In patients with type 2 diabetes mellitus (T2DM) the vaso-vagal syncope (VVS) recurrence could be due to the alteration of autonomic system function, evaluated by heart rate variability (HRV), and by ...123I-metaiodobenzylguanidine (123I-mIBG) myocardial scintigraphy indexes: Heart to Mediastinum ratio (H/Mlate), and Washout rate (WR). The SGLT2-I could modulate/reduce autonomic dysfunction in T2DM patients with VVS. This effect could reduce the VVS recurrence in T2DM patients.
In a prospective multicenter study, after propensity score matching, we studied a population of 324 T2DM patients with VVS, divided into 161 SGLT2-I-users vs. 163 Non-SGLT2-I users. In these patients as SGLT2-I-users vs. Non-SGLT2-I users, we investigated the HRV and 123I-MIBG modifications and VVS recurrence at 12 months of follow-up.
At follow-up end, the SGLT2-I-users vs. Non-SGLT2-I users had best glucose homeostasis and lower values of inflammatory markers, and resting heart rate (p < 0.05). The SGLT2-I-users vs. Non-SGLT2-I users evidenced the lowest low frequency/high frequency ratio (LF/HFr), a significant difference for all the indexes of autonomic dysfunction via ECG Holter analysis, and higher values of H/Mlate (p < 0.05). Finally, comparing SGLT2-I-users vs. Non-SGLT2-I users, we found a higher rate of VVS recurrence events, specifically of the vasodepressor VVS recurrence at 1-year follow-up (p < 0.05). We did not find a significant difference of mixed and cardio-inhibitory VVS recurrence events at 1 year of follow-up in the study cohorts (p > 0.05). At the Cox regression analysis H/Mlate (0.710, 0.481–0.985), and SGLT2-I therapy (0.550, 0.324–0.934) predicted all causes of syncope recurrence at 1 year of follow-up.
Non-SGLT2-I users vs. SGLT2-I-users had alterations of the autonomic nervous system, with a higher rate of VVS recurrence at 1 year of follow-up. The indexes of cardiac denervation predicted the VVS recurrence, while the SGLT2-I reduced the risk of VVS recurrence.
Clinical trial registration number: NCT03717207.
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•Type 2 diabetes mellitus (T2DM) causes higher rate of vaso-vagal syncope (VVS) recurrence.•VVS recurrence could be due to alteration of autonomic system function.•heart rate variability and 123I-mIBG myocardial scintigraphy could evaluate these alterations.•SGLT2-I could reduce autonomic dysfunction and the VVS recurrence in T2DM patients.
Background: Femoral arteries are the preferred site of peripheral cannulation for arterial inflow in type A aortic dissection operations. The presence of aortoiliac aneurysms, severe peripheral ...occlusive disease, atherosclerosis of the femoral vessels, and distal extension of the aortic dissection may preclude their utilization. Axillary artery cannulation may represent a valid alternative in these circumstances.
Methods: Between January 15, 1989, and August 20, 1998, in our institution, 22 of 152 operations (14.4%) for acute type A aortic dissection were performed with the use of the axillary artery for the arterial inflow. Axillary artery cannulation was undertaken in the presence of femoral arteries bilaterally compromised by dissection in 12 patients (54.5%), abdominal aorta and peripheral aneurysm in 5 patients (22.7%), severe atherosclerosis of both femoral arteries in 3 patients (13.6%), and aortoiliac occlusive disease in 2 patients (9.1%). In all patients, distal anastomosis was performed with an open technique after deep hypothermic circulatory arrest. Retrograde cerebral perfusion was used in 9 patients (40.9%).
Results: Axillary artery cannulation was successful in all patients. The left axillary artery was cannulated in 20 patients (90.9%), and the right axillary artery was cannulated in 2 patients (9.1%). Axillary artery cannulation followed an attempt of femoral artery cannulation in 15 patients (68.2%). All patients survived the operation, and no patient had a cerebrovascular accident. No axillary artery thrombosis, no brachial plexus injury, and no intraoperative malperfusion were recorded in this series. Two patients (9.1%) died in the hospital of complications not related to axillary artery cannulation.
Conclusions: In patients with type A aortic dissection in whom femoral arteries are acutely or chronically diseased, axillary artery cannulation represents a safe and effective means of providing arterial inflow during cardiopulmonary bypass. (J Thorac Cardiovasc Surg 1999;118:324-9)
The aim of this retrospective multicenter study was to compare early clinical and hemodynamic outcomes of Perceval-S sutureless (Livanova, London, United Kingdom) and Intuity rapid-deployment ...(Edwards Lifesciences, Irvine, Calif) bioprostheses.
Data from patients who underwent isolated or combined aortic valve replacement with Perceval-S and with Intuity bioprostheses at 18 cardiac surgical institutions were analyzed. Propensity matching was performed to identify similar patient cohorts.
We included 911 patients from March 2011 until May 2017. Perceval-S and Intuity valves were implanted in 349 (38.3%) and in 562 (61.7%) patients, respectively. Propensity score identified 117 matched pairs. In the matched cohort, device success was 99.1% and 100% in Perceval-S and Intuity group, respectively (P = 1.000). Thirty-day Valve Academic Research Consortium mortality occurred in 2 (1.7%) and 4 (3.4%) patients in the Perceval-S and in Intuity group, respectively (P = .6834). The rate of postoperative new permanent pacemaker implantation was 6% (7 patients) and 6.8% (8 patients) in the Perceval-S and in Intuity group, respectively (P = .7896). Perceval-S valve implantation requires significantly shorter aortic crossclamp and cardiopulmonary bypass times than Intuity valve implantation (aortic crossclamp time for isolated, 52 ± 14 minutes vs 62 ± 24 minutes; P < .0001). Peak transaortic gradients were 22.4 ± 8.1 mm Hg and 19.6 ± 6.7 mm Hg (P = .0144), whereas mean gradients were 11.8 ± 4.7 mm Hg and 10.5 ± 3.9 mm Hg (P = .0388) in the Perceval-S and Intuity groups, respectively.
Sutureless Perceval-S and rapid-deployment Intuity bioprostheses provide good and similar early clinical and hemodynamic outcomes. Perceval-S valve implantation requires shorter crossclamp and cardiopulmonary bypass times, whereas Intuity valve implantation provides lower transaortic peak and mean gradients.
The main findings of this study are that the Perceval-S (Livanova, London, United Kingdom) and Intuity (Edwards Lifesciences, Irvine, Calif) bioprostheses provide similar outcomes in terms of major early clinical end points, including pacemaker implantation rate. The Perceval-S valve requires shorter surgical times, whereas the Intuity valve provides lower postoperative aortic gradients. Display omitted
In patients with severe mitral regurgitation (MR) referred for cardiac surgery, left atrial (LA) remodeling and enlargement are accompanied by mechanical stress, mediated cellular hypertrophy, and ...interstitial fibrosis that finally lead to LA failure. Speckle tracking echocardiography is a novel non–Doppler-based method that allows an objective quantification of LA myocardial deformation, becoming useful for LA functional analysis. We conducted a study to evaluate the relation between the traditional and novel atrial indexes and the extent of ultrastructural alterations, obtained from patients with severe MR who were undergoing surgical correction of the valvular disease. The study population included 46 patients with severe MR, referred to our echocardiographic laboratory for a diagnostic examination before cardiac surgery. The global peak atrial longitudinal strain (PALS) was measured in all subjects by averaging all atrial segments. LA tissue samples were obtained from all patients. Masson's trichrome staining was performed to assess the extent of the fibrosis. The LA endocardial thickness was measured. A close negative correlation between the global PALS and grade of LA myocardial fibrosis was found (r = −0.82, p <0.0001), with poorer correlations for the LA indexed volume (r = 0.51, p = 0.01), LA ejection fraction (r = 0.61, p = 0.005), and E/E′ ratio (0.14, p = NS). Of these indexes, global PALS showed the best diagnostic accuracy to detect LA fibrosis (area under the curve 0.89), and it appears to be a strong and independent predictor of LA fibrosis. Furthermore, we also demonstrated an inverse correlation between the global PALS and LA endocardial thickness (r = −0.66, p = 0.0001). In conclusion, in patients with severe MR referred for cardiac surgery, impairment of LA longitudinal deformation, as assessed by the global PALS, correlated strongly with the extent of LA fibrosis and remodeling.
Aims
We sought to assess the efficacy of a heart valve clinic (HVC) follow-up programme for patients with severe aortic stenosis (AS).
Methods and results
Three hundred and eighty-eight consecutive ...patients with AS (age 71 ± 10 years; aortic-jet velocity 5.1 ± 0.6 m/s) and an indication for aortic valve replacement (AVR) were included. Of these, 290 patients presented with an indication for surgery at their first visit at the HVC and 98 asymptomatic patients who had been enrolled in an HVC monitoring programme developed indications for surgery during follow-up. Time to symptom detection was significantly longer in patients that presented with symptoms at baseline (352 ± 471 days) than in patients followed in the HVC (76 ± 75 days, P < 0.001). Despite being educated to recognize and promptly report new symptoms, 77 of the 98 patients in the HVC programme waited until the next scheduled consultation to report them. Severe symptom onset (NYHA or CCS Class ≥III) was present in 61% of patients being symptomatic at the initial visit and in 34% of patients in the HVC programme (P < 0.001).
Conclusion
Delays in referral and symptom reporting as well as symptom denial are common in patients with AS. These findings support the concept of risk stratification to identify patients who may benefit from elective surgery. A structured HVC programme results in the detection of symptoms at an earlier and less severe stage and thus in an optimized timing of surgery.
The survival of patients after prolonged cardiac arrest is still inadequate. Extracorporeal life support (ECLS) represents an alternative therapeutic method for patients who do not respond to ...conventional cardiopulmonary cerebral resuscitation. This technology is used to support the circulation of a patient with severe cardiac failure.
Between June 1997 and January 2003, 40 ECLS procedures were performed in patients who presented with refractory cardiac arrest. During external cardiac massage, the patient was connected to an extracorporeal circuit by the insertion of an arterial and venous cannula through the femoral vessels. The extracorporeal circuit included a centrifugal pump and an oxygenator. Mean age was 42 +/- 15 years; the average time of external cardiac massage was 105 +/- 44 minutes.
Once the circulation was restored, 22 patients were disconnected from the extracorporeal circulation because of brain death or multiorgan failure; after 24 hours, among the 18 survivors, 6 were weaned off the pump, 9 were bridged to a ventricular assist device, and 2 patients were directly bridged to cardiac transplantation. Eight patients are alive and without any sequelae at 18 month's follow-up.
In prolonged cardiac arrest with failing conventional measures, rescue by extracorporeal support provides an ultimate therapeutic option with a good outcome in survivors. Our results encourage the wider application of ECLS for refractory cardiocirculatory arrest in selected patients. The high rate of neurologic death needs further improvements in the early phase of resuscitation maneuvers.
Abstract Coronary artery bypass grafting is the most common cardiac surgery operation performed worldwide. It is the most effective revascularization method for several categories of patients ...affected by coronary artery disease. Although coronary artery bypass grafting has been performed for more than 40 years, no detailed guidelines on the choice of coronary artery bypass grafting conduits have been published and the choice of the revascularization strategy remains more a matter of art than of science. Moreover, there is a clear contradiction between the proven benefits of arterial grafting and its very limited use in everyday clinical practice. In the hope of encouraging wider diffusion of arterial revascularization and to provide a guide for clinicians, we discuss current evidence for the use of different conduits in coronary artery bypass surgery and propose an evidence-based algorithm for the choice of the second conduit during coronary artery bypass operations.
Abstract
Background and aims
The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for the treatment of cardiogenic shock (CS) may result in left ventricle overload and distension. ...Percutaneous microaxial flow pump Impella in addition to VA-ECMO (ECPELLA) is an emerging option to overcome these collateral effects. Aim of this study is to assess whether the addition of Impella to VA-ECMO is an effective and safe unloading strategy.
Methods and results
We performed a systematic literature review of studies comparing ECPELLA vs. ECMO alone in patients with CS. The primary endpoint was early mortality (in-hospital or 30-day mortality). The secondary endpoints were bleeding, need for kidney replacement therapy, haemolysis, infections, and limb ischaemia. A total of 3469 potentially relevant articles were screened and eight retrospective studies including 11.137 patients were selected. There was no significant difference in early mortality (Risk Ratio, RR 0.90, 95% CI 0.78–1.03) between ECPELLA and ECMO. Nevertheless, there was a borderline significant reduction in early mortality with ECPELLA (RR 0.74, 95% CI 0.55–1.00) at sensitivity analysis selectively including studies reporting propensity matched analysis. ECPELLA was associated with increased bleeding (RR 1.45, 95% CI 1.20–1.75), need for kidney replacement therapy (RR 1.54, 95% CI 1.19–1.99), haemolysis (RR 1.71, 95% CI 1.41–2.07) and limb ischaemia (RR 1.43, 95% CI 1.17–1.75) and with a non-significant increase in severe infections (RR 1.26, 95% CI 0.84–1.89), compared with ECMO alone.
Conclusion
Among patients with cardiogenic shock, ECPELLA is associated with increased complications compared with ECMO. Whether reducing ventricular overload with Impella among patients treated with ECMO reduces early mortality needs to be confirmed by further investigations.
Graphical Abstract
Graphical Abstract
Results of the meta-analysis for each outcome comparing ECMO plus percutaneous ventricular unloading versus ECMO alone.
Operative closure of atrial septal defect is today considered a high-benefit and low-risk operation. Patients are often young and sensitive to the cosmetic results of the procedure. The midline scar ...of median sternotomy may be unsightly and can provoke dissatisfaction and psychological distress. For cosmetic reasons, an alternative operative approach, such as right anterolateral thoracotomy, can be proposed, with better aesthetic results and without increasing operative risks.
Our study reviews retrospectively the longterm results of a consecutive series of 56 young patients in whom the atrial septal defect was closed through a right submammary approach. The indication for this approach was isolated atrial septal defect in female patients with complete development of the breasts.
In-hospital morbidity included three postpericardiotomy syndromes with one operative drainage for a moderate pericardial effusion (subxiphoid approach); 6 patients had supraventricular tachycardia in the early postoperative period. One patient presented with a symptomatic supraventricular arrhythmia and was treated medically for atrial flutter or fibrillation. Follow-up ranged from 12 to 240 months and included 41 of 57 patients. There were no early or late deaths. All patients were in normal sinus rhythm and free of symptoms, in New York Heart Association functional class I. Electrocardiography results showed 4 patients with firstdegree atrioventricular block and 5 with complete right bundle branch block. Echocardiographic study results showed 3 patients with a trivial residual shunt. There were no other late complications. Breast volume and symmetry and the character of the scar were evaluated objectively by a physician and subjectively by a multiple-choice questionnaire completed by the same patients. The answers suggested that the patients' subjective impressions were at least commensurate with the objective findings. Most of the patients perceived the cosmetic results as good or excellent. No serious psychological problems related to the scar were found.
Right thoracotomy incision is a safe alternative approach to median sternotomy to repair isolated atrial septal defect in young female patients.
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