LPS In Patients With Left Ventricular Dysfunction Of Ischemic And Non-Ischemic Origin.

BACKGROUND: We decided to examine whether there are differences in the levels of lipopolysaccharide (LPS) in various groups of patients suffering from left ventricular dysfunction, requiring no intravenous therapy. MATERIALS AND METHODS: We studied 37 patients (ranging from 39 to 80 years, mean age of 59.8 years, SD 9.5) with left ventricular dysfunction caused by dilated cardiomyopathy, valvular heart disease or chronic ischemic cardiomyopathy. These patients were compared to 29 healthy subjects and 7 acute myocardial infarction (AMI) patients. The LPS levels were analyzed and correlated to the echocardiographic index of left ventricular impairment and to the clinical parameters. RESULTS: The plasma levels of LPS were lower in patients with a chronic LV dysfunction than in the control group but without reaching any statistical significance (chronic LV dysfunction patients 6.33±5.03 pg/ml, AMI patients 13.58±19.14 pg/ml, healthy controls 11.12±12.97 pg/ml). The values observed in AMI patients were similar to those of the control group, without any significant differences. No significant correlation of the LPS levels was obseved either with the echocardiographic index of left ventricular impairment or with the clinical parameters. CONCLUSIONS: It is probable that LPS does not play any major role in the progression of LV dysfunction. The possible role of LPS in critical heart failure should therefore be better evaluated.

The C-reactive protein levels in left ventricular dysfunction of different etiology.

BACKGROUND: We have investigated variations in the C-reactive protein levels in groups of patients with left ventricular dysfunction of various causes. MATERIALS AND METHODS: We have studied 59 patients (ranging from 40 to 80 years, mean age of 64, SD 9) with left ventricular dysfunction caused by dilated cardiomyopathy, valvular heart disease, chronic ischemic cardiomyopathy. These patients have been compared to 30 healthy subjects and to 15 others with acute myocardial infarction. The C-reactive protein levels have been analyzed and correlated to echocardiographic index of the left ventricular function as well as to the clinical parameters. RESULTS: The levels of C-reactive protein show a statistically significant difference between healthy controls and patients with chronic left ventricular dysfunction (0.95mg/l +-0.9 vs 10.17+-13.77; p <0.0001); a statistically significant difference between patients with chronic left ventricular dysfunction and patients with acute myocardial infarction (10.17mg/l+-13.7 vs 30.78+-22.53, p<0.0001), and a statistically significant difference between the group of patients with chronic left ventricular dysfunction of both ischemic and non ischemic origin (15.39mg/l +-18.19 vs 6.83+-8.77, p = 0.0095). When all chronic patients were analyzed together, the levels of C-reactive protein correlated with the New York Heart Association class (r = 0.282, p = 0.015), age (r = 0.231, p = 0.039) and with the end diastolic volume of left ventricle (r = -0.230, p = 0.040). CONCLUSIONS: As shown by increment of C-reactive protein values, the immune system is activated in patients with the chronic left ventricular dysfunction. The patients with the chronic left ventricular dysfunction of an ishemic origin have higher levels of C-reactive protein than those of a non-ischemic origin. This difference could depend on the atherosclerotic process present presumably only in the first group.

Non-cardiovascular mortality, low-density lipoprotein cholesterol and statins: a meta-regression analysis.

BACKGROUND: As of today, the effect of statins on non-cardiovascular mortality is still being debated. Single studies have not been able to provide definite answers. We performed a meta-regression analysis on randomized statin trials in order to provide evidence that non-cardiovascular mortality is related to statin treatment and low-density lipoprotein (LDL) cholesterol plasma level. METHODS: We selected 29 randomized controlled trials of statins versus placebo, a total of 90,480 patients, with a follow-up of >12 months. Baseline and follow-up LDL levels and all-cause, cardiovascular and non-cardiovascular mortality were recorded. Weighted linear regression analysis was carried out separately for placebo and treatment groups. RESULTS: LDL level was inversely related to overall mortality (p = 0.0105) and non-cardiovascular mortality (p = 0.0171) in the treatment group. By contrast, in the placebo group only non-cardiovascular mortality was inversely correlated to LDL (p = 0.0032). The regression lines have similar slopes and run almost parallel to each other, with the treatment line lying below the placebo line. To identify the threshold of risk for starting statin therapy, we analysed the relationship between baseline cardiovascular risk and overall mortality in the two groups. Both correlations are highly significant and regression lines intersect at a risk of 0.29% per year. This implies that the effects of statins are favourable when the baseline cardiovascular risk exceeds approximately 3% in 10 years. CONCLUSIONS: A trend of increased non-cardiovascular mortality with decreased LDL exists both in placebo and treatment groups. However, at each given LDL cholesterol level, non-cardiovascular mortality is lower in treated patients. Therefore, statin therapy may improve the biological impact of LDL on non-cardiovascular mortality.

[Role of multidetectori compted tomography angiography and three-dimensional post-processing in a case of a Valsalva graft in aortic valve repair and replacement with the Cabrol procedure]. / Ruolo dell'angio-tomografia multidetettore e del post-processing tridimensionale in un caso di ectasia aortica corretta secondo la tecnica di Cabrol.

Patients with combined valvular-aortic disease undergo surgical reconstruction of the aortic root with a valved composite graft. Two of the techniques used to replace the aortic valve and ascending aorta are Bentall and Cabrol procedures. Cabrol surgical procedure uses a Dacron tube that enables coronary artery revascularization. Graft limb occlusion may however occur. Digital subtraction angiography, magnetic resonance angiography and multidetector computed tomography angiography are useful imaging methods for the evaluation of surgical-related complications. We report the case of a patient treated by the Cabrol technique, who was studied with contrast-enhanced multidetector computed tomography angiography to evaluate long-term post-surgical complications and coronary vessels patency.

Long-term survival and functional results after aortic valve replacement in asymptomatic patients with chronic severe aortic regurgitation and left ventricular dysfunction.

OBJECTIVES: We examined the influence of medical treatment on the results of surgery in terms of long-term survival and functional results in patients with chronic, severe aortic regurgitation (AR). BACKGROUND: Asymptomatic patients with AR and a reduced left ventricular ejection fraction (LVEF) are at high risk because of a higher-than-expected long-term mortality. The influence of preoperative medical therapy on the outcome after aortic valve replacement (AVR) is not well known. METHODS: Surgery was indicated for the appearance of a reduced LVEF (<50%). At the time of AVR, there were 134 patients treated with nifedipine (group A), and 132 received no medication (group B). RESULTS: Operative mortality was similar in the two groups (0.75% vs. 0.76%, p = NS). The LVEF normalized in all of group A, whereas it remained abnormal in 36 group B patients (28%). At 10-year follow-up, LVEF persisted higher in group A (62 +/- 5% vs. 48 +/- 4%, p < 0.001). Five-year survival was similar in the two groups (94 +/- 2% vs. 94 +/- 3%, p = NS). Group A showed a 10-year survival not different from expected and significantly higher than that in group B (85 +/- 4% vs. 78 +/- 5%, p < 0.001), which had a worse survival than expected. CONCLUSIONS: Unloading treatment with nifedipine in AR allows one to indicate AVR at the appearance of a reduced LVEF with a low operative mortality and an optimal long-term outcome. The concept of surgical correction of AR indicated for reduced LVEF may not be applied to all patients. Indeed, in a large amount of untreated patients, a reduced LVEF preoperatively is not reversed by prompt surgery, indicating irreversible myocardial damage, and 10-year survival is worse than expected.

Heart rate variability in arrhythmogenic right ventricular cardiomyopathy correlation with clinical and prognostic features.

The identification of subjects with arrhythmogenic right ventricular cardiomyopathy (ARVC) at higher risk for sudden death is an unresolved issue. An influence of the autonomic activity on the genesis of ventricular arrhythmias was postulated. Heart rate variability (HRV) analysis provides a useful method to measure autonomic activity, and is a predictor of increased risk of death after myocardial infarction. For these reasons, the aim of the study was to evaluate HRV and its correlations with ventricular arrhythmias, heart function, and prognostic outcome in patients with ARVC. The study included 46 patients with ARVC who were not taking antiarrhythmic medications. The diagnosis was made by ECG, echocardiography, angiography, and endomyocardial biopsy. Exercise stress test and Holter monitoring were obtained in all patients. Time-domain analysis of HRV was expressed as the standard deviation of all normal to normal NN intervals (SDNN) detected during 24-hour Holter monitoring. Thirty healthy subjects represented a control group for HRV analysis. The mean follow-up was 10.8 +/- 1.86 years. SDNN was reduced in patients with ARVC in comparison with the control group (151 +/- 36 vs 176 +/- 34, P = 0.00042). Moreover, there was a significant correlation of this index with the age of the patients (r = - 0.59, P < 0.001), with the left (r = 0.44, P = 0.002) and right (r = 0.47, P = 0.001) ventricle ejection fraction, with the right ventricular end diastolic volume (r = - 0.62, P < 0.001), and with the ventricular arrhythmias, detected during the same Holter record used for HRV analysis (patients with isolated ventricular ectopic beats < 1,000/24 hours, 184 +/- 34; patients with isolated ventricular ectopic beats > 1,000/24 hours and/or couplets, 156 +/- 25; patients with repetitive ventricular ectopic beats (> or = 3) and/or ventricular tachycardia, 129 +/- 25; P < 0.001). During follow-up two patients showed a transient but significant reduction of SDNN and a concomitant increase of the arrhythmic events. In eight patients an episode of sustained ventricular tachycardia occurred, but the mean SDNN of this subgroup did not differ from the mean value of the remaining patients (152 +/- 15 vs 150 +/- 39; P = NS). Only one subject died after heart transplantation during follow-up (case censored). Time-domain analysis of HRV seems to be a useful method to assess the autonomic influences in ARVC. A reduction of vagal influences correlates with the extent of the disease. The significant correlation between SDNN and ventricular arrhythmias confirmed the influences of autonomic activity in the modulation of the electrical instability in ARVC patients. However, SDNN was not predictive of spontaneous episodes of sustained ventricular tachycardia.

Life expectancy and quality of life in adult patients with congenital heart disease.

The survival and quality of life of patients with congenital heart disease have significantly improved in the last 20 years. This is due to more effective medical and surgical care. The new community of grown-up congenital heart patients consists of a few natural survivors with trivial congenital lesions or very rare complex cardiac abnormalities which are naturally compensated, and of more than 75% of patients who had been submitted to cardiac surgery during infancy or childhood. Clinical follow-up is however mandatory for many of them with scheduled times and types of exams to control the effects of sequelae and late complications, and to prevent deterioration and premature death because cardiac surgery may not have resulted in normality. Moreover, these patients have many needs and even more, many questions. Not giving a correct answer to each specific question reduces the entity of surgical success.