Aortomesenteric fat thickness with ultrasound predicts metabolic diseases in obese patients.

BACKGROUND: The relation between visceral fat accumulation and development of cardiovascular and metabolic disorders has been demonstrated. The aim of this study was to determine the relationship between a new ultrasound visceral fat thickness (VFT) measurement and clinical and anthropometric data in a consecutive series of obese patients. METHODS: Fifty-five consecutive male obese patients underwent ultrasound evaluation and metabolic and anthropometric parameters determination at baseline and after 3 weeks of a very low-calorie diet (VLCD) therapy. The new ultrasound measurement, the thickness of the fat between the aorta and the superior mesenteric artery (AMFT), was determined along with the maximum thickness of preperitoneal fat and the global VFT. RESULTS: AMFT showed a better correlation than VFT and preperitoneal fat with all anthropometric and metabolic parameters, both at baseline and after VLCD regimen. At baseline, patients in the middle and high AMFT and VFT tertiles had a significantly higher prevalence of metabolic diseases with respect to AMFT and VFT low tertile patients, whereas after VLCD period, AMFT only showed significant difference within tertiles. The odds ratios for the various metabolic diseases were higher in the middle and high AMFT tertiles than those in the middle and high VFT tertiles, remaining significant after adjustment for age, body mass index and VLCD regimen only in the middle and high AMFT tertiles. CONCLUSIONS: The ultrasonographic AMFT evaluation is strongly correlated to the presence of metabolic syndrome and could be a valuable tool to predict metabolic diseases and associated cardiovascular risks in men.

Doxycycline prevents intimal hyperplasia in vitro and may improve patency of the internal thoracic artery.

OBJECTIVES: The development of intimal hyperplasia and graft failure is an important problem in cardiac surgery. A fundamental process in intimal hyperplasia is the degradation of extracellular matrix by metalloproteases which induces the vascular smooth-muscle cells migration and sets the scene for graft atherosclerosis. This study investigated whether doxycycline, a metalloproteases inhibitor, can prevent the intimal hyperplasia occurrence in cultured human internal mammary artery, thus extending graft patency. METHODS: Segments of internal mammary artery from 20 consecutive patients were prepared and cultured for 2 weeks in serum-supplemented medium (control) or in medium supplemented with 10⁻5 M and 10⁻6 M doxycycline concentrations. Tissues were fixed, sectioned, and stained, and neointimal thickness was measured by computer-aided image analysis. Further sections were cultured and prepared for gel enzymography to measure the matrix metalloproteinase-2 and -9 levels. RESULTS: At the end of the culture period, neointimal thickness was significantly (P = 0.001) dose-dependently reduced in samples treated with doxycycline when compared with controls. Gelatin enzymography demonstrated a reduction in values for both latent and active forms of metalloproteases. CONCLUSIONS: Doxycycline, in a model of internal mammary artery intimal hyperplasia, has a specific role in inhibiting metalloproteases activity and may prevent graft stenosis.

Asymmetric septal hypertrophy in patients with severe aortic stenosis: the usefulness of associated septal myectomy.

OBJECTIVE: Asymmetric septal hypertrophy frequently coexists with severe aortic stenosis and can be unmasked after successful aortic valve replacement (AVR), jeopardizing the clinical and echocardiographic results. The aim of our study was to investigate, at 5 years postoperatively, the effectiveness of myectomy associated with AVR on left ventricular (LV) mass regression and LV diastolic function. METHODS: From 1997 and 2004, 86 patients with a diagnosis of severe aortic stenosis and asymmetric septal hypertrophy consecutively underwent AVR (group A) or AVR and concomitant myectomy (group B). To assess the improvement in LV mass and LV diastolic function, we studied the 52 survivors (23 in group A and 29 in group B) who had the same prosthesis type (beleaflet mechanical), the same size (21 mm), and the same follow-up length. RESULTS: In group A, the LV mass index regressed from 119.2 ± 22.0 to 113.8 ± 21.8, and in group B, it regressed from 121.6 ± 20.8 to 112.7 ± 20.0 (P < .0005). In group A, the E/E' ratio improved from 15.3 ± 3.0 to 11.8 ± 3.0, and in group B, it improved from 16.2 ± 3.2 to 12.1 ± 3.3 (P = .02). CONCLUSIONS: Surgeons should inspect the LV outflow tract at AVR. Concomitant myectomy at AVR is a safe and effective procedure that improves LV mass regression and LV diastolic function.

Endothelial nitric oxide synthase expression in postmenopausal women: a sex-specific risk factor in coronary surgery.

BACKGROUND: After coronary artery bypass graft surgery, older women have less favorable clinical outcome and lower conduit patency compared with men. This less favorable outcome can be in part ascribed to impaired endothelium-derived nitric oxide (eNOS) production. This study evaluated endothelial nitric oxide synthase expression in internal mammary artery from postmenopausal women undergoing coronary artery bypass graft surgery. METHODS: Internal mammary artery segments were obtained from 20 postmenopausal woman and 20 matched male patients. Twenty more segments from younger patients were used as controls. Expression of eNOS messenger RNA in internal mammary artery endothelial cells were evaluated by polymerase chain reaction and real-time quantitative reverse transcription polymerase chain reaction. The eNOS protein level was assayed by Western blot. Vascular dynamics of specimens were evaluated by organ chamber methodology. RESULTS: In postmenopausal women, the band of messenger RNA for eNOS was reduced by 37.4% and by 25.2%, respectively, compared with matched men and the control group (62.6%±4.8% versus 74.8%±5.3%, p<0.001). In comparison with the control group lane, the eNOS protein immunoreactive band was 44.2% decreased in postmenopausal women and 34.5% decreased in matched men, and was significantly decreased in postmenopausal women as compared with matched men (55.8%±4.6% versus 65.5%±5.2%, p<0.001). Nitric oxide-mediated vasomotor dynamics were consistent with reduced eNOS production. CONCLUSIONS: Internal mammary artery endothelial cells from women after menopause undergoing coronary surgery have impaired expression of messenger RNA for eNOS and reduced eNOS levels. Reduced bioactivity of nitric oxide translates into impaired endothelial metabolism that could contribute to worse surgical outcome.

Combination therapy with warfarin plus clopidogrel improves outcomes in femoropopliteal bypass surgery patients.

BACKGROUND: Patients having undergone femoropopliteal bypass surgery remain at significant risk of graft failure. Although antithrombotic therapy is of paramount importance in these patients, the effect of oral anticoagulation therapy (OAT) on outcomes remains unresolved. We performed a randomized, prospective study to assess the impact of OAT plus clopidogrel vs dual antiplatelet therapy on peripheral vascular and systemic cardiovascular outcomes in patients who had undergone femoropopliteal bypass surgery. METHODS: Three hundred forty-one patients who had undergone femoropopliteal surgery were enrolled and randomized: 173 patients received clopidogrel 75 mg/d plus OAT with warfarin (C + OAT), and 168 patients received dual antiplatelet therapy with clopidogrel 75 mg/d plus aspirin 100 mg/d (C + acetylsalicylic acid [ASA]). Study end points were graft patency and the occurrence of severe peripheral arterial ischemia, and the incidence of bleeding episodes. RESULTS: Follow-up ranged from 4 to 9 years. The graft patency rate and the freedom from severe peripheral arterial ischemia was significantly higher in C + OAT group than in C + ASA group (P = .026 and .044, respectively, Cox-Mantel test). The linearized incidence of minor bleeding complications was significantly higher in C + OAT group than in C + ASA group (2.85% patient-years vs 1.37% patient-years; P = .03). The incidence of major adverse cardiovascular events, including mortality, was found to be similar (P = .34) for both study groups. CONCLUSIONS: In patients who have undergone femoropopliteal vascular surgery, combination therapy with clopidogrel plus warfarin is more effective than dual antiplatelet therapy in increasing graft patency and in reducing severe peripheral ischemia. These improvements are obtained at the expenses of an increase in the rate of minor anticoagulation-related complications.

Preoperative intraaortic balloon pump for off-pump coronary arterial revascularization.

BACKGROUND: Prophylactic intraaortic balloon pump (IABP) support showed better outcomes in critical patients undergoing coronary revascularization compared with intraoperative or postoperative insertion. We conducted a prospective, randomized study to determine the optimal timing for preoperative IABP insertion in high-risk patients undergoing off-pump coronary artery revascularization. METHODS: The study enrolled 230 consecutive high-risk patients (having a logistic European System for Cardiac Operative Risk Evaluation score of ≥10) undergoing off-pump coronary artery revascularization. They were randomized for preoperative IABP starting at 2 hours (2T, n=115) or 12 hours (12T, n=115). Clinical, biochemical, and hemodynamic results, and the need for inotropic drug support, were markers of outcome and compared between groups. RESULTS: Hospital mortality in group 12T was reduced by 60%, but the difference between groups was not statistically significant (hazard ratio, 0.4; 95% confidence interval, 0.1 to 1.5; p=0.1). Twelve hours of preoperative IABP therapy reduced postoperative low output syndrome (hazard ratio, 0.4; 95% confidence interval, 0.1 to 0.9; p=0.03) and biomarker leakage upper normal limit (hazard ratio, 0.3; 95% confidence interval, 0.1 to 0.7; p=0.001). Postoperative left ventricular function was similar between the groups. Group 2T patients required higher inotropic support for a longer average duration and prolonged postoperative intensive care unit and hospital length of stay. CONCLUSIONS: Twelve hours preoperative IABP therapy improved treatment efficacy. Postoperative morbidity was reduced, but hospital mortality rate was not affected. The IABP-related complication rate was low and not related to the length of treatment.

Coronary perfusion: impact of flow dynamics and geometric design of 2 different aortic prostheses of similar size.

BACKGROUND: Aortic valve replacement leads to improvement of coronary flow but not to complete normalization. Coronary hypoperfusion contributes to higher left ventricular mass persistence, arrhythmias, congestive heart failure and sudden death. This prospective study compares 2 similarly sized aortic prostheses (mechanical and porcine) regarding coronary flow and hemodynamic performances in patients who underwent surgery for pure aortic stenosis. METHODS: Sixty patients having undergone aortic valve replacement for pure aortic stenosis with Medtronic Mosaic Ultra bioprosthesis 21 mm (n = 30) or St Jude Regent mechanical valve 19 mm (n = 30) were evaluated preoperatively and 12 months postoperatively comparing the coronary flow and the hemodynamic behavior. Echocardiography and cardiac positron emission tomography were performed at rest and during exercise or adenosine maximal stimulation, respectively. RESULTS: The St Jude Regent mechanical valve, compared with the Medtronic Mosaic Ultra bioprosthesis, had reduced coronary flow reserve (2.1 ± 0.3 vs 2.3 ± 0.2; P = .003), less favorable systolic/diastolic time ratio (0.87 ± 0.02 vs 0.78 ± 0.03; P < .001), and higher mean transprosthetic gradient (46 ± 11 vs 38 ± 9; P = .003) during exercise. Multivariate analysis of impaired coronary reserve related indexed effective orifice area less than 0.65 cm/m(2) (risk ratio [RR], 1.9; 95% confidence intervals [CI], 1.5-2.8; P < .001), mechanical valve (RR, 2.5; 95% CI, 1.7-3.3; P < .001), and systolic/diastolic time ratio greater than 0.75 (RR, 2.6; 95% CI, 1.8-3.8; P < .001), as well as high transprosthetic gradient (RR, 1.7; 95% CI, 1.3-2.4; P < .001) ) during exercise with coronary reserve less than 2.2. CONCLUSIONS: Improvement of coronary flow and reserve was more evident for bioprostheses than for mechanical valves. The bioprostheses demonstrated superior hemodynamics during exercise, which may have some impact on exercise capability during normal daily life.

Myocardial metabolism and diastolic function after aortic valve replacement for aortic stenosis: influence of patient-prosthesis mismatch.

OBJECTIVE: This study evaluated the impact of patient-prosthesis mismatch on myocardial function and high-energy phosphate metabolism after aortic valve replacement for pure aortic stenosis. Patients with and without patient-prosthesis mismatch were compared using magnetic resonance techniques. METHODS: Thirty patients who had undergone aortic valve replacement with Medtronic Mosaic bioprosthesis were evaluated. Fifteen patients with patient-prosthesis mismatch were compared to 15 matched patients without patient-prosthesis mismatch. These two homogeneous groups were studied for myocardial metabolism and left ventricle function preoperatively and at 12 months postoperatively with magnetic resonance imaging and (31)P spectroscopy. RESULTS: All patients experienced improvement in myocardial metabolism and left ventricle function. Left ventricle mass regression was impaired in both groups. Impaired diastolic filling was associated with increased left ventricle wall mass in both groups (patient-prosthesis mismatch: R(2) = -0.71, p = 0.002; no patient-prosthesis mismatch: R(2) = -0.88, p < 0.001). Myocardial phosphocreatine/adenosine triphosphate ratio revealed a modest correlation with left ventricle function as evaluated by early acceleration peak (patient-prosthesis mismatch: R(2) = 0.37, p = 0.03; no patient-prosthesis mismatch: R(2) = 0.17, p = 0.02) and early deceleration peak (patient-prosthesis mismatch: R(2) = 0.30, p = 0.01; no patient-prosthesis mismatch: R(2) = 0.39, p = 0.008). No significant correlation between the phosphocreatine/adenosine triphosphate ratio and left ventricle mass was found (patient-prosthesis mismatch: R(2) = 0.39, p = 0.6; no patient-prosthesis mismatch: R(2) = 0.40, p = 0.08). CONCLUSION: Aortic valve replacement leads to early improvement of left ventricle function and myocardial metabolism in all patients regardless of the occurrence of patient-prosthesis mismatch.

Serial evaluation of flow in single or arterial Y-grafts to the left coronary artery.

BACKGROUND: It is unclear whether composite Y-grafts can withstand the flow demand of the coronary system at rest and under stress. This study compared the graft flow and flow reserve of the left internal mammary artery (LIMA) intraoperatively and over a 2-year follow-up in single or composite Y-graft configurations using the radial artery (RA). METHODS: One hundred patients who underwent off-pump myocardial revascularization with a composite Y-graft (group 2) were compared with a homogeneous group of 100 patients treated with a single independent LIMA graft on the left anterior descending artery (LAD) (group 1). Intraoperative baseline flow and flow after adenosine infusion into the left ventricle were analyzed. Over a 2-year follow-up, noninvasive longitudinal evaluation of flow was carried out at rest and during maximal hyperemic response by transthoracic Doppler ultrasonography. Final functional evaluation was obtained through a 2-day stress/rest 99mTc-sestamibi myocardial perfusion single-photon emission computed tomographic scan. RESULTS: The proximal LIMA in a Y-graft configuration showed adaptability to flow dynamics. It had a greater average peak velocity (p = 0.02), flow volume (p < 0.01), and diameter (p < 0.01) than independent single LIMA grafts. Distal flow at rest and during adenosine recruitment was similar between groups both intraoperatively and at all time points of the follow-up. No steal phenomenon occurred at rest, nor was it induced by adenosine in the Y-graft group. Exercise nuclear scintigraphy showed satisfactory exercise tolerance and no inducible significant perfusion defects in both groups. CONCLUSIONS: Left internal mammary artery Y-grafting with the RA is adequate for flow requirements of distal branches at rest and during maximal hyperemia and is able to adapt its dimension to flow demand. Optimal results for RA anastomoses are possible only in arteries with critical stenosis and of good size and quality.

The association of acute aortic dissection with Helicobacter pylori virulence specific serotypes: Distinct diversity of systemic antibodies to CagA and VacA genotypes.

BACKGROUND: Previous studies reported an association between chronic Helicobacter pylori infection and cardiovascular disease; however, controversy still exists regarding the presence of bacterial genomic material in atherosclerotic plaques. Currently, the genetic polymorphisms of H. pylori have been investigated and many virulence factors have been identified. No one has tried to associate these polymorphisms with aortic dissections. This study evaluated whether more virulent strains of H. pylori represent a risk factor for acute ascending aorta dissections. METHODS: The serologic status for H. pylori and type I strains were determined in 100 patients who underwent operative repair of acute, ascending aorta dissection and in 100 population-based control subjects matched fully for clinical, demographic, and socioeconomic characteristics. The specimens from dissected aorta were evaluated to identify the presence of bacterial genomic material in surgical patients. RESULTS: No evidence of genomic material from H. pylori was found in the specimens. The prevalence of positive H. pylori serology was greater in patients than in controls (72 vs 50) with an adjusted odds ratio 2.8 (95% confidence interval, 1.8-4.1; P = .006). Patients with aortic dissection also had a greater prevalence of vacuolating cytotoxin gene subtypes s1m1 (73% vs 31%) with an odds ratio of 6.0 (95% confidence interval, 3.1-11; P < .001). Patients who were positive for vacuolating cytotoxin gene subtypes s1m1 were similar in demographic and clinical features compared with other patients. CONCLUSION: The findings provide support for the hypothesis that an association exists between the more virulent type I strains of H. pylori (vacuolating cytotoxin gene subtypes s1m1) infection and acute aortic dissection. The mechanism(s) underlying the association remain to be elucidated.

Randomized flow capacity comparison of skeletonized and pedicled left internal mammary artery.

BACKGROUND: The preferential harvesting technique of the internal mammary artery has been periodically debated. This randomized study evaluated the flow outcome of the skeletonized versus pedicled left internal mammary artery. METHODS: Two hundred patients undergoing surgery for left anterior descending coronary artery revascularization were enrolled and randomized to pedicled (n=100) or skeletonized (n=100) harvesting. Intraoperative baseline flow and post adenosine infusion into the left ventricle, hospital outcome, echocardiographic results, and troponin I leakage were analyzed. Noninvasive periodic evaluation of flow was carried out at rest and during intravenous adenosine infusion by transthoracic Doppler ultrasound, and was stratified according to the harvesting technique. Final angiographic evaluation was performed by 64-slice multidetector computed tomography. RESULTS: Skeletonized left internal mammary arteries demonstrated better flow capacity at rest and during adenosine recruitment perioperatively and at all time points of follow-up. Troponin I leakage was significantly higher in the pedicled group (59 vs 42, p=0.02). Pedicled harvesting (hazard ratio [HR] 3.6, 95% confidence interval [CI] 2.5 to 6.9, p<0.001); indexed left ventricular mass greater than 150 g/m2 (HR 4.6, 95% CI 3.1 to 7.5, p<0.001); and baseline corrected thrombolysis in myocardial infarction frame count greater than 30 (HR 4.4, 95% CI, 3.8 to 7.2, p<0.001) were the most powerful multivariable predictors of graft flow reserve less than 2.0. Postoperative echocardiographic results and clinical and angiographic outcomes were comparable between the two groups. CONCLUSIONS: Skeletonization of the left internal mammary artery, beyond traditional proven advantages, provided significantly higher flow capacity and better graft flow reserve.

Chylothorax after abdominal surgery.

Chylothorax is usually a complication of thoracic surgery procedures. Over a 5-year period we encountered three cases of chylothorax following abdominal surgery performed in general surgery units. The initial effusions, not lactescent, were ascribed to a pleural reaction that sometimes is observed during the postoperative period after abdominal surgery. Once the diagnosis was established, the initial conservative treatment failed, and surgery was necessary. In our patients, their debilitated physical condition precluded a thoracotomy approach. A video-assisted thoracoscopy procedure was undertaken, but the extensive pleural effusions, caused in part by the delay in the diagnosis, prevented the exact localization of the duct and its closure. Talc pleurodesis was successfully employed in all patients. Even after abdominal surgery, a persistent pleural effusion should always induce us to suspect a chylothorax.

Left ventricular-assisted myocardial revascularization favorably affects levels of circulating adhesion molecules and lung function.

BACKGROUND: We investigated whether the use of left ventricular-assisted (LVA) technique in beating heart myocardial revascularization would exert less impact on patients adhesion molecules and oxygenation index as compared with conventional cardiopulmonary bypass (CPB). METHODS: Sixty-six consecutive patients undergoing myocardial revascularization were randomly assigned either to LVA (group A, 34 patients) or CPB (group B, 32 patients). Adhesion molecules and oxygenation indexes were measured at baseline and at various time points postoperatively. RESULTS: Pre-operative clinical and demographic data did not differ between the 2 groups. The 2 groups were also similar with respect to mortality, number of grafts performed, duration of extracorporeal circulation, and need for inotropes. However, postoperatively patients treated with LVA had a reduced levels of adhesion molecules compared with patients treated with CPB, as indicated by a significant difference in endothelial leukocyte adhesion molecule-1 (P = .002), intercellullar adhesion molecule-1 (P = .0001), and vascular cell adhesion molecule-1 (P = .004). The oxygenation index at 1 (P = .04) and 3 hours (P = .03) postoperatively was better in the LVA group than in the CPB group. CONCLUSION: Patients undergoing beating heart myocardial revascularization with LVA show reduced levels of adhesion molecules and better oxygenation index than patients treated with CPB.

Left heart pump-assisted myocardial revascularization favorably affects neutrophil apoptosis.

OBJECTIVES: Granulocyte apoptosis is a key control process in the clearance of neutrophils from inflammatory sites, and its rate is modulated by a number of inflammatory mediators. In this study, we investigated whether the use of left ventricular-assisted technique (LVA) in beating heart myocardial revascularization would exert less impact on neutrophil apoptosis compared with conventional cardiopulmonary bypass (CPB). METHODS: Forty consecutive patients who underwent myocardial revascularization were randomly assigned to LVA (group A, 21 patients) or CPB (group B, 19 patients). Blood samples for detection of interleukin-6, interleukin-8, and tumor necrosis factor-alpha were measured at baseline and at various time points postoperatively. Neutrophil apoptosis was detected by light microscopy as well as by the annexin-V assays together with the activity of caspase 3 on postoperative samples. RESULTS: Preoperative clinical and demographic data did not differ between the two groups. The two groups also were similar with respect to mortality, number of grafts performed, duration of extracorporeal circulation, and need for inotropes. However postoperatively, spontaneous apoptosis was significantly delayed in neutrophils from CPB patients compared with LVA patients. Neutrophils were activated, as indicated by increased surface expression of CD11b. Caspase 3 activity was found to be significantly reduced in neutrophils from CPB patients after 18 and 24 hours of culture. CONCLUSIONS: Patients who underwent beating heart myocardial revascularization with LVA show a better preserved neutrophil apoptosis than patients treated with the CPB.

Aortic valve replacement: a prospective randomized evaluation of mechanical versus biological valves in patients ages 55 to 70 years.

OBJECTIVES: The aim of this study was to determine long-term results between bioprosthetic (BP) and mechanical (MP) aortic valves in middle-aged patients. BACKGROUND: It has not been established which is the best aortic valve substitute in patients ages 55 to 70 years. We conducted a randomized study to compare long-term outcomes between BP and MP aortic valves. METHODS: Between January 1995 and June 2003, 310 patients were randomized to receive a BP or an MP aortic valve. Primary end points of the study were survival, valve failure, and reoperation. RESULTS: One hundred fifty-five patients received a BP valve, and 155 patients received an MP valve. Four patients died, perioperatively, in the MP group (2.6%), and 6 patients died in the BP group (3.9%, p = 0.4). At late follow-up (mean 106 +/- 28 months) 41 patients died in the MP group and 45 patients died in the BP group (p = 0.6). There was no difference in the survival rate at 13 years between the MP and BP groups. Valve failures and reoperations were more frequent in the BP group compared with the MP group (p = 0.0001 and p = 0.0003, respectively). There were no differences in the linearized rate of thromboembolism, bleeding, endocarditis, and major adverse prosthesis-related events (MAPE) between the MP and BP valve groups. CONCLUSIONS: At 13 years, patients undergoing aortic valve replacement either with MP or BP valves had a similar survival rate as well the same rate of occurrence of thromboembolism, bleeding, endocarditis, and MAPE, but patients who had undergone aortic valve replacement with BP valves faced a significantly higher risk of valve failure and reoperation.

Systematic strategy of prophylactic coronary angiography improves long-term outcome after major vascular surgery in medium- to high-risk patients: a prospective, randomized study.

OBJECTIVES: This study was undertaken to determine the impact of a strategy of systematic coronary angiography on immediate- and long-term outcome of patients at medium-high risk who were undergoing surgical treatment of peripheral arterial disease. BACKGROUND: Despite pre-operative risk stratification according to the current guidelines, vascular surgery patients still represent a high-risk population, as 30-day cardiovascular complications and mortality rates still remain as high as 15% to 20% and 3% to 5%, respectively. METHODS: In all, 208 consecutive patients scheduled for elective surgical treatment of major vascular disease and with a revised cardiac risk index > or =2 were randomly allocated to either a "selective strategy" group (group A, n = 103), in whom coronary angiography was performed based on the results of noninvasive tests, or to a "systematic strategy" group (group B, n = 105), consisting of patients who systematically underwent pre-operative coronary angiography. RESULTS: The 2 groups were similar with respect to baseline clinical characteristics, revised cardiac risk index, and type of vascular surgery performed. The myocardial revascularization rate in group B was higher than in group A (58.1% vs. 40.1%; p = 0.01). In-hospital major adverse cardiovascular event rate was not significantly lower in group B (p = 0.07). At 58 +/- 17 months of follow-up, group B showed significantly better survival (p = 0.01) and freedom from death/cardiovascular events (p = 0.003). CONCLUSIONS: In this study, a strategy of routine coronary angiography positively impacted long-term outcome of peripheral arterial disease surgical patients at medium-high risk. This is the first such demonstration in a randomized, prospective trial. Multicenter trials to confirm this finding in a larger population are warranted.

Surgery for left ventricular aneurysm: is there still any role for simple linear repair?

The aim of left ventricular aneurysm (LVA) surgery is to eliminate the diskinetic portion of the left ventricle and to restore the patient's clinical condition. This can be obtained with two surgical procedures: linear repair and endoventricular patch technique. We investigated early- and long-term results in patients who underwent both procedures. From January 1980 to December 2004, 158 patients underwent surgical repair of LVA: 86 had linear repair and 72 patch repair. Operative mortality was 6.9%, with no differences between the two groups. Logistic regression revealed older age, higher left ventricular end-diastolic volume, and an ejection fraction (EF) less than 30% as independent risk factors for in-hospital mortality; the type of operation "per se" did not influence the early mortality. At the follow-up extending up to 25 years, there was no statistically significant difference in survival between the two study groups, as well as in New York Heart Association and Canadian Cardiovascular Society classes. Cox regression revealed older age, EF less than 30%, urgent operation, and a history of cerebrovascular accident as independent risk factors for late mortality: the type of operation did not influence mortality at follow-up. We conclude that aneurysm resection associated with myocardial revascularization is the best treatment for LVA. The choice of the technique should be tailored on an individual basis, according to aneurism location, extension, residual ventricular function, and septal involvement.

Myocardial revascularization by left ventricular assisted beating heart is associated with reduced systemic inflammatory response.

BACKGROUND: The present study was designed to investigate whether use of left ventricular assisted technique (LVA) in beating-heart myocardial revascularization would exert less impact on patients' inflammatory response, as compared with minimal extracorporeal circulation (MECC). METHODS: Seventy-three consecutive high-risk patients undergoing myocardial revascularization were randomly assigned either to LVA (group A) or to MECC (group B). Monocyte count and plasma concentration of C-reactive protein, inflammatory cytokines interleukin-1beta, interleukin-6, and tumor necrosis factor-alpha, and polymorphonuclear elastase were measured at baseline and at various time points postoperatively. RESULTS: Preoperative clinical and demographic data did not differ between the two groups. The two groups also were similar with respect to mortality, number of grafts performed, duration of extracorporeal circulation, and need for inotropes. However, LVA was associated with significantly less inflammatory response postoperatively compared with MECC, as indicated by a significant difference in interleukin-6 (p = 0.002), C-reactive protein (p = 0.002), monocyte percentage (p = 0.006), tumor necrosis factor-alpha (p = 0.002), and polymorphonuclear elastase (p = 0.001). CONCLUSIONS: High-risk patients undergoing beating-heart myocardial revascularization with LVA show reduced inflammatory response compared with patients treated with the MECC.

A rapidly expanding descending thoracic aortic aneurysm: an unusual complication.

The rate of enlargement of a descending thoracic aortic aneurysm is usually low, related to initial size and anatomical position. We report a case of an old, diabetic woman, with previous history of ischemic heart disease, admitted for a broncopneumia, in which a small descending thoracic aortic aneurysm was detected by a routine computed tomography (CT) scan. Because of the presence of comorbid condition, especially in the woman with an infectious respiratory disease, a closer follow-up by a 3-month CT scan was programmed. An impressive enlargement of the aneurysm, occurred in the next 2 months, caused patient's asphyxia and subsequent death. In patients with thoracic aortic aneurysm, mostly in females with comorbid condition, a closer CT scan control should be carried out, irrespective of the previous aneurysm size.