Preoperative atorvastatin treatment in CABG patients rapidly improves vein graft redox state by inhibition of Rac1 and NADPH-oxidase activity.

BACKGROUND: Statins improve clinical outcome of patients with atherosclerosis, but their perioperative role in patients undergoing coronary artery bypass grafting (CABG) is unclear. We hypothesized that short-term treatment with atorvastatin before CABG would improve the redox state in saphenous vein grafts (SVGs), independently of low-density lipoprotein cholesterol (LDL)-lowering. METHODS AND RESULTS: In a randomized, double-blind controlled trial, 42 statin-naïve patients undergoing elective CABG received atorvastatin 40 mg/d or placebo for 3 days before surgery. Circulating inflammatory markers and malondialdehyde (MDA) were measured before and after treatment. SVG segments were used to determine vascular superoxide (O(2)(*-)) and Rac1 activation. For ex vivo studies, SVG segments from 24 patients were incubated for 6 hours with atorvastatin 0, 5, or 50 µmol/L. Oral atorvastatin reduced vascular basal and NADPH-stimulated O(2)(*-) in SVGs (P<0.05 for all versus placebo) and reduced plasma MDA (P<0.05), independently of LDL-lowering and of changes in inflammatory markers. In SVGs exposed to atorvastatin ex vivo, without exposure to LDL, basal and NADPH-stimulated O(2)(·-) were significantly reduced (P<0.01 for both concentrations versus 0 µmol/L) in association with a striking reduction in Rac1 activation and 1 membrane-bound Rac1 and p67(phox) subunit. The antioxidant effects of atorvastatin were reversed by mevalonate, implying a dependence on vascular HMG-CoA reductase inhibition. CONCLUSIONS: Short-term treatment with atorvastatin 40 mg/d before CABG improves redox state in SVGs, by inhibiting vascular Rac1-mediated activation of NADPH-oxidase. These novel findings suggest that statin therapy should be maintained or initiated in patients undergoing CABG, independently of LDL levels. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01013103.

Successful percutaneous aortic valve implantation via a stenotic left subclavian artery access.

Severe aortic valve stenosis may be tackled with percutaneous aortic valve replacement instead of surgical replacement. At present, two CE marked prosthetic valves are available. The CoreValve ReValving System is primarily designed to be introduced transfemorally, while implantation via subclavian arteries has been described in cases of unsuitable femoral access. However, this route has been used when subclavian artery is free of disease. In this case report we describe a successful CoreValve ReValving System implantation via a diseased and tortuous left subclavian artery after predilatation balloon angioplasty. The prosthesis was then advanced in the native aortic valve, deployed, and successfully implanted. Techniques and manipulations are provided.

Management of catheter-related injuries to the coronary sinus.

BACKGROUND: Although coronary sinus catheter-related injuries (CSCRIs) are rare, they are potentially lethal. The purpose of this study was to evaluate such injuries, the repair methods used, and to identify related risk factors for mortality. METHODS: A retrospective review of 10,552 cardiac surgical procedures from 1995 to 2000 in which retrograde cardioplegia was used revealed 10 cases (n = 10) of CSCRIs (0.095%) at our center. These injuries occurred during coronary bypass, valve replacement, and combined procedures. Management included direct suture, vein patch, or pericardial "on-lay" patch repair. RESULTS: Two deaths occurred (20% mortality) from failure of CSCRI repair; 8 of 10 injuries (80%) were successfully repaired. One patient had delayed, localized pericardial tamponade, which resolved spontaneously. Two patients had recurrent angina that was assessed 3 and 5 years later by coronary angiography; the coronary sinus was found to be patent in both cases. The remaining 6 patients have been asymptomatic. CONCLUSIONS: Repair of CSCRIs can be challenging as it can be complicated by inadequate myocardial protection, inadvertent coronary artery injuries, and possibly, subsequent coronary sinus thrombosis. Repair of CSCRIs should be carried out on an arrested, well-protected heart providing secure hemostasis and coronary sinus patency.