A 45% complication rate and a mortality of 20% were reported previously in patients undergoing non-cardiac surgery after coronary artery stenting. Discontinuation of antiplatelet drugs appeared to be ...of major influence on outcome. Therefore we undertook a prospective, observational multicentre study with predefined heparin therapy and antiplatelet medication in patients undergoing non-cardiac procedures after coronary artery stenting.
One hundred and three patients from three medical institutions were enrolled prospectively. Patients received coronary artery stents within 1 yr before non-cardiac surgery (urgent, semi-urgent or elective). Antiplatelet drug therapy was not, or only briefly, interrupted. Heparin was administered to all patients. All patients were on an intensive/intermediate care unit after surgery. Main outcome was the combined (cardiac, bleeding, surgical, sepsis) complication rate.
Of 103 patients, 44.7% (95% CI 34.9–54.8) suffered complications after surgery; 4.9% (95% CI 1.6–11.0) of the patients died. All but two (bleeding only) adverse events were of cardiac nature. The majority of complications occurred early after surgery. The risk of suffering an event was 2.11-fold greater in patients with recent stents (<35 days before surgery) as compared with percutaneous cardiac intervention more than 90 days before surgery.
Despite heparin and despite having all patients on intensive/intermediate care units, cardiac events are the major cause for new perioperative morbidity/mortality in patients undergoing non-cardiac surgery after coronary artery stenting. The complication rate exceeds the re-occlusion rate of stents in patients without surgery (usually <1% annually). Patients with coronary artery stenting less than 35 days before surgery are at the greatest risk.
Obesity might be a cause of limited aerobic exercise capacity. It is often associated with metabolic syndrome (MS) that includes cardiovascular comorbidities as arterial hypertension. Cardiopulmonary ...exercise testing (CPET) is the gold-standard to assess aerobic capacity and discriminate causes of dyspnea.
To evaluate aerobic capacity in obesity and if MS or hypertensive treatment impacts on the CPET profile.
CPET of 146 obese patients, whom 33 and 31 were matched for MS and antihypertensive medication, were analyzed. VO2peak (mL/min/Kg) was reported in percentage of predicted value, or, divided by body weight, fat free mass (FFM) or body weight expected for a body mass index of 24 (BMI24).
VO2peak (20,8 ± 4,4 mL/min/Kg) was normal when expressed in percentage predicted for obesity (111 ± 22%pred) or divided by FFM and weightBMI24 (33,6 ± 5,6 and 30,6 ± 6,2 respectively). The latter correlated better with maximal work rate (r = 0,7168, p < 0,001). Obese patients showed normal ventilatory efficiency (ventilation to carbon dioxide production slope: 28 ± 4), VO2 to work rate (10,2 ± 1,6 mLO2/Watt) and, slightly elevated heart rate to VO2 slope (4,0 ± 1,1 bpm/mL/min/Kg). Compared to normotensives, hypertensive medicated patients had higher blood pressure at anaerobic threshold (142 ± 23 vs 158 ± 26 mmHg, p = 0,001) but not at maximal exercise (189 ± 31 vs 201 ± 23 mmHg, p = NS), and, had lower actual maximal heart rate (155 ± 23 vs 143 ± 25 bpm, p = 0,03). There was no difference between obese patients with or without MS.
Obese people with or without MS present with similar and normal aerobic profile related to the excessive body weight. VO2peak divided by weightBMI24 is an easy and clinical meaningful index for obese patients.
•Obese patients present with normal cardiopulmonary exercise adaptation.•Metabolic syndrome does not impact cardiopulmonary exercise adaptation.•VO2peakBMI24 is a meaningful index of aerobic capacity.
Aims The influence of permanent atrial fibrillation on exercise tolerance and cardio-respiratory function during exercise in heart failure (HF) is unknown. Methods and results We retrospectively ...compared the results of 942 cardiopulmonary exercise tests, performed consecutively at seven Italian laboratories, in HF patients with atrial fibrillation (n = 180) and sinus rhythm (n = 762). By multivariable logistic regression analysis, peak VO2 (OR 0.376, 95% CI 0.240–0.588, P < 0.0001), O2pulse (VO2/heart rate, HR) (OR 0.236, 95% CI 0.152–0.366, P < 0.0001), VCO2 (OR 3.97, 95% CI 2.163–7.287, P < 0.0001), and ventilation (OR 1.38, 95% CI 1.045–1.821, P = 0.0231) were independently associated with atrial fibrillation. Anaerobic threshold (AT) was identified in 132 of 180 (73%) atrial fibrillation and in 649 of 762 (85%) sinus rhythm patients (P = 0.0002). By multivariable logistic regression analysis, only peak VO2 (OR 0.214, 95% CI 0.155–0.296, P < 0.0001) was independently associated with unidentified AT. At AT, atrial fibrillation HF patients had higher HR (P < 0.0001) and higher VO2 (P < 0.001) compared with sinus rhythm HF patients. Among AT variables, by multivariable logistic regression analysis, only HR was an independent predictor of atrial fibrillation. Conclusion In HF patients with permanent atrial fibrillation, exercise performance is reduced as reflected by reduced peak VO2. The finding of unidentified AT is associated with a poor performance. In atrial fibrillation patients, VO2 is higher at AT whereas lower at peak. This last observation raises uncertainties about the use of AT data to define performance and prognosis of HF patients with atrial fibrillation.
The principal aim of the INSIDE project (INdividual air pollution exposure, extracellular vescicles SIgnaling and hypertensive disorder DEvelopment in pregnancy) is to assess the molecular effects of ...environmental exposure to airborne particulate matter (PM) of susceptible subject. Different approaches are considered to evaluate these effects, including an exposure-effect study performed on a selected population. The short-term exposure to different pollutants (PM and NO2) was evaluated considering 51 subjects recruited from October 2017 to April 2018. Each subject was asked to carry personal instruments for few hours before a clinical evaluation (blood and cardiological examination) from home to hospital. Instruments used in the study were: (I) CairClip - CairPol (NO2) and (II) Aerocet 831 - Aerosol Mass Monitor, Met One Instruments (size-fractionated PM). Moreover, a (III) smartphone with a GPS application and a (IV) Time Activity Diary (TAD) were used in this study to acquire information about the microenvironments (MEs) visited by subjects during the monitoring sessions. The experimental design of the project allowed to further investigate issues related to the mode of exposure: through the analysis of TADs and GPS data, it was possible to document the time spent by each subject in the different MEs and characterize the average exposure and inhaled dose associated to different MEs. The microenvironmental inhaled dose of pollutants was estimated considering the average exposure to PM and NO2, the time spent across these MEs and the specific ventilation rate of each subject. Moreover, to understand which of these parameters has the major impact of the dose model, a sensitivity analysis was performed, on the total and on the MEs dataset.
Abstract
Chylous ascites is the accumulation of triglyceride–rich fluid in abdominal cavity. It is caused by lymphatic ducts injury, usually as consequence of surgery, neoplasia, or infection. ...Rarely, it can also occur from heart failure, pericarditis, or cirrhosis. We report the case of a 66–year–old man electively hospitalized for acute renal failure and anasarca state. The cardiological history was significant due to acute myocardial infarction treated with CABG, PM implantation for complete AV block, atrial fibrillation, and type 2 diabetes mellitus. The entero–hepatological history started in 2019 when, two months after abdominal surgery for an incarcerated hernia, he developed chylous ascites and chylotorax. Starting from 2021, the patient presented recurrent episodes of tense ascites, requiring periodic paracentesis. Haematological and infectious disease evaluation resulted negative, liver biopsy showed congestive hepatopathy with fibrosis, while venous catheterization found high right filling pressure with not portal hypertension. Patient was treated with Apixaban 2.5 mg b.i.d., Furosemide 50 mg b.i.d., Metformin 1500 mg, Enalapril 20 mg, and Simvastatin 20 mg. During the hospitalization other paracentesis confirmed the chylous nature of the effusion, echocardiography (despite very bad acoustic windows) showed preserved left ventricle systolic function (LVEF 55%), 3rd degree LV diastolic disfunction, and dilatation of right ventricle, atria, and inferior Vena Cava. Right heart catheterization confirmed the presence of LV restrictive physiology, combined pulmonary hypertension, and ruled out the diagnosis of constrictive pericarditis. In hospital treatment focused on resolving acute renal failure and hypervolemia through intravenous diuretic and Albumin and on optimizing cardiological therapy. The patient was discharged with the following treatment: Apixaban 2.5 mg b.i.d., Furosemide 50 mg b.i.d., Canrenone 100 mg b.i.d., Empagliflozin 10 mg, Simvastatin 20 mg, and indication to hypo–lipidic diet. This case highlights how the coexistence of different predisposing factors of chylous ascites (past abdominal surgery, heart failure and liver disease) can amplify each other. Recognizing the single role of each of them is of pivotal importance to elaborate targeted treatment. Moreover, in literature, there are some cases of chylous ascites associated with constrictive pericarditis and with severe heart failure, but to our knowledge not with coexistence of HFpEF.
Despite clinical and laboratory evidence of perioperative hypercoagulability, there are no consistent data evaluating the extent, duration, and specific contribution of platelets and procoagulatory ...proteins by in vitro testing. We tested the hypothesis that the parallel use of standard and abciximab-cytochalasin D-modified thromboelastography (TEG) can assess 7 days' postoperative hypercoagulability and can estimate the independent contribution of procoagulatory proteins and platelets. Thromboelastograms were performed before surgery, at the end of surgery, 6 h after surgery, and on postoperative days 1, 2, 3, and 7; they were analyzed for the reaction time and the maximal amplitude (MA). We calculated the elastic shear modulus of standard MA (G(t)) and modified MA (G(c)), which reflect total clot strength and procoagulatory protein component, respectively. The difference was an estimate of the platelet component (G(p)). There was a 10% perioperative increase of standard MA, corresponding to a 50% increase of G(t) (P < 0.0001) and an 86%-90% contribution of the calculated G(p) to G(t). We conclude that serial standard and modified thromboelastography may reveal prolonged postoperative hypercoagulability and the independent contribution of platelets and procoagulatory proteins to clot strength.
Postoperative hypercoagulability, occurring for at least 1 wk after major abdominal surgery, may be demonstrated by standard and modified thromboelastography. This hypercoagulability is not reflected by standard coagulation monitoring and seems to be predominantly caused by increased platelet reactivity.
Abstract
Introduction
Cardiac amyloidosis is an infiltrative disease that remains an under–diagnosticated cause of heart failure. Diagnostic algorithms focus on identifying the two most frequent ...forms of the disease, light chains amyloidosis (AL) and transthyretin amyloidosis (ATTR), by the initial use of 99mTc–DPD scintigraphy coupled to assessment of monoclonal proteins. Etiological distinction is and of pivotal importance since the availability of specific disease modifying treatments.
Case Description
We report the case of a 61–year–old man hospitalized for new onset of heart failure. Past medical history highlights bilateral carpal tunnel syndrome and monoclonal gammopathy of undetermined significance (MGUS). Cardiovascular examination reveals clinical signs of pulmonary and peripheric congestion. ECG shows conduction disturbances and low QRS voltage. Transthoracic echocardiography reveals left ventricular hypertrophy, normal systolic function (LVEF 58%), 3rd degree LV diastolic disfunction and mild pericardial effusion. Laboratory tests shows abnormal levels of TnT and pro–BNP. A diagnosis of cardiac amyloidosis is considered, and further exams are executed: cardiac magnetic resonance, haematological laboratory tests and 99mTc–DPD scintigraphy (tab. 1). Since both bone scintigraphy and monoclonal proteins tests are positive, diagnosis of cardiac amyloidosis cannot be made without non–invasive modalities (fig.1) and the patient is referred to an Amyloidosis Centre. Haematological evaluation and abdominal fat pad biopsy show stability of haematological disease and confirms the deposition of amyloidogenic TTR both in wild–type and mutated Ile88Arg variants. The results of genetic analysis confirms the presence of a heterozygous mutation of TTR gene (p.Ile88Arg – c.263T>G) (fig. 2). This mutation is not reported in database ClinVar nor in gnomAD, but according to the ACMG criteria it can be considered likely pathogenic. Considering the final diagnosis of cardiac hATTR the patient is considered eligible for treatment with Tafamidis.
Discussion and Conclusion
Despite clinical history with cardiac conduction system abnormalities and bilateral carpal tunnel syndrome, some gene TTR variants can bring false negative results at 99mTc–DPD scintigraphy, so ATTR form should not be excluded basing on non–invasive modalities. Performing a compete diagnostic workup led us to discover a new TTR pathogenic variant and confirm ATTR form without performing endomyocardial biopsy.
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