Stereotactic Body Radiotherapy Versus Metastasectomy in Patients With Pulmonary Metastases From Soft Tissue Sarcoma.

The lung is the preferred site of metastasis from soft tissue sarcoma (STS). This systematic review aims to evaluate the outcomes of stereotactic body radiotherapy (SBRT) and metastasectomy (MTS) for the treatment of lung metastases from STS. A systematic review was carried out according to the PRISMA protocol. PubMed, Medline, EMBASE, Cochrane Library, Ovid and Web of Knowledge databases were searched for English-language articles to December 2018 using a predefined strategy. Retrieved studies were independently screened and rated for relevance. Data were extracted by two researchers. In total, there were 1306 patients with STS: 1104 underwent MTS and 202 had SBRT. The mean age ranged from 40 to 55.8 years in the MTS group and from 47.9 to 64 years in the SBRT group. The cumulative death rate was 72% (95% confidence interval 59-85%) in the MTS group and 56% (38-74%) in the SBRT group. The cumulative mean overall survival time was 46.7 months (36.4-57.0%) in the MTS group and 47.6 months (33.7-61.5%) in the SBRT group. The cumulative rate of patients alive with disease was 5% (2-9%) in the MTS group and 15% (6-36%) in the SBRT group. Finally, the cumulative rate of patients alive without disease in the two groups was 19% (9-29%) and 20% (10-50%), respectively. Our study showed that local treatment of pulmonary metastases from STS with SBRT, compared with surgery, was associated with a lower cumulative overall death rate and similar overall survival time and survival rates without disease. By contrast, SBRT was associated with a higher survival rate with disease than MTS. Large randomised trials are necessary to confirm these findings and to establish whether SBRT may be a reliable option for early stage disease.

Contemporary use of arterial and venous conduits in coronary artery bypass grafting: anatomical, functional and clinical aspects.

Although the benefits of using the left internal mammary artery to bypass the left anterior descending artery (LAD) have been extensively ascertained, freedom from major cardiovascular events and survival after coronary artery bypass grafting (CABG) also correlate with the completeness of revascularisation. Hence, careful selection of the second-best graft conduit is crucial for CABG success. The more widespread use of saphenous vein grafts contrasts with the well-known long-term efficacy of multiple arterial grafting, which struggles to emerge as the procedure of choice due to concerns over increased technical difficulties and higher risk of postoperative complications. Conduit choice is at the discretion of the operator instead of being discussed by the heart team, where cardiologists are not usually engaged in such decisions due to a hypothetical lack of technical knowledge. Furthermore, according to the ESC/EACTS guidelines, traditional CABG remains the gold standard for multi-vessel coronary artery disease with complex LAD stenosis, but hybrid procedures using percutaneous coronary intervention for non-LAD targets could combine the best of two worlds. With the aim of raising the cardiologist's awareness of the surgical treatment options, we provide a comprehensive overview of the anatomical, functional and clinical aspects guiding the decision-making process in CABG strategy.

The symbiosis of contact force catheter use for hybrid ablation for atrial fibrillation.

OBJECTIVE: Reconduction across an ablation line is a common reason for arrhythmia recurrence over time. The hybrid procedure combines epicardial ablation of the pulmonary vein (PV) and creation of a box lesion with endocardial touch-ups for any electrical gaps. A high contact force (CF) between the ablation tip and cardiac tissue may increase the risk of thrombus formation, catheter tip charring, steam pop formation, and even cardiac perforation. CF monitoring is a significant new parameter for titration of the CF for creating an adequate lesion. METHODS: Thirty-eight consecutive patients underwent epicardial ablation using bipolar radiofrequency devices. After checking electrical bidirectional block of the ablation lines, an endocardial CF catheter was used for further ablation (if needed) to complete the isolation of PVs, box lesion, cavotricuspid isthmus (CTI), and complex fractionated atrial electrograms (CFAE). RESULTS: Endocardial touch-up was needed for 2 PVs (1.3 %) and 10 (26.3 %) box lesions. It was also used for the CTI line in 7 (18.4 %) patients, atrial tachycardia in 3 (7.9 %) patients, and additional CFAE ablation in 17 (44.7 %) patients. All 5 patients with arrhythmia recurrence had a mean CF < 10 g (p = 0.03). Procedure duration was significantly shorter in the CF group (223 ± 57 vs. 256 ± 60 min, p = 0.03) compared with control group. CONCLUSION: Use of CF catheters is safe, feasible, and complementary to a hybrid procedure setup for atrial fibrillation ablation. Its real-time monitoring may predict future arrhythmia recurrence, and decrease procedure time.

Effects of transcatheter aortic valve implantation on left ventricular mass and global longitudinal strain: tissue Doppler and strain evaluation.

INTRODUCTION: Transcatheter aortic valve implantation is the option of choice for high surgical risk patients suffering from symptomatic aortic stenosis. We aimed to evaluate the influence of baseline global longitudinal strain on left ventricular mass regression after the procedure. METHODS: We enrolled 23 patients with pure symptomatic severe aortic stenosis who underwent CoreValve prosthesis (Medtronic, Minneapolis, MN) implantation. Everyone had echocardiography registration before the procedure and after six months in order to analyze two-, three-, and four-chamber peak longitudinal strain and global longitudinal strain. RESULTS: After the procedure New York Heart Association class, peak and mean aortic valve gradients (p<0.001 for all) improved. Interventricular septum and posterior wall thicknesses decreased (p<0.001 for both). Moreover, left ventricular mass index for body surface area changed from 190±44 to 143±30 g/m(2), (p<0.001). Finally, global longitudinal strain significantly increased (from 9.4±0.9 to 11.5±0.8%; p<0.001), as well as its components. Baseline global longitudinal strain correlated with left ventricular mass regression (r=0.560; p=0.005; 2-sided) and predicted it at linear regression analysis (B=23.707; p=0.005; adjusted R(2)=0.281). CONCLUSIONS: Global longitudinal strain and its components improved six months after the procedure. Moreover, baseline global longitudinal strain seemed to predict left ventricular mass regression in patients with pure aortic stenosis undergoing transcatheter aortic valve implantation. This finding could be related to the extent of myocardial fibrosis which is also responsible for lack of left ventricular mass regression and poorer prognosis.

Elastic aortic properties in hypertrophic cardiomyopathy: a single center echocardiographic evaluation.

OBJECTIVE: Previous studies revealed that hypertrophic cardiomyopathy (HCM) patients have impaired aortic elastic properties with contrasting data about aortic dimensions. We aimed to extend our knowledge about this topic, considering tissue Doppler imaging (TDI) and tissue strain. PATIENTS AND METHODS: 25 HCM patients and 25 healthy volunteers matched for age and sex were enrolled. They underwent transthoracic echocardiography to measure aortic dimensions at four levels (Valsalva sinuses, sinotubular junction, tubular tract, aortic arch), elastic properties (i.e., distensibility, stiffness, M-mode strain, tissue strain), and TDI aortic wall velocities (S', E', A' waves). RESULTS: Aortic dimensions differed between the two groups only at sinotubular junction (18 ± 6 vs. 15 ± 3 mm/m2; p = 0.039) and aortic arch levels (19 ± 5 vs. 11 ± 8 mm/m2; p < 0.001). Aortic stiffness was significantly higher among patients (16.4 ± 23.2 vs. 5.9 ± 3.4; p = 0.034), and TDI waves greater (S': 5.2 ± 1.9 vs. 8.0 ± 2.7 cm/s, p < 0.001; E': -5.3 ± 2.4 vs. -7.2 ± 2.7 cm/s, p = 0.012; A': -5.3 ± 1.6 vs. -8.6 ± 4.5 cm/s, p = 0.002). M-mode and tissue strains, and aortic distensibility did not reach statistical significance, although showing a tendency to altered values in the HCM group. CONCLUSIONS: Patients affected by HCM show a larger aorta and altered aortic elastic properties compared with healthy volunteers. These findings could help to investigate treatment response and prognosis of these alterations.

Surgical RF ablation of atrial fibrillation in patients undergoing mitral valve repair for Barlow disease.

OBJECTIVES: At present, limited experience exists on the treatment of atrial fibrillation (AF) in patients undergoing mitral valve repair (MVR) for Barlow disease. The aim of this investigation was to prospectively evaluate the radiofrequency ablation of AF in patients undergoing MVR for severe regurgitation due to Barlow disease. METHODS: From January 1, 2007 to December 31, 2010, out of 85 consecutive patients with Barlow disease, 27 with AF underwent RF ablation associated with MVR. They were examined every 4 months in the first year after surgery and thereafter twice yearly. RESULTS: At follow-up, AF was observed in 4/25 (16.0%). NYHA (New York Heart Association) functional class improved significantly, with no patients in class III or IV (before surgery, 81.5% had been). Otherwise, among 58 patients in sinus rhythm, 6 (11%) developed AF during follow-up. No clinical or echocardiographic predictive factor was found in this subgroup. CONCLUSIONS: Results from our investigation suggest that radiofrequency ablation of AF in patients with Barlow disease undergoing MVR for severe regurgitation is effective and should be considered in every patient with Barlow disease and AF undergoing valve surgical repair.

Aortic valve stenosis and lipid-lowering therapy: the state of the art.

Aortic valve stenosis is the most common native valve disease and its most common cause in the United States and Europe is the calcification of a normal trileaflet. Recently, there is increasing evidence indicating that valve calcification has common underlying mechanisms with atherosclerosis. This connection raises interest in the potential efficacy of antiatherosclerosis medications in calcific valve stenosis (AS) therapy. Among them statins, are one of the most promising candidates, because of their pleiotropic effects. The aim of this review is to summarize and analyze the findings of contemporary studies and to discuss the rationale for statin usage in AS populations.

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.

"Side balloon stenting": a novel technique for bifurcation lesions.

We describe a new technique to treat stenoses of coronary bifurcations. The aim of this technique, called "side balloon stenting," is to treat the bifurcation lesions with the kissing balloon technique, implanting one or more stents without removing the guidewires which remain in place during the whole procedure, avoiding potential problems of access to the vessels jailed by stent struts. In addition, implanting the stent using the kissing balloon technique would prevent the "snow-plow" phenomenon (plaque shifting) in the side branch. The "side balloon stenting" technique was applied in 29 cases at various levels of coronary artery segments involving bifurcations (Table 1). The technical success rate of the side balloon stenting was 90% (25 procedures). The elective placement of one stent in the main vessel was done in 20/25 procedures (80%), and in only 5/25 (20%), it was also necessary to insert a second one in the side branch (due to suboptimal results), using the "culotte" technique in two and the T-technique in the other three. We were unable to advance the system to the right position in 4 patients (13%): in 2 due to twisting of the guidewires and in the other due to vessel tortuosity and insufficient backup of the system (guiding catheter and guidewires). In these four last cases, the delivery system was retrieved and a stent was successfully implanted in the right position in the main branch. Angiographic success (residual stenoses < 30% and TIMI 3 flow in both branches) was obtained in 100% of the cases. The post-intervention period was uneventful. These preliminary results show that the side balloon stenting technique is both feasible and safe in th treatment of coronary bifurcations with a satisfactory rate of procedural success and often (82%) positioning only one stent in the parent vessel, thus avoiding stenting the side branch. It will be necessary, however, to assess, based mainly on restenosis rate, whether these promising immediate results will persist in the long run.

Left ventricular mass regression after aortic valve replacement with CryoLife-O'Brien stentless aortic bioprosthesis.

BACKGROUND AND AIM OF THE STUDY: Left ventricular (LV) hypertrophy has been shown adversely to affect LV function and late outcome after aortic valve replacement (AVR). The study aim was to assess the time course of LV mass regression (LVMR) after AVR with a CryoLife-O'Brien stentless bioprosthesis, and to identify factors affecting late reduction of myocardial hypertrophy. METHODS: In total, 113 patients (60 males, 73 females; mean age 70.9+/-6.5 years) were studied by echocardiography preoperatively, at discharge, at six and 12 months postoperatively, and yearly thereafter. LV diameter and thickness were measured using M-mode echocardiography; LV mass was calculated using the Devereux formula and indexed by body surface area (BSA). RESULTS: LV end-systolic diameter, end-diastolic diameter, septal thickness and wall thickness decreased significantly after surgery (p <0.001). LV mass index (LVMI) was reduced by 16.6, 13.6, 10.1, 3.1, 3.3, 1.7, 2.6, and 1.8% at discharge and at 6 months and 1, 2, 3, 4, 5, and 6 years, respectively. Most LVMR occurred within the first year, with further (not significant) reductions at later examinations. Male sex (p = 0.002), arterial blood pressure > or =150 mmHg (p <0.001), LV ejection fraction (LVEF) < or =35% (p = 0.01), NYHA functional class > or = III (p = 0.01), atrial fibrillation (p <0.001), mean transvalvular gradient > or =40 mmHg (p = 0.001), and prevalent aortic incompetence (p <0.001) were factors influencing LVMR, independently of baseline effective orifice area and prosthesis size. CONCLUSION: AVR with the CryoLife-O'Brien stentless prosthesis resulted in significant LVMR. These findings encourage the use of this bioprosthesis in appropriate 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.

Early and midterm results of model 300 CryoLife O'Brien stentless porcine aortic bioprosthesis.

BACKGROUND: The Cryolife O'Brien (CLOB) is a composite stentless bioprosthesis constructed from noncoronary leaflets of three porcine aortic valves. This study aimed to investigate early and midterm results after aortic valve replacement with CLOB xenograft. METHODS: Between 1993 and 2000, the CLOB was implanted in 125 patients (62 men; mean age 71.3+/-6.4 years). Mean prosthesis size was 23.6+/-2 mm. Mean follow-up time was 37.0+/-12.1 months. Patients underwent echocardiographic studies preoperatively, at discharge, at 6 and 12 months postoperatively, and yearly thereafter. RESULTS: Early (30-day) mortality rate was 2.4% (3 of 125 patients). Of the four late deaths, none was valve related. Actuarial 7-year survival was 93.6%+/-3%. Seven-year freedom from primary valve failure was 98.1%+/-1.8%. All patients showed an improvement of functional status (p < 0.001). ANOVA revealed a significant reduction over time in peak and mean systolic gradients (p < 0.001). Effective orifice area index increased (p < 0.001) and left ventricular mass index significantly reduced in all valve sizes (p < 0.001) during this time interval. CONCLUSIONS: Because the early and midterm results with CLOB xenograft have been satisfactory, we encourage its use as a valve substitute, particularly in patients with small aortic roots.

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.

Aortic repair in Marfan's syndrome: prevention of mechanical leaflets damage.

Aortic incompetence in Marfan's syndrome results from distortion or dilatation of the sinuses of Valsalva, annuloaortic ectasia or a combination of these problems. Valve leaflets in these patients are macroscopically normal in spite of aortic insufficiency. Replacement of the ascending aorta, root and aortic valve with a composite graft was, for a long time, the treatment of choice for Marfan patients. Valve-preserving procedures (remodeling or reimplantation) provide the advantages of avoiding the shortcomings of standard surgical techniques, and maintaining the functional integrity of the left ventricular (LV) outflow tract, aortic root and ascending aorta. We developed a modified valve-sparing reimplantation technique for avoiding leaflet damage. This was achieved by leaving a 'cushion' of aortic wall (8--10 mm) that, sewn on the Dacron graft, works as a 'damper' and prevents leaflets injury during the systolic opening of the valve. For final judgment of this operative method long-term results are necessary.

The CryoLife O'Brien stentless porcine aortic bioprosthesis: 5-year follow-up.

BACKGROUND: Mortality, morbidity, complication rates, and echo hemodynamic results using the Cryolife O'Brien stentless aortic bioprosthesis over a 5-year period are reported. METHODS: The stentless valve was implanted in 97 conscecutive patients, 54 male and 43 female, mean age 70.9 +/- 6.5 years. All patients underwent preoperative, discharge (early study), 6-month (intermediate study), and late (18.3 +/- 10.4 months) echocardiography. RESULTS: The actuarial 5-year survival rate was 93.9% +/- 3%. Aortic regurgitation was absent in 95.5%, mild in 3.4%, and moderate in 1.1%. Peak and mean systolic gradients were significantly lower at discharge (p < 0.001) and at the 6-month follow-up (p < 0.001) but did not significantly fall further at the late study (p = NS). The effective orifice area index at discharge (p < 0.001) and at 6 months (p < 0.001) differed significantly from preoperative values, but variations at late study were not significant (p = NS). Left ventricular mass index decreased early postoperatively (p < 0.001) and at 6-month assessment (p < 0.001) with a further significant reduction at late echocardiography (p = 0.04). CONCLUSIONS: The 5-year results of this stentless valve showed a low rate of valve-related complications with excellent hemodynamic performance in all valve sizes.