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Abstract Background Cardiac surgery-associated acute kidney injury (AKI) is a serious complication of cardiac surgery, even when renal replacement therapy (RRT) is not required. The existing risk models for cardiac surgery associated AKI are designed to predict AKI requiring RRT (RRT-AKI). The aim of this study is to validate three risk models for the prediction of RRT-dependent and non-RRT AKI after cardiac surgery. Methods Retrospective analysis on 7675 consecutive adult patients undergoing cardiac surgery with cardiopulmonary bypass. AKI was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria for stage 1 and 2. RRT AKI and non-RRT AKI were defined according to the need for RRT. Three risk models were validated separately for RRT and non-RRT AKI: the Cleveland Risk Score, the Bedside Risk Score, and the Simplified Renal Index Scoring Scheme. Discrimination power was assessed with Receiver Operating Characteristics analysis and c-statistics. Results There were 502 (6.5%) non-RRT AKI events, 128 (1.7%) RRT-AKI events, and 7045 (91.8%) no-events. The three models performed well for predicting RRT-AKI (c-statistics 0.75–0.79) and poorly for predicting non-RRT AKI (c-statistics 0.54–0.59). The models had an excellent calibration for RRT-AKI but not for non-RRT AKI. Preoperative serum creatinine and estimated glomerular filtration rate were associated with RRT AKI but not with non-RRT AKI. Mortality was 12.2% in non-RRT AKI and 46.9% in RRT-AKI, significantly (P = 0.001) higher than in patients without AKI (1.3%). Conclusions The existing risk models are inadequate for predicting non-RRT AKI following cardiac surgery, both in terms of discrimination and calibration. Highlights • Acute kidney injury (AKI) after cardiac surgery determines bad outcomes, even in absence of renal replacement therapy (RRT). • The risk scores for AKI following cardiac surgery predict the risk of RRT-AKI, but are used to predict non-RRT AKI too. • This study demonstrates that the existing risk scores provide an inadequate discrimination and calibration for non-RRT AKI. [ABSTRACT FROM AUTHOR]

Background In Australia it has been suggested that heart valve surgery, particularly for rheumatic heart disease (RHD), should be consolidated in higher volume centres. International studies of cardiac surgery suggest large volume centres have superior outcomes. However the effect of site and surgeon case load on longer term outcomes for valve surgery has not been investigated. Methods The Australian and New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database was analysed. The adjusted association between both average annual site and surgeon case load on short term complications and short and long-term survival was determined. Results Outcomes associated with 20,116 valve procedures at 25 surgical sites and by 93 surgeons were analysed. Overall adjusted analysis showed increasing site and surgeon case load was associated with longer ventilation, less reoperation and more anticoagulant complications. Increasing surgeon case load was also associated with less acute kidney injury. Adjusted 30-day mortality was not associated with site or surgeon case load. There was no consistent relationship between increasing site case load and long term survival. The association between surgeon case load and outcome demonstrated poorer adjusted survival in the highest volume surgeon group. Conclusions In this Australian study, the adjusted association between surgeon and site case load was not simple or consistent. Overall larger volume sites or surgeons did not have superior outcomes. Mandating a particular site case load level for valve surgery or a minimum number of procedures for individual surgeons, in an Australian context, cannot be supported by these findings. [ABSTRACT FROM AUTHOR]

Introduction Post-operative atrial fibrillation (POAF) is one of the most common complications following cardiac surgery. However, it is unclear whether there is a relationship between obesity and POAF. We thus assessed all available evidence investigating the association between obesity and POAF, also considering any link between POAF and other post-operative conditions such as mortality, stroke, myocardial infarctions and respiratory complications. Methods Five electronic databases were searched and relevant studies were identified. Data was extracted and meta-analyzed from the identified studies. Results We found that obese patients had significantly higher odds of POAF when compared with non-obese patients (P = 0.006). There was also significant heterogeneity among the identified studies. POAF when compared with no-POAF was associated with an increased risk of stroke (P < 0.0001), 30-day mortality (P = 0.005) and respiratory complications (P < 0.00001). However, we found no significant link between POAF and myocardial infarctions (P = 0.79). Conclusions Our findings suggest that obesity is associated with a moderately higher risk of POAF. While POAF is also associated with an increased incidence of stroke, 30-day mortality and respiratory complications, further studies must be conducted before conclusions can be made about the long-term outcomes. [ABSTRACT FROM AUTHOR]

Background Rupture of the ventricular septum following acute myocardial infarction (AMI) is an uncommon but serious complication, usually leading to congestive heart failure and cardiogenic shock. Surgical repair is the only definitive treatment for this condition. Methods We review our experience of surgical repair of post-infarction ventricular septal defects (VSDs), analyze the associated risk factors and outcomes, and do a complete review of the literature. A retrospective study was performed on 34 consecutive patients who had undergone surgical repair for VSDs following AMI from December 1991 to July 2014. Preoperative, clinical and echocardiographic variables were studied by uni-and multivariate analyses. Results Mortality was analyzed for the entire group of patients. Mean age was 69 ± 7 years with 44% women. VSDs were anterior in 11 (32%) and posterior in 23 (68%) patients. A majority, 24 (71%) patients were in cardiogenic shock. Median interval from myocardial infarction to VSDs repair was 7 days. The 30 days operative mortality was 65%. Mortality within the posterior VSDs group was 74% and the anterior VSDs group was 46% (P = 0.14). Concomitant coronary artery bypass graft (CABG) did not influence early or late survival. Multivariate analysis identified older age (HR = 1.11, P = 0.0001) and shorter time between AMI and surgery (HR = 0.90, P = 0.015) as independent predictors of 30-day and long-term mortality. Conclusion In conclusion, surgical repair of post-AMI VSDs carries a high operative mortality. An algorithm of treatment for the management of these patients is suggested. [ABSTRACT FROM AUTHOR]

Background Supravalvular pulmonary stenosis (SPS) remains a worrisome complication in the long term of simple transposition of the great arteries. Issues of scar formation and inability to grow are considered at the base of this phenomenon. We pioneered the use of a tissue engineering approach to guide the maturation and the growth of pulmonary autograft in the Ross procedure with encouraging results. We therefore sought to investigate the use of a similar approach in the reconstruction of neopulmonary trunk (NPT) with the aim to recreate a vascular conduit that retains the structural architecture and the same biological potential of native pulmonary artery and prevents long-term SPS. Methods A model of NPT reconstruction in growing lambs was used. NPT was constructed with autologous pericardium and reinforced with a four-layered knitted polydioxanone mesh (PDS n = 10) or left unreinforced (control n = 10). Animals were left growing for 6 months and angiographic and transesophageal echocardiographic measurements were performed at day 1 and at the end of the study together with histological analysis. Results Control group developed SPS while PDS reinforcement allowed a progressive increase in diameter with an optimal size to match the pulmonary artery of healthy growing controls. Histological analysis showed in the control group disruption of endothelial lining with fibrosis, while demonstrated in the PDS group a trilaminar vessel-like structure. Conclusions The bioresorbable reinforcement induced the formation over time of a neopulmonary conduit able to both face the hemodynamic load of the pulmonary system and guarantee a harmonious increase in size during the somatic growth. [ABSTRACT FROM AUTHOR]

Background Postoperative atrial fibrillation (AF) is a common complication after cardiac surgery. Inflammation is believed to play a pivotal role in the etiology of postoperative AF. There is a suggestion from small studies that perioperative treatment with corticosteroids may reduce postoperative AF. The DExamethasone for Cardiac Surgery (DECS) study was a large randomized trial showing no protective effect of dexamethasone on major adverse events. The aim of this study was to investigate the effect of dexamethasone treatment on the occurrence of AF after cardiac surgery. Methods The DECS study compared intra-operative dexamethasone (1 mg/kg) or placebo treatment in 4494 adult patients undergoing cardiac surgery. AF was defined by the occurrence of any reported AF within 30 days after surgery. We also performed an in-depth analysis of a subset of 1565 patients on new-onset AF. Relative risks (RRs) with 95% confidence intervals (CIs) were calculated. Results The incidence of any AF in the main study of 4494 patients was 33.1% in the dexamethasone and 35.2% in the placebo group (RR 0.94, 95% CI: 0.87-1.02, p = 0.14). In the substudy of 1565 patients, the incidence of new-onset AF was 33.0% vs. 35.5% (RR 0.93, 95% CI: 0.81-1.07, p = 0.31), respectively. There was no protective effect of dexamethasone across clinically important patient subgroups. Conclusion Intraoperative administration of dexamethasone had no protective effect on the occurrence of any or new-onset atrial fibrillation after cardiac surgery. Therefore, the use of dexamethasone for the reduction of postoperative AF should not be recommended. [ABSTRACT FROM AUTHOR]

Background Acute Kidney Injury (AKI) after cardiac surgery is a complication influencing postoperative outcome. Preoperative hemoglobin is a predictor of postoperative AKI. We aimed to identify preoperative predictors of Renal Replacement Therapy (RRT) and to develop a new risk-scoring system including hemoglobin to better stratify the risk of events. Methods We evaluated 3288 consecutive patients of the Regional Cardiac Surgery Registry of Puglia operated in 2011-2012. Chronic dialysis and renal transplantation patients were excluded. Primary outcome was post-operative RRT incidence. Results The study sample was divided in two cohorts: 1642 patients (70 RRT) operated during the year 2011 as derivation cohort and 1646 patients (69 RRT) of the year 2012 as validation. In a multivariable logistic regression model using a stepwise method, six preoperative risk factors were associated with RRT in the derivation cohort: creatinine clearance, preoperative hemoglobin, neurological dysfunction, left ventricular ejection fraction, urgency and combined procedures (discrimination c-index 0.844 and 0.818 in the validation cohort). Scoring system included risk factors obtained from derivation cohort adjusting their relative weight with updated rounded coefficients in the validation cohort: creatinine clearance < 50 ml/min (1 point), hemoglobin ≤ 12.5 g/dl (1 point), left ventricular ejection fraction ≤ 30% (1 point), urgent operation (1 point), emergency-salvage surgery (2 points), and combined procedures (1 point). In both cohorts, outcomes were strongly correlated with score points. Conclusions Our simple bedside prognostic score demonstrates good performance in predicting RRT. Hemoglobin plays an important role and future studies will clarify if preoperative anemia correction will lead to decreased RRT risk. [ABSTRACT FROM AUTHOR]

Abstract: Background: The additive effects of cognitive impairment and depression on mortality risk after cardiac surgery are unknown. Methods: Patients were assessed on a battery of six neurocognitive measures before cardiac surgery (N=521) and at six month follow up (N=377/521, 72.4%). Cognitive impairment classification was based on cognitive test scores 1 SD below age and sex matched normative data, and classified according to amnestic, non-amnestic and mixed cognitive impairment subtypes. Survival analyses entered cognitive impairment subtypes and depression interactions terms adjusted for 12 common risk factors. Results: There were 5407 person years for analysis (median 11.1year survival, interquartile range of 7.9 to 13.1) and 176 deaths (33.8%) by the census date. Before cardiac surgery, patients with a mixed-cognitive impairment (adjusted hazard ratio (HR)=2.53; 95% confidence interval (CI), 1.57–4.06, p <.001) and non-amnestic cognitive impairment (adjusted HR=1.51; 95%, 1.00–2.32, p =.05) were at greater mortality risk. Six month analyses corroborated that the mixed-cognitive impairment group were at higher mortality risk (adjusted HR=2.35; 95% CI, 1.30–4.25, p =.005). When change in neurocognitive functioning over time was analyzed, a higher mortality risk was evident only amongst patients with cognitive impairment evident at baseline and six months (adjusted HR=1.83; 95% CI, 1.08–3.10, p =.03). No cognition by depression interaction term was significant. Conclusions: These data suggest that a mixed cognitive impairment subtype, and continuing cognitive impairment before and six months after cardiac surgery, is associated with long term mortality, independent of depression and common risk factors. [Copyright &y& Elsevier]

Abstract: Background: Aortic stenosis (AS) causes significant disturbances in left ventricular (LV) and left atrial (LA) function irrespective of the extent of myocardial hypertrophy which associates the increased afterload. We hypothesize that aortic valve replacement (AVR) and removal of LV outflow tract obstruction should result in LA size and function recovery, even partial, and were set to study this in a group of patients with AVR for AS. Methods: Peak atrial longitudinal strain (PALS) was evaluated in 43 patients with severe isolated AS and normal EF (56.6±3.8%) and no obstructive coronary artery disease candidates for AVR, pre-operatively and then 40days and 3months after surgery. Results were compared with those from 34 age- and gender-matched healthy controls. Results: LVEF remained unchanged and LV mass regressed after AVR. Global PALS was reduced pre-operatively and increased 40days after surgery (p=0.002) and showed only a slight further increase at 3months follow-up (p<0.0001). Indexed LA volume was increased before surgery, but significantly fell 40days after surgery (p<0.0001) and showed only a slight further reduction after 3months (p<0.0001). Trans-aortic mean gradient change after surgery was the only independent predictor of the recovery of LA size and function. Conclusions: AVR reverses LA abnormalities and regains normal atrial function, a behavior which is directly related to the severity of pre-operative LV outflow tract obstruction. Early identification of LA size enlargement and functional disturbances might contribute to better patient's recruitment for AVR. [Copyright &y& Elsevier]

Background: Atrial enlargement may reflect ventricular diastolic dysfunction. Although patients with tetralogy of Fallot (TOF) have been studied extensively, little is known about atrial size and function. We assessed bi-atrial size and function in patients after TOF repair, and related them to biventricular systolic and diastolic function, and clinical parameters. Methods: 51 Patients (21±8years) and 30 healthy controls (31±7years) were included and underwent magnetic resonance imaging to assess bi-atrial and biventricular size, systolic and diastolic function. Patients also underwent exercise testing, and N-terminal prohormone brain natriuretic peptide (NT-proBNP) assessment. Results: In patients, right atrial (RA) minimal volume (34±8ml/m2 vs. 28±8ml/m2, p =0.001) and late emptying fraction were increased; RA early emptying fraction was decreased. Patients had longer right ventricular (RV) deceleration time (0.24±0.10 vs. 0.13±0.04, p <0.001), reflecting impaired RV relaxation, and larger RV volumes. Patients with end-diastolic forward flow (EDFF) had larger RA and RV size, abnormal RA emptying, higher NT-proBNP levels, higher VE/VCO2 slope (ventilatory response to carbon dioxide production), and the most abnormal LV diastolic function (impaired compliance). Patients with abnormal RA emptying (reservoir function <30% and pump function >24%) had higher NT-proBNP levels and worse exercise capacity. RA minimal volume was associated with RV end-diastolic volume (r =0.35, p =0.013). Conclusions: In TOF patients with moderate RV dilatation, abnormal bi-atrial function and biventricular diastolic dysfunction are common. Abnormal RA emptying was associated with signs of impaired clinical condition, as was the presence of EDFF. These parameters, together with RA enlargement, could serve as useful markers for clinically relevant RV diastolic dysfunction. [ABSTRACT FROM AUTHOR]

Abstract: Despite the high burden of rheumatic fever in sub-Saharan African, there is currently no sustained and comprehensive strategy to control the disease. Consequently in this area the number of patients affected by rheumatic valve disease (RVD), most with a surgical indication, is 10–20 fold higher than in industrialised countries and estimates indicate that more than 50% of African RVD patients will die before age 25. In this paper, we review clinical and management issues of RVD in children in sub-Saharan Africa. Severe heart failure and undergrowth are the prevalent presentation of the illness. Severe mitral regurgitation is the commonest rheumatic valvulopathy observed in the first and second decades. Valve repair, the approach of choice, may be associated with unfavourable outcomes in patients with extreme cardiomegaly. In young people, whenever correct anticoagulation may reasonably be achieved, mechanical mitral prostheses should be preferred, even in females. The early deterioration of biologic mitral prostheses strongly suggests limiting their use to those cases in which correct anticoagulation is not feasible. In most sub-Saharan countries, socioeconomic factors strongly limit access to health services and to cardiac surgery in particular. Efforts to overcome these barriers have resulted in humanitarian projects along two patterns: creation of high tech on site health care structures or transfer of children with complex diseases to receive highly specialised cardiac surgical care abroad. We summarise the experience of our programme that followed the latter approach. [Copyright &y& Elsevier]

Abstract: Background: Atrial arrhythmias (AAs) occur frequently after cardiac surgery. However, most authors do not differentiate postoperative atrial fibrillation (AF) from atrial flutter (AFL). Our study sought to investigate the incidence and predictors of AFL following non-congenital cardiac surgery, and the long-term outcome of this arrhythmia. Methods and results: We conducted an observational, retrospective, single-centre study. Among 821 patients in sinus rhythm (SR) before non-congenital cardiac surgery, AFL occurred in 42 patients (5.1%) and AF in 77 (9.4%). Independent predictors of AAs were older age (odds ratio (OR): 1.06, 95% confidence interval (CI): 1.01–1.11, p =0.02), low postoperative hemoglobin level (OR: 0.43, CI: 0.29–0.63, p <0.0001) and long cross-clamp time (OR: 1.02, CI: 1.002–1.037, p =0.03). Compared to AF patients, those with AFL were younger (67±10 versus 72±8years, p =0.005) and less likely to have valve surgery (57% versus 76%, p =0.03). After conversion to SR, of 41/42 patients with AFL, 5 (12%) developed AFL and 5 (12%) had AF within a mean follow-up of 9.6±8.4months: only 32% of patients were on long-term antiarrhythmic therapy and 5% had radiofrequency ablation of AFL in the early postoperative period. Conclusion: AFL following non-congenital cardiac surgery is not frequent. Compared to patients in AF, those with AFL are younger and less likely to have valve surgery. After conversion of AFL to SR, recurrence rate of AAs is relatively low. Therefore, AFL occurring in this setting does not require systematic catheter ablation in the postoperative period. [Copyright &y& Elsevier]

Abstract: Background: Several patients with acute coronary syndrome (ACS) are discharged home after the acute phase of ACS and are suitable for elective coronary artery bypass graft (CABG) surgery. The aim of the study was to assess the optimal timing for surgical revascularization and its effect on 12-month outcome in patients discharged from hospital after ACS and referred for elective CABG surgery. Methods: The analysis involved 2028 patients enrolled into the ongoing Polish Registry of Acute Coronary Syndromes (PL-ACS) who were discharged from hospital with the intention to undergo elective CABG surgery. Results: Among 2028 patients 1216 (60.0%) underwent surgery during 12months of follow-up. Patients who underwent surgical revascularization had a lower prevalence of mortality (5.7% vs 11.5%, p<0.0001). Patients who underwent surgery within the first month had a significantly higher prevalence of mortality than those who did not undergo surgery (5.7% vs 1.6%, p<0.0001). By the third month, the two cumulative mortalities were similar (4.2% vs 4.6%, p=0.65). From the beginning of the fourth month, the cumulative mortality was significantly higher among patients who did not undergo surgery. Conclusions: [1.] Only half of the survivors from ACS eligible for CABG surgery after hospital discharge have the procedure within 6months. [2.] Patients eligible for surgery and who do not undergo surgery have a twofold higher mortality twice at 12months. [3.] Surgical revascularization done during the first month after ACS is associated with a higher prevalence of mortality. The delay of CABG surgery should probably not exceed 3months. [Copyright &y& Elsevier]

Abstract: Background: Isolated ventricular noncompaction is considered to predominantly affect the left ventricle. It is characterized by increased left ventricular wall thickness and deep intertrabecular recesses with to-and-fro blood flow that remains in continuity with the ventricular flow. Aim of the study was to present a group of patients with isolated noncompaction of both ventricles mimicking arrhythmogenic right ventricular cardiomyopathy (ARVC). Methods: Reported group consisted of 9 pts initially diagnosed with ARVC (mean age 37.9 y, 7 male), who underwent basic clinical evaluation. CMR was performed in 8 pts, cardiac catheterization in 2 pts and endomyocardial biopsy in 2 pts. Mean age at presentation of first symptoms was 23.5 y (5–44 y). Heart failure symptoms were observed in 4 pts, atrial fibrillation in 3 pts, ventricular tachycardia in 2 pts (polymorphic — in 2 pts) and syncope in 3 pts. Final diagnosis of noncompaction was established according to generally accepted criteria. Results: Morphologic and/or functional changes in the right ventricle were seen in 9 pts (100%): enlargement and hypertrabeculation of the right ventricle in all pts, global hypokinesis in 4 pts, focal wall motion abnormalities and/or bulges typical for ARVC in 5 pts. Two pts had significant tricuspid regurgitation. Endomyocardial biopsy (2 pts) showed abnormal thick endocardium, interstitial fibrosis, myocardial damage and lymphocyte infiltration. Conclusions: 1) Noncompaction of ventricular myocardium should be considered during the evaluation of right ventricular cardiomyopathies with excessive trabeculation. 2) In problematic cases Task Force criteria for ARVC should be used to improve the accuracy of assessment. [ABSTRACT FROM AUTHOR]

Abstract: Background: Statin therapy prior to percutaneous coronary intervention (PCI) is associated with reduced mortality and periprocedural myocardial injury after PCI. We studied whether single high dose statin loading is beneficial on the outcome of patients with acute coronary syndrome (ACS) underwent PCI. Methods: Consecutive 445 patients with ACS who underwent PCI were randomly assigned to either the group of no statin treatment before PCI (Control group: n =220, 63±11 years, male 62%) or the group of 40 mg rosuvastatin loading before PCI (Rosuvastatin group: n =225, 64±10 years, male 60%). Incidence of periprocedural myocardial injury was assessed by analysis of creatinine kinase-MB (CK-MB) and cardiac troponin T before PCI, at 6 h and the next morning after PCI. Result: There were no significant differences in clinical characteristics between the two groups. After PCI, incidence of periprocedural myocardial injury was higher in control than in rosuvastatin group (11.4% versus 5.8%, p =0.035). Mean preprocedural CK-MB and high sensitivity C-reactive protein were similar between the two groups, whereas after PCI, peak values of both markers were elevated significantly higher in control than in rosuvastatin group. Multivariate analysis revealed that no prior use of statin (OR=2.2; 95% CI=1.1–4.6; p =0.029), procedural complication (OR=3.1; 95% CI=1.4–6.9; p =0.007) and multi-vessel disease (OR=2.6; 95% CI=1.0–6.6; p =0.039) were the independent predictors for periprocedural myocardial infarction. Conclusion: Single high dose of rosuvastatin prior to PCI reduces periprocedural myocardial injury in patients with ACS. [Copyright &y& Elsevier]

Abstract: Objective: To characterize mortality and morbidity outcomes in patients undergoing surgical Fontan conversion. Background: Indications for and anticipated clinical outcomes associated with Fontan conversion are controversial. Methods: A retrospective single-center cohort study of consecutive patients undergoing Fontan conversion between 1990 and 2006 stratified according to concomitant arrhythmia surgery. Results: Forty patients underwent Fontan conversion at a median age of 19.0 years and were followed for 4.2 years. Six (15%) died, two perioperatively, three early postoperatively, and one following heart transplant. Older age was a univariate risk factor. Major perioperative complications occurred in 9 of 35 (26%) early survivors. Patients with concomitant arrhythmia surgery (N =21) were older at conversion and had longer interoperative intervals. They experienced a reduction in prevalence (95% vs. 28%, P <0.0001) and severity (severity score 7.3 vs. 3.3, P =0.001) of atrial tachyarrhythmias, in contrast to patients without arrhythmia surgery (47% vs. 53%; 3.3 vs. 3.9, P =NS). NYHA functional class improved in both groups. In a subgroup (N =14) with non-urgent late postoperative catheterization, filling pressures were unchanged from preoperative values. Conclusions: Mortality and morbidity after Fontan conversion are substantial, but survivors experience a subjective improvement in functional status. Concomitant arrhythmia surgery reduces the arrhythmia burden without a detectable increase in complication rates. [Copyright &y& Elsevier]

Abstract: Although all beta blockers appear to be effective in the prevention of postoperative atrial fibrillation (AF) following coronary artery bypass surgery (CABG), carvedilol was found to be much more effective than metoprolol in this respect as the current study clearly delineated. We believe that the ongoing COMPACT trial will answer the question of whether or not carvedilol is more superior than metoprolol to prevent postoperative AF in patients undergoing CABG. [Copyright &y& Elsevier]

Abstract: Background: Triple antiplatelet therapy may have a beneficial effect on prevention of thrombotic complication in patients undergoing coronary stenting. We investigated the prevalence of aspirin and clopidogrel resistance in patients treated with dual and triple antiplatelet regimen after percutaneous coronary intervention (PCI) with drug-eluting stents (DES). Methods: A total of 400 consecutive patients underwent successful PCI with DES were randomly assigned to therapy with dual antiplatelet regimens (aspirin plus clopidogrel, Group I, n = 200) and triple antiplatelet regimens (aspirin plus clopidogrel plus cilostazol, Group II, n = 200) At two weeks after PCI, aspirin and clopidogrel resistance were assayed in 379 patients (Group I, n = 186; Group II, n = 193) by using the VerifyNow System. Results: In Group I, 21 (11.3%) patients had aspirin resistance and 74 (40.0%) had clopidogrel resistance. In Group II, 19 (9.8%) were resistant to aspirin and 38 (19.7%) to clopidogrel. The aspirin reaction unit (ARU) was not significantly different between groups (448±67 vs. 439±64, P = 0.200), but the percent inhibition of clopidogrel was higher in Group II (41.4±24.3%,) comparing with that of Group I (26.5±18.7%, P < 0.001). Conclusion: With triple antiplatelet therapy, the prevalence of clopidogrel resistance can be attenuated in patients undergoing PCI with DES. [Copyright &y& Elsevier]

Abstract: Background: Recent concerns have emerged on the potential higher risk of stent thrombosis after DES implantation, that might be even more pronounced among STEMI patients. Thus, the aim of the current study was to perform a meta-analysis to evaluate the benefits and safety of DES as compared to BMS in patients undergoing primary angioplasty for STEMI. Methods: The literature was scanned by formal searches of electronic databases (MEDLINE and CENTRAL). We examined all completed randomized trials of DES for STEMI. The following key words were used for study selection: randomized trial, myocardial infarction, reperfusion, primary angioplasty, stenting, DES, sirolimus-eluting stent (SES), Cypher, paclitaxel-eluting stent (PES), Taxus. Information on study design, type of stent, inclusion and exclusion criteria, primary endpoint, number of patients, angiographic and clinical outcome, were extracted by two investigators. Disagreements were resolved by consensus. Results: A total of 11 trials were included in the meta-analysis, involving 3605 patients (1888 or 52.3% randomized to DES and 1719 or 47.7% randomized to BMS). At 12 months follow-up, no significant difference was observed in mortality (4.1% vs 4.4%, OR [95% CI]=0.91 [0.66–1.27], p =0.59, reinfarction (3.1% vs 3.4%, OR [95% CI]=0.85 [0.58, 1.23], p =0.38 or stent thrombosis (1.6% vs 2.2%, OR [95% CI]=0.76 [0.47, 1.23], p =0.22), whereas DES were associated with a significant reduction in TVR (5.0% vs 12.6%, OR [95% CI]=0.36 [0.28, 0.47], p <0.0001). Safety and efficacy of DES were confirmed at 18 to 24 months follow-up (data available from 4 trials including 1178 patients). Conclusions: This meta-analysis shows that among selected STEMI patients undergoing primary angioplasty, SES and PES, as compared to BMS, are safe and associated with a significant reduction in TVR at 1 and 2 years follow-up. [Copyright &y& Elsevier]

Abstract: Background: Percutaneous coronary intervention (PCI) is a widely performed technique for coronary revascularization. Men and women seem to have different in-hospital outcomes, although results remain unclear. We assessed the gender impact on in-hospital outcomes in men and women undergoing PCI. Methods: In a single center, from 1998 to 2002, a total of 413 patients who underwent PCI were included in this analysis. From a dedicated database, the presence of risk factors, angiographic characteristics, left ventricular function and in-hospital outcomes were recorded and compared between men (n =244) and women (n =169). For comparison, unpaired t test and chi-square were used for continuous and dichotomous variables respectively. An alpha <0.05 was considered significant. Results: Women were older (65.3±10.39×60±10.68 years, p =0.001), presented better ejection fraction (67.01±12.28%×64.26±14.31%, p =0.028) and higher prevalence of stable angina (63.90%×45.90%, p <0.001) than men. There were no differences related to family history for cardiovascular disease, hypertension, diabetes or hyperlipidemia; but there was an observed reduction in tobacco use (17.71%×32.31%, p <0.001) by women. Similar rates of in-hospital successful procedures (94.3%×94.90%, p =0.93) and death (0.41%×1.18%, p =0.40) were observed in men and women, respectively. Neither vascular complications nor stroke occurred. There was a higher incidence of urgent surgical myocardial revascularization (1.77%×0%, p =0.036) and a trend in the combined outcome of death/surgical myocardial revascularization (2.69%×0.41%, p =0.06) in the women''s group. Conclusion: Women present a higher incidence of urgent surgical myocardial revascularization following percutaneous coronary intervention when compared to men. [Copyright &y& Elsevier]

Abstract: Background: Preoperative risk analysis for Fontan candidates is still less than optimal in that patients with apparently low risks may have a poor outcome, such as prolonged pleural drainage, protein-losing enteropathy, pulmonary thromboembolism and death. We hypothesized that low pulmonary vascular compliance (PVC) is a risk factor for persistent pleural effusion after the Fontan operation. Methods: A retrospective review of 85 patients who underwent the extracardiac Fontan procedures (median age: 3.87 years) was performed. Fontan risk score (FRS) was calculated from 12 categorized preoperative anatomical and physiological variables. PVC (mm2/m2·mmHg) was defined as pulmonary artery index (mm2/m2) divided by total pulmonary resistance (Wood Unit·m2) and pulmonary blood flow (L/min/m2), based on the electrical circuit analogy of the pulmonary circulation. Chest tube indwelling time was log-transformed (log indwelling time, LIT) to fit normal distribution, and the relationship between perioperative predictors and LIT was analyzed by multiple linear regression. Results: Preoperative PVC, chest tube indwelling time and LIT ranged from 6 to 94.8 mm2/mmHg/m2 (median: 24.8), 3 to 268 days (median: 20 days), and 1.1 to 5.6 (mean: 2.9, standard deviation: 0.8), respectively. FRS, PVC, cardiopulmonary bypass time (CPB) and central venous pressure at postoperative 12 h were correlated with LIT by univariable analyses. By multiple linear regression, PVC (p =0.002) and CPB (p =0.003) independently predicted LIT, explaining 22% of the variation. The regression equation was LIT=2.744−0.016 PVC+0.007 CPB. Conclusion: Low pulmonary vascular compliance is an important risk factor for prolonged pleural effusion drainage after the extracardiac Fontan procedure. [Copyright &y& Elsevier]

Abstract: Stents are the most important advance for percutaneous coronary revascularization. After introduction of drug eluting stents, in-stent restenosis ist not more a major problem of coronary intervention. However, restenosis by bare metal stents, peripheral embolism following stent implationtan in old vein grafts, and conditions in which there is a discontinuity of the coronary lumen (rupture or perforation, aneurysm, and fistula) remain a problem in interventional therapy. Stent grafts with integration of a membrane into a coronary stent represent an interesting concept to possibly prevent intraluminal proliferation, to seal degenerated vein grafts, and to cover coronary artery perforations, symptomatic aneurysms, and fistula with high success and acceptable rates of acute complications. We presents case reports and a review article. [Copyright &y& Elsevier]

Abstract: Background and objectives: The incidence of thromboembolic events (TE) in the early period following mitral valve repair (MV repair) is poorly documented. The aim of this prospective study was to evaluate it, and to determine predictive factors. Methods and results: In this prospective multicenter non-randomized study, 350 consecutive patients were included after MV repair and monitored until post-operative day 44±6. 65.7% received Vitamin K antagonists (VKA), 18.8% aspirin (ASA), 5.4% ASA+VKA and 10% received no antithrombotic therapy (AT). All patients with AF received VKA or VKA+ASA. Twelve patients had a cerebral TE during follow-up:14.3% among untreated patients, 3.0% in the VKA group, and 0% in the ASA and in the ASA+VKA groups (p =0.03 for comparison no AT group versus the three other combined groups; p =NS for VKA versus ASA). In univariate analysis, only the absence of post-operative AT was related to the risk of TE (HR=6.7, CI 95%[2.1–21], p =0.0002). In a prespecified subgroup (n =185) of patients with sinus rhythm and without concomitant cardiac surgery (in which the choice of AT is not influenced by these associate conditions), only the absence of post-operative AT remained related to the risk of TE (HR=10.0, CI 95%[2.45–40], p =0.001). Conclusion: In the first six weeks following MV repair, the incidence of thromboembolic events is far from negligible (3.5%), even in patients with sinus rhythm. The main predictive factor for thromboembolic event determined in this study is the absence of an antithrombotic therapy. [Copyright &y& Elsevier]

Total 198 episodes of Duke “definite” infective endocarditis (IE) in 192 patients observed over last 10 years were studied [141 males and 51 females, mean age 27.6±12.7 years (range 4–68 years)]. Majorities of patients (76.5%) were below 40 years of age. Rheumatic heart disease (RHD) was the commonest underlying heart disease (present in 46.9% patients). Probable source of infection could be identified in only 16.6% episodes. None of our patient was intravenous drug abuser. Fever (90.0%), anemia (81.0%), clubbing (58.1%), splenomegaly (60.6%), changing/new murmur (22.7%) were the common clinical findings. Vegetations were present in 89.9% episodes. Blood cultures were positive in 134 (67.7%) episodes (streptococci in 23.2%, staphylococci in 19.7%, gram negative in 13.6%, enterococci in 8.1%, polymicrobial and fungal in 1.5% episodes each). Complications were cardiovascular [congestive heart failure (CHF) in 41.9%, atrioventricular block in 1.5%, cardiac temponade and acute myocardial infarction in 0.5% each), neurological in 16.6%, renal in 13.1% and embolisms in total 21.7% episodes. Total 182 (91.9%) episodes in 176 patients were managed completely [(medical in 140 (76.9%) and surgical in 42 (23.1%) episodes] while patients in remaining 16 (8.1%) episodes left against medical advises before completion of therapy. Total 21% patients (37 out of 176 completely treated patients) died during therapy (cause of deaths; CHF in 11, septicemia in 10, cerebral embolism in 7, post cardiac surgery in 5, ruptured cerebral mycotic aneurysm in 2, ventricular tachycardia in 2 patients). On stepwise logistic regression analysis; cardiac abscess and CHF were independent predictors of cardiac surgery. Similarly, CHF, renal failure and prosthetic valve dysfunction were independent predictors of mortality. To conclude, spectrum of IE in our country is different from the west, but quite similar as reported from developed countries about 40 years ago. IE in our country occurs in relatively younger population with RHD as the commonest underlying heart disease. Streptococci are still the commonest responsible microorganisms. Morbidity and mortality are still high. Early cardiac surgery, whenever indicated, helps in improving outcome of these patients. [Copyright &y& Elsevier]

Congenital absence of the pericardium is an uncommon finding that may or may not be symptomatic. Asymptomatic patients are discovered incidentally during cardiac surgery for an unrelated condition or postmortem. However, symptomatic patients may experience non-exertional paroxysmal stabbing chest pain. It may occur with other cardiac or extracardiac abnormalities and a variety of imaging modalities may identify the condition. Complete cases are more rare than partial effects. However, complications are more common with partial absence due to strangulation of the heart into the defect thus requiring surgical intervention. [Copyright &y& Elsevier]

Abstract: Iatrogenic stenosis of the coronary ostia is a rare but life-threatening complication which may follow aortic valve replacement. We report a case treated with a drug-eluting stent with subsequent severe restenosis at 24months. In-stent restenosis was successfully treated with reimplantation of a further drug-eluting stent with no restenosis on surveillance angiography at 11months and no recurrence of symptoms at 5years. [Copyright &y& Elsevier]

Abstract: Transradial approach is known to reduce access-site complications of coronary procedures. However, the diffusion of transradial approach in the interventional cardiology community is limited by its higher failure rate compared to transfemoral. Transradial approach failures are mainly caused by a series of anatomic variants which may be encountered in the upper limb arteries. Such anatomic variants have been variously classified based on postmortem studies or systematic angiographic studies. We propose a simplified “operative” classification of anatomic vascular variants and physiopathologic conditions of the arterial axis, from radial to aortic root, possibly affecting transradial cardiovascular procedures. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: To evaluate the association between statins, N-acetylcysteine (NAC) and angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) and postoperative atrial fibrillation (AF). Methods: A total of 590 patients undergoing coronary artery bypass and/or valve surgery were studied. An AF episode lasting >5 min during hospitalization was accepted as endpoint. Results: AF rate was 18% (n =106). Multivariable positive predictors of AF included age ≥65, left atrial diameter ≥45 mm, cross clamp time; negative predictors included use of left internal mammarian artery, NAC, and ACEIs or ARBs. Conclusions: ACEIs or ARBs and NAC is associated with low incidence of postoperative AF, however, this association was not found with statin or combined use these agents. [ABSTRACT FROM AUTHOR]

Abstract: Acute aortic dissection presents with a wide range of manifestations and it is frequently confused with acute coronary syndrome, leading to delayed diagnosis and inappropriate treatment. A high clinical index of suspicion is necessary. Longstanding arterial hypertension, elevated D-dimer levels and new onset atypical chest pain can help the clinician to perform a difficult differential diagnosis. We present a case of acute aortic dissection in a 68-year-old Italian woman with longstanding arterial hypertension, unknown ascending aortic aneurysm, normal D-dimer levels, new onset atypical chest pain and electrocardiographic images mimicking acute coronary syndrome. Also this case focuses attention on the importance of a correct evaluation of new onset chest pain. [Copyright &y& Elsevier]

Abstract: The current recommended weight-adjusted dosing regimen of unfractionated heparin and target activated clotting time (ACT) in percutaneous coronary intervention (PCI) is based on limited data from the western population, and the applicability in the various Asian ethnic groups remains unknown. This is a retrospective study in an Asian university teaching hospital. Among the 1287 patients who have undergone PCI, Chinese constituted 70.4% (n =906), Malay 15.5% (n =199) and Indian 14.1% (n =182). Overall, the mean total heparin dose was 6224±1548 U, mean weight-adjusted heparin dose was 95±30 U/kg, and mean ACT was 325±95 s. There was no significant difference in the 3 ethnic groups. Both the incidences of in-hospital ischemic complications (Chinese 2.4%, Malay 3.5%, Indian 2.2%, p =0.641) as well as in-hospital bleeding complications (Chinese 4.5%, Malay 3.5%, Indian 6.0%, p =0.490) were similar in the 3 ethnic groups. When the patients were divided based on ACT into 3 groups:<250, 250–350 and>350 seconds, the incidence of ischemic complication (2.5%, 2.5%, 2.7%) was similar (p =819), while that of bleeding complications (4.1%, 3.5%, 6.8%) showed a strong trend (p =0.057) of increased risk in patients with ACT>350 s. In conclusion, the recommended weight-adjusted heparin-dosing regimen in PCI derived from the western population is equally applicable to the Asian patients. ACT does not correlate with in-hospital ischemic complications, but increased bleeding complications were observed with ACT>350 s. [Copyright &y& Elsevier]

Abstract: Background and objectives: Catheter ablation is effective in treating patients with atrial fibrillation (AF). The aim of the study was to evaluate the safety, efficacy and outcome of catheter ablation for AF in octogenarians. Methods and results: 377 consecutive patients were divided into three groups based on age: ≥80 years (group 1; n =49), 70–79 years (group 2; n =151), 60–69 years (group 3; n =177). The efficacy and safety for those three groups were determined. The success rate after one procedure was similar in three groups (70% in group 1, 72% in group2 and 74% in group 3, P =NS) during a mean follow-up of 18 months. Major complication rates were comparable between the three groups. However, the octogenarians were less likely to undergo a repeated procedure than other groups (8% in group 1, 15% in group 2 and 18% in group 3, P <0.05), and were more likely to remain on antiarrhythmic drugs. Conclusion: Catheter ablation for AF attempted in octogenarians appears to be effective and with low risk. Ablation results are comparable with those noted in younger patients. [ABSTRACT FROM AUTHOR]

Abstract: Renal impairment is an important complication in patients with coronary disease, acute or chronic. First because it is frequent and secondly because it implies a worse prognosis. Unfortunately, some physicians do not perceive the real risk that renal dysfunction implies. An integral approach, through on-going educational activities, is needed to emphasize the relevance of this complication. [ABSTRACT FROM AUTHOR]

Abstract: There is currently conjecture in the literature as to whether percutaneous closure of patent foramen ovales (PFO) leads to an improvement in migraine symptoms. The present study reports the migraine status at 30 days, of 57 consecutive patients who underwent closure PFO closures for cryptogenic stroke at our institution. Our findings suggest a significant change in migraine character following PFO closure with the majority of these patients reporting a worsening in migraine severity. Those patients with more severe migraine prior to the procedure were more likely to experience deterioration. Patients should be counselled about the possibility of changing or worsening migraine prior to percutaneous closure for cryptogenic stroke. [ABSTRACT FROM AUTHOR]

Abstract: We report on a patient in whom a right-to-left shunt with normal pulmonary arterial pressures occurred after surgery of an inferior vena caval sinus venosus-type atrial septal defect. In addition to the inferior vena cava to left atrium anatomic defect, the exceptional occurrence of a post-operative right atrial inflow stenosis contributed to the right-to-left shunting. [Copyright &y& Elsevier]

Abstract: Coronary artery infection after angioplasty or stent implantation is a rare and dreaded complication of percutaneous coronary intervention. 80% of the cases are due to Staphylococcus aureus. About half the cases lead to rupture or perforation of the coronary artery while the other half presents as abscesses or aneurysms. Surgical treatment is the conventional therapeutic modality but it carries a high mortality. We report a case of a high risk patient who had methicillin resistant Staphylococcus aureus infection of left main stem stent leading to rupture and pseudoaneurysm formation that is successfully treated with stent graft. [ABSTRACT FROM AUTHOR]

Abstract: We described a complication during percutaneous coronary intervention. A bleeding into the left atrial wall occurred after stenting of the right coronary artery. Echocardiography revealed the diagnosis of a left atrial intramural hematoma. Conservative treatment was performed. After 4 weeks the hematoma resolved completely. Left atrial intramural hematoma as a complication after percutaneous coronary intervention has not been reported in the literature yet. [Copyright &y& Elsevier]

Abstract: Antiplatelet therapy has been shown to reduce cardiac events after coronary stenting. However, despite aggressive antiplatelet therapy, stent thrombosis remains a serious complication of coronary stenting with drug-eluting stent (DES). Although several predictors for DES thrombosis have been suggested by investigators, this serious condition is still not completely preventable now. In particular, patients undergoing non-cardiac surgery or invasive procedures with bleeding risk may interrupt antiplatelet therapy and occasionally experience stent thrombosis. We report a case of DES thrombosis after cilostazol withdrawal for colonoscopic polypectomy in a patient previously treated with triple antiplatelet therapy. The patient presented with acute myocardial infarction but survived after successful emergency coronary revascularization. We discuss a plausible mechanism for DES thrombosis in the described case. [Copyright &y& Elsevier]

Abstract: A stent fracture (SF) is one of the responsible factors for in-stent restenosis after a percutaneous coronary intervention. Factors that have an important role for a SF are vessel tortuosity, the presence of a right coronary artery lesion, overlapping stents, and the use of a drugeluting stent (DES) such as a sirolimus-eluting stent. Unlike with the use of bare metal stents, most SFs have occurred with the use of DES, and a DES may be a possible factor for a SF. A SF can cause clinical problems that range from stable angina to acute coronary syndrome. We experienced a case of acute myocardial infarction that was combined with a SF. We describe here the coronary angiography findings and the 64-multidetector computed tomography images before and after the SF. [Copyright &y& Elsevier]

Abstract: Discrete subvalvar aortic stenosis is a variable and progressive disease. Recurrent obstruction may reappear despite the adequacy of surgical excision. Aortic regurgitation is associated with numerous eponymous signs, it is also a complication of discrete subvalvar aortic stenosis and its detection often triggers referral for surgery. It has also been suggested that an infant or young child with a well-defined 30 mm Hg or more peak gradient should have removal of the subvalvar obstruction. We describe a case of subvalvular aortic stenosis associated with aortic regurgitation in a 10-year-old Italian boy. [Copyright &y& Elsevier]

Abstract: Severe emotional or physical stress precedes Tako-Tsubo cardiomyopathy (TTC) which is characterized by transient left ventricular impairment in absence of coronary artery disease. In this case we report from a female patient presenting with characteristic features of TTC after examination of upper gastrointestinal. Additionally, severe mitral regurgitation due to acute rupture of the posteromedial papillary muscle was present. Normal left ventricular function was documented before surgical valve repair was performed. TTC is reported to be associated with several complications. This is the first report of TTC accompanied by severe mitral valve regurgitation due to rupture of a papillary muscle. [Copyright &y& Elsevier]

Abstract: A 68-year-old Japanese man was admitted for evaluation of right pleural effusion and bilateral leg edema that had progressively worsened over 6 months. As chest computed tomography revealed marked pericardial thickening, we performed a pericardiectomy, resulting in the remarkable improvement of his clinical manifestations. However, pleural fibrosis associated with fever of unknown origin soon developed. An elevated serum level of serum IgG4 and infiltration of IgG4-positive plasma cell in the resected pericardium were identified; thus, our patient might have hyper-IgG4 disease. Our case is the first report describing constrictive pericarditis as an initial manifestation of hyper-IgG4 disease. [Copyright &y& Elsevier]