Abstract Introduction Patients with ST-elevation myocardial infarction (STEMI) and late arrival (>12h) may have worse outcome following percutaneous coronary intervention (PCI). A worse TIMI flow after PCI is associated with poor outcome. Our aim was to compare the TIMI flow after PCI and to find its effect on outcomes in patients with late-arrival STEMI Compared with that of patients presenting early (<12h). Methods Data source was available for patients enrolled in the biennial acute coronary syndrome Israeli Surveys (ACSIS) during 2000-2021. TIMI flow data was reviewed in patients with late arrival STEMI (12-48h and >48h) who underwent PCI. We analyzed its effect on clinical outcomes in patients with late-arrival STEMI compared with that of patients presenting early (<12h). Results Available data regarding the time from symptom onset to hospital arrival was available in 6,466 patients with STEMI. Data regarding TIMI flow following primary PCI was available in 2,437/6466 (38%) patients. Pre procedural TIMI-0 flow in the infarct related artery (IRA) was present in 59% of patients, irrespective of time of presentation (Figure). The rate of TIMI-3 flow following PCI was similar in all groups, 89% in patients arriving 12-48h, 96% in those arriving >48h after symptoms onset and 92% in patients presenting within 12h (p=0.632). Most importantly, PCI significantly reduced the rate of 30 days MACE only in those arriving less than 12 H from symptoms onset (Table). Conclusions In patients participating in the Israeli ACSIS registry, TIMI-3 flow after primary PCI was achievable in most STEMI patients, but PCI improved the outcome only in those arriving less than 12hour.

Background Estimation of kidney function by glomerular filtration rate (eGFR) is affected by age and is important for decision making regarding treatment and prognosis of patients with cardiovascular disease. We investigated the impact of eGFR on long-term cardiovascular outcomes in an elderly population undergoing coronary angiography for evaluation or treatment of coronary artery disease. Methods GFR was estimated according to Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation in 3690 elderly patients (aged 70–100 years) undergoing coronary angiography. Patients receiving maintenance dialysis were excluded. The association between eGFR and major adverse cardiovascular events (MACE) including myocardial infarction, ischemic stroke or death, was investigated. GFR was further calculated according to modification of diet in renal disease (MDRD) and the Cockcroft–Gault equations, and compatibility between estimations was analyzed. Results Cardiovascular comorbidities were more prevalent with the reduction in kidney function as was the proportion of patients presenting with acute coronary syndromes. The adjusted hazard ratio (95% confidence interval) for MACE during a mean follow-up of 5 years was 0.95 (0.77–1.16), 1.04 (0.84–1.29), 1.56 (1.16–1.84), 2.22 (1.65–2.97) and 3.74 (2.20–6.38) in patients with eGFR 60-89, 45–59, 30–44, 15–29 and <15 ml/min/1.73m2, respectively, compared to >90 ml/min/1.73m2. Reclassification of eGFR stages by MDRD (upward 23.8%, downward 0.4%) and Cockcroft–Gault (upward 4.3%, downward 28.1%) compared to CKD-EPI estimation, was noted. However, the association between eGFR stages and MACE was similar between equations. Conclusions Kidney function, as manifested by eGFR, has a graded inverse association with the burden of cardiovascular comorbidities and long-term adverse events in elderly patients undergoing coronary angiography.

Abstract Background A risk score for secondary prevention after myocardial infarction (TRS2P) was recently developed from the TRA2°P-TIMI50 trial based on 9 established clinical factors [age≥75, hypertension, diabetes, smoking, kidney dysfunction, peripheral artery disease, heart failure, prior stroke and prior coronary artery-bypass surgery (CABG)], classifying the risk for major adverse cardiovascular events (MACE). We aimed to evaluate the performance of TRS2P for predicting long-term outcomes in real-world patients presenting for coronary angiography. Methods Retrospective analysis of 13,593 patients that were referred to angiography for the assessment or treatment of coronary artery disease between 2000–2015 in a single center. Risk stratification for 10-year MACE (myocardial infarction, ischemic stroke or all-cause death) was performed using the TRS2P score, divided into 6 categories (0 to ≥5 points), and in relation to the presenting coronary syndrome. Results All clinical variables, except of prior CABG, were independent risk predictors. The annualized incidence rate of MACE increased in a graded manner with increasing TRS2P score, ranging from 1.65 to 16.6 per 100 person-years (ptrend<0.001). The pattern was similar for 10-year cumulative incidence of MACE. Compared to the lowest-risk group (risk indicators=0), the hazard-ratios (95% confidence interval) for MACE were 1.60 (1.36–1.89), 2.58 (2.21–3.02), 4.31 (3.69–5.05), 6.43 (5.47–7.56) and 10.03 (8.52–11.81), in those with 1,2,3,4 and ≥5 risk indicators, respectively. Risk gradation was consistent across the individual clinical endpoints. TRS2P score showed reasonable discrimination with c-statistics of 0.704 for MACE and 0.735 for mortality. The graded relationship between the risk score and event rates was observed in both patients presenting with acute and non-acute coronary syndromes. Cumulative 10-year incidence of MACE Conclusions The use of TRS2P, a simple risk score based on routinely collected variables, enables risk stratification in patients undergoing coronary angiography. Its predictive value was demonstrated in real-world setting with long-term follow-up, and irrespective of the acuity of coronary presentation. Acknowledgement/Funding None

ìAcute coronary syndrome (ACS), a spectrum of clinical scenarios including ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction and unstable angina, is one of the main reasons of hospital admissions and the leading cause of mortality in the developed nations. The underlying pathological substrate in ACS is a rupture of the atherosclerotic plaque leading to either complete or partial thrombosis of the infarct-related vessel. Both activation of platelets and coagulation cascade play a crucial role in thrombus formation. Multiple pharmacological agents have been developed to interfere in this process and to achieve ruptured plaque stabilization. Given the unfavorable impact of bleeding events on clinical outcomes, the development of newer drugs inhibiting platelet aggregation or thrombin formation used for the treatment of patients during acute ACS phase or for the prophylaxis of future ischemic events is targeted on the optimal balance of benefits and risks for each individual. This review provides comprehensive analysis of the current status of antiplatelet and antithrombotic therapy in patients with ACS.

BACKGROUND:Standard mechanical ventilation may cause adverse cardiovascular effects in addition to those already related to positive-pressure pneumoperitoneum (PP) during laparoscopic surgery. High-frequency jet ventilation (HFJV) is associated with much less airway pressure, with potentially less influence on venous return, thus potentially it may reduce those effects. The aim of this study was to evaluate the benefits of HFJV to reduce the adverse cardiovascular effects during laparoscopic cholecystectomy.METHODS:We conducted a randomized prospective trial, comparing 12 patients undergoing elective laparoscopic cholecystectomy under conventional mechanical ventilation (control) with 13 similar subjects under HFJV (study). Both groups were categorized as ASA I-II and underwent total intravenous anesthesia. Cardiac functionality was continuously evaluated by analysis of arterial pressure wave changes (Edwards Flo-Trac sensor and Vigileo monitor).RESULTS:There was no significant difference between both groups regarding age, gender, BMI, and general medical condition, as well as hemodynamic stability and blood gases throughout surgery. A significant reduction in cardiac output was noted in the control group under PP during the initiation of anti-Trendelenburg position (from 5.6 to 5.0 l/min, P = 0.049). A reciprocal change was observed regarding stroke volume. Such changes were not noticed under HFJV. Total peripheral resistance was significantly increased during PP, and heart rate was not significantly affected throughout surgery in both groups. Unexpectedly, we did not observe marked adverse hemodynamic changes in the control group during PP without position adjustment.CONCLUSIONS:The use of HFJV in upper laparoscopic surgery can impede the adverse cardiovascular changes that usually occur during induction of PP. We also suggest that the use of total intravenous anesthesia (as used in our study) may also lessen the cardiovascular impairment during PP.

The filler/matrix interface in fiber-reinforced polymer composites is critical in controlling load transfer from the matrix to the fiber, failure mechanisms, and degradation. It is not clear, however, how the mechanisms of load transfer in traditional composites apply to nanofiber-filled polymers. This paper is focused on understanding the reinforcement mechanisms in multiwalled carbon nanotube (MWCNT)/bisphenol-A polycarbonate (PC) composites. Strain dependent Raman spectroscopy shows that there is load transfer from the matrix to the nanotubes, and that the efficiency of the load transfer is improved by surface modification of the MWCNT. Dynamic mechanical analysis as well as electron microscopy reveals the presence of a large annular interphase region of immobilized polymer surrounding the embedded nanotubes. Micromechanical modeling of the elastic modulus of the composite that accounts for the limited load transfer to the interior shells of the MWCNT suggests this immobilized polymer provides an additional reinforcement mechanism that is unique for nano-filled composites.

BACKGROUND:Carbon dioxide pneumoperitoneum (PP) is known to induce increased cardiac sympathetic expression. The role of the insufflated gas involved in this mechanism should be elucidated in an attempt to eliminate its possible serious consequences.METHODS:Twenty-five patients undergoing elective laparoscopic cholecystectomy were prospectively analyzed for cardiac autonomic nervous activity by spectral heart rate variability. In 15 patients, helium was used as CO(2) substitution for abdominal insufflation (study group). Four frequency bands of interest were obtained from the power spectrum of R-R intervals, as well as the ratio between the low and high frequency (LF/HF), using the fast Fourier transformation algorithm to characterize the synergy of both autonomic branches during PP.RESULTS:Significantly increased values of the power spectrum related to the LF and VLF bands (from 130 to 377 msec(2)/Hz and from 145 to 516 msec(2)/Hz, respectively) were inspected during CO(2) PP, as well as increased LF/LH ratio (2.1). Using helium as CO(2) substitution has eliminated the significant changes in the power spectrum that reflect increased cardiac sympathetic activity.CONCLUSIONS:The elimination of sympathetic predominance by helium PP indicates the central role of CO(2) in establishing this phenomena. Considering this information and its other known advantages, helium should be considered for use during prolonged laparoscopic procedures for high-risk patients.

The impact of embedded carbon nanotubes on the effective viscoelastic response of a nanotube-reinforced polycarbonate system is characterized by studying the temperature- and frequency-dependent behaviour of the material. Macroscale experimental results demonstrate that the effective relaxation spectra of the samples is consistent with non-bulk polymer regions of restricted molecular mobility. Such low mobility regions are attributed to localized nanoscale interactions between the nanotubes and individual polymer chains.

Hypothesis: The creation of positive-pressure pneumoperitoneum during laparoscopic operations can lead to adverse hemodynamic changes, mainly decreased cardiac output. We hypothesized that pneumatic compression sleeves worn on the legs during pneumoperitoneum could abolish the pressure gradient between the abdominal cavity and the legs and so eliminate these adverse hemodynamic changes.Design: Prospective, randomized, controlled clinical trial with an additional calibration group.Setting: A regional referral center.Patients: Forty-five consecutive patients undergoing laparoscopic cholecystectomy who developed hemodynamic changes on induction of positive-pressure pneumoperitoneum were randomized to 3 groups.Interventions: Low-pressure, nonsequential pneumatic compression sleeves, wrapped around the legs, were used to equilibrate the pressure gradient in the study group and to gradually exceed it in the calibration group. In the control group, no sleeves were used.Main Outcome Measures: Transesophageal Doppler cardiac output, stroke volume, and systemic vascular resistance were monitored noninvasively.Results: The creation of positive-pressure pneumoperitoneum caused a significant decrease of cardiac output and stroke volume and increased systemic vascular resistance. In the experimental groups of patients, pressurizing the sleeves to the pneumoperitoneal pressure caused a significant increase of cardiac output (from 4.82 to 6.74 L/min), increased stroke volume, and decreased systemic vascular resistance (P<.001). This was not seen in the control group. Additional gradual pressure increase in the sleeves of the calibration group produced no further improvement. Releasing the pressure abolished the hemodynamic advantages.Conclusions: Applying pressure on the legs equivalent to the positive-pressure pneumoperitoneum improves hemodynamic performance during pneumoperitoneum by nullifying the pressure gradient that is responsible for the adverse consequences. This might be of major practical value, especially for cardiac patients undergoing prolonged laparoscopic operations.

Background The creation of positive pressure pneumoperitoneum (PP) may lead to adverse cardiovascular effects during laparoscopic operations. It can also lead to increased sympathetic cardiac activity, that might have serious consequences. We hypothesized that by reversing the hemodynamic effects, the use of intermittent sequential pneumatic compression device (Lympha-press) on the lower extremities would lead to improved cardiac autonomic control. Methods This was a prospective cohort study, in which patients served as their own control. Fifteen patients without cardiorespiratory disease undergoing elective laparoscopic cholecystectomy were enrolled prospectively. The activity of the cardiac autonomic nervous system was evaluated by using spectral analysis of heart rate variability, with the Del Mar Avionics 363 (Irvine, California), based on the fast Fourier transformation. The Lympha-press was manipulated several minutes after induction of PP. In each frequency band we measured and compared the power values during anesthesia against those of PP, as well as those of PP against those recorded during activation of Lympha-press. Results Creation of PP caused increased sympathetic activity, as was manifested by increased power of the low frequency band. Manipulation of the Lympha-Press compression device caused increased parasympathetic activity, as was evident by significant increased power of the high frequency band in all patients. Conclusions Using an intermittent sequential pneumatic compression device during laparoscopic cholecystectomy may improve cardiac autonomic control by enhancing protective parasympathetic activity. That may have clinical significance, especially in patients suffering from cardiac disease, by improving heart rate variability and elevating the threshold of the occurrence of ventricular arrhythmia.

The ability to modify the surface of carbon nanotubes is of crucial importance for their utilization in different applications. In the present paper we report on the chemical modification of multiwalled carbon nanotubes (MWNT) by means of epoxide-based functional groups. MWNT were first carboxylated along their walls. This was followed by further reactions to attach di-glycidyl ether of bisphenol-A-based epoxide resin. The behavior of the modified nanotubes in various solvents was altered due to the chemical changes, and analytical techniques were utilized to detect the chemical attachments. The implications of the surface modification achieved are discussed primarily in terms of nanotube-polymer composite applications.

Gold nanoparticles were selectively attached to chemically functionalized surface sites on nitrogen-doped carbon (CN(x)) nanotubes. A cationic polyelectrolyte was adsorbed on the surface of the nanotubes by electrostatic interaction between carboxyl groups on the chemically oxidized nanotube surface and polyelectrolyte chains. Negatively charged 10 nm gold nanoparticles from a gold colloid suspension were subsequently anchored to the surface of the nanotubes through the electrostatic interaction between the polyelectrolyte and the nanoparticles. This approach provides an efficient method to attach other nanostructures to carbon nanotubes and can be used as an illustrative detection of the functional groups on carbon nanotube surfaces.

A series of observations of polymer sheathing in multiwalled carbon nanotube (MWCNT)−polycarbonate composites are presented. This sheathing was observed in images of the composite fracture surface and is consistent with diameter distributions of the as-received and embedded MWCNTs. A novel nanomanipulation experiment, where the sheathing balls up when contacted by an AFM tip, confirms this phenomenon. This sheathing layer is direct evidence of substantial MWCNT−polymer interaction and will influence the mechanical properties of MWCNT-polymer composites.

BACKGROUND:Positive pressure pneumoperitoneum (PPP) effects on the autonomic nervous system (ANS) might be of clinical importance, as imbalance in the autonomic cardiac control might lead to serious consequences.METHODS:Fifteen healthy patients undergoing elective laparoscopic cholecystectomy were analyzed for cardiac autonomic nervous activity by spectral heart rate variability, during awake state, before and after intubation, during CO2 PPP (14 mmHg), and after CO2 evacuation. The very low, low, high and very high frequency (VLF, LF, HF, VHF respectively) bands of the spectral density of the heart rate variability (HRV) and their normalized values, as well as the LF/HF ratio, were obtained from the power spectra of R-R intervals, using the fast-Fourier transformation algorithm.RESULTS:Using Friedman's nonparametric test, only the difference between the power of LF during anesthesia (median 30.74) and the middle of PPP (median 195.66) was found to be significant (p<0.012). Such change was recorded in 14 patients (p = 0.001, sign test).CONCLUSIONS:Increased LF power reflects sympathetic cardiac activation. As the LF range accounts for regulation of blood pressure and baroreflex, several mechanisms may explain this activation. This in turn may predispose patients who suffer from cardiac disease to higher risk of developing ventricular arrhythmias, besides the possible adverse hemodynamic consequences of PPP.

Background: The laparoscopic approach to incisional hernia repair is already well established because of its advantages. We evaluated the possibility of using a laparoscopically assisted approach whenever conversion to open repair was considered.Patients and Methods: We operated laparoscopically on 62 patients for postoperative ventral hernia (POVH), seven of whom had undergone laparoscopically assisted repair. The reasons for considering conversion were mainly technical difficulties in adhesiolysis and hernia reduction, and the suspected possibility of intestinal injury during dissection. The assisted approach included creation of a short incision over the fascial defect, exploration of the hernia contents and correction of any intestinal injury, completion of adhesiolysis, closure of the abdominal cavity, and laparoscopic accomplishment of the repair.Results: Following open exploration, two iatrogenic intestinal perforations and one serosal injury were found and repaired. In four cases, only the completion of adhesiolysis was necessary. The postoperative convalescence was uneventful, and no recurrence has been recorded to date.Conclusions: The laparoscopically assisted approach to difficult POVH repair is feasible and safe, and it helps to preserve the advantages of the laparoscopic approach. We recommend this approach whenever conversion to open surgical repair is under consideration during laparoscopic repair.

An alternative procedure for detection breast cancer was examined based on the observation that lymphocytes re-exposed in vitro to antigenic stimulation will change their intracellular structuredness as measured by polarization of fluorescent light emitted by fluorescein labeled cells (SCM test). The specific antigen MUC-l/SEC was used to elicit such response in lymphocytes of patients with and without breast cancer. Eighty-five samples with breast cancer were tested, of which 72 were correctly diagnosed. Of the 41 controls, 35 were correctly identified as healthy subjects. The sensitivity of the test was 85% and the specificity was 81%. These results suggest a possible valuable method for screening and early detection of breast cancer. The clinical importance of this procedure lies in the ability to screen high-risk populations with higher specificity and sensitivity than any combinations of currently available procedures for breast cancer detection.