Intraoperative transesophageal echo-Doppler evaluation of stentless aortic xenografts. Incidence and significance of moderate gradients.

BACKGROUND: The aim of this study was to assess the utility of intraoperative transesophageal echocardiography (TEE) in the evaluation of patients undergoing aortic valve replacement with the CryoLife-O'Brien (CLOB) Stentless Porcine Aortic Bioprosthesis. METHODS: Between May 1994 and March 1995, 26 patients (15 men, mean age 68.4+/-10.78 years) had a CLOB valve in the aortic position. Transprosthetic gradients and valve regurgitation were detected by intraoperative TEE. Prosthetic regurgitation and transvalvular gradients were evaluated at six-month intervals using transthoracic echo-Doppler (TTE). RESULTS: The majority of implants resulted in low gradients (83.7%), with only four patients exhibiting a moderate gradient (15.3%). Color flow Doppler imaging showed central aortic regurgitation in only four of 25 patients (trivial, n=4; mild, n=1). There was one paravalvular leak (trivial, n=1). At follow-up examination (mean 37+/-12 months), 24 of 25 patients exhibited low mean gradients (7.25+/-2.81 mmHg). At follow-up one patient who had low velocities in the LVOT at perioperative evaluation exibited a moderate gradient (45 mmHg) with an effective orifice area of 0.8-0.9 cm(2). CONCLUSIONS: Intraoperative TEE was effective in assessing prosthetic stentless valve function.

Stentless aortic valve replacement in elderly patients.

OBJECTIVE: Seven-year clinical and hemodynamic results of the Cryolife O'Brien (CLOB) stentless bioprosthesis in elderly patients are reported. METHODS: From 1993 to 2000, 36 patients aged >75 years had a CLOB implanted in the aortic position. Eighteen (50%) were male. All patients were monitored with serial echocardiograms performed preoperatively, at discharge, six months, one year and yearly thereafter. RESULTS: The 30-day mortality was 2.4% (1/36). Actuarial survival at one, five and seven years were 96.7+/-1.5, 94.8+/-2.0 and 94.8+/-2.0%, respectively. Peak and mean gradients (PG and MG) reduced and effective orifice area index (EOAI) increased over time (P<0.001). Left ventricular mass index (LVMI) reduced by 32 g/m2 at discharge (P<0.001) and by 33 g/m2 at six months (P<0.001) without further significant changes. CONCLUSIONS: In our series CLOB xenograft resulted to be a satisfactory valve substitute in elderly patients.

The A-Med right heart support for off-pump coronary artery bypass grafting.

BACKGROUND: Off-pump coronary artery bypass grafting (OPCAB) presents several advantages but, mainly due to the impaired diastolic filling of the right ventricle, the displacement of the heart can cause hemodynamic instability. The aim of this study was to investigate the possible role of the A-Med right heart support during OPCAB. METHODS: We report our early experience with the A-Med system (A-Med, West Sacramento, CA, USA) during OPCAB. The system consists of a coaxial cannula, a microcentrifugal pump and a control console. The coaxial cannula is passed through the right atrium with the tip of the cannula positioned in the main pulmonary artery. Thus the blood is actively removed from the right atrium and returned to the pulmonary artery. RESULTS: We successfully used this right heart support in 2 patients undergoing elective OPCAB. In both cases the system was used during the exposure of the proximal portion of the obtuse marginal branch. A mean pump flow of 3.2 l/min guaranteed normal cardiac output and hemodynamic stability during the exposure of the posterior target area. No complication occurred and the patients were discharged shortly after surgery. CONCLUSIONS: In our early experience the A-Med right heart support was safe and effective and allowed achievement of hemodynamic stability during exposure of the posterior areas of the left ventricle.

Time course of left ventricular remodeling after stentless aortic valve replacement.

BACKGROUND: Stentless aortic valves are associated with a significant decrease in left ventricular hypertrophy. This study examined the time course and factors affecting left ventricular mass regression (LVMR) after aortic valve replacement (AVR) with Cryolife O'Brien (CLOB) (Cryolife International, Atlanta, Ga) stentless valves. METHODS: Between 1993 and 2000, 130 consecutive patients underwent AVR with CLOB. Mean age was 71.3 +/- 6.3 years. Sixty-four (49.2%) were male. Mean body surface area (BSA) was 1.7 +/- 0.2 m(2). Mean valve size implanted was 23.6 +/- 2.0 mm. All patients were monitored with serial echocardiograms; the first study was performed preoperatively, and subsequent controls were at 6 months, 1, 2, 3, 4, 5, 6, and 7 years, respectively. Left ventricular mass was calculated by the Devereux formula and indexed by BSA. RESULTS: Analysis of variance showed a significant reduction in the left ventricular mass index (LVMI) over time (P < .001). Most LVMRs occurred within the first 6 months, and after 1 year LVMI had decreased by 37.5% with further, but not statistically significant, reductions at later examinations. We found that baseline BSA > 1.75 m(2), male sex, arterial blood pressure > or = 150 mm Hg, left ventricular ejection fraction < or = 35%, New York Heart Association functional class > or = III, non-sinus rhythm, and prevalent aortic incompetence to be factors influencing LVMR. LVMR was not related to postoperative effective orifice area < or = 0.85 cm/m(2) and prosthetic size. CONCLUSIONS: AVR with a CLOB valve is followed by a significant LVMR that occurs soon after surgery. It is influenced by several patient-related factors: most of them can be predicted preoperatively.

Coronary artery bypass grafting in patients with dialysis-dependent renal failure: ten-year results.

BACKGROUND: Coronary artery disease has been reported to be accelerated in patients with chronic renal failure on maintenance dialysis. Coronary artery bypass grafting (CABG) in patients on long-term dialysis is still a debated issue. METHODS: We retrospectively reviewed 19 patients (12 men, 7 women, mean age 64 +/- 11.2 years) with end-stage renal disease who underwent CABG between 1990 and 2000. Operative procedures were CABG alone in 15 (78.9%) patients and CABG associated with valve procedures in 4 (21.1%) patients. RESULTS: The early (30-day) mortality rate was 10.5% (2 of 19 patients). Non-fatal complications occurred in 6 patients (31.5%). Four delayed deaths occurred; the actuarial survivals at 1, 2, 5 and 10 years were 0.86 +/- 0.14, 0.78 +/- 0.10, 0.68 +/- 0.13 and 0.54 +/- 0.15 respectively. Among 13 survivors the mean Canadian Cardiovascular Society class was 1.3 +/- 0.3 (p < 0.001 vs preoperatively). ANOVA procedures showed age (p = 0.01), Canadian Cardiovascular Society class > or = III (p < 0.001), urgent/emergency operation (p < 0.001), left ventricular ejection fraction < 0.50 (p < 0.001), a prior myocardial infarction (p = 0.01), a preoperative mean creatinine level > or = 5 mg/dl (p = 0.02) and a duration of dialysis > or = 60 months (p = 0.03) to be strongly related to early and delayed mortality. CONCLUSIONS: CABG in patients with dialysis-dependent chronic renal failure is associated with acceptable results. Accurate patient selection, early referral to surgery, and adequate perioperative management are advisable.

Early recovery of left ventricular function after stentless versus stented aortic valve replacement for pure aortic stenosis and severe cardiac dysfunction.

OBJECTIVE: The aim of this study was to evaluate early recovery of systolic function after stentless aortic valve replacement (AVR) versus stented AVR. METHODS: Fifty-four consecutive patients with pure aortic stenosis and impaired left ventricular function (LVEF < or = 35%) were studied retrospectively. Aortic regurgitation, concomitant valvular or coronary artery surgery, atrial fibrillation, and a previous AVR were exclusion criteria. Twenty-two patients (mean age, 70.0 +/- 6.5 years) received a stentless bioprosthesis and 32 (mean age, 58.9 +/- 6.2 years, P =.031 between groups) a mechanical or stented biologic valve. Patients underwent echocardiography preoperatively, at discharge, at 6 months, and at 1 year after surgery. RESULTS: At 6 months, analysis of variance demonstrated significant differences between groups in fractional shortening measured at the endocardium and midwall fractional shortening (<0.001), velocity of circumferential shortening (P <.001) ejection fraction (P =.02), left ventricular mass index (P <.001), systolic meridional wall stress, and circumferential wall stress (P <.001), One-year studies confirmed these findings. CONCLUSION: LV function showed, after a stentless AVR, an early recovery greater than in patients receiving a stented valve.

Causes of death and clinical diagnostic errors in extreme aged hospitalized people: a retrospective clinical-necropsy survey.

BACKGROUND: There are little data on causes of death in extreme aged. We compared, using autopsy findings, main cause of death, overall disease status, and accuracy rate of clinical diagnoses in extreme aged and persons dying at younger ages. METHODS: We reviewed the complete clinical and autopsy records of 114 consecutive inpatients (97 women, 17 men, age range 97-106, mean 99, median 98) who died in Trieste, Italy, and represented 99% of all extreme-aged person deaths in the hospital and 70% in the area. The control group included 151 patients (66 women, 85 men, age range 65-74, mean 70, median 70) who died during the same period in that hospital. RESULTS: Vascular and respiratory diseases together caused 84% of deaths in extreme aged. The main causes of death were pneumonia (n = 40, 35%), pulmonary embolism (n = 16, 14%), stroke (n = 12, 11%), and myocardial infarction (n = 8, 7%). Cancer was responsible for 6% (7/114) of deaths in extreme aged and 42% (64/151) in the control group. In 5% of extreme aged, autopsy findings did not explain death. The premortem diagnostic accuracy rate for clinical diagnoses was good in 44% of extreme aged, sufficient in 18%, poor in 28%, and not evaluable in 10%, and was significantly different from controls. Pneumonia, pulmonary embolism, and myocardial infarction were markedly underestimated by clinicians in both groups. CONCLUSIONS: Extreme aged die mainly of cardiovascular and respiratory diseases and, in most cases, of acute events. Senescence is a rare cause of death. Death from cancer is substantially lower than in persons dying at younger ages. In contrast to no autopsy studies, most extreme aged in our study were found to have specific diseases that explained their deaths.

Polymorphism of the apolipoprotein E gene and early carotid atherosclerosis defined by ultrasonography in asymptomatic adults.

Clinical and autoptical studies have suggested a predisposing role of the allele E4 of apolipoprotein E (apoE) in the development of atherosclerosis and cardiovascular disease. To investigate the possible contribution of apoE allele polymorphism to the carotid intima-media thickness (IMT) as assessed by ultrasound, we studied 260 asymptomatic nondiabetic subjects (121 men, 139 women; mean +/- SD age, 53 +/- 7 years), randomly selected from the population register of the inhabitants of Trieste, Italy. B-mode ultrasound was used to quantify the maximum IMT at 12 sites on the near and far wall of the common, bifurcation, and internal carotid arteries. ApoE genotypes were determined from amplified apoE sequences by restriction isotyping. The frequencies of E2, E3, and E4 alleles were 0.073, 0.827, and 0.100, respectively. As expected, subjects with E4 allele had the highest levels of total serum cholesterol and LDL cholesterol, subjects with E2 allele had the lowest levels, and those with E3 genotype had intermediate levels. The echographic measurements of carotid IMT showed increasing values from E2 to E4 carriers. After adjustment for total and LDL cholesterol serum levels, triglycerides, ratio of LDL to HDL cholesterol, age, sex, and body mass index, ANCOVA showed that the common carotid IMT was significantly greater (P = .029) in subjects with E4 allele compared with E3 carriers. Our data confirm the influence of apoE4 on cholesterol levels and clearly show that apoE genotype affects carotid atherosclerosis in its early stages in middle-aged asymptomatic subjects.

Activation of coagulation by a LDL-apheresis device.

LDL-apheresis often induces an almost constant and progressive increase of the differential pressure of plasma flowing through the dextran sulphate cellulose column, reducing the efficacy of the treatment. On two occasions we were able to identify a fibrin plug by immunofluorescence. Our aim was to verify the modification of some coagulation indicators in patients undergoing LDL-apheresis and whether an activation of coagulation occurs in the LDL-apheresis device. Blood samples were obtained from six patients with familial hypercholesterolaemia who were undergoing LDL-apheresis. During the same session further blood/ plasma samples were taken from the LDL-apheresis device at different sites and at different volumes of filtered blood. In patients after LDL-apheresis the following modifications were found: a 25% decrease of fibrinogen and a slight increase in F1 + 2 plasma levels. No relevant changes in thrombin-antithrombin complexes and fibrinopeptide A plasma levels were noted. In the LDL-apheresis device the main results were: (a) fibrinogen was trapped in the dextran sulphate cellulose column in the early phases; (b) activation of coagulation was recognisable in the plasma separator during the procedure and progressively increased with duration of LDL-apheresis; (c) thrombin-antithrombin complexes, formed in the plasma separator, were retained by the dextran sulphate cellulose column. In conclusion, LDL-apheresis activates coagulation in the device. Shortening cycle time or using nafamostat mesilate as an anticoagulant, could be interesting alternatives for improving the procedure.

Carotid atherosclerosis: echographic patterns versus histological findings.

The study was carried out on 25 whole carotid arteries explanted from a corpse and perfused at constant pressure to reproduce the conditions of an in vivo examination as much as possible. Out of 5 samples with intimal thickening detected by echo, fibrosis of the tunica media was observed by the pathologist in 4 and microcalcification in 1. In 4 vessels with soft plaques at echo scanning, a wide necrotic area (2 cases), slack connective tissue (1 case) and cystic lesions (1 case) were observed. Hard lesions with (5 cases) or without (2 cases) a cone of shadow at echo evaluation corresponded to fibrous (2 cases) or fibrocalcific (3 cases) plaques. The histological study of the two echo-diagnosed thrombi showed an intermediate echographic pattern and the main feature of the non-occluding thrombus was the absence of a lumen-lesion interface. Mixed plaques were diagnosed at echo in 9 arteries and the correspondent histological aspect was a typical atheromatous lesion in all cases. Thus, the comparison of the ultrasound image with the histological findings proved the reliability of echography in the detection of atheromatous lesions with an excellent agreement between the results at the 2 examinations. Since the type of carotid lesions has an impact upon clinical events these results might support the use of vascular ultrasound images in clinical applications.

Fibrinogen, D-dimer and thrombin-antithrombin complexes in a random population sample: relationships with other cardiovascular risk factors.

Fibrinogen is an independent risk factor for cardiovascular disease and both D-Dimer and Thrombin-Antithrombin complexes may be suitable as laboratory markers of deep venous thrombosis and are becoming more widespread in clinical practice. The aim of our study was to evaluate their normal range and to examine their correlation with various cardiovascular risk factors. Fibrinogen, D-Dimer and Thrombin-Antithrombin complexes were assessed in 516 normal subjects randomly selected from the National Health Service register of Trieste (Italy). In our community the mean value of fibrinogen was 283 +/- 71 mg/dl. Fibrinogen increases with age in males and was significantly higher in male smokers. In non-smokers, females had significantly higher fibrinogen values than males. The mean value of D-Dimer was 306 +/- 130 ng/ml. In females it is significantly higher. The fibrinogen and D-Dimer correlation coefficient was 0.20 (p < 0.001). The mean level of Thrombin-Antithrombin complexes was 6.25 +/- 6.8 ng/ml with a distribution markedly skewed towards the left; males had lower concentration than females (p = 0.047). Multiple regression analysis for fibrinogen as a dependent variable showed that D-Dimer, LDL-cholesterol, Body-Mass Index and Thrombin-Antithrombin complexes were poor predictors for fibrinogen plasma levels (R2 = 0.23) and that fibrinogen, ApoA1 and age can explain only about 10% of the observed variability in D-Dimer.

Early carotid atherosclerosis in asymptomatic adults with primary moderate hypercholesterolemia: a case-control study.

It has been shown that severe hypercholesterolemia is associated with carotid atherosclerosis but it is unclear whether this is true for moderate hypercholesterolemia. The aim of the study was to determine the prevalence of ultrasound detectable extent and severity of carotid intima-media thicknesses in 143 asymptomatic (79 males, 64 females, age range 45-64 years) primary moderate hypercholesterolemic patients (serum LDL cholesterol range 160-190 mg/dl). This group was compared with 143 asymptomatic normolipidemic subjects (serum LDL cholesterol < or = 130 mg/dl and serum triglycerides < 200 mg/dl) matched for age, sex and other cardiovascular risk factors. The maximum intima-media thickness (IMT) was measured using B-mode ultrasonography at 12 sites on the near and the far wall of the common, bifurcation and internal carotid arteries. The mean-maximum IMT at the 12 sites was compared in cases and controls. Moreover, the prevalence of intima-media thickening (i.e. at least one of the 12 sites with an IMT equal to or greater than 1.0 mm but less than 1.3) and plaques (i.e. at least one of the 12 sites with an IMT equal to or greater than 1.3 mm) was considered in the two groups. The mean-maximum intima-media thickness was 0.97 +/- 0.12 mm in hypercholesterolemic patients and 0.93 +/- 0.05 mm in controls (P < 0.0001). Intima-media thickening and plaques were detected in 76% of hypercholesterolemics vs. 57% of controls (P < 0.0002). Gender did not influence these differences.(ABSTRACT TRUNCATED AT 250 WORDS)

Lipoprotein(a) serum concentration in familial combined hyperlipidemia.

The lipoprotein(a) (Lp(a) concentrations in serum were measured by an ELISA technique in 53 subjects affected by familial combined hyperlipidemia (FCHL) and in 347 healthy individuals. Lp(a) geometric means did not differ significantly between the two groups despite the different distributions. In hyperlipidemic subjects, the distribution was markedly shifted to the right (median 17 mg/dl) while in controls it was highly skewed to the left (median = 11 mg/dl). In FCHL, Lp(a) serum levels did not differ between patients with or without coronary heart disease (CHD). It was concluded that, differently from familial hypercholesterolemia (FH), in FCHL Lp(a) may not be elevated in comparison with an adequate control population.

Efficacy of ciprofibrate in primary type II and IV hyperlipidemia: the Italian multicenter study.

The 127 diet-resistant primary hyperlipidemic patients received 100 mg of ciprofibrate daily for 12 weeks. In the 63 patients with type IIa hyperlipidemia and 41 patients with type IIb hyperlipidemia, serum levels of total cholesterol, very-low-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides, very-low-density lipoprotein triglycerides, and apolipoprotein (apo) B decreased significantly and levels of high-density lipoprotein cholesterol and apo A-I increased significantly. Similar changes occurred in the 23 type IV patients, except that high-density lipoprotein cholesterol levels increased significantly and apo B levels did not change. No clinically significant side effects or drug-related abnormal laboratory test results were noted. It is concluded that ciprofibrate is a safe and potent hypolipidemic agent.

[Effects of low-dose cholestyramine in long-term therapy of hypercholesterolemia]. / Effetti della colestiramina a basse dosi nella terapia a lungo termine dell'ipercolesterolemia.

Sixty-nine patients (mean age 49 +/- 13 years), affected by primary hypercholesterolemia (65 type IIa and 4 type IIb), were treated for 2 years with 12 gr/day cholestyramine subdivided in two doses. Total serum cholesterol decreased from 353 (sd 66) mg/dl to 291 (sd 62) mg/dl (p less than 0.001) at the third month active treatment remaining thereafter constant. Overall, LDL-cholesterol reduced by 30% in cases with a familial form of the metabolic disorder, by 27% and 30% in those with polygenic or indefinite hypercholesterolemia, respectively. HDL-cholesterol remained unchanged during the study whereas serum triglycerides tended toward an increase. The frequency of reported side effects ranged between 11% and 23% of cases. Mostly they were constipation and abdominal discomfort which, however, did not cause a definitive discontinuation of the resin. The favourable side effect profile and the efficacy confirmed that low-dose cholestyramine represents the first choice drug for hypercholesterolemia.

Ketanserin in mild to moderate hypertension in the elderly: a double-blind study versus methyldopa.

In a double-blind study of 30 elderly patients with mild to moderate essential hypertension, the antihypertensive effects of ketanserin and methyldopa were compared. The patients were randomly assigned to receive 20 mg of ketanserin or 250 mg of methyldopa twice daily for two weeks; the dose was then doubled for the rest of the three-month period. Two of the ketanserin group dropped out of treatment, one because of psychic depression, the other because of epigastric pain. After three months of therapy with ketanserin, systolic blood pressure decreased in a dose-dependent manner from 190 +/- 20 to 175 +/- 20 mmHg (P less than 0.05) and diastolic blood pressure from 106 +/- 8 to 91 +/- 9 mmHg (P less than 0.001). Blood pressure was reduced to 160/90 mmHg or less in eight of the 13 ketanserin patients and in five of the 15 methyldopa patients. In both groups heart rate and body weight remained constant. No orthostatic hypotension or hypertensive rebound after ketanserin withdrawal was recorded. It is concluded that 40 mg of ketanserin twice daily can control hypertension in the elderly.

Primary familial hypoparathyroidism with an autosomal dominant mode of inheritance.

A family with primary isolated hypoparathyroidism transmitted by an autosomal dominant gene was documented; the proband was a 38-year-old woman with a history of weakness and carpopedal spasm. The family study revealed that 6 out of 13 members belonging to 3 generations were affected by hypoparathyroidism without any evidence of an autoimmune disease. Vertical male-to-male, female-to-female and female-to-male transmission were demonstrated. Having excluded the recessive form of familial hypoparathyroidism, pseudohypoparathyroidism, primary familial hypomagnesemia and any immunological disorder, the autosomal dominant inheritance seems to be the most important etiology of idiopathic hypoparathyroidism.

A hyperalphalipoproteinaemic family with normal cholesteryl ester transfer/exchange activity.

Reports of two independent studies suggest that familial hyperalphalipoproteinaemia (FHALP) may be caused by a deficiency of cholesteryl ester transfer/exchange activity (CETP). We also have studied CETP in the plasma of an Italian FHALP kindred. The study group was divided into blood relatives with greater than 1.70 mM high-density-lipoprotein cholesterol (HDL-C) (group I, n = 9), with less than 1.70 mM-HDL-C (group II, n = 12) and in spouses (group III, n = 6). Two different assays were performed to measure CETP activity. In method A the interfering endogenous lipoproteins in the plasma samples were removed by poly(ethylene glycol) precipitation or by ultracentrifugation at a relative density (d) of 1.180. The CETP-activity of these samples was measured in a system consisting of fixed amounts of HDL and cholesteryl [1-14C]oleate-labelled low-density lipoproteins (LDL). In method B, trace amounts of HDL (radiolabelled with cholesteryl [1-14C]oleate) were incubated with plasma for 3 h at 37 degrees C and the distribution of the label among lipoproteins was measured (CET activity). The results can be summarized as follows. The mean CETP activities measured by method A were 187, 213 and 243 nmol/h per ml in groups I, II and III respectively. The proband with the highest HDL-C (4.98 mM) had a CETP activity of 231 nmol/h per ml. The corresponding CET activities measured by method B and expressed as percentage transfer/h were 4.3, 8.0 and 11.2 in groups I-III. The proband with HDL-C = 4.98 mM had a value of only 1.7%/h. There was a strong negative correlation between percentage CE transfer and HDL-C concentration. Calculating these data in terms of CE exchange (nmol/h per ml), groups I, II and III exhibited mean activities of 86, 124 and 110 nmol/h per ml respectively; for the proband this value was 80 nmol/h per ml. Only a slight correlation was found between these values and the HDL-C value. Thus by both methods, (A), measuring the CETP activity per se and (B), measuring the activity in whole plasma (reflecting the activity of the protein and the concentration and composition of lipoproteins), no major differences could be found between the three groups. In our family, therefore, no connection between FHALP and CETP deficiency could be found. It is concluded that, for hyper- and dys-lipoproteinaemic samples, a careful selection of the assay procedure as well as the mode of calculating results is essential. Since this may not hold the previous studies, the supposed connection between FHALP and CETP deficiency is challenged.