries and implanted conduits. Mean age was 65.6 years and 3 were female. All patients received from 3 to 5 distal anastomoses, including use of the left internal mammary artery. During the same time period, 18 patients experienced perioperative vasospasm of a single coronary artery or of a grafted conduit. Results All diffuse RVS events occurred between 3 and 8 hours after surgery. All patients had diffuse ischemic-like electrocardiographic changes, and 5 patients rapidly developed cardiogenic shock in the intensive care unit. Angiography was quickly performed in all patients and showed diffuse RVS involving either the native coronary arteries or the anastomosed arterial and venous conduits. The first 5 patients of this series died in the catheterization lab due to rapidly evolving refractory cardiogenic shock and unresponsive cardiac arrest, despite intraaortic counterpulsation and aggressive pharmacologic interventions (selective vasodilators and systemic inotropes). In the last 2 patients, extracorporeal membrane oxygenation was quickly instituted (1 in the catheterization lab, 1 in the operating room) and RVS could be successfully managed with complete resolution of ongoing vasospasm. In the single vascular spasm, there was only 1 death for refractory cardiac arrest, whereas all the other patients were successfully treated with direct infusion of vasodilators. Conclusions Diffuse RVS after CABG is a rare but lethal condition. Our experience, although limited, indicates that in such cases an aggressive treatment, that is, prompt extracorporeal membrane oxygenation institution and controlled cardiocirculatory assistance, represents the preferred solution to face such a dramatic event and may save patient lives.
Pheochromocytomas and paragangliomas are chromaffin cell tumors arising from neuroendocrine cells. At least 1/3 of paragangliomas are related to germline mutations in 1 of 17 genes. Although these ...tumors can occur throughout the body, cardiac paragangliomas are very rare, accounting for <0.3% of mediastinal tumors. The purpose of this study was to determine the clinical characteristics of patients with cardiac paragangliomas, particularly focusing on their genetic backgrounds. A retrospective chart analysis of 15 patients with cardiac paragangliomas was performed to determine clinical presentation, genetic background, diagnostic workup, and outcomes. The average age at diagnosis was 41.9 years. Typical symptoms of paraganglioma (e.g., hypertension, sweating, palpitations, headache) were reported at initial presentation in 13 patients (86.7%); the remaining 2, as well as 4 symptomatic patients, initially presented with cardiac-specific symptoms (e.g., chest pain, dyspnea). Genetic testing was done in 13 patients (86.7%); 10 (76.9%) were positive for mutations in succinate dehydrogenase (SDHx) subunits B, C, or D. Thirteen patients (86.7%) underwent surgery to remove the paraganglioma with no intraoperative morbidity or mortality; 1 additional patient underwent surgical resection but experienced intraoperative complications after removal of the tumor due to co-morbidities and did not survive. SDHx mutations are known to be associated with mediastinal locations and malignant behavior of paragangliomas. In this report, the investigators extend the locations of predominantly SDHx-related paragangliomas to cardiac tumors. In conclusion, cardiac paragangliomas are frequently associated with underlying SDHx germline mutations, suggesting a need for genetic testing of all patients with this rare tumor.
Background Limited information exists about the real impact of the etiology of shock on early and late outcome after emergency surgery in acute native mitral valve endocarditis (ANMVE). This ...multicenter study analyzed the impact of the etiology of shock on early and late outcome in patients with ANMVE. Methods Data were collected in eight institutions. Three hundred-seventy-nine ANMVE patients undergoing surgery on an emergency basis between May 1991 and December 2009 were eligible for the study. According to current criteria used for the differential diagnosis of shock, patients were retrospectively assigned to one of three groups: group 1, no shock (n = 154), group 2, cardiogenic shock (CS n = 118), and group 3, septic shock (SS n = 107). Median follow-up was 69.8 months. Results Early mortality was significantly higher in patients with SS ( p < 0.001). At multivariable logistic regression analysis, compared with patients with CS, patients with SS had more than 3.8 times higher risk of death. That rose to more than 4 times versus patients without shock. In addition, patients with SS had 4.2 times and 4.3 times higher risk of complications compared with patients with CS and without shock, respectively. Sepsis was also an independent predictor of prolonged artificial ventilation ( p = 0.04) and stroke ( p = 0.003) whereas CS was associated with a higher postoperative occurrence of low output syndrome and myocardial infarction ( p < 0.001). No difference was detected between groups in 18-year survival, freedom from endocarditis, and freedom from reoperation. Conclusions Our study suggests that emergency surgery for ANMVE in patients with CS achieved satisfactory early and late results. In contrast, the presence of SS was linked to dismal early prognosis. Our findings need to be confirmed by further larger studies.
Background Recent evidence supports the important role of inflammation in atrial fibrillation (AF) after coronary artery bypass grafting (CABG) and there is growing evidence that statin has cardiac ...antiarrhythmic effects. The aim of this study was to assess the efficacy of preoperative statins in preventing AF after CABG in a longitudinal observational study. Methods Over a two-year period, 405 consecutive patients underwent isolated CABG procedures. Univariate analysis was performed exploring the relationship regarding statin use and AF development. A propensity score for treatment with statins was obtained from core patient characteristics. The role of statin therapy on postoperative AF was assessed by means of a conditional logistic model, while stratifying on the quintiles of the propensity score. All analysis was performed retrospectively. Results Postoperative AF occurred in 29.5% of the patients with preoperative statin therapy compared with 40.9% of those patients without it ( p = 0.021). No statistical differences among development of AF and type, dose, or duration of preoperative statin therapy were observed. Preoperative statins were associated with a 42% reduction in risk of AF development after CABG surgery (odds ratio OR 0.58, 95% confidence interval CI 0.37 to 0.91, p = 0.017, while stratifying on the propensity score). No different effect of statins on AF was observed with respect to age groups (≤ 70 and >70 years) (interaction p = 0.711). Conclusions Preoperative statins may reduce postoperative AF after CABG. Patients undergoing elective revascularization may benefit from a preventive statin approach.
Acute Bowel Ischemia After Heart Operations Lorusso, Roberto, MD, PhD; Mariscalco, Giovanni, MD, PhD; Vizzardi, Enrico, MD ...
The Annals of thoracic surgery,
06/2014, Letnik:
97, Številka:
6
Journal Article
Recenzirano
Acute bowel ischemia is a perioperative complication that is frequently unrecognized as a cause of death after cardiac surgical procedures, with an in-hospital mortality of 50% to 100%. In recent ...years, controversy regarding the most appropriate approach to resolve clinical or laboratory suspicion and the limited therapeutic options have led to very little improvement in patient prognosis. This article reviews the related literature examining the actual prevalence, pathophysiologic mechanisms, predisposing factors, diagnostic tests, and therapeutic approaches providing a glance at new promising tools in diagnostic workup.
Background We investigated leaflet and subvalvular configurations to identify mechanisms leading to recurrent mitral regurgitation after combined undersized mitral annuloplasty and coronary artery ...bypass and to preoperatively recognize patients who are unlikely to benefit from this approach. Methods Among 261 subjects with chronic ischemic mitral regurgitation undergoing undersized annuloplasty and coronary bypass surgery at one institution between September 2001 and September 2007, 31 were excluded: 4 had intraoperative annuloplasty failure, 12 showed residual regurgitation, and 15 had incomplete echocardiograms available. The study population consisted of 230 patients who were divided into 2 groups: patients without (group 1, n = 176) or with (group 2, n = 54) late recurrent mitral regurgitation. Fifty healthy subjects were used as control subjects. Serial echocardiographic analysis was performed preoperatively, at discharge, and at follow-up appointments (early: median, 6 months interquartile range, 5–6 months; late: median, 33 months interquartile range, 17–51 months). Results Subjects with late regurgitation had preoperatively more symmetric tethering ( P < .001), more accentuated anterior mitral leaflet tethering ( P < .001), and more restricted anterior leaflet excursion ( P = .003) than patients in group 1. Postoperatively, tethering of the posterior leaflet increased ( P < .001) and was predominant in both groups, whereas tethering of the anterior leaflet was reduced at discharge ( P = .01 and P = .03, respectively), remaining constant afterward. Multivariable analysis showed an anterior tethering angle of 39.5° or greater ( P < .001), an anterior/posterior tethering angle ratio of 0.76 or greater ( P < .001), an anterior leaflet excursion angle of 35° or less ( P = .001), and a coaptation height of 11 mm or greater ( P = .04) to be predictors of recurrent mitral regurgitation. Conclusions Preoperative symmetric tethering with anterior mitral leaflet predominance was strongly associated with recurrence of mitral regurgitation. Measures of leaflet tethering resulted in fundamental findings to identify ischemic patients who can really benefit from restrictive annuloplasty. Further larger studies are necessary to confirm our results.
Background Changes in hemodynamics, coronary circulation, visceral flow, and biochemical marker rate reduction or volume deflation for intraaortic balloon pump discontinuation were assessed. Methods ...Twelve healthy pigs were randomly assigned to two groups, the rate-based (RB, n = 6) and volume-based weaning groups (VB, n = 6). Hemodynamics and visceral and coronary flows were measured at baseline after 2 hours of intraaortic balloon pump 1:1, during the first 5 hours of weaning (frequency rate reduced to 1:2 in the RB group and volume decreased by 10%/h in the VB group), after 1 hour of frequency rate 1:3 in the RB group or a volume decrease by 75% in the VB group, 2 hours after withdrawal, and 4 hours after withdrawal. Results The animals weaned by progressive VB deflation showed a greater degree of vasodilation, better cardiac output and stroke volume, fewer negative values of cardiac cycle efficiency, and higher dP/dTmax compared with those weaned by RB reduction ( p < 0.05 for all). The VB group also exhibited increased coronary flow, lower oxygen consumption of the myocardium, and coronary resistance during VB weaning ( p < 0.05 for all). The serum lactate level was lower in the VB group at each experimental point ( p < 0.05 for all), but visceral flows were scarcely affected by the weaning method. Conclusions Volume reduction was the most effective weaning method considering that frequency reduction weaning was responsible for significant negative effects on hemodynamics and coronary circulation.
PDF
