Interleukin-1 receptor-related protein ST2 and mitral valve repair outcome in patients with chronic degenerative mitral regurgitation.

BACKGROUND: ST2 is a member of the interleukin-1 receptor family that is markedly upregulated in cultured cardiomyocytes subjected to mechanical strain. Serum soluble ST2 (sST2) levels can be detected in patients with acute myocardial infarction and severe chronic heart failure. This study sought to assess for the first time the activation of the ST2 pathway in patients with severe chronic degenerative mitral regurgitation. MATERIALS AND METHODS: Serum sST2 levels were measured in 20 patients scheduled for mitral valve (MV) repair at baseline, at the end of the intervention, on postoperative day 1, at hospital discharge, and after 6 months. Patients also underwent measurement of N-terminal pro-brain natriuretic peptide and echocardiographic evaluation at each time point. RESULTS: At baseline, sST2 was detected in 10 (50%) patients (mean value, 60 ± 74 pg/mL; range, 0-234 pg/mL; median, 8 pg/mL). MV repair was performed successfully in all patients. Cardiac surgery with cardiopulmonary bypass was associated with a rapid and transient increase in sST2 levels. Patients with baseline higher versus lower sST2 levels (≥ 8 vs. < 8 pg/mL) had significantly higher levels of sST2 on postoperative day 1 (1,050 ± 593 vs. 440 ± 312 pg/mL; p = 0.009). At follow-up, patients with preoperative sST2 ≥ 8 pg/mL had significantly higher ejection fraction (EF) (64.7 ± 5.8 vs. 57.6 ± 5.9; p = 0.03) and lower left ventricular end-diastolic diameter (LVEDD) (50.6 ± 5.8 vs. 56 ± 4.2; p = 0.03) compared with patients with preoperative sST2 < 8 pg/mL. CONCLUSION: Preoperative ST2 activation, evidenced by the presence of serum sST2 levels, is present in half of the patients with chronic degenerative mitral regurgitation and is associated with higher levels of EF and lower levels of LVEDD after MV repair.

Correction of anterior mitral prolapse: the parachute technique.

OBJECTIVES: To evaluate a new surgical technique for the correction of anterior mitral leaflet prolapse. METHODS: From October 2006 to November 2011, 44 consecutive patients (28 males, mean age 55 ± 13 years) underwent mitral valve repair because of anterior mitral leaflet prolapse. Echocardiography was performed to evaluate the distance from the tip of each papillary muscle to the annular plane. A specially designed caliper was used to manufacture a parachute-like device, by looping a 4-0 polytetrafluoroethylene suture between a Dacron strip and Teflon felt pledget, according to the preoperative echocardiographic measurements. This parachute was then used to resuspend the anterior mitral leaflet to the corresponding papillary muscle. Of the 44 patients, 35 (80%) required concomitant posterior leaflet repair. Additional procedures were required in 16 patients (36%). The preoperative logistic European System for Cardiac Operative Risk Evaluation was 4.3 ± 6.9. RESULTS: The clinical and echocardiographic follow-up were complete. The total follow-up was 1031 patient-months and averaged 23.4 ± 17.2 months per patient. The overall mortality rate was 4.5% (n = 2). Also, 2 patients (4.5%) with recurrent mitral regurgitation required mitral valve replacement, 1 on the first postoperative day and 1 after 13 months. In the latter patient, histologic analysis showed complete endothelialization of the Dacron strip. At follow-up, all non-reoperated survivors (n = 40) were in New York Heart Association class I, with no regurgitation in 40 patients (93%) and grade 2+ mitral regurgitation in 3 (7%). CONCLUSIONS: This technique offers a simple and reproducible solution for correction of anterior leaflet prolapse. Echocardiography can reliably evaluate the length of the chordae. However, the long-term results must be evaluated and compared with other surgical strategies.

Activation of the ubiquitin proteolytic pathway in human septic heart and diaphragm.

OBJECTIVE: Mechanisms of sepsis-induced myocardial and diaphragmatic alteration are multiple and remain largely unknown, particularly in humans. In the present study, we compared the inducible nitric oxide synthase (NOS-2) expression, the peroxynitrite production and the expression and activation of the ubiquitin proteolytic pathway in the wall of the 4 cardiac chambers, in the diaphragm, and in the rectus abdominis. PATIENTS: Seven patients who died from septic shock associated with a myocardial depression and 5 nonseptic (control) patients. MEASUREMENTS AND RESULTS: We evaluated protein expression by Western blot. Nitrotyrosin and ubiquitin residues were localized by immunofluorescence. NOS-2, nitrated proteins, free ubiquitin, and ubiquitinated proteins are overexpressed in the wall of the four cardiac cavities, in the diaphragm and in the rectus abdominis of septic patients at a similar level. Ubiquitinated proteins with a molecular mass of 50, 35, 30, and 25 kD were consistently detected in heart, diaphragm, and rectus abdominis of septic shock patients but lacking in nonseptic patients. In situ immunolabelling of ubiquitin showed a colocalisation with nitrotyrosine residues at the sarcomeric level of cardiac myocytes in septic patients. CONCLUSIONS: This study showed the first evidence for the activation of the proteolytic ubiquitin-proteasome pathway in human heart and diaphragm in septic shock.

Frailty after aortic valve replacement (AVR) in octogenarians.

In order to analyze the quality of life (QoL) or frailty after AVR for octogenarians, we studied 84 patients older than 80 years who underwent aortic valve replacement alone or in combination with coronary artery bypass, between April 1998 and December 2001. Follow-up was performed in May 2002 with a telephonic interview to evaluate the self-rated QoL, health, and three frailty markers: falls, activity of daily living (ADL) and mood disorder. In-hospital mortality was 16.7%. Fourteen deaths occurred during the follow-up: survival estimates were 85.5% at 1 year and 68.6% at 3 years. Forty-one patients (73.2%) were in New York Heart Association (NYHA) classes I-II for dyspnea and 42 patients (75.0%) were free of angina. Fifty-one patients (91.1%) lived in their own homes. Forty-eight (85.7%) had at least one frailty marker: falls (26.8%), loss of autonomy for ADL (27.0%) or suspected depression (20.2%). All frailty markers were associated with self-rated QoL but not with self-rated health. AVR for octogenarians is associated with good outcome but this population is frail and further studies should assess the usefulness of pre- and postoperative geriatric approach.

Edge-to-edge technique to treat post-mitral valve repair systolic anterior motion and left ventricular outflow tract obstruction.

BACKGROUND: Systolic anterior motion of the mitral valve causing left ventricular outflow tract obstruction is an uncommon complication of mitral valve repair that may necessitate immediate additional surgical action. We prospectively evaluated the technique of the edge-to-edge suture on post-mitral repair systolic anterior motion, which persisted despite conservative treatment. METHODS: From March 2002 to March 2004, 4 of 112 patients requiring mitral valve repair surgery for chronic degenerative mitral regurgitation had systolic anterior motion with severe left ventricular outflow tract obstruction and mitral regurgitation. All 4 patients (mean age, 50 years) had posterior leaflet prolapse with chordal rupture with a billowing anterior leaflet, but without chordal rupture. Repair was achieved through a quadrangular resection of the posterior leaflet, completed by plication of the annulus in 2 patients and leaflet sliding in the other 2. All patients had mitral annuloplasty; two patients had a complete CE Physio ring (Edwards Lifesciences, Irvine, CA) inserted, whereas the other 2 patients had an open CG Future band (Medtronic, Minneapolis, MN). Routine perioperative transesophageal echocardiography showed systolic anterior motion, severe left ventricular outflow tract obstruction (> 50 mm Hg), and mitral regurgitation. After resuming cardiopulmonary bypass, all patients had an edge-to-edge suture at the middle part of the free edge of the anterior and posterior leaflets. RESULTS: The control transesophageal echocardiography showed in all cases disappearance of the systolic anterior motion, of the left ventricular outflow tract obstruction and of mitral regurgitation. Mean follow-up was 14 months (range, 6 to 28 months). All patients were in New York Heart Association's functional class I. CONCLUSIONS: With the edge-to-edge repair, the early and 2-year results were satisfactory with total disappearance of the systolic anterior motion, of the left ventricular outflow tract obstruction and of the recurrent mitral regurgitation.

Efficacy of esmolol as a myocardial protective agent during continuous retrograde blood cardioplegia.

OBJECTIVE: Esmolol, an ultra-short-acting beta-blocker, is known to attenuate myocardial ischemia-reperfusion injury. The aim of this study was to compare the effects of esmolol and potassium on myocardial metabolism during continuous normothermic retrograde blood cardioplegia. METHODS: Forty-one patients operated on for isolated aortic valve stenosis were randomly assigned to continuous coronary infusion with either potassium or esmolol during cardiopulmonary bypass. Myocardial metabolism was assessed by measuring the transmyocardial gradient of oxygen content indexed to left ventricular mass of glucose, lactate, and nitric oxide. To do so, blood samples were simultaneously withdrawn upstream (in the cardioplegia line) and downstream of the myocardium (in the left coronary ostium) 10 and 30 minutes after aortic crossclamping. RESULTS: Although the cardioplegia flow rate and pressure were similar, esmolol markedly reduced the transmyocardial gradient of oxygen content indexed to left ventricular mass compared with potassium: 13 +/- 6 vs 20 +/- 6 mL of oxygen per liter of blood per 100 g of myocardium, respectively, at 10 minutes and 16 +/- 8 vs 24 +/- 8 mL of oxygen per liter of blood per 100 g of myocardium, respectively, at 30 minutes (P =.009). Coronary glucose and lactate transmyocardial gradients were similar in both groups, indicating adequate myocardial perfusion in all patients at all times. In addition, during retrograde cardioplegia, esmolol showed a lower nitric oxide release compared with that caused by potassium (39 +/- 49 micro mol x L(-1) for potassium vs 14 +/- 8 micro mol x L(-1) for esmolol at 10 minutes and 39 +/- 47 micro mol x L(-1) for potassium vs 6 +/- 8 micro mol x L(-1) for esmolol at 30 minutes, P =.05). However, hemodynamic parameters and plasma troponin I levels remained unchanged postoperatively between the 2 types of cardioplegia. CONCLUSION: Esmolol provides potent myocardial protection in hypertrophied hearts, at least in part, by reducing myocardial oxygen metabolism.

Frequency, risk factors, and outcome of hyperlactatemia after cardiac surgery.

STUDY OBJECTIVE: To determine the respective frequencies, risk factors, and outcomes of no hyperlactatemia (NHL), immediate hyperlactatemia (IHL), or late hyperlactatemia (LHL) > 3 mmol/L after cardiac surgery. DESIGN: Prospective and observational study. SETTING: Cardiac surgery ICU in a 130-bed private community nonteaching hospital. PATIENTS: Consecutive patients (n = 325) undergoing cardiopulmonary bypass (CPB) for cardiac surgery. INTERVENTION: None. MEASUREMENTS: Arterial blood gas levels and lactate concentrations were measured at ICU admission, 4 h after surgery, between 6 h and 16 h after surgery, and on day 1. MAIN RESULTS: Sixty-seven patients (20.6%) had an IHL on ICU admission, and 56 patients (17.2%) acquired LHL during their ICU stay. ICU mortality was 1.5% for NHL, 3.6% for LHL, and 14.9% for IHL groups (p < 0.0001). The three groups differed significantly for elective surgery, type of operation, CPB duration, intraoperative mean arterial pressure, and intraoperative and postoperative use of vasopressor. Independent risk factors for IHL were nonelective surgery, CPB duration, and intraoperative use of vasopressor. Logistic regression identified hyperglycemia and epinephrine therapy for LHL as postoperative risk factors. Receiver operating characteristic curves showed that IHL more accurately predicted ICU mortality than LHL. CONCLUSIONS: Hyperlactatemia is common after cardiac surgery. A lactate threshold of 3 mmol/L at ICU admission is able to identify a population at risk of morbidity and mortality after cardiac surgery.

Total replacement of the ascending aorta without circulatory arrest.

OBJECTIVE: If the aortic arch is clamped between the brachiocephalic trunk and the left common carotid artery and the brachiocephalic trunk is also clamped, the total ascending aorta can be replaced without circulatory arrest. Candidates for this technique need to have the following characteristics: preoperative demonstration of Willis polygon patency by means of transcranial Doppler ultrasonography, preoperative computed tomographic scan that shows no calcification in the arch or in the brachiocephalic trunk, and preoperative or intraoperative evidence of separate origins of the brachiocephalic trunk and the left common carotid artery. METHODS: In three different institutions (with different time frames in each) from December 2000 to December 2001, the possibility of replacing the total ascending aorta without circulatory arrest was evaluated in 14 cases. In 10 of them it was possible (feasibility of 71.4%). During the procedure continuous electroencephalographic monitoring was performed. RESULTS: No patient died in the early or midterm follow-up. None of the patients had any cerebral complications. The electroencephalographic activity was normal during the period of brachiocephalic trunk occlusion. In 5 patients a postoperative spiral computed tomographic scan showed good surgical results. CONCLUSIONS: The technique described here allows replacement of the total ascending aorta without circulatory arrest in selected cases. Furthermore, the evidence of lack of right cerebral hypoperfusion in all the procedures we performed allows future exploration of the possibility of avoiding cerebral monitoring.

La mamaria interna en la revascularización miocárdica. A propósito de 486 casos. Técnica quirurgica y resultados / Internal mammary artery in miocardic revascularization. Experience in 486 cases. Surgical technique and results

La arteria mamaria interna (AMi) es el conducto ideal en la cirugia coronaria por su mayor, temprana y tardia, permeabilidad en comparacion con la vena safena. En este articulo presentamos nuestra experiencia con el proposito de contribuir a la difusion del uso de esta arteria en nuestro medio. Desde 1986 hasta 1992 operamos 486 pacientes quienes recibieron al menos una AMi. 386 pacientes fueron intervenidos en Francia (Grupo I) y 100 en el Perú (Grupo II). En 95 por ciento de casos la arteria mamaria interna izquierda (AMiI) fue colocada en la arteria coronaria descendente anterior, en 4 casos la arteria mamaria derecha se utilizo como puente libre y en 12 casos se empleo asociada a la AMiI. La mortalidad hospitalaria fue de 3.5 por ciento. En el resto hubo minimas complicaciones postoperatorias. La sobrevida actuarial a 7 años, libre de enfermedad cardiaca, fue de 94 por ciento en el grupo II con pocas complicaciones cardiacas tardias comparado con resultados de publicaciones internacionales. El buen uso técnico de la AMi con la indicación apropiada, no aumenta la morbimortalidad temprana de los pacientes operados, y tiene muy buenos resultados a largo plazo, como lo demuestra el seguimiento a siete años de los pacientes del grupo II operados en Lima, Perú

Cirurgia reconstrutiva da valva mitral: nova classificaçäo e técnica operatória; série de 130 pacientes / Reconstructive surgery of the mitral valve: new classification and surgical technic; series of 130 patients

Entre janeiro de 1975 e janeiro de 1982, foram realizadas 130 plastias da valva mitral para correçäo de insuficiência pura ou predominante. A idade média era 30 + ou - 17 anos. A moléstia reumática foi a principal causa da insuficiência mitral (112/130). Cinqüenta e nove pacientes (45,4%) tinham outra lesäo valvar associada, necessitando correçäo cirúrgica simultânea (tricuspídea em 36 e aórtica em 23). A técnica operatória variou de acordo com as lesöes encontradas. Três pacientes morreram no período pós-operatório imediato (2,3%). Cinco pacientes foram perdidos de controle e os demais (112) foram seguidos por um período médio de 38 + ou - 27 meses. Sete pacientes foram reoperados e três morreram. Um outro paciente morreu sem ser reoperado. A mortalidade tardia foi 3.1% (4/112). Todos os pacientes restantes (116/118), estäo na classe funcional I (105) ou II (11) da New York Heart Association. O índice cardiotorácico passou de 60,6% + ou - 7,7% no pré-operatório, para 53,7 + ou - 6,2% no pós-operatório (p < 0,001). Episódios trombembólicos foram observados em 4 pacientes, todos apresentando fibrilaçäo atrial. Curvas atuariais, incluindo a mortalidade hospitalar, mostram sobrevivência de 92,0% em 7 anos para todas as séries: 93,7% + ou - 4,9% em 7 anos para as plastias isoladas da mitral e de 89,9% + ou - 5,6% para as plastias mitral-tricúspide em 5 anos. A freqüência de trombembolismo foi de 1,0% paciente/ano. Oitenta e oito por cento dos pacientes näo necessitaram reoperaçäo em 7 anos. A freqüência de reoperaçöes foi 1,7 + ou - 0,7% paciente/ano. A plastia da valva mitral pode dar um resultado funcional estável, baixa mortalidade imediata ou tardia e uma aceitável incidência de reoperaçöes