Aortic surgery complications evaluated by an implanted continuous electrocardiography device: a case report.

INTRODUCTION: Cardiac arrhythmias are a major cause for morbidity and mortality in patients undergoing non-cardiac vascular surgery. REPORT: An implantable loop recorder (Reveal(®) XT) was used for continuous heart rhythm monitoring to detect perioperative arrhythmias in a 69-year-old man undergoing major vascular surgery for an infected aortobifemoral prosthesis. The Reveal(®) detected several episodes of asymptomatic new-onset atrial fibrillation postoperatively, associated with elevated serum levels of troponin-T and N-terminal pro-B-type natriuretic peptide NT-proBNP). DISCUSSION: Continuous heart rhythm monitoring with assessment of serum cardiac biomarkers may allow early identification and treatment of patients at high risk of perioperative cardiovascular complications, in particular, cardiac arrhythmias.

Prognosis of vascular surgery patients using a quantitative assessment of troponin T release: is the crystal ball still clear?

BACKGROUND: Cardiac troponin T (cTnT) assays with increased sensitivity might increase the number of positive tests. Using the area under the curve (AUC) with serial sampling of cTnT an exact quantification of the myocardial damage size can be made. We compared the prognosis of vascular surgery patients with integrated cTnT-AUC values to continuous and standard 12-lead electrocardiography (ECG) changes. METHODS: 513 Patients were monitored. cTnT sampling was performed on postoperative days 1, 3, 7, 30 and/or at discharge or whenever clinically indicated. If cTnT release occurred, daily measurements of cTnT were performed, until baseline was achieved. CTnT-AUC was quantified and divided in tertiles. All-cause mortality and cardiovascular events (cardiac death and myocardial infarction) were noted during follow-up. RESULTS: 81/513 (16%) Patients had cTnT release. After adjustment for gender, cardiac risk factors, and site and type of surgery, those in the highest cTnT-AUC tertile were associated with a significantly worse cardiovascular outcome and long-term mortality (HR 20.2; 95% CI 10.2-40.0 and HR 4.0; 95% CI 2.0-7.8 respectively). Receiver operator analysis showed that the best cut-off value for cTnT-AUC was <0.01 days*ng m for predicting long-term cardiovascular events and all-cause mortality. CONCLUSION: In vascular surgery patients quantitative assessment of cTnT strongly predicts long-term outcome.

Prognosis of atrial fibrillation in patients with symptomatic peripheral arterial disease: data from the REduction of Atherothrombosis for Continued Health (REACH) Registry.

BACKGROUND: Atrial fibrillation (AF) is a significant risk factor for cardiovascular (CV) mortality. This study aims to evaluate the prognostic implication of AF in patients with peripheral arterial disease (PAD). METHODS: The International Reduction of Atherothrombosis for Continued Health (REACH) Registry included 23,542 outpatients in Europe with established coronary artery disease, cerebrovascular disease (CVD), PAD and/or > or =3 risk factors. Of these, 3753 patients had symptomatic PAD. CV risk factors were determined at baseline. Study end point was a combination of cardiac death, non-fatal myocardial infarction (MI) and stroke (CV events) during 2 years of follow-up. Cox regression analysis adjusted for age, gender and other risk factors (i.e., congestive heart failure, coronary artery re-vascularisation, coronary artery bypass grafting (CABG), MI, hypertension, stroke, current smoking and diabetes) was used. RESULTS: Of 3753 PAD patients, 392 (10%) were known to have AF. Patients with AF were older and had a higher prevalence of CVD, diabetes and hypertension. Long-term CV mortality occurred in 5.6% of patients with AF and in 1.6% of those without AF (p<0.001). Multivariable analyses showed that AF was an independent predictor of late CV events (hazard ratio (HR): 1.5; 95% confidence interval (CI): 1.09-2.0). CONCLUSION: AF is common in European patients with symptomatic PAD and is independently associated with a worse 2-year CV outcome.

The effect of statins on perioperative events in patients undergoing vascular surgery.

Despite recent advancements in perioperative care and guideline recommendations, patients undergoing vascular surgery remain at risk for perioperative cardiovascular complications. In this review, the results are summarized of the most recent studies on the effectiveness and safety of perioperative statin use for the prevention of these perioperative cardiovascular complications. Perioperative statin therapy was associated with an improvement in postoperative cardiovascular outcome and a reduction in serum lipid levels and levels of inflammation markers.

Prognosis of transient new-onset atrial fibrillation during vascular surgery.

BACKGROUND: Chronic atrial fibrillation (AF) in a non-surgical setting is associated with cardiovascular events. However, the prognosis of transient new-onset AF during vascular surgery is unknown. OBJECTIVE: The purpose of this study is to investigate the prognosis of new-onset AF during vascular surgery using continuous electrocardiographic monitoring (continuous-ECG). METHODS: In this study, 317 patients, all in sinus rhythm, scheduled for major vascular surgery were screened for cardiac risk factors. Continuous-ECG recordings for 72h and standard ECG on days 3, 7 and 30 were used to identify new-onset AF. Cardiac troponin T (cTnT) was measured routinely after surgery. Study endpoint was a composite of cardiac death, myocardial infarction, unstable angina and stroke (cardiovascular events) at 30 days after surgery and during late follow-up. Median follow-up was 12 (interquartile range 2-28) months. RESULTS: New-onset AF was noted in 15 (4.7%) patients. All but three patients returned spontaneously to sinus rhythm. The composite endpoint of cardiovascular events within 30 days and during late follow-up occurred in 34 (11%) and 62 (20%) patients, respectively. Multivariate regression analysis showed that new-onset AF was associated with perioperative (hazard ratio (HR) 6.0; 95% CI: 2.4-15) and late cardiovascular events (HR 4.2, 95% CI: 2.1-8.8). CONCLUSION: New-onset AF during vascular surgery is associated with an increased incidence of 30-day and late cardiovascular events.

Long-term cardiac outcome in high-risk patients undergoing elective endovascular or open infrarenal abdominal aortic aneurysm repair.

OBJECTIVES: To assess long-term outcome of patients at high cardiac risk undergoing endovascular or open AAA repair. METHODS: Patients undergoing open or endovascular infrarenal AAA repair with >or=3 cardiac risk factors and preoperative cardiac stress testing (DSE) at 2 university hospitals were studied. Main outcome was cardiac event free and overall survival. Multivariate Cox regression analysis was used to evaluate the influence of type of AAA repair on long-term outcome. RESULTS: In 124 patients (55 endovascular, 69 open) the number and type of cardiac risk factors, medication use and DSE results were similar in both groups. In multivariable analysis, adjusting for cardiac risk factors, stress test results, medication use, and propensity score endovascular repair was associated with improved cardiac event free survival (HR 0.54; 95% CI 0.30-0.98) but not with an overall survival benefit (HR 0.73; 95% CI 0.37-1.46). Importantly, statin therapy was associated with both improved overall survival (HR 0.42; 95% CI 0.21-0.83) and cardiac event free survival (HR 0.45; 95% CI 0.23-0.86). CONCLUSIONS: The perioperative cardiac benefit of endovascular AAA repair in high cardiac risk patients is sustained during long-term follow-up provided patients are on optimal medical therapy but it is not associated with improved overall long-term survival.

Ontogeny modifies the effects of water stress on stomatal control, leaf area duration and biomass partitioning of Pennisetum glaucum.

• Experiments are presented that test the relative importance, during ontogeny, of stomatal control and leaf area expansion to optimum seasonal water use in pearl millet (Pennisetum glaucum). These parameters play a key role in the compromise between plant growth and water saving under unpredictable conditions of semiarid environments. • The response of growth and water use of crops to successive 15 d drought periods was measured under field conditions in Niger (West Africa). • From emergence to anthesis, biomass partitioning to stems and panicles depended strongly on leaf area development. Water use was linearly related to green leaf area duration in well watered plots, but was reduced proportionally more than green leaf area in drought-affected plots. The relations of crop growth rate and transpiration efficiency to leaf area depended on ontogenetic changes in biomass partitioning. • In P. glaucum, stomata play a dominant role in reducing crop water use under preanthesis drought, although this control becomes negligible after anthesis because of ontogenetic decline in the range of stomatal conductance. The rate of leaf senescence after anthesis is not drought-dependent.

MHC-antigens: constituents of the envelopes of human and simian immunodeficiency viruses.

Immunoelectron microscopy was applied to study the antigenic make-up of human and simian immunodeficiency viruses (HIV, SIV) grown in cells expressing either MHC class I (Molt-3) or MHC class I and II (H9) antigens. A variety of antibodies directed against the surface glycoprotein gp120 of HIV and against MHC class I and II antigens were employed. Consistent with earlier observations on the loss of HIV envelope components, gp120 was only weakly demonstrable on the mature virion. MHC class I determinants were present regularly in small amounts on HIV and SIV. Class II antigens, e.g. HLA-DR were found in high density on HIV and SIV grown in H9 cells, but were absent, as expected, on virus grown in Molt-3 cells. These cellular surface antigens are constituents of the virion. The presence of MHC class II antigens in virus preparations used for diagnostic purposes might explain some of the false positive results in HIV serology. Possible biological implications of these virus associated cellular antigens for the pathogenicity of HIV are discussed.

Ultrastructural findings in oral Kaposi's sarcoma (AIDS).

Ten biopsies of oral Kaposi's sarcoma were examined histologically and ultrastructurally. Histologically, early and late tumor stages could be differentiated. On the ultrastructural level, endothelial-like and spindle-shaped tumor cells were revealed. Tumor cells associated with vessel-like spaces showed partly interrupted basal membranes, Weibel-Palade bodies, desmosomes and tight-junctions, while spindle-shaped cells lacked these ultrastructural features of endothelial cells. Within the cytoplasm of endothelial-like cells, aggregates of tubular structures were observed. Histological and ultrastructural findings in oral Kaposi sarcoma are comparable to those of such other organs as skin and intestines. The ultrastructural findings indicate an endothelial origin, at least of endothelial-like tumor cells.