Prophylactic use of eculizumab during surgery in chronic cold agglutinin disease.

Primary chronic cold agglutinin disease (CAD) is an autoimmune haemolytic anaemia in which a specific bone marrow lymphoproliferative disorder causes production of cold agglutinins (CA). Binding of CA to erythrocyte surface antigens results in a predominantly extravascular haemolysis that is entirely complement dependent. Because of complement activation, exacerbations are common during febrile infections, trauma or major surgery. Involvement of the terminal complement pathway with C5-mediated intravascular haemolysis is probably not prominent in stable disease but is supposed to be of importance in exacerbations following acute phase reaction.We report on a patient with CAD prone to exacerbation of haemolysis during acute phase reactions who was scheduled for cardiac surgery. To prevent her having an exacerbation of haemolysis, we chose to treat her prophylactically with eculizumab along with the usual perioperative precautions. Aortic valve replacement was undertaken with full cardiopulmonary bypass at normothermia. The procedure was successful; no exacerbation of haemolysis was observed, and transfusion requirements did not exceed what could be expected.

Outcome of mitral valve plasty or replacement: atrial fibrillation an effect modifier.

BACKGROUND: Advances in the understanding of mitral valve pathology have laid to mitral valve plasty (MPL) as the procedure of choice of all the mitral intervention as compared to mitral valve replacement (MVR). MATERIAL AND METHODS: A cohort of 355 patients with mitral valve disease operated between January 1993 to January 2007 with closing date first of mars 2011. There were 214 MPL and 141 MVR at the Hospital discharge. This retrospective cohort had the design of exposed (MPL) versus non-exposed (MVR) with outcome total mortality and reoperation during follow up. Also echocardiography follow-up was undertaken to estimate the true long-term failure rate of repair. RESULTS: The mean follow up was 5.3 years SE (3.82) maximum follow up was 14.1 years. Considering the patient time model the association between repair/replacement and total mortality RR = 0.43 95% (0.28-074) p = 0.002 controlling for the confounding effect of 3-vessels disease. Those results were confirmed by propensity score analysis. CONCLUSION: In a cohort of patient with mitral valve disease undergoing MPL/MVR was examined. MPL was associated with better survival, and lower reoperation rate for patients without AF but same rate for patients with AF. We advocate more attention in controlling risk factors of AF in the clinical management of mitral disease. Long-term failure rate of MPL was low during follow up time. A replication of our results by a randomized clinical trial is mandatory.

Plasma IL-18 and IL-18BP are altered differently in reverse remodeling following aortic valve replacement.

OBJECTIVES: Patients with aortic stenosis (AS) develop left ventricular remodeling characterized by changes in extracellular matrix (ECM) and cardiomyocyte-hypertrophy. Aortic valve replacement (AVR) reverses this process (reverse remodeling). We examined plasma levels of interleukin-18 (IL-18) and its binding protein (IL-18BP) before and after AVR for AS since these mediators have been shown experimentally to exert effects on myocardial remodeling. DESIGN: Plasma levels of IL-18 and IL-18BP were analyzed in 22 patients with AS undergoing AVR, preoperatively, two days, six and 12 months postoperatively. Echocardiography and functional testing were performed. RESULTS: IL-18BP was significantly increased by 28% and 15% at two days and six months after AVR, compared to preoperative values. In contrast, IL-18 showed a later peak (increased by 24% at 12 months postoperatively) when IL-18BP was normalized. IL-18 correlated positively with deceleration time (R = 0.44) at this time-point which might indicate an association with diastolic function. CONCLUSIONS: We report for the first time that plasma IL-18 and IL-18BP are differentially regulated after AVR for AS with an early increase in IL-18BP postoperatively followed by a later peak in IL-18 at 12 months. Given the known effects of these mediators on myocardial remodeling and function, they might play a role in the reverse and remodeling process associated with AVR.

Traumatic aortic valve rupture after a high-speed motor-vehicle accident: case report.

The case is reported of a 32-year-old male with an aortic valve injury received in a high-speed traffic accident. Several non-cardiac concomitant injuries were present, none of them life-threatening. Cardiac surgery was performed on day 2 due to a grade III aortic valve insufficiency. The presence of a large tear of the non-coronary cusp, and several concomitant injuries, led to valve replacement being considered the most optimal treatment for this patient.

Traumatic aortic valve rupture after a high-speed motor vehicle accident.

The case is reported of a 32-year-old male who sustained an aortic valve injury after a high-speed traffic accident. Several non-cardiac concomitant injuries were present, none of which was life-threatening. Cardiac surgery was performed on day 2 due to a grade III aortic valve insufficiency. As a large tear of the non-coronary cusp was evident, together with several concomitant injuries, valve replacement was considered to be the most optimal treatment in this case.

Alterations in circulating activin A, GDF-15, TGF-beta3 and MMP-2, -3, and -9 during one year of left ventricular reverse remodelling in patients operated for severe aortic stenosis.

BACKGROUND: Patients with aortic stenosis (AS) develop left ventricular remodelling with cardiomyocyte hypertrophy and increased fibrosis. Following aortic valve replacement (AVR) reverse remodelling usually takes place. AIMS: To examine circulating levels of members of the transforming growth factor (TGF) beta superfamily and matrix metalloproteinases (MMP), known to have important effects on hypertrophy and extracellular matrix, in patients operated for AS. METHODS: Circulating levels of activin A, GDF-15, TGF-beta3, MMP-2, -3, and -9 were measured in twenty-two patients undergoing AVR preoperatively, and 2 days, six months and 12 months postoperatively. Echocardiography and a six minute walking test evaluated reverse remodelling and physical performance. RESULTS: Activin A increased at six (1081.00+/-98.05 pg/ml, p<0.05) and twelve months (1263.09+/-141.43 pg/ml, p<0.05) compared to the preoperative value (855.00+/-76.30 pg/ml) and correlated negatively to physical performance. The preoperative value was also increased compared to controls (639.54+/-63.05 pg/ml, p<0.05). GDF-15, MMP-3 and -9 were all increased at two days postoperatively (p<0.05). MMP-3 correlated with left ventricular end diastolic dimension (p<0.05). MMP-2 did not change during the study period. TGF-beta3 was only slightly reduced at six months postoperatively. CONCLUSION: The observed alteration in circulating levels of members of the TGF-beta superfamily and MMPs might play a role in the reverse remodelling process following AVR for AS.

Myocardial cooling with ice-slush provides no cardioprotective effects in aortic valve replacement.

OBJECTIVES: Topical cooling of the heart with ice-slush has been widely used for myocardial protection. No prospective, randomized study has evaluated the effect of ice-slush on acknowledged markers (CK-MB, troponin-T) of myocardial damage during aortic valve replacement (AVR). This was the first aim of the present study. A second aim was to examine whether performing a study per se reduced myocardial damage. DESIGN: Sixty patients undergoing AVR were receiving cold crystalloid antegrade cardioplegia every 20 min. Thirty patients were randomized to achieve additional topical cooling with ice-slush. CK-MB and troponin-T were compared between groups as well as to a group of patients undergoing AVR immediately prior to the study. RESULTS: There were no significant differences in myocardial markers between patients with or without ice-slush. However, we found significantly higher levels of troponin-T and CK-MB in patients undergoing AVR prior to start of the study. CONCLUSIONS: Topical cooling with ice-slush does not provide additional cardioprotective effects. Comparison with an historical cohort indicates that administration of crystalloid cardioplegia following a rigid protocol might reduce myocardial damage.

The effect of aortic valve replacement on plasma B-type natriuretic peptide in patients with severe aortic stenosis--one year follow-up.

BACKGROUND: B-type natriuretic peptide (BNP) is synthesized in cardiac tissue in response to increased wall stress and myocardial hypertrophy. AIMS: In patients with severe aortic stenosis (AS) we examined the effect of aortic valve replacement (AVR) on plasma BNP and association between BNP and left ventricular mass index (LVMI) preoperatively and in the reverse-remodeling phase twelve months postoperatively. We also examined the correlation between BNP and NYHA-class and between BNP and age. METHODS AND RESULTS: Plasma BNP analyses and echocardiographic measurements were performed preoperatively, before discharge after AVR, and at twelve months in twenty-two patients. BNP was additionally measured at six months. Preoperatively, BNP was 283+/-45 pg/ml (mean+/-SEM). Following an immediate postoperative increase (441+/-38 pg/ml), BNP values decreased towards normal values at six and twelve months (139+/-25 and 130+/-18 pg/ml, respectively). LVMI was 206.5+/-15.8 g/m(2) preoperatively and decreased to 119.7+/-7.2 g/m(2) at twelve months with a correlation between LVMI and BNP preoperatively only (r=0.45, p<0.05). There was no correlation between BNP and NYHA-class, whereas BNP correlated to age both pre- and post-operatively. CONCLUSION: We report an increase in plasma BNP in patients with AS. Following a further transient increase postoperatively, BNP levels decreased at six and twelve months after AVR. BNP correlated with LVMI preoperatively, and with age both preoperatively and at twelve months.