Mini-extracorporeal circulation minimizes coagulation abnormalities and ameliorates pulmonary outcome in coronary artery bypass grafting surgery.

Hemostasis is impaired during CABG and coagulation abnormalities often result in clinically relevant organ dysfunctions, eventually increasing morbidity and mortality rates. Fifteen consecutive patients with coronary artery disease submitted to conventional extracorporeal circulation (cECC) have been compared with 15 matched patients, using mini-ECC (MECC). Postoperative lung function was evaluated according to gas exchange, intubation time and lung injury score. In the MECC group, thrombin-antithrombin complex levels (TaTc), prothrombin fragments (PF1+2) formation and thromboelastography (TEG) clotting times were lower compared to the cECC group (p=0.002 and p<0.001, respectively) whereas postoperative blood loss was higher in the cECC group (p=0.030) and more patients required blood transfusion (p=0.020). In the MECC group, postoperative gas exchange values were better, intubation time shorter and lung injury score lower (p<0.001 for all comparisons). Our study suggests that MECC induces less coagulation disorders, leading to lower postoperative blood loss and better postoperative lung function. This approach may be advantageous in high-risk patients.

Mitral valve repair for the treatment of degenerative mitral valve disease with or without prosthetic ring annuloplasty: long-term outcomes.

AIM: Aim of the study was to evaluate late outcomes of mitral valve repair with and without the use of prosthetic ring annuloplasty and standardized techniques for the treatment of degenerative mitral regurgitation (MR). METHODS: Three hundred and five patients (mean age 62 ± 12 years) underwent mitral valve repair between January 1992 and February 2010 for degenerative MR. In the last five years, all repair techniques were performed routinely using prosthetic ring annuloplasty, with or without quadrangular or triangular resection of posterior leaflet and/or edge-to-edge technique. Mean follow-up (99% complete) was 78 ± 46 (2-220) months. RESULTS: Operative mortality was 0.9% (3/305), 15-year actuarial survival 82% ± 4%. At 15 years freedom from cardiac death was 89% ± 3.7%, from reoperation 84% ± 5.8%, from endocarditis 100%. Independent predictors of all-causes mortality were advanced age at operation (P=0.0006) and mitral valve repair without reductive prosthetic annuloplasty (P=0.0019). Death for cardiac causes was significantly higher when reductive annuloplasty was performed without the use of prosthetic ring (P<0.01). Late progression to moderate or severe MR was observed in 23/299 patients (7.7%). Independent predictors of progression to moderate or severe MR was annuloplasty without the use of prosthetic ring (P=0.0053) and postoperative residual mild MR (P=0.0014). Reoperation was required in 13/299 patients (4.4%). At 10 years freedom from moderate or severe MR was 86% ± 6% and 92% ± 4% in patients with postoperative absent or trivial residual MR, respectively, as compared to 38% ± 15% in those with postoperative residual mild MR (P<0.0001), freedom from reoperation 94% ± 4% and 90% ± 14% vs. 56% ± 16% (P<0.0001). CONCLUSION: Prosthetic annuloplasty in association with standardized techniques confers over 10 years survival advantage and better durability.

Multidetector computed tomographic coronary angiography as an alternative to conventional coronary angiography in non-coronary surgical patients.

AIM: Aim of our study was to evaluate multidetector 64-slice spiral computed tomography (MSCT) as an alternative to traditional coronary angiography (CA) to detect concomitant coronary artery disease (CAD) in patients initially admitted for non-coronary surgical procedures. METHODS: We have analyzed data of 380 consecutive patients operated from 2006 to 2008 initially admitted for aortic (N.=170) or mitral (N.=67) valve disease, ascending aorta aneurysm ± aortic valve disease (N.=99), and other (combined valve diseases, tumors; N.=44). These patients were submitted either to MSCT (Group CT, N.=112) or to CA (Group A, N.=268). Inclusion criteria to perform MSCT were no previous myocardial infarction or documented CAD, normal left ventricular function, sinus rhythm, less than 2-3 premature ventricular or atrial contractions /min. RESULTS: In Group CT, CAD was definitively excluded in 95 patients (85%) and was detected in 17; 8 of those 17 patients were subsequently submitted to CA and coronary artery bypass surgery for significant CAD. As compared to those in Group A, patients in Group CT were younger (64±15 vs. 70±10 years, P<0.0001), had less hypertension (P=0.0001), chest pain (P<0.05), peripheral vascular disease (P<0.05). NYHA class, incidence of diabetes, smoking habit, family history of CAD were similar. The incidence of operative mortality, postoperative myocardial infarction was not significantly different in both Group CT (0%) and A (0.4%) (P=NS). CONCLUSION: In selected cardiac surgical patients less invasive 64-slice MSCT can be with some limits an alternative to CA to rule out CAD, as confirmed by the absence of postoperative ischemic complications.

Surgical treatment of femoral artery pseudoaneurysms after cardiac catheterization.

AIM: To report a clinical experience about surgical treatment of iatrogenic peripheral artery pseudoaneurysms (FPA). METHODS: This is a retrospective review of 90 consecutive patients (46 males, 44 females, mean age 66.2 years, range 33-86) with FPA complicating coronary angiography or angioplasty, observed between October 1990 through June 2006. RESULTS: A 3 cm pseudoaneurysm or larger was confirmed by duplex ultrasound scanning in 90 out of 21 454 cardiac patients (0.42%), occurring more frequently in interventional (59/3 983) rather than diagnostic (31/17 471) procedures (1.48% vs 0.17%). The surgical treatment consisted in direct closure with polypropilene suture and occasionally, patch angioplasty or bypass. No limb loss occurred. There were 4 wound complications (4.4%), one pulmonary embolism (1.1%), 3 deaths (3.3%). CONCLUSION: Classical results reported in literature demonstrate that the surgical repair of femoral pseudoaneurysms following cardiac catheterization is safe, effective and durable. In these series, although low major morbidity (1.1%) and no cases of limb loss were reported, the authors observed 3 death (4.4%), resulting from the severity of cardiac disease in 2 cases and from the vascular repair itself in one case (femoral endoarteritis). These results substantiate the common observation that patients who actually require invasive coronary diagnosis and treatment are often affected by advanced cardiovascular disease and suffer the occurrence of complications, having a high risk of death. Therefore, any surgical treatment should be performed with strict adherence to sound vascular surgical principles.

Influence of sternal size and inadvertent paramedian sternotomy on stability of the closure site: a clinical and mechanical study.

BACKGROUND: The influence of sternal size and of inadvertent paramedian sternotomy on stability of the closure site is not well defined. METHODS: Data on 171 consecutive patients undergoing cardiac surgery through a midline sternotomy were prospectively collected. Intraoperative measurements of sternal dimension included thickness and width at the manubrium, the third and fifth intercostal spaces; paramedian sternotomy was defined as width of one side of the sternum equaling 75% or more of the entire width, at any of the three levels. The chest was closed with simple peristernal steel wires and inspected to detect deep wound infection and/or instability for 3 postoperative months. The sternal factors and several patient/surgery-related factors were included in a multivariate analysis model to identify factors affecting stability. An electromechanical traction test was conducted on 6 rewired sternal models after midline or paramedian sternotomy and separation data were analyzed. RESULTS: Chest instability was detected in 12 (7%) patients and wound infection in 2 (1.2%). Patient weight (P = .03), depressed left ventricular function (P = .04), sternum thickness (indexed to body weight, P = .03), and paramedian sternotomy (P = .0001) were risk factors of postoperative instability; paramedian sternotomy was the only independent predictor (P = .001). The electromechanical test showed more lateral displacement of the two rewired sternal halves after paramedian than midline sternotomy (P = .002); accordingly, load at fracture point was lower after paramedian sternotomy (220 +/- 20 N vs 545 +/- 25 N, P = 0.001). CONCLUSIONS: Inadvertent paramedian sternomoty strongly affects postoperative chest wound stability independently from sternal size, requiring prompt reinforcement of chest closure.

Preoperative shift from glibenclamide to insulin is cardioprotective in diabetic patients undergoing coronary artery bypass surgery.

AIM: The cardioprotective effects afforded by volatile anesthetics, i.e. isoflurane, during heart surgery may be due to preconditioning of the myocardium through the activation of KATP channels. The aims of this study were to establish whether glibenclamide prevents the isoflurane-induced cardioprotection in diabetic patients undergoing coronary surgery (CABG) and whether this cardioprotective effect can be restored by preoperative shift from glibenclamide to insulin therapy. METHODS: We enrolled 60 patients undergoing CABG. Twenty consecutive non-diabetic patients were randomized to receive conventional anesthesia (CA) or conventional anesthesia plus isoflurane (ISO) (added to the inspired oxygen before starting cardiopulmonary bypass); 40 consecutive diabetic patients in chronic treatment with oral glibenclamide were randomized to conventional anesthesia (G-CA), conventional anesthesia plus isoflurane (G-ISO), conventional anesthesia after shifting to insulin (I-CA) or conventional anesthesia plus isoflurane after shifting to insulin (I-ISO). Serum levels of cardiac troponin I (CTnI) and CK-MB, as markers of ischemic injury, were obtained 1, 24, 48 and 96 hours, postoperatively. RESULTS: Postoperative peak levels of CTnI and CK-MB were lower in ISO than in CA (0.5+/-0.3 vs 2.8+/-2.2 ng/ml, p<0.05 and 61+/-27 vs 79+/-28 U/L, p<0.05, respectively), as well as in I-CA and I-ISO than G-CA and G-ISO groups (0.5+/-0.7 and 0.7+/-0.9 vs 3.5+/-3 and 2.7+/-2.5 ng/ml, p<0.05; 47+/-7 and 41+/-5 vs 85+/-28 and 50+/-23 U/L, p<0.05, respectively). No significant differences were detected in postoperative hemodynamic variables or in-hospital outcome. CONCLUSION: This prospective randomized study shows a cardioprotective effect of preoperative administration of isoflurane during CABG. Such an effect is prevented by glibenclamide, but can be restored in diabetic patients by preoperative shift from glibenclamide to insulin.

A comparison of coronary artery stenting with angioplasty for isolated stenosis of the proximal left anterior descending coronary artery: five year clinical follow up.

BACKGROUND: Stent implantation for isolated stenosis of the proximal left anterior descending coronary artery (LAD) with preserved left ventricular function has been found to have a better clinical and angiographic outcome at one year than balloon angioplasty (PTCA). OBJECTIVE: To establish whether those results are maintained at five year follow up. METHODS: Patients were followed at least every six months. For those who died during follow up, data were obtained from medical records. MAIN OUTCOME MEASURES: Freedom from death, non-fatal myocardial infarction, cerebrovascular accident, and repeated target lesion revascularisation. Secondary end points were revascularisation in a remote region and freedom from angina. RESULTS: Follow up was complete in all patients. At five years, the primary end point was reached more often by patients randomised to stent implantation than to PTCA (80% v 53%; odds ratio (OR) 0.29 (95% confidence interval (CI) 0.13 to 0.69); p = 0.0034). In the PTCA group, 35% of patients underwent target lesion revascularisation v 15% in the stent group (OR 0.33, 95% CI 0.13 to 0.80; p = 0.014). There was a trend towards increased mortality in the PTCA group than in the stent group (17% v 7%; OR 0.36, 95% CI 0.10 to 1.21; p = 0.098). No significant differences were found between PTCA and stent groups for non-fatal myocardial infarction (8% v 5%; OR 0.58, 95% CI 0.13 to 2.54; p = 0.46) or cerebrovascular accident (2% v 0%). CONCLUSIONS: In patients with isolated stenosis of the proximal LAD, a five year clinical follow up confirmed a better outcome in those treated with stenting than with PTCA.

Early diagnosis of acute mesenteric ischemia after cardiopulmonary bypass.

BACKGROUND: The aim of this study is to identify significant risk factors and eventual clinical markers associated with acute mesenteric ischemia (AMI) after cardiopulmonary bypass. METHODS: The study was retrospectively performed on a group of 19 patients (group A) undergoing cardiac surgery between January 1991 and December 1999, who developed AMI within 30 days of their hospitalization. A control group of 48 patients (group B) was compared in order to define preoperative and operative risk factors for AMI. RESULTS: At the abdominal operation, a non-occlusive mesenteric ischemia was found in every case. In-hospital mortality was 84.2% (16/19). Compared to the control, there was a significant difference in aortic cross-clamp time (p<0.001) and use of inotropic drugs (p<0.01). Postoperatively, the studied group (group A) had a significantly higher mean value of the enzymatic serum levels at any time. CONCLUSIONS: A high index of suspicion for mesenteric ischemia after cardiopulmonary bypass should be considered in patients with conditions of hypoperfusion. The early laboratory signs of AMI might be searched during the first postoperative hours.

Troponin I release after CABG surgery using two different strategies of myocardial protection and systemic perfusion.

BACKGROUND: Controversies still exist over the optimal temperature for blood cardioplegia and systemic perfusion. This study investigates the effect of temperature of blood cardioplegia and systemic perfusion on the release of troponin I and other biochemical markers. METHODS: One hundred and fifty-four consecutive patients were randomly assigned to one of two cardioplegic and systemic perfusion strategies of cold blood cardioplegia with moderate systemic hypothermia (27 degrees C) or tepid blood cardioplegia with mild systemic hypothermia (33 degrees C). Cardiac troponin I and other biochemical markers were measured at baseline, at the end of surgery, at 12 hours and daily thereafter. A two-way ANCOVA for repeated measure was performed to test the effect of cardioplegia on enzyme release independently of variables that were different between the two groups. RESULTS: The time course of dismission of troponin I, creatine kinase MB, and lactate dehydrogenase were significantly lower with tepid blood cardioplegia and mild systemic perfusion independently of the number of distal anastomoses, CPB time, cross clamp time or total volume of cardioplegia. There were no differences between the two groups in the release of total creatine kinase, aspartate transaminase and alanine transferase. CONCLUSIONS: Both strategies of myocardial protection and systemic perfusion guarantee subclinical minor myocardial damage. The strategy of tepid whole blood cardioplegia and mild systemic hypothermia seems to preserve myocardium better than whole blood cold cardioplegia.

Clinical evaluation of St Jude Medical Hemodynamic Plus versus standard aortic valve prostheses: The Italian multicenter, prospective, randomized study.

OBJECTIVE: Hemodynamic and clinical performances of 21-mm and 23-mm St Jude Medical Hemodynamic Plus aortic valves (St Jude Medical, Inc, St Paul, Minn) were compared with those of 21-mm and 23-mm St Jude Medical standard cuff aortic valves in the first such multicenter, prospective, randomized study. Hemodynamic Plus valves are mechanical, bileaflet prostheses suitable for the small aortic anulus. METHODS: Patients with 21-mm and 23-mm anulus diameters were randomized to receive either a Hemodynamic Plus or a standard cuff valve. Postoperatively and at 6 months after the operation, patients underwent 2-dimensional Doppler echocardiography. Ejection fraction, cardiac output, peak gradient, mean gradient, effective orifice area, effective area index, and performance index were calculated. Postoperative and 6-month echocardiographic measurements and their variations across observation times were analyzed statistically. RESULTS: Of the 140 patients enrolled, 5 died at operation and 1 died of aortic dissection during the follow-up period. Eight patients were lost to follow-up. A total of 125 patients completed the study. In 1 patient a sewing cuff escaped intraoperatively. At 6 months the 21-mm and 23-mm Hemodynamic Plus valves showed significantly lower peak gradients and mean gradients than those of the 21-mm and 23-mm standard cuff valves. The 21-mm Hemodynamic Plus valves had gradients similar to those of the 23-mm Hemodynamic Plus valves. The effective orifice area did not differ significantly between the Hemodynamic Plus and standard cuff valves at either measurement. No valve mismatch was found in the 4 groups of patients. A more enhanced decrease of peak gradients and mean gradients and a more enhanced increase of effective orifice areas, effective area indices, and performance indices were found across observation times for patients with Hemodynamic Plus valves compared with those with standard cuff valves. CONCLUSIONS: Clinical hemodynamic performances of 21-mm and 23-mm St Jude Medical Hemodynamic Plus valves correspond closely with those of standard cuff valves, and gradients are substantially better than those of standard cuff valves of the same diameter. Therefore, use of this valve may minimize the need for aortic anulus enlargement. Early follow-up results with the Hemodynamic Plus valves were excellent, although more time is required to confirm this outcome.

[Aortocoronary bypass in severe left ventricular dysfunction: 9 years of clinical experience and mid-term results]. / Il bypass aortocoronarico nella disfunzione ventricolare sinistra severea: nove anni di esperienza clinica e risultati a medio termine.

BACKGROUND: Compared with medical therapy alone, coronary artery bypass surgery improves survival in patients with coronary disease and left ventricular dysfunction. Many of these patients have a hibernating myocardium secondary to chronic ischemia with the potential for improvement in left ventricular function and heart failure symptoms following revascularization therapy. Cardiac transplantation remains the treatment of choice for patients with severe congestive heart failure. METHODS: From January 1992 to June 2000, 351 consecutive patients (318 men, 33 women, mean age 62.8 +/- 8.9 years) with a left ventricular ejection fraction (EF) < or = 35% and with multivessel coronary artery disease underwent isolated coronary artery bypass grafting. Preoperatively 226 patients were in CCS class III-IV and 113 in NYHA class III-IV. The mean number of grafts was 3.4 +/- 0.8/patient and complete revascularization was achieved in 98.6% of cases. The internal mammary artery was used in 341 patients (97.2%) and in 328 (96%) as a graft for the left anterior descending artery. Follow-up was obtained in 97% of the patients and on average lasted 42 +/- 28 months. RESULTS: The hospital mortality was 5.9%. At multivariate analysis urgent operation (p < 0.01) and a lower EF (25.9% in deaths vs 29.1%, p < 0.05) were predictors of an increased operative mortality. EF (assessed postoperatively at transthoracic echocardiography in survivors) improved from 28.9 +/- 5.7 to 34.4 +/- 7.7% (p < 0.0001). At 1, 3, 5, 7, and 9 years respectively, the all-cause survival was 93 +/- 1.5, 85 +/- 2.2, 77 +/- 3.1, 69 +/- 4.9, and 60 +/- 7.3% and the freedom from cardiac death was 94 +/- 1.4, 89 +/- 1.9, 88 +/- 2, 80 +/- 4.7, and 76 +/- 5.7% with an improvement in the anginal and congestive heart failure status (p < 0.0001). CONCLUSIONS: In patients with coronary artery disease and severe left ventricular dysfunction, after evaluation of the clinical presentation, of the usefulness of vessels as grafts and of the presence of myocardial viability, 1) coronary artery bypass grafting can be performed with a low mortality and a good mid-term survival, 2) improvement in left ventricular function can be documented after coronary bypass surgery, 3) the internal mammary artery can be safely used as a graft, 4) the quality of life is improved as demonstrated by the improvement in the anginal and congestive heart failure status.

Unstable angina and elevated c-reactive protein levels predict enhanced vasoreactivity of the culprit lesion.

BACKGROUND: Because plaque inflammation may modulate coronary vasomotion, the association between systemic levels of C-reactive protein (CRP) and coronary vasoreactivity was assessed in patients with stable or unstable angina. METHODS AND RESULTS: In 31 patients with stable angina and 23 patients with unstable angina undergoing coronary angiography, minimal luminal diameter (MLD) of the culprit lesion was measured by quantitative coronary angiography at baseline, during the cold pressor test (CPT), and after intracoronary administration of nitroglycerin (NTG) and expressed as percent change from baseline. MLD of patients with unstable angina exhibited a greater reduction during CPT and a greater increase after NTG than did patients with stable angina (-17+/-14% versus -5+/-12%, P=0.0013, and 34+/-25% versus 8+/-20%, P<0.001, respectively). According to preprocedural serum levels of CRP, 36 patients had normal (

[Isolated aortic valve replacement with CarboMedics mechanical prosthesis: 9-year clinical experience and mid-term results]. / Sostituzione valvolare aortica isolata con protesi meccanica carbomedics: nove anni di esperienza clinica e risultati a medio termine.

BACKGROUND: Appraisal of the medium-term results of isolated aortic valve replacement with a CarboMedics mechanical prosthesis. METHODS: We assessed the clinical data of 195 consecutive patients (mean age 59.7+/-10.9 years) operated on between January 1992 and June 2000. Valve disease consisted of aortic stenosis regurgitation in 94 patients (48.2%), isolated aortic failure in 57 (29.2%) and isolated stenosis in 44 (22.6%). One hundred and four patients were in NYHA functional class III and 25 in NYHA functional class IV Follow-up was by telephone interview to 100% of the patients (average follow-up 39+/-20 months). RESULTS: The operative mortality was 3.6% (5% in the period January 1992-December 1995, 1.3% in the period January 1996-June 2000). Sixteen deaths occurred in the long term. Thus, the actuarial survivals at 36 and 72 months were 92+/-7% and 82+/-16% respectively. In the group of survivors, 139 patients (81%) were in NYHA class 1,26 (15%) in NYHA class II, and 7 (4%) in NYHA class III. The freedom from embolic events was 96+/-3.7% and that from hemorrhagic events was 90+/-9.4%. All the events occurred during the first 36 months; none of the patients developed infections or periprosthetic leaks. CONCLUSIONS: At the medium term, the CarboMedics mechanical valve prosthesis appears to be reliable, with an actuarial survival, quality of life and incidence of morbidity comparable to those reported for other types of second-generation mechanical prostheses.

Opening and closing characteristics of the aortic valve after valve-sparing procedures using a new aortic root conduit.

BACKGROUND: The durability of aortic valve-sparing procedures is negatively affected by increased leaflet stress in the absence of normally shaped sinuses of Valsalva. We compared valve motion after remodeling procedures using a standard conduit and a specifically designed aortic root conduit. METHODS: Echocardiographic studies of the aortic valve dynamics were performed in 14 patients after remodeling of the aortic root (7 standard conduits, group A; 7 new conduits, group B) and in 7 controls (group C). Opening and closing leaflet velocities and percent of slow closing leaflet displacement were measured. Root distensibility and the pressure strain of the elastic modulus were measured at all root levels. RESULTS: Root distensibility and the pressure strain of the elastic modulus were different in group A and B only at the sinuses (p < 0.001). Opening and closing leaflet velocities were not different among groups. Slow closing leaflet displacement was markedly more evident in group B patients (24.2%+/-1.9% versus 2.5%+/-1.9% in group A, p < 0.001) and similar to controls (22.1%+/-7.9%). CONCLUSIONS: The new conduit guarantees dynamic features of the aortic valve leaflets superior to those obtained with standard conduits and more similar to normal subjects.

Mid-term follow-up of aortic root remodelling compared to Bentall operation.

OBJECTIVES: Aortic valve sparing with root remodelling has proven useful in cases of aortic regurgitation secondary to ascending aorta disease. An excessive rate of re-operation for recurrent aortic regurgitation after this conservative approach might compensate the prosthesis-related risk of the Bentall operation. METHODS: From January 1995 to September 2000, 69 consecutive patients with aortic expansive aneurysm and concomitant aortic valve disease, were submitted to the Bentall operation (group A, n=37) in the presence of an abnormal valve, or to root remodelling (group B, n=32) in cases of secondary aortic incompetence. One patient in group A and four in group B had Marfan syndrome. The follow-up was 1021 patient-months (range, 1-68 months) in group A and 926 in group B (1-64 months). The event-free survival was calculated using the Kaplan-Meier method, and the difference between curves was evaluated using the Mantel-Cox log-rank test. RESULTS: The operative mortality was 5% in group A and 0% in group B. One patient died at follow-up in group A and none in group B. Four patients (three Marfan) in group B were re-operated on because of recurrent aortic regurgitation. The 5-year event-free survival was 88+/-7% in group A and 82+/-8% in group B (P=0.58). Early residual aortic regurgitation remained stable over time only in patients with good early results. CONCLUSIONS: Mid-term follow-up failed to reveal statistically significant differences in the clinical outcome between remodelling and the Bentall operation. Our results support the widespread use of root remodelling, provided that an indication to this conservative approach is achieved after careful, case-by-case evaluation. A good early operative result is likely to remain stable over time.

Bentall procedure with a stentless valve and a new aortic root prosthesis.

We describe a technique to replace the aortic root by means of a stentless valve and a new aortic root Dacron graft (Gelweave Valsalva, Sulzer Vascutek, Renfrewshire, Scotland) that allows an anatomical reconstruction of the sinuses of Valsalva.

The use over time of statins in coronary patients in an Italian tertiary referral center.

BACKGROUND: In the last decade, large-scale clinical trials have consistently shown that therapy with statins is of great benefit to patients with and at risk of developing coronary artery disease. We assessed, in a sample of patients with coronary artery disease in whom coronary angiography was indicated and hospitalized in the last 10 years, the use of statins at admission. METHODS: One hundred patients with stable coronary artery disease were randomly selected per year from 1991 to 2000. The final study population consisted of 1000 patients. The prescription of statins for > or = 6 months before hospital admission was determined from a hospital-wide clinical database. RESULTS: From 1995, the prevalence of patients treated with statins at hospital admission progressively increased. In 1991, only 2% of patients were treated with statins before hospital admission while in the year 2000, 38% of patients were receiving this treatment. The mean prevalence of patients treated with statins before and after 1995 was 3 vs 22% (p < 0.0001) respectively. The distribution of the demographic and clinical parameters and the prevalence of conventional cardiovascular risk factors were similar in patients treated or not treated with statins. CONCLUSIONS: After 1994, in coincidence with the publication of the results of clinical trials showing the benefit of statins in patients with coronary artery disease, the use of these drugs increased significantly. This finding suggests that the widespread diffusion of the results of the major clinical trials and of guidelines drawn up by medical associations have had a significant impact on statin prescription in patients with coronary artery disease. Nevertheless our data also indicate that, despite overwhelming evidence on the benefits of statin therapy, in current clinical practice cardiologists are not optimally utilizing lipid management and that statins are frequently prescribed without an appropriate analysis of risk factors.

Mechanisms of myocardial ischemia in a patient with left main coronary artery atresia.

This report describes the different clinical and instrumental manifestations of coronary ischemia in a patient with left main coronary artery atresia. Exercise test and thallium-201 perfusion scintigraphy during isometric exercise test were negative for angina and electrocardiographic changes. Conversely, dipyridamole infusion caused severe angina, marked ST-segment changes and diffuse thallium-201 uptake abnormalities. This peculiar anatomical condition offers the opportunity of high-lighting the role played by the microcirculation in determining myocardial ischemia.