Unfortunately, the 2nd affiliation of Shalaby has been missed out in the original publication.

AIM:Aim of the study was to evaluate late outcomes of mitral valve repair with and without the use of prosthetic ring annuloplasty and standardized techniques for the treatment of degenerative mitral regurgitation (MR).METHODS:Three hundred and five patients (mean age 62 ± 12 years) underwent mitral valve repair between January 1992 and February 2010 for degenerative MR. In the last five years, all repair techniques were performed routinely using prosthetic ring annuloplasty, with or without quadrangular or triangular resection of posterior leaflet and/or edge-to-edge technique. Mean follow-up (99% complete) was 78 ± 46 (2-220) months.RESULTS:Operative mortality was 0.9% (3/305), 15-year actuarial survival 82% ± 4%. At 15 years freedom from cardiac death was 89% ± 3.7%, from reoperation 84% ± 5.8%, from endocarditis 100%. Independent predictors of all-causes mortality were advanced age at operation (P=0.0006) and mitral valve repair without reductive prosthetic annuloplasty (P=0.0019). Death for cardiac causes was significantly higher when reductive annuloplasty was performed without the use of prosthetic ring (P<0.01). Late progression to moderate or severe MR was observed in 23/299 patients (7.7%). Independent predictors of progression to moderate or severe MR was annuloplasty without the use of prosthetic ring (P=0.0053) and postoperative residual mild MR (P=0.0014). Reoperation was required in 13/299 patients (4.4%). At 10 years freedom from moderate or severe MR was 86% ± 6% and 92% ± 4% in patients with postoperative absent or trivial residual MR, respectively, as compared to 38% ± 15% in those with postoperative residual mild MR (P<0.0001), freedom from reoperation 94% ± 4% and 90% ± 14% vs. 56% ± 16% (P<0.0001).CONCLUSION:Prosthetic annuloplasty in association with standardized techniques confers over 10 years survival advantage and better durability.

Purpose: Aim of this study was to verify how Marfan Syndrome (MFS) patients followed by our Centre were distributed in the different subgroups highlighted by new 2010 Ghent nosology: 3 in the presence of family history (FH), FH and aortic dilatation (Ao), FH e score system ≥7 (SS), FH and ectopia lentis (EL), 4 in the absence of family history (Ao e EL, Ao e SS, Ao e FBN1, EL e FBN1 mutation) and to define the impact of aortic root dilatation in the diagnosis of the syndrome to support a cardiac surgery department's management of a Marfan Diagnostic Centre. Methods: We reviewed clinical features of 500 subjects visited in our Centre from January 2008 to December 2012; 146 patients (74 men and 72 women) had MFS clinical diagnosis. The population included 29 children (age <14 years) 117 adults (17 age between 15 and 19 y, 64 between 20 and 40 y and 36 with age >40 y). All patients was submitted to echocardiographic exam and measurement of aortic root along the American Society of Echocardiography guidelines, genetic advice, orthopedic visit, eye and dental examination and pediatric counseling, the last for patients younger than 14 y. In all cases spine and hips X-ray were performed. Results: In presence of family history 78 patients (53%) were in FH and Ao subgroup, 8 patients (5,4%) in FH and SS and 3 (2%) in FH and EL. In 45 patients the was no FH and the diagnosis was possible for the concomitance of Ao and EL in 33 patients (22%), of Ao and SS in 20 (13%), in 2 cases (1,3%) for Ao and FBN1 mutation, and in 2 cases (1,3%) for EL and FBN1 gene mutation. Among the 78 patients with FH, 32 belong to one big kin family with high incidence of sudden cardiac death for dissection. Main characteristics in our population were aortic dilation with Z-score ≥2 in adults and ≥3 in children present in 133 (91%) patients, FH in 89 (61%), SS≥7 in 55 (37%), ectopia lentis in 36 (24%), the FBN1 mutation response was present in 31 (21%). Fifty-four patient (37%) underwent to cardiac surgery, 50 patient for aortic root replacement and 4 patients for mitral valve procedure. We had no deaths for aortic dissection in 4 years of observation. Conclusions: New 2010 Ghent Criteria allow an excellent clinical definition of MFS and a rapid diagnosis thanks the possibility to include patients in a specific subgroup. Aortic dilation was the main feature of our population. A clear diagnosis and a cardiac surgery vision of follow-up are crucial for an optimal management and surgical decision.

We report a case of acute left ventricular failure after transcatheter closure of a single secundum atrial septal defect in a 68-year-old man with coronary artery disease. Just before the procedure, two coronary lesions had been treated with direct stenting. Transcatheter closure of atrial septal defects should always be deferred in ischemic heart disease patients who need percutaneous myocardial revascularization.

BACKGROUND:Compared with medical therapy alone, coronary artery bypass surgery improves survival in patients with coronary disease and left ventricular dysfunction. Many of these patients have a hibernating myocardium secondary to chronic ischemia with the potential for improvement in left ventricular function and heart failure symptoms following revascularization therapy. Cardiac transplantation remains the treatment of choice for patients with severe congestive heart failure.METHODS:From January 1992 to June 2000, 351 consecutive patients (318 men, 33 women, mean age 62.8 +/- 8.9 years) with a left ventricular ejection fraction (EF) < or = 35% and with multivessel coronary artery disease underwent isolated coronary artery bypass grafting. Preoperatively 226 patients were in CCS class III-IV and 113 in NYHA class III-IV. The mean number of grafts was 3.4 +/- 0.8/patient and complete revascularization was achieved in 98.6% of cases. The internal mammary artery was used in 341 patients (97.2%) and in 328 (96%) as a graft for the left anterior descending artery. Follow-up was obtained in 97% of the patients and on average lasted 42 +/- 28 months.RESULTS:The hospital mortality was 5.9%. At multivariate analysis urgent operation (p < 0.01) and a lower EF (25.9% in deaths vs 29.1%, p < 0.05) were predictors of an increased operative mortality. EF (assessed postoperatively at transthoracic echocardiography in survivors) improved from 28.9 +/- 5.7 to 34.4 +/- 7.7% (p < 0.0001). At 1, 3, 5, 7, and 9 years respectively, the all-cause survival was 93 +/- 1.5, 85 +/- 2.2, 77 +/- 3.1, 69 +/- 4.9, and 60 +/- 7.3% and the freedom from cardiac death was 94 +/- 1.4, 89 +/- 1.9, 88 +/- 2, 80 +/- 4.7, and 76 +/- 5.7% with an improvement in the anginal and congestive heart failure status (p < 0.0001).CONCLUSIONS:In patients with coronary artery disease and severe left ventricular dysfunction, after evaluation of the clinical presentation, of the usefulness of vessels as grafts and of the presence of myocardial viability, 1) coronary artery bypass grafting can be performed with a low mortality and a good mid-term survival, 2) improvement in left ventricular function can be documented after coronary bypass surgery, 3) the internal mammary artery can be safely used as a graft, 4) the quality of life is improved as demonstrated by the improvement in the anginal and congestive heart failure status.

We describe a technique to replace the aortic root by means of a stentless valve and a new aortic root Dacron graft (Gelweave Valsalva, Sulzer Vascutek, Renfrewshire, Scotland) that allows an anatomical reconstruction of the sinuses of Valsalva.

BACKGROUND Annulo-aortic ectasia is a dilation of the aortic root with the involvement of the Valsalva sinuses. In 1968 Bentall and DeBono proposed to replace the aortic valve, the Valsalva sinuses and the ascending aorta with a composite tube graft containing aortic valve prosthesis. Consequently coronary ostia had to be reimplanted on the prosthetic tube. Recently the use of new materials has resulted in a more acceptable operative risk, and postoperative bleeding and late mortality have been reduced. METHODS From January 1991 to December 1998, 44 out of 241 patients were operated on with the Bentall-DeBono procedure, affected by dissecting or expansive aneurysm of the ascending aorta. Of the 44 patients (35 males, 9 females, mean age 53.7 years), 3 presented with acute aortic dissection, 5 were asymptomatic, 10 were in NYHA functional class II, 14 in class III, 9 in class IV, and 2 in CCS class 4; 1 patient had dysphonia; 37 patients presented with isolated aortic regurgitation, and 7 associated aortic valvular stenosis. The diagnosis of acute dissection was made by transesophageal echocardiography and that of expansive aneurysm by thorax helical computed tomographic scanning and/or magnetic resonance imaging and cardiac catheterization. Follow-up was obtained in 100% of the patients for an average of 23 +/- 20.9 months (range 4-79 months). RESULTS Four patients (9%) died; in 4 patients (9%) postoperative bleeding needed reoperation, in 5 (11.4%) a permanent pacemaker for atrioventricular block was implanted, and 1 patient (2.3%) had transient hemiparesis. At univariate analysis predictive factors for operative risk were NYHA functional class IV (p < 0.005) and atherosclerotic etiology (p < 0.05). At follow-up 7 late deaths occurred for an actuarial survival at 24 months of 75 +/- 9%. Causes were sudden death in 3 patients, cardiac failure in 3 and stroke in 1 patient; 31 surviving patients (94%) were in NYHA functional class I and 2 patients in class II (6%). CONCLUSIONS The Bentall-DeBono procedure involves moderate risk with good results; clinical presentation and associated valvular pathology influence early and mid-term results.

BACKGROUND:Classic experimental studies have shown that in the presence of a flow-limiting coronary artery stenosis, myocardial ischemia during metabolic or pharmacological arteriolar vasodilation causes wall motion abnormalities, which precede electrocardiographic (ECG) changes in the myocardial regions supplied by the stenotic branch. The aim of this study was to establish whether in patients with chronic stable angina the regional distribution of wall motion changes and sequence of ischemic events are similar to that observed in experimental models, as currently believed.METHODS:The study population consisted of 20 men and 4 women (mean age 59 +/- 10 years) who were recruited on the basis of the following criteria: 1) a history of chronic stable angina without clinical and instrumental evidence of previous myocardial infarction; 2) reproducible positive exercise tests for ECG myocardial ischemia and anginal pain; 3) angiographically normal left ventricular function; 4) isolated stenosis of the left anterior descending coronary artery (LAD). Patients underwent continuous 12-lead ECG and echocardiographic monitoring during dipyridamole infusion.RESULTS:During dipyridamole infusion 3 patients (13%) did not develop echocardiographic changes, ECG changes or angina, 14 (58%) exhibited ECG changes, 18 (75%) lamented angina and 16 (67%) developed echocardiographic changes. In 5 of these 16 patients (31.5%) echocardiographic changes occurred in LAD-dependent territories only, in 5 they occurred in non-LAD-dependent territories only (31.5%) and in 6 (37%) they occurred in both LAD- and non-LAD-dependent territories. A total of 14 patients exhibited both echocardiographic and ECG changes and/or angina. In 6 of these 14 patients (43%) echocardiographic changes were the first ischemic events; in the remaining 8 patients (57%) ECG changes and/or angina were the first ischemic events.CONCLUSION:In the majority of patients during dipyridamole infusion regional wall motion changes occur in territories supplied by non-stenotic coronary artery branches; they are probably caused, therefore, by distal vessel dysfunction. Furthermore, the sequence of ischemic events is different in individual patients. These findings indicate that in stable angina the mechanisms of ischemia are multiple and that the link between coronary stenoses and myocardial ischemia is very elusive.

BACKGROUND:Coronary artery bypass grafting is reported to have a higher (2-3 times) mortality in women than in men, most likely due to older age, higher incidence of hypertension, diabetes mellitus, hypercholesterolemia, obesity, angina and preoperative myocardial infarction, smaller diameter of coronary arteries, and smaller body surface area.METHODS:From January 1992 to December 1997, 347 female and 2098 male patients were submitted to isolated coronary artery bypass grafting. For both groups were considered: a) clinical presentation (age, height, weight, body surface area, NYHA and CCS functional classes, incidence of preoperative myocardial infarction); b) risk factors for cardiovascular diseases (diabetes mellitus, smoking habit, dyslipidemia, hypertension, familiarity); c) concomitant diseases (obesity, chronic obstructive pulmonary disease, peripheral vascular disease, thyroid dysfunction); d) hemodynamic and anatomical data (extent of coronary artery disease, diameter of coronary arteries, left ventricular function); e) surgical procedure (number and type of grafts used, urgent procedures, incidence of redo procedures). Early (up to 30 days after surgery) results were evaluated in terms of complications and mortality.RESULTS:On admission, women were older than men (p = 0.0001), were shorter (p < 0.0001), weighed less (p < 0.0001), and had a smaller body surface area (p < 0.0001); they had more severe angina (p = 0.002), diabetes mellitus (p = 0.002), hypercholesterolemia (p = 0.003), thyroid dysfunction (p < 0.0001), their coronary arteries were smaller (left anterior descending artery, p = 0.05; obtuse marginal branch, p = 0.008; diagonal branch, p = 0.01), and had less grafts implanted at surgery (p = 0.02). There was no difference between women and men in the use of the internal thoracic artery. Women did not have a higher mortality than men (4.6 vs 3.2%). Uni- and multivariate analysis did not show extraoperative risk factors for women; for men older age (p = 0.005) and poor left ventricular function (p = 0.01) were independent predictive factors of operative mortality.CONCLUSIONS:In spite of what is suggested by the literature, coronary artery bypass grafting does not have a significant higher operative risk for women than men, probably due to surgical technique refinements and extensive use of the internal thoracic artery.

BACKGROUND:Volatile anesthetics enhance postischemic functional recovery in animal models; this effect has not been investigated in man. METHODS:Twenty-two patients undergoing coronary surgery were randomized to enflurane administration (0.5% to 2%) for 5 minutes to reduce systolic blood pressure by 20% to 25% immediately before cardioplegic arrest. Left ventricular contractility was assessed by pressure-area relations using echocardiographic automated border detection during inflow occlusion before and after cardiopulmonary bypass. Linear regression analysis in 16 patients with paired data sets assessed changes in contractility. RESULTS:The relation was highly linear (r = 0.95+/-0.02). A change of slope versus the change in x intercept was detected in controls (mean difference, 16.1 mm Hg/cm2, 95% confidence limits, 5.9 to 26.3; 2.2 cm2, 95% confidence limits, -1.1 to 5.5; p = 0.007), which was different from those of treated patients (mean difference, 0.7 mm Hg/cm2, 95% confidence limits, -2.2 to 3.7; -0.06 cm2, 95% confidence limits, -1.6 to 1.5; p > 0.2). Analysis of covariance in the overall group confirmed a significant effect of treatment (p = 0.002). CONCLUSIONS:Enflurane enhances postischemic functional recovery, possibly through pharmacologic preconditioning of myocardium.

BACKGROUND:Experimental studies indicate that isoflurane, a commonly used volatile anesthetic, mimics the cardioprotective effects of ischemic preconditioning, probably through ATP-sensitive K+ (KATP) channel activation. The aim of this study was to evaluate the impact of isoflurane during coronary bypass surgery (CABG) on troponin I release.MATERIAL AND METHODS:Forty consecutive patients with chronic stable angina and multivessel disease undergoing isolated CABG were randomized to a control (16 men and 4 women, aged 51 to 73 years, mean 62) or isoflurane (15 men and 5 women, aged 51 to 77 years, mean 65) group before aortic cross-clamping and cardioplegia. Serum levels of troponin I and creatine kinase (CK)-MB, as markers of ischemic injury, were obtained at 24 hours after CABG. Regional wall motion score and left ventricular ejection fraction (LVEF) at transthoracic echocardiography were assessed 5 days postoperatively. Comparisons between groups were performed in the entire population and, subsequently, in those patients with preoperative LVEF < 50%.RESULTS:There were no significant differences between isoflurane-treated patients and controls in cross-clamp time (49 +/- 14 vs 51 +/- 13 min, p = ns), peak values of troponin I (0.9 +/- 0.7 vs 1.4 +/- 1.3 ng/ml, p = ns) and CK-MB (62 +/- 27 vs 64 +/- 27 U/l, p = ns), or postoperative echocardiographic score (26 +/- 7 vs 22 +/- 5, p = ns) and LVEF (53 +/- 10 vs 55 +/- 7%, p = ns). When the comparisons were restricted to those patients with preoperative LVEF < 50%, at 24 hours the isoflurane-treated patients exhibited a smaller release of troponin I and of CK-MB than controls (1.1 +/- 0.7 vs 2.3 +/- 1.3 ng/ml, p = 0.03, and 39 +/- 10 vs 57 +/- 22 U/l, p = 0.04, respectively).CONCLUSIONS:Isoflurane reduces myocardial injury in patients with impaired left ventricular function undergoing CABG; thus, it can be safely used as an additional cardioprotective tool during routine CABG in high-risk patients with poor left ventricular function.

We performed a prospective study to establish the efficacy of coronary stent placement in a highly selected group of patients with focal coronary artery spasm in whom anginal attacks could not be prevented by full medical therapy. The results of this study indicate that intracoronary stent placement may represent an alternative and feasible treatment for patients with vasospastic angina refractory to aggressive medical therapy.

We report a case of cardiac echinococcosis in a patient who had sustained an acute myocardial infarction 1 month previously. The coronary angiographic study revealed an isolated complete intrinsic obstruction of the left anterior descending coronary artery in the area of the cyst. The cyst was surgically removed. Coronary artery bypass grafting was not performed because of distal myocardial scarring. Coronary arteriography should routinely be performed in all patients with cardiac echinococcosis.

BACKGROUND:Intracoronary stenting, conventional coronary artery bypass with cardiopulmonary bypass and minimally invasive direct coronary artery bypass without extracorporeal circulation are the three accepted options for revascularizing the left anterior descending coronary artery. We compare the effects of these three procedures in terms of minor myocardial damage and systemic inflammatory response.METHODS:Ninety patients undergoing left anterior descending coronary artery revascularization with these three different techniques (thirty patients per group) were considered. Blood samples were collected preoperatively and immediately postoperatively, and then 24, 48 and 72 hours after the procedures to measure troponin I, creatine kinase, its MB fraction and C-reactive protein levels.RESULTS:Postoperative levels of troponin I and MB-creatine kinase were significantly higher in conventional coronary grafting group than in PTCA-stent and in the minimally invasive surgery groups (p < 0.0003), while in both surgery groups there were higher post-operative levels of total creatine kinase and C-reactive protein (p = 0.0001).CONCLUSIONS:Minimally invasive direct coronary artery bypass surgery and PTCA-stent are similar in terms of virtual absence of minor myocardial damage. Skeletal muscle damage and inflammatory reaction are comparable in surgical patients, but they do not appear to have any clinical relevance.

OBJECTIVE:To assess the extent and pattern of regression of left ventricular hypertrophy after valve replacement for aortic stenosis, we studied 26 patients receiving either 19 or 21 mm CarboMedics valves (group I, 13 patients) or either 23 or 25 mm CarboMedics valves (group II, 13 patients). The studies were done before the operation and after 3 years, and results were compared with those of 10 control patients.METHODS:Left ventricular end-diastolic and end-systolic diameters and volumes, ejection fraction and fractional shortening, and interventricular septum and posterior wall thickness were measured. The ratio between interventricular septum and posterior wall thickness, the ratio between left ventricular wall thickness and left ventricular chamber radius, and the left ventricular mass were then calculated.RESULTS:At follow-up there was a significant reduction in the left ventricular mass, interventricular septum, and posterior wall thickness for both patient groups (p < 0.01). However, only the posterior wall thickness reached normal values; the interventricular septum and the left ventricular mass indices were still significantly greater than in the control group (p < 0.01). Because of the incomplete regression of interventricular septal hypertrophy, the ratio between interventricular septum and posterior wall thickness was similar between both patient groups but it was significantly higher than in control subjects (p < 0.01). The ratio between wall thickness and chamber radius did not decrease significantly in group II patients, in whom it remained above the control values.CONCLUSION:Having a bileaflet aortic prosthesis of one size larger did not seem to significantly influence the pattern and the extent of regression of left ventricular hypertrophy after an intermediate period of follow-up.

BACKGROUND AND AIMS OF THE STUDY:Optimal hemodynamic performances are of paramount importance when implanting a mechanical valve in patients with a small aortic annulus. A Doppler echocardiographic study was performed to compare the hemodynamic performances of small CarboMedics and St. Jude valves.MATERIALS AND METHODS:Twenty-nine patients receiving either a 19 mm (n = 10) or a 21 mm (n = 10) CarboMedics valve or a 19 mm (n = 9) St. Jude Med HP valve were evaluated. A Doppler echocardiographic study was performed at rest and two minutes after treadmill exercise with the Bruce protocol. Peak and mean gradients across the valve were estimated; effective orifice area, performance index and discharge coefficient were calculated. Heart rate, blood pressure and cardiac output were all significantly increased with exercise.RESULTS:Peak and mean gradients at rest were significantly higher (p < 0.05) in the 19 mm CarboMedics valve (40.2 +/- 15 mmHg and 22.6 +/- 9 mmHg, respectively) when compared either with 21 mm CarboMedics valve (27.6 +/- 6.8 mmHg and 14.2 +/- 3.4 mmHg, respectively) or with the 19 mm St. Jude HP valve (23.6 +/- 10.4 mmHg and 13.6 +/- 5 mmHg, respectively). Peak and mean gradients were not modified with exercise for the 19 mm CarboMedics valve and significantly increased for the 21 mm CarboMedics and the 19 mm St. Jude HP valves. Although these values were still higher in the 19 mm CarboMedics valve, they did not reach the level of statistical significance when compared with the other two valve groups.CONCLUSIONS:The 19 mm St. Jude HP valve shows hemodynamic performances at rest that are similar to those of the 21 mm CarboMedics valve and superior to those of the 19 mm CarboMedics valve. With exercise both sizes of the CarboMedics valve show an in vivo discharge coefficient close to one, testifying to a full utilization of the internal orifice area.

OBJECTIVE The role of A1 adenosine receptors in preconditioning in humans is unknown. To establish whether bamiphylline, a selective antagonist of A1 adenosine receptors, abolishes ischaemic preconditioning in man, 36 consecutive patients undergoing single-vessel coronary angioplasty were randomized to receive intravenous infusion of bamiphylline (5 mg.kg-1) or placebo (0.9% NaCl) immediately prior to the procedure. DESIGN The mean values (+/- 1 SD) of ST segment shifts on the surface and intracoronary electrocardiograms were measured at the end of the first and second balloon inflations, both 2 min long. The severity of cardiac pain was obtained at the same time using a visual analogue scale. RESULTS In bamiphylline-treated patients, the mean ST segment shift and the severity of cardiac pain during the second inflation were similar to those during the first inflation (14 +/- 15 vs 16 +/- 16 mm, ns and 31 +/- 28 vs 31 +/- 29, ns, respectively). Conversely, in placebo-treated patients both the mean ST segment shift and the severity of cardiac pain during the second inflation were significantly less than those during the first inflation (10 +/- 6 vs 17 +/- 7 mm, P < 0.001 and 25 +/- 21 vs 39 +/- 31 mm, P < 0.01, respectively). Thus, bamiphylline abolishes ischaemic preconditioning observed in man during repeated coronary balloon inflations. CONCLUSION These results suggest that, in this setting, ischaemic preconditioning is mediated, at least in part, by A1 adenosine receptors.