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1.
Am Heart J ; 188: 118-126, 2017 Jun.
Article in English | MEDLINE | ID: mdl-28577667

ABSTRACT

BACKGROUND: The SYNTAX score (SS) is a determinant of outcome in patients undergoing percutaneous coronary intervention. In addition, it has been recently shown that the clinical SYNTAX score (cSS), obtained by adding clinical variables to the SS, improves the predictive power of the resulting risk model. We assessed the hypothesis that the use of the cSS may predict outcomes of patients undergoing coronary artery bypass grafting (CABG). METHODS: We measured the SYNTAX score in 874 patients undergoing isolated first time on-pump CABG. The clinical SYNTAX score was calculated at the time of the study using age, creatinine clearance and ejection fraction, the modified ACEF score, and analyses performed for major adverse cardiac and cerebrovascular events (MACCE) and all-cause mortality at 3-year follow-up. RESULTS: The mean age of the study population was 70.9 ± 8.1 years, and the median cSS 14.2 (range 2.1-286.5). The ROC curve analysis showed that a cSS >14.5 (81.4% sensitivity and 67.8% specificity) was a reliable tool in discrimination of patients for the occurrence of MACCE (AUC 0.78) and all-cause mortality (AUC 0.74). Kaplan-Meier survival analysis confirmed that patients belonging to higher cSS quartiles have poorer 3-year survival (P = .0001) and MACCE-free survival (P = .0001), with respect to those with lower cSS. CONCLUSIONS: This observational study has shown that the clinical SYNTAX score, incorporating the lesion-based SS and clinical-based ACEF score, predicted mid-term adverse outcomes of patients undergoing CABG and may play an important role in the risk stratification of this population. Further studies are needed to confirm these findings.


Subject(s)
Coronary Artery Bypass/methods , Coronary Artery Disease/diagnosis , Risk Assessment , Stroke Volume/physiology , Ventricular Function, Left/physiology , Aged , Cause of Death/trends , Coronary Artery Disease/mortality , Coronary Artery Disease/surgery , Echocardiography , Elective Surgical Procedures/methods , Female , Follow-Up Studies , Humans , Italy/epidemiology , Kaplan-Meier Estimate , Male , ROC Curve , Reproducibility of Results , Retrospective Studies , Risk Factors , Severity of Illness Index , Survival Rate/trends , Switzerland/epidemiology , Time Factors , Treatment Outcome
2.
Eur J Cardiothorac Surg ; 51(3): 547-553, 2017 03 01.
Article in English | MEDLINE | ID: mdl-28007880

ABSTRACT

Objectives: To quantify residual coronary artery disease measured using the SYNTAX score (SS) and its relation to outcomes after coronary artery bypass grafting (CABG). Methods: We conducted a retrospective analysis on a consecutive series of 1608 patients [mean age 68 years, standard deviation (SD): 7, F:M, 242:1366] undergoing first-time isolated CABG from 2004 to 2015. The baseline SS was retrospectively determined from preoperative angiograms, and the residual SS (rSS) was measured during assessment of the actual operative report for each patient after CABG. Patients were then stratified according to tercile cut points of low (rSS low 0-11, N = 537), intermediate (rSS mid >11-18.5, N = 539) and high residual SS (rSS high >18.5, N = 532). The Cox regression model was used to investigate the impact of rSS on major adverse cardiac and cerebrovascular events (MACCE) at 1 year. Results: The mean preoperative SS was 26.6 (SD: 9.4) (range 10.1-53), and the residual SS after CABG was 15.3 (SD: 8.4) (range 0-34) ( P < 0.001 versus preoperative). At 1 year, cumulative incidence of MACCE in the low rSS was 1.5% ( N = 8/537), 4.5% ( N = 24/539) in the intermediate and 8.8% ( N = 47/532) in the high rSS group. Kaplan-Meier analysis showed a statistically significant difference of MACCE-free survival between the three groups (log-rank test, P < 0.001). The estimated MACCE-free survival rate at 1 year was 98.1% [standard error (SE): 1.6] for the rSS low , 95.5% (SE: 1.9) for the rSS mid , and 90.5% (SE: 1.3) for the rSS high group, respectively. After multivariable adjustment, the rSS high group was independently associated with a higher incidence of MACCE at 1 year (hazard ratio 1.92, 95% confidence interval 1.21-3.23) compared to the rSS low group. Conclusions: These unanticipated findings suggest that a residual SS may be a useful tool for risk stratification of patients undergoing isolated first-time CABG. Our study may set the stage for further investigations addressing this important clinical question.


Subject(s)
Coronary Artery Bypass/adverse effects , Coronary Artery Disease/surgery , Severity of Illness Index , Aged , Coronary Artery Bypass/methods , Coronary Artery Disease/diagnosis , Female , Follow-Up Studies , Humans , Kaplan-Meier Estimate , Male , Middle Aged , Postoperative Care/methods , Retrospective Studies , Risk Assessment/methods , Treatment Outcome
3.
Int J Cardiol ; 191: 52-5, 2015 Jul 15.
Article in English | MEDLINE | ID: mdl-25965598

ABSTRACT

BACKGROUND: Pleiotropic effects of statins have been advocated for remodeling of the vascular wall. The aim of the present study was to investigate whether statin therapy influences the growth rate of ascending aorta (AA) diameter. METHODS: A total of 1348 patients was referred to our outpatient clinic for initial AA ectasia from September 2005 to December 2011. A propensity score was built to perfectly match (1:1) patients administered (Group A) or not (Group B) with statin therapy. Clinical and echocardiographic follow-up was 100% completed at 3 years after the first visit. Treatment groups were investigated for differences in AA maximum diameter, furthermore rates of survival free from death and/or complications were assessed by Kaplan-Meier analysis. RESULTS: Finally, two fairly-comparable groups of 329 patients each were obtained (Propensity model c-statistic 0.86, p<0.0001). At baseline, mean AA diameters were 38.88 ± 2.48 mm and 39.09 ± 2.60 mm in Groups A and B, respectively. At 3-years, similar rates of hypertension control (86 ± 12% vs. 85 ± 14%) were found, whilst growth rate of AA diameter was +2.84 ± 1.33 mm (or +0.95 mm/year) in Group A and +3.80 ± 1.69 mm (or +1.27 mm/year) in Group B (p<0.0001). Three-year survival free from the composite outcome (death, dissection/rupture, need for operative repair) was found to be significantly improved in Group A (85.4 ± 2.0%) rather than in Group B (79.7 ± 2.2%), with a log-rank p=0.05 (HR 0.69, 95% CI 0.47 to 1.01). CONCLUSIONS: In this study, statin treatment is associated with reduced growth rate of ascending aorta aneurysms. The latter resulted in improved survival free from complications for patients receiving statins.


Subject(s)
Aorta/drug effects , Aortic Aneurysm, Thoracic/drug therapy , Hydroxymethylglutaryl-CoA Reductase Inhibitors/therapeutic use , Aged , Aged, 80 and over , Aortic Dissection/diagnostic imaging , Aortic Dissection/prevention & control , Aorta/diagnostic imaging , Aorta/surgery , Aortic Aneurysm, Thoracic/diagnostic imaging , Aortic Aneurysm, Thoracic/prevention & control , Aortic Rupture/diagnostic imaging , Aortic Rupture/prevention & control , Echocardiography/methods , Female , Humans , Kaplan-Meier Estimate , Male , Middle Aged , Propensity Score , Retrospective Studies , Survival Analysis
4.
Ann Thorac Surg ; 99(6): 2024-31, 2015 Jun.
Article in English | MEDLINE | ID: mdl-25890664

ABSTRACT

BACKGROUND: In the context of complex aortic surgery, despite the wide consensus about the use of moderate hypothermia in association with antegrade selective cerebral perfusion (ASCP), its bilateral administration is not always warranted. The aim of the present meta-analysis was to investigate outcomes of unilateral versus bilateral ASCP. METHODS: Outcomes investigated were postoperative mortality and neurologic permanent and temporary disease (PND and TND); separate analysis of heterogeneity using the Cochrane Q statistic was used to perform comparisons. Circulatory arrest (CA) time and temperature, and sample size were explored as potential causes for heterogeneity with meta-regression analysis. RESULTS: The study population consisted of 3,723 patients receiving bilateral ASCP and 3,065 patients receiving unilateral ASC. Pooled analysis showed similar rates of postoperative mortality: 9.8% (95% confidence interval [CI], 7.8% to 12.3%) for bilateral ASCP versus 7.6% (95% CI, 5.7% to 10.2%) for unilateral ASCP; p = 0.19. Postoperative PND rates as well did not differ significantly: 6.9% (95% CI, 5.0% to 9.4%) for bilateral ASCP versus 5.8% (95% CI, 3.8% to 8.7%) for unilateral ASCP; p = 0.53. Similar results yielded from TND analysis: 9.3 % (95% CI, 7.0% to 12.2%) versus 6.5% (95% CI, 4.5% to 9.5%), respectively, p = 0.14. Meta-regression analysis showed that longer CA times were associated with significantly increased mortality only among patients administered with unilateral ASCP (model Q 65.8, p < 0.0001). Furthermore, higher CA temperatures were associated with significantly reduced rates of mortality (Q 64.1, p = 0.001), PND (Q 52.3, p = 0.01), and TND (Q 62.2, p = 0.002) in both groups. CONCLUSIONS: Unilateral versus bilateral ASCP administration did not result in different mortality and neurologic morbidity rates. Nevertheless, among prolonged CA times unilateral ASCP resulted in poorer outcomes with respect to bilateral ASCP. Furthermore, moderate hypothermia was associated with best outcomes in both groups.


Subject(s)
Aorta, Thoracic/surgery , Aortic Diseases/surgery , Blood Vessel Prosthesis Implantation/methods , Brain Ischemia/prevention & control , Cerebrovascular Circulation , Hypothermia, Induced/methods , Perfusion/methods , Humans
5.
Clin Exp Hypertens ; 37(5): 404-10, 2015.
Article in English | MEDLINE | ID: mdl-25496379

ABSTRACT

BACKGROUND: Many drugs combinations are available and equally recommended for the initial treatment of patients with marked blood pressure (BP) elevation and high cardiovascular risk. HYPOTHESIS: To investigate safety and efficacy of such combination therapies. METHODS: Prospectively collected data were retrospectively reviewed, inclusion criteria were: initial single-pill combination therapy, availability of clinical and echocardiographic 6-month follow-up. Six treatment groups were identified: Enalapril 20 mg+ Hydrochlorothiazide 12.5 mg (E/H), E 20 mg + Lercanidipine 10 mg (E/L), Ramipril 2.5 mg+ H 12.5 mg (R/H), Perindopril 5 mg+ Amlodipine 5 mg (P/A), Olmesartan 40 mg+ H 12.5 mg (O/H) and Telmisartan 40 mg+ H 12.5 mg (T/H). To avoid selection bias a Propensity score (goodness of fit: c-statistic 0.78, p = 0.0001) was used to select comparable cohorts of patients (n = 142 each). RESULTS: After 4 weeks of treatment BP goal was achieved by 624/852 (73.2%) patients, and adverse events were registered in 24/852 (2.8%) patients. After 6 months, 562/624 (90.1%) patients maintained the BP goal. Six-month responder rate was significantly higher in the E/L (69.0%) and P/A (68.3%) groups (p = 0.05); especially among diabetics (52.0% and 51.0%, respectively; p = 0.003). Patients receiving E/L (-19.8 ± 3.2 mmHg) and P/A (-19.9 ± 4.6 mmHg) showed greater reductions of diastolic BP (p = 0.03); whereas reductions of systolic BP were similar between treatment groups (p = 0.46). Echocardiographic follow-up revealed greater left ventricular reverse remodeling among patients receiving ACE-inhibitors (E/L, R/H, E/H and P/A), but this trend did not reach statistical significance. CONCLUSIONS: Single-pill fixed-dose combination therapies are highly effective and safe in the study settings. Best clinical and echocardiographic outcomes were noted among patients receiving E/L, R/H and P/A.


Subject(s)
Antihypertensive Agents/administration & dosage , Blood Pressure/drug effects , Hypertension/drug therapy , Amlodipine/administration & dosage , Benzimidazoles/administration & dosage , Benzoates/administration & dosage , Dihydropyridines , Dose-Response Relationship, Drug , Drug Combinations , Enalapril/administration & dosage , Female , Humans , Hydrochlorothiazide/administration & dosage , Hypertension/physiopathology , Imidazoles/administration & dosage , Male , Middle Aged , Perindopril/administration & dosage , Propensity Score , Ramipril/administration & dosage , Retrospective Studies , Risk Factors , Telmisartan , Tetrazoles/administration & dosage
6.
Aorta (Stamford) ; 2(2): 74-6, 2014 Apr.
Article in English | MEDLINE | ID: mdl-26798717

ABSTRACT

Alkaptonuria is an autosomal recessive trait resulting in an error of aromatic amino acids metabolism. Heyde's syndrome is a condition clustering together aortic valve stenosis and gastrointestinal bleeding from colonic angiodysplasia. At present, there is no report describing the association of the latter two syndromes in the same patient. Here we present the case of a patient with severe aortic stenosis, alkaptonuria, and Heyde's syndrome. The patient underwent aortic valve replacement by means of a valvular bioprosthesis and the histological examination of the aortic cusps revealed calcific degeneration. This was associated with stromal degeneration characterized by extra-cellular deposition of granular, brownish-pigmented material along with macrophages and multiple foci of calfication showing the same brownish pigmentation. This configuration represents the typical pattern of homogentisic acid accumulation known as ochronosis. The postoperative course was uneventful and the echocardiographic follow-up at 6 months postoperatively showed good-functioning of the aortic valve bioprosthesis.

7.
Int J Cardiol ; 168(4): 4150-4, 2013 Oct 09.
Article in English | MEDLINE | ID: mdl-23931967

ABSTRACT

BACKGROUND: Mitral PPM can be equated to residual mitral stenosis, which may halt the expected postoperative improvement of PH and concomitant functional tricuspid regurgitation (fTR). Aim of the present study is to evaluate the impact of mitral prosthesis-patient mismatch (PPM) on late tricuspid valve regurgitation and pulmonary hypertension (PH). METHODS: A total of 210 patients undergoing isolated mitral valve replacement (MVR) were investigated. Mitral valve effective orifice area was determined by the continuity equation and indexed for body surface area (EOAi) and PPM was defined as EOAi ≤ 1.2 cm(2)/m(2). Pulmonary hypertension (PH) was defined as systolic pulmonary artery pressure (sPAP) > 40 mmHg. Clinical and echocardiographic follow-up (median 27 months) was 100% completed. A total of 88/210 (42%) patients developed mitral PPM. RESULTS: There were no significative differences in baseline and operative characteristics between patients with and without PPM. At follow-up, the prevalence of fTR ≥ 2+ (57%vs.22%; p = 0.0001), and PH (62%vs.24%;p < 0.0001) were significantly higher in patients with PPM. On multivariable regression analysis, EOAi (p < 0.0001) and preoperative left ventricular (LV) end-diastolic diameter (p < 0.0001) were found to be independently associated with fTR decrease after MVR. In addition, EOAi (p < 0.0001) and LV ejection fraction (p < 0.0001) were independently associated with PH decrease after MVR. No significant differences in mortality rates were found between patients having or not PPM. CONCLUSIONS: This study shows that mitral PPM is associated with the persistence of fTR and PH following MVR. These findings support the realization of tricuspid valve annuloplasty when PPM is anticipated at the time of operation.


Subject(s)
Heart Valve Prosthesis Implantation/adverse effects , Heart Valve Prosthesis/adverse effects , Hypertension, Pulmonary/diagnosis , Mitral Valve Insufficiency/diagnosis , Mitral Valve Insufficiency/surgery , Tricuspid Valve Insufficiency/diagnosis , Aged , Aged, 80 and over , Cohort Studies , Female , Follow-Up Studies , Humans , Hypertension, Pulmonary/epidemiology , Male , Middle Aged , Mitral Valve/pathology , Mitral Valve/surgery , Mitral Valve Insufficiency/epidemiology , Prospective Studies , Retrospective Studies , Treatment Outcome , Tricuspid Valve Insufficiency/epidemiology
8.
Int J Cardiol ; 167(5): 1961-6, 2013 Sep 01.
Article in English | MEDLINE | ID: mdl-22633430

ABSTRACT

BACKGROUND: Perioperative administration of enoximone has been shown to improve hemodynamics, organ function, and inflammatory response. Aim of the present study is to evaluate the impact of enoximone on postoperative renal function after on-pump cardiac surgery. METHODS: A total of 3727 patients undergoing cardiac surgery at one Institution between May 2004 and November 2010 were reviewed. A propensity score was built and a 1:1 perfect matching was performed, providing two fairly comparable cohorts of 712 patients each, receiving or not enoximone after surgery. Renal function was evaluated by lower glomerular filtration rate (GFR) value reached postoperatively. RESULTS: Overall 30-day mortality rate was 4.3% (62/1424). Cumulative incidence of postoperative renal failure (RF) was 157/1424(11%), of which 99/1424(7%) needed renal replacement therapy. Mean lower postoperative GFR in patients who received or not enoximone was 63 ± 30.1 and 53.5 ± 26.1 ml/min/1.73 m(2) (p<0.0001), respectively. At multivariable analysis age (OR2.75, p=0.0004), diabetes (OR1.82, p=0.006), preoperative GFR (OR3.81, p<0.0001), preoperative cardiogenic shock (OR1.65, p=0.004), previous cardiac surgery (OR2.12, p=0.0002), type of intervention (OR1.96, p=0.005), and enoximone (OR0.38, p=0.001) were found to be independently associated with postoperative RF. Logistic regression analysis showed that the administration of enoximone (OR0.41, p=0.0001), and of no inotropes (OR0.27, p<0.0001) were protective vs. the occurrence of postoperative RF. CONCLUSION: Patients perioperatively receiving enoximone showed a statistically significant better renal function after cardiac surgery.


Subject(s)
Cardiac Surgical Procedures/mortality , Enoximone/administration & dosage , Glomerular Filtration Rate/physiology , Kidney/physiology , Perioperative Care/methods , Propensity Score , Aged , Aged, 80 and over , Cardiac Surgical Procedures/adverse effects , Cardiac Surgical Procedures/trends , Cohort Studies , Female , Glomerular Filtration Rate/drug effects , Humans , Kidney/drug effects , Male , Middle Aged , Retrospective Studies , Vasodilator Agents/administration & dosage
9.
Ann Thorac Surg ; 95(2): 525-31, 2013 Feb.
Article in English | MEDLINE | ID: mdl-23040827

ABSTRACT

BACKGROUND: ß-Blockers are known to improve survival of patients with cardiovascular disease, but their administration in patients with chronic obstructive pulmonary disease (COPD) remains controversial. The aim of the present study was to assess the effect of ß-blocker administration in patients with COPD undergoing coronary artery bypass grafting. METHODS: A total of 388 consecutive patients with COPD who underwent isolated coronary artery bypass grafting were studied, and clinical follow-up was completed. Diagnosis of COPD was based on preoperative forced expiration volume; exacerbation episodes were defined as a pulsed-dose prescription of prednisolone or a hospital admission for an exacerbation. Two propensity-matched cohorts of 104 patients each either receiving or not receiving ß-blockers were identified. RESULTS: At baseline, there was no significant difference among groups. After a median follow-up of 36 months, there were 8 deaths in 104 patients (7.7%) receiving ß-blockers versus 19 deaths in 104 patients (18.3%) who did not receive ß-blockers (p = 0.03). Kaplan-Meyer analysis showed a survival of 91.8% ± 2.8% for patients taking ß-blockers versus 80.6% ± 4.0% for control subjects (χ(2), 29.4; p = 0.003; hazard ratio, 0.38). In addition, ß-blocker administration did not increase rates of COPD exacerbation, which was experienced by 46 of 104 patients (44.2%) receiving ß-blockers versus 45 of 104 patients (43.3%) not receiving ß-blockers (p = 0.99). CONCLUSIONS: This study showed that in patients with COPD undergoing coronary artery bypass grafting the administration of ß-blockers is safe and significantly improves survival at mid-term follow-up. Further randomized studies are needed to confirm these findings.


Subject(s)
Adrenergic beta-Antagonists/therapeutic use , Coronary Artery Bypass/mortality , Coronary Artery Disease/complications , Coronary Artery Disease/surgery , Pulmonary Disease, Chronic Obstructive/complications , Aged , Coronary Artery Disease/mortality , Female , Follow-Up Studies , Humans , Male , Prospective Studies , Pulmonary Disease, Chronic Obstructive/mortality , Survival Rate
10.
J Cardiovasc Med (Hagerstown) ; 14(2): 104-9, 2013 Feb.
Article in English | MEDLINE | ID: mdl-21826019

ABSTRACT

BACKGROUND: n-3 Polyunsaturated fatty acids (n-3 PUFAs) have been proposed as prophylactic therapy in the prevention of postoperative atrial fibrillation (POAF) in patients undergoing cardiac surgery. We conducted a meta-analysis of randomized controlled trials to better clarify this issue. METHODS: An electronic database search for randomized controlled trials on the effect of n-3 PUFAS on POAF was conducted, limited to English language publications until December 2010. For each study, data regarding the incidence of POAF were used to generate risk ratio (<1, favors n-3 PUFA; >1, favors placebo). Pooled summary effect estimate was calculated by means of a fixed or random effect according to heterogeneity. Meta-regression was used to investigate the effect of eicosapentaenoic acid (EPA)/docosahexaenoic acid (DHA) ratio and preoperative ß-blockers on the effect of n-3 PUFA on POAF. RESULTS: Three publications were included in the analysis, enrolling a total of 431 patients. Overall incidence of POAF ranged from 24 to 54%. Pooling data, n-3 PUFA did not show a significant effect on the risk of POAF [risk ratio 0.89; 95% confidence interval (CI) 0.55-1.44; P=0.63]. However, meta-regression analysis showed a trend toward a benefit from n-3 PUFA supplementation when the EPA/DHA ratio was 1:2 (Q model=7.4; p model=0.02) and when preoperative ß-blocker rate was lower (Q model=8.0; p model=0.01). CONCLUSION: In conclusion, the results of the present meta-analysis of randomized controlled trials suggest that preoperative n-3 PUFA therapy may not reduce POAF in patients undergoing cardiac surgery. However, several aspects may have influenced this negative result, which need to be investigated.


Subject(s)
Atrial Fibrillation , Cardiac Surgical Procedures/adverse effects , Dietary Supplements , Fatty Acids, Omega-3/administration & dosage , Randomized Controlled Trials as Topic , Atrial Fibrillation/epidemiology , Atrial Fibrillation/etiology , Atrial Fibrillation/prevention & control , Humans , Postoperative Complications
11.
J Thorac Cardiovasc Surg ; 143(3): 632-8, 2012 Mar.
Article in English | MEDLINE | ID: mdl-22244561

ABSTRACT

OBJECTIVE: Progression of functional tricuspid regurgitation is not uncommon after mitral valve surgery and is associated with poor outcomes. We tested the hypothesis that concomitant tricuspid valve annuloplasty in patients with tricuspid annulus dilatation (≥40 mm) prevents tricuspid regurgitation progression after mitral valve surgery. METHODS: We enrolled 44 patients undergoing mitral valve surgery (both repair or replacement) showing less than moderate (≤+2) tricuspid regurgitation and dilated tricuspid annulus (≥40 mm) at preoperative echocardiography. They were randomized to receive (n = 22) or not receive (n = 22) concomitant tricuspid annuloplasty (Cosgrove-Edwards annuloplasty ring; Edwards Lifesciences, Irvine, Calif) at the time of mitral valve surgery. Clinical and echocardiographic follow-up was 100% completed at 12 months after surgery. RESULTS: Preoperative clinical and echocardiographic characteristics were comparable in the 2 groups. Operative mortality was 4.4% (1 death in each group). At 12 months follow-up, tricuspid regurgitation was absent in 71% (n = 15) versus 19% (n = 4) of patients in the treatment and control groups, respectively (P = .001). Moderate to severe tricuspid regurgitation (≥+3) was present in 0% versus 28% (n = 6) of patients in the treatment and control groups, respectively (P = .02). Pulmonary artery systolic pressure significantly decreased from baseline in all cases (P < .001) and was comparable in the 2 groups (41 ± 8 mm Hg vs 40 ± 5 mm Hg; P = .4). Right ventricular reverse remodeling was marked in the treatment group (right ventricular long axis: 71 ± 7 mm vs 65 ± 8 mm; P = .01; short axis: 33 ± 4 mm vs 27 ± 5 mm; P = .001) but only minimal in the control group (right ventricular long axis: 72 ± 6 mm vs 70 ± 7 mm; P = .08; short axis: 34 ± 5 mm vs 33 ± 5 mm; P = .1). The 6-minute walk test improved from baseline in both groups (P < .001), but this improvement was greater in the treatment group (+115 ± 23 m from baseline vs +75 ± 35 m; P = .008). CONCLUSIONS: Prophylactic tricuspid valve annuloplasty in patients with dilated tricuspid annulus undergoing mitral valve surgery was associated with a reduced rate of tricuspid regurgitation progression, improved right ventricular remodeling, and better functional outcomes.


Subject(s)
Cardiac Valve Annuloplasty , Heart Valve Prosthesis Implantation , Mitral Valve Annuloplasty , Mitral Valve/surgery , Tricuspid Valve Insufficiency/prevention & control , Tricuspid Valve/surgery , Aged , Aged, 80 and over , Cardiac Valve Annuloplasty/adverse effects , Cardiac Valve Annuloplasty/mortality , Dilatation, Pathologic , Exercise Test , Female , Heart Valve Prosthesis Implantation/adverse effects , Heart Valve Prosthesis Implantation/mortality , Hemodynamics , Hospital Mortality , Humans , Italy , Male , Middle Aged , Mitral Valve Annuloplasty/adverse effects , Mitral Valve Annuloplasty/mortality , Time Factors , Treatment Outcome , Tricuspid Valve/diagnostic imaging , Tricuspid Valve Insufficiency/diagnosis , Tricuspid Valve Insufficiency/etiology , Tricuspid Valve Insufficiency/physiopathology , Ultrasonography , Ventricular Function, Right , Ventricular Remodeling
12.
Ann Thorac Surg ; 93(2): 537-44, 2012 Feb.
Article in English | MEDLINE | ID: mdl-22197615

ABSTRACT

BACKGROUND: Metabolic syndrome (MetS) is frequently associated with coronary artery disease, but data on the impact of MetS on long-term outcome of patients undergoing coronary artery bypass grafting are still lacking. The aim of the present study was to assess the effect of MetS on mortality and morbidity late after coronary artery bypass grafting. METHODS: A total of 1,726 consecutive patients who had elective coronary artery bypass grafting were retrospectively reviewed and clinical follow-up was completed (mean follow-up time, 34.4 months; range, 6 to 79 months). The MetS was diagnosed using the modified Adult Treatment Panel III criteria, and to eliminate covariate differences, a propensity score adjustment was used. Major adverse cerebral and cardiovascular events were investigated, and C-reactive protein levels were assessed both preoperatively, postoperatively, and at follow-up. RESULTS: A total of 798 of 1,726 patients (46.2%) met the diagnostic criteria for MetS. At follow-up, all-cause mortality (7% versus 4.6%; p=0.04), cardiac arrhythmias (35.3% versus 25.2%; p<0.0001), renal failure (12% versus 8.7%; p=0.03), and major adverse cerebral and cardiovascular events (52.4% versus 39.5%; p<0.0001) showed a significantly higher incidence in MetS patients. Variables correlated with late mortality at propensity-adjusted Cox proportional-hazards regression were age (p=0.0008), preoperative left ventricular ejection fraction (p=0.001), preoperative renal failure (p=0.001), and MetS (p=0.006). Higher C-reactive protein levels were found preoperatively (8.6±2.3 versus 5.14±3.1 mg/L; p<0.0001) and both early (71.2±9 versus 49.6±8.7 mg/L; p<0.0001) and late (7.4±2.7 versus 4.8±2.5 mg/L; p<0.0001) after surgery. CONCLUSIONS: The main finding of our study was the association between MetS and mortality both early and late after coronary artery bypass grafting. Thus, MetS should be recognized as an independent preoperative variable that can lead to the identification of high-risk patients and as a risk factor to correct with lifestyle modifications and pharmacologic therapy.


Subject(s)
Coronary Artery Bypass/statistics & numerical data , Metabolic Syndrome/epidemiology , Aged , Arrhythmias, Cardiac/mortality , Blood Glucose/analysis , C-Reactive Protein/analysis , Cause of Death , Diabetes Complications/blood , Diabetes Complications/epidemiology , Female , Follow-Up Studies , Heart Diseases/epidemiology , Humans , Inflammation/blood , Kaplan-Meier Estimate , Kidney Failure, Chronic/mortality , Lipids/blood , Male , Metabolic Syndrome/blood , Middle Aged , Postoperative Complications/epidemiology , Proportional Hazards Models , Retrospective Studies , Risk Factors , Stroke/epidemiology , Treatment Outcome
13.
Circ Cardiovasc Imaging ; 5(1): 36-42, 2012 Jan.
Article in English | MEDLINE | ID: mdl-22138006

ABSTRACT

BACKGROUND: Secondary mitral regurgitation (SMR) is generally reduced after isolated aortic valve replacement (AVR), but there is important interindividual variability in the magnitude of this reduction. Prosthesis-patient mismatch (PPM) may hinder normalization of left ventricular geometry and pressure overload following AVR, therefore we aimed to investigate the relationship between PPM and regression of SMR following AVR for aortic valve stenosis. METHODS AND RESULTS: A total of 419 patients with AS who underwent isolated AVR at 2 institutions and presenting moderate SMR (mitral regurgitant volume 30 to 45 mL/beat) not considered for surgical correction were included in this study. Clinical and echocardiographic follow-up were completed at a median follow-up time of 37 months. PPM was defined as an indexed effective orifice area ≤0.85 cm(2)/m(2) and was found in 170/419 patients (40.6%). There were no significant differences in baseline and operative characteristics between patients with or without PPM. Patients with PPM had less regression of SMR following AVR compared with those with no PPM (change in mitral regurgitant volume: -11±4 versus -17±5 mL, respectively; P<0.0001). Variables significantly associated with postoperative change in mitral regurgitant volume on univariable analysis were entered in a multivariable linear regression model, which showed indexed effective orifice area (P<0.0001) and left atrial diameter (P=0.006) to be independently associated with mitral regurgitant volume improvement. Patients with PPM also had less postoperative improvement in 6-minute walking test distance (80±78 versus 42±41 m, P<0.0001). CONCLUSIONS: PPM is associated with lesser regression of SMR following AVR. This unfavorable effect was associated with worse functional capacity. These findings emphasize the importance of operative strategies aiming to prevent PPM in patients with aortic valve stenosis and concomitant SMR.


Subject(s)
Aortic Valve Stenosis/surgery , Bioprosthesis , Heart Valve Prosthesis , Mitral Valve Insufficiency/diagnostic imaging , Mitral Valve Insufficiency/surgery , Aged , Aortic Valve/diagnostic imaging , Aortic Valve/surgery , Aortic Valve Stenosis/complications , Echocardiography, Doppler/methods , Exercise Test , Female , Follow-Up Studies , Heart Valve Prosthesis Implantation , Humans , Kaplan-Meier Estimate , Male , Mitral Valve Insufficiency/complications , Postoperative Complications/diagnostic imaging , Prosthesis Design , Prosthesis Fitting , Retrospective Studies , Severity of Illness Index , Treatment Outcome
14.
J Am Coll Cardiol ; 58(12): 1271-9, 2011 Sep 13.
Article in English | MEDLINE | ID: mdl-21903062

ABSTRACT

OBJECTIVES: The goal of this study was to assess the prognostic significance of midwall and infarct patterns of late gadolinium enhancement (LGE) in aortic stenosis. BACKGROUND: Myocardial fibrosis occurs in aortic stenosis as part of the hypertrophic response. It can be detected by LGE, which is associated with an adverse prognosis in a range of other cardiac conditions. METHODS: Between January 2003 and October 2008, consecutive patients with moderate or severe aortic stenosis undergoing cardiovascular magnetic resonance with administration of gadolinium contrast were enrolled into a registry. Patients were categorized into absent, midwall, or infarct patterns of LGE by blinded independent observers. Patient follow-up was completed using patient questionnaires, source record data, and the National Strategic Tracing Service. RESULTS: A total of 143 patients (age 68 ± 14 years; 97 male) were followed up for 2.0 ± 1.4 years. Seventy-two underwent aortic valve replacement, and 27 died (24 cardiac, 3 sudden cardiac deaths). Compared with those with no LGE (n = 49), univariate analysis revealed that patients with midwall fibrosis (n = 54) had an 8-fold increase in all-cause mortality despite similar aortic stenosis severity and coronary artery disease burden. Patients with an infarct pattern (n = 40) had a 6-fold increase. Midwall fibrosis (hazard ratio: 5.35; 95% confidence interval: 1.16 to 24.56; p = 0.03) and ejection fraction (hazard ratio: 0.96; 95% confidence interval: 0.94 to 0.99; p = 0.01) were independent predictors of all-cause mortality by multivariate analysis. CONCLUSIONS: Midwall fibrosis was an independent predictor of mortality in patients with moderate and severe aortic stenosis. It has incremental prognostic value to ejection fraction and may provide a useful method of risk stratification.


Subject(s)
Aortic Valve Stenosis/mortality , Hypertrophy, Left Ventricular/diagnostic imaging , Aged , Aged, 80 and over , Aortic Valve Stenosis/complications , Female , Fibrosis , Gadolinium , Heart Ventricles/diagnostic imaging , Heart Ventricles/pathology , Humans , Hypertrophy, Left Ventricular/etiology , Hypertrophy, Left Ventricular/pathology , Kaplan-Meier Estimate , Magnetic Resonance Imaging , Male , Middle Aged , Prognosis , Prospective Studies , Radionuclide Imaging , Radiopharmaceuticals , Registries , Risk Assessment
15.
Ann Thorac Surg ; 92(1): 68-73, 2011 Jul.
Article in English | MEDLINE | ID: mdl-21636071

ABSTRACT

BACKGROUND: Whether statins can improve postoperative outcome in patients without coronary artery disease undergoing heart valve operations was assessed. METHODS: Data for 3,217 patients undergoing isolated valve procedures at 2 institutions between May 2003 and May 2009 were reviewed. Clinical follow-up was completed. Two propensity-matched cohorts of 1,104 patients each were identified. Multivariable regression and Kaplan-Meyer survival analysis were performed to investigate risk factors correlated with death, stroke, myocardial infarction, and cardiac arrhythmias. RESULTS: The overall 30-day mortality rate was 2.7%, and 2,096 of 2,149 hospital survivors were alive at a median follow-up of 27 months. Preoperative statin treatment was independently associated with a significant reduction in the risk of hospital death (odds ratio [OR], 0.48; 95% confidence interval [CI], 0.32 to 0.89; p=0.001), postoperative cardiac arrhythmias (OR, 0.76; 95% CI, 0.62 to 0.93; p<0.006), and stroke (OR, 0.54; 95% CI, 0.32 to 0.92; p=0.02) but was not independently associated with a reduced risk of postoperative myocardial infarction. At follow-up, Kaplan-Meyer survival analysis showed statistically significant lower rates of mortality (χ2, 4.41; hazard ratio [HR], 1.59; 95% CI, 1.13 to 2.27; p=0.03), stroke (χ2, 11.42; HR, 2.15; 95% CI, 1.37 to 3.27; p=0.0007), cardiac arrhythmias (χ2, 19.9; HR, 2.13; 95% CI, 1.81 to 2.72; p<0.0001), and major adverse cardiac and cerebrovascular events (χ2, 3.74; HR, 1.37; 95% CI, 0.99 to 1.74; p=0.05) in patients receiving statin treatment. No statistically significant difference was found between groups in myocardial infarction incidence at follow-up. CONCLUSIONS: Statin therapy is associated with a lower rate of adverse cardiovascular events after isolated heart valve operations.


Subject(s)
Heart Valve Diseases/drug therapy , Heart Valve Diseases/surgery , Heart Valve Prosthesis Implantation/mortality , Heart Valve Prosthesis Implantation/methods , Hydroxymethylglutaryl-CoA Reductase Inhibitors/therapeutic use , Age Factors , Aged , Case-Control Studies , Cause of Death , Confidence Intervals , Female , Follow-Up Studies , Heart Valve Diseases/diagnosis , Heart Valve Diseases/mortality , Hospital Mortality/trends , Humans , Kaplan-Meier Estimate , Logistic Models , Male , Middle Aged , Multivariate Analysis , Odds Ratio , Postoperative Complications/mortality , Postoperative Complications/physiopathology , Reference Values , Retrospective Studies , Risk Assessment , Sex Factors , Time Factors , Treatment Outcome , United Kingdom
16.
Ann Thorac Surg ; 90(6): 1899-903; discussion 1903, 2010 Dec.
Article in English | MEDLINE | ID: mdl-21095333

ABSTRACT

BACKGROUND: Patients with prosthesis-patient mismatch (PPM) continue to show some degrees of left ventricular hypertrophy after aortic valve replacement for aortic stenosis. The renin-angiotensin system plays a major role in promoting and sustaining hypertrophy. In a controlled, randomized study, we tested the hypothesis that the combination of angiotensin-converting enzyme inhibitors (ACEi) plus angiotensin II receptor blocker (ARB) can be more effective in decreasing hypertrophy than a largely employed association such as ACEi plus ß-blockers in PPM patients. METHODS: We enrolled a total of 72 patients with aortic valve replacement and evidence of PPM (effective orifice area <0.85 cm(2)/m(2)) at postoperative echocardiography. At discharge, they were randomly assigned to ramipril plus candesartan (n = 36) or ramipril plus metoprolol (n = 36). RESULTS: At baseline, age, 24-hour blood pressure, left ventricular measurements, and transprosthetic gradients were similar between the two groups. After 12 months, the extent of 24-hour systolic and diastolic blood pressure decrease was similar between the two groups (-13.3% and 16.3% versus -12.3% and 15.8%, respectively; p = 0.7 and 0.8, respectively). Left ventricular mass index significantly decreased in both groups (ACEi plus ARB 165 ± 19 g/m(2) to 117 ± 17 g/m(2); p < 0.0001; ACEi plus ß-blockers 161 ± 15 g/m(2) to 128 ± 20 g/m(2); p < 0.0001). However, patients receiving ACEi plus ARB had a higher decrease of left ventricular mass (-46 ± 15 g/m(2) versus -35 ± 12 g/m(2); p = 0.001) and a lower rate of residual left ventricular hypertrophy (22% versus 47%; p = 0.04). CONCLUSIONS: This study shows that in patients with PPM, the association ACEi and ARB has a greater antiremodeling effect compared with ACEi and ß-blockers, and is independent of blood pressure.


Subject(s)
Adrenergic beta-1 Receptor Antagonists/therapeutic use , Angiotensin II Type 1 Receptor Blockers/therapeutic use , Angiotensin-Converting Enzyme Inhibitors/therapeutic use , Aortic Valve Stenosis/surgery , Heart Valve Prosthesis/adverse effects , Hypertrophy, Left Ventricular/drug therapy , Renin-Angiotensin System/drug effects , Adrenergic beta-1 Receptor Antagonists/administration & dosage , Aged , Angiotensin II Type 1 Receptor Blockers/administration & dosage , Angiotensin-Converting Enzyme Inhibitors/administration & dosage , Aortic Valve Stenosis/diagnosis , Benzimidazoles/administration & dosage , Benzimidazoles/therapeutic use , Biphenyl Compounds , Blood Pressure/drug effects , Dose-Response Relationship, Drug , Drug Therapy, Combination , Echocardiography , Female , Follow-Up Studies , Heart Ventricles/diagnostic imaging , Heart Ventricles/physiopathology , Humans , Hypertrophy, Left Ventricular/diagnosis , Hypertrophy, Left Ventricular/etiology , Male , Metoprolol/administration & dosage , Metoprolol/therapeutic use , Prosthesis Design , Prosthesis Failure , Ramipril/administration & dosage , Ramipril/therapeutic use , Retrospective Studies , Tetrazoles/administration & dosage , Tetrazoles/therapeutic use , Treatment Outcome
17.
J Heart Valve Dis ; 19(2): 171-6, 2010 Mar.
Article in English | MEDLINE | ID: mdl-20369499

ABSTRACT

BACKGROUND AND AIM OF THE STUDY: It has been shown previously that elevated plasma levels of B-type natriuretic peptide (BNP) and its N-terminal fragment (NT-pro-BNP) are related to the degree and progression of native aortic valve disease. In addition, NT-pro-BNP levels have been shown to decrease after successful aortic valve replacement (AVR). The presence of a valve prosthesis-patient mismatch (PPM) may affect the beneficial effects of AVR, however. The study aim was to investigate the relationship between PPM and NT-pro-BNP plasma levels late after AVR. METHODS: A series of consecutive patients (42 males, 31 females; mean age 66 +/- 13 years) who had undergone isolated AVR between May 2004 and July 2007 was enrolled into the study. Patients with preoperative moderate to severe mitral regurgitation, coronary artery disease, left ventricular (LV) dysfunction (ejection fraction <45%) and serum creatinine >150 mmol/l were excluded. PPM was defined severe as an indexed effective orifice area (EOAi) < or = 0.65 cm2/m2, or moderate when the EOAi was 0.66-0.85 cm2/m2. Plasma NT-pro-BNP levels and echocardiographic assessments were performed in all patients during routine follow up after surgery. RESULTS: The patients received either a biological (n = 42) or mechanical (n = 31) prosthesis. Among the patients, 21 had no PPM, 27 moderate PPM, and 25 severe PPM. At a median follow up of 18 months, the mean NT-pro-BNP plasma level was 532 pg/ml (95% CI: 393.1-671.6), and the mean LV mass index (LVMI) 120 +/- 4 g/m2, the LVEF 60 +/- 1%, the peak aortic prosthesis gradient 28 +/- 2 mmHg, and the EOAi 0.74 +/- 0.02 cm2/m2. Multivariate statistical analysis showed that NT-pro-BNP level correlated with age (beta = 0.57, p<0.0001), LVMI (beta = 0.32, p = 0.02), NYHA class (beta = 0.50, p = 0.003) and EOAi (beta = -0.38, p = 0.02). CONCLUSION: The study results showed that NT-pro-BNP levels were independently related to PPM late after isolated AVR in patients with preserved LV function. However, further investigations are required to confirm these findings and to identify their clinical implications.


Subject(s)
Aortic Valve/surgery , Heart Valve Prosthesis Implantation , Heart Valve Prosthesis , Natriuretic Peptide, Brain/blood , Aged , Aortic Valve/diagnostic imaging , Aortic Valve/pathology , Aortic Valve Stenosis/surgery , Echocardiography , Female , Humans , Male , Middle Aged , Peptide Fragments/blood , Prosthesis Fitting , Ventricular Function, Left
18.
J Thorac Cardiovasc Surg ; 140(2): 464-70, 2010 Aug.
Article in English | MEDLINE | ID: mdl-20416892

ABSTRACT

OBJECTIVE: In clinical situations in which rhabdomyolysis is common, renal dysfunction association with myoglobinemia is well described. After coronary artery bypass grafting, a rapid increase in serum myoglobin concentration is generally seen, but whether it might independently increase the risk of acute kidney injury remains to be determined. METHODS: The study population consisted of 731 consecutive patients undergoing coronary artery bypass grafting. Creatine kinase, myoglobin, and creatinine concentrations were assessed in each patient preoperatively and postoperatively. Acute kidney injury was defined as an absolute increase in serum creatinine concentration of 0.3 mg/dL or greater. RESULTS: Overall, 295 (40.3%) of 731 patients had acute kidney injury. Patients' risk profiles were significantly worse in those with acute kidney injury, and 31 (4.2%) of 731 patients required dialysis. Acute kidney injury was associated with a higher increase in serum myoglobin concentration after 1 hour from aortic declamping (534 microg/mL [interquantile range, 354-733 microg/mL] vs 377 microg/mL [interquantile range, 278-528 microg/mL], P < .0001), which persisted at 24 and at 48 hours. After adjusting for confounding factors, myoglobin concentration was found to independently predict postoperative acute kidney injury (odds ratio, 1.0011 [1 microg/mL increase]; 95% confidence interval, 1.0003-1.0019; P = .005), and this result persisted when patients with perioperative myocardial infarction were excluded from the analysis (odds ratio, 1.0007; 95% confidence interval, 1.0002-1.0009; P = .01). Myoglobin concentration had a better accuracy to discriminate patients having acute kidney injury than creatine kinase concentration at any time. CONCLUSIONS: An increase in laboratory findings of muscle injury postoperatively, especially serum myoglobin concentration, predicts the incidence of acute kidney injury and renal replacement therapy requirement, as reported in other surgical settings. Perioperative myocardial injury cannot totally explain the occurrence of increased myoglobinemia. These results suggest an important role of skeletal muscle breakdown and necrosis in determining an increased myoglobinemia concentration after coronary artery bypass grafting.


Subject(s)
Coronary Artery Bypass/adverse effects , Kidney Diseases/etiology , Rhabdomyolysis/etiology , Acute Disease , Aged , Biomarkers/blood , Chi-Square Distribution , Coronary Artery Bypass/mortality , Creatine Kinase/blood , Creatinine/blood , Female , Humans , Incidence , Kidney Diseases/blood , Kidney Diseases/mortality , Kidney Diseases/therapy , Logistic Models , Male , Middle Aged , Myoglobin/blood , Odds Ratio , Renal Dialysis , Rhabdomyolysis/blood , Rhabdomyolysis/mortality , Risk Assessment , Risk Factors , Time Factors , Treatment Outcome , Up-Regulation
19.
J Thorac Cardiovasc Surg ; 139(4): 881-6, 2010 Apr.
Article in English | MEDLINE | ID: mdl-20304136

ABSTRACT

OBJECTIVE: Left ventricular hypertrophy regression is assumed to be one of the most important goals after aortic valve replacement for aortic stenosis. A moderate decrease in the glomerular filtration rate is associated with a significantly increased risk of left ventricular hypertrophy in hypertensive patients. The effect of moderate kidney disease on left ventricular hypertrophic remodeling in other conditions of chronic left ventricular pressure overload, such as aortic stenosis, remains unknown. Therefore we tested the hypothesis that moderate chronic kidney disease affects left ventricular mass regression in patients undergoing isolated aortic valve replacement for aortic stenosis. METHODS: In 157 patients with aortic stenosis, left ventricular mass regression was assessed at 18 months after aortic valve replacement. Among them, 73 (46%) had a moderate chronic kidney disease (glomerular filtration rate between 60 and 30 mL/min per 1.73 m(2)). Patients with severely impaired kidney function (glomerular filtration rate of <30 mL/min per 1.73 m(2)) were excluded. RESULTS: After surgical intervention, left ventricular mass was significantly lower from baseline value in both groups, but patients with moderate chronic kidney disease continued to show an increased left ventricular mass (61 +/- 18 vs 50 +/- 16 g/m(2.7), P = .0001). The baseline glomerular filtration rate was significantly related to left ventricular mass at 18 months after surgical intervention (beta = -0.17, r(2) = 0.45, P = .01) and left ventricular mass absolute (beta = 0.18, r(2) = 0.19, P = .03) and relative (beta = 0.20, r(2) = 0.21, P = .02) regression. These associations persisted after adjusting for confounding factors, including hypertension and patient-prosthesis mismatch. After a mean time of 34 +/- 12 months from surgical intervention, congestive heart failure symptoms developed mainly in subjects with moderate chronic kidney disease (adjusted hazard ratio, 1.9; 95% confidence interval, 1.2-3.9; P = .035). CONCLUSIONS: Patients with aortic stenosis with concomitant moderate chronic kidney disease present a less evident left ventricular mass regression after aortic valve replacement. Moreover, this condition is related to an increased occurrence of congestive heart failure after surgical intervention.


Subject(s)
Aortic Valve Stenosis/surgery , Heart Valve Prosthesis Implantation , Hypertrophy, Left Ventricular/etiology , Kidney Diseases/etiology , Aged , Aged, 80 and over , Aortic Valve Stenosis/complications , Chronic Disease , Female , Humans , Hypertrophy, Left Ventricular/physiopathology , Kidney Diseases/complications , Male , Middle Aged , Remission Induction
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