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Endophytes can enhance plant stress tolerance by promoting growth and affecting elemental accumulation, which may be useful in phytoremediation. In earlier studies, up to 35% elemental selenium (Se0) was found in Se hyperaccumulator Astragalus bisulcatus. Since Se0 can be produced by microbes, the plant Se0 was hypothesized to be microbe-derived. Here we characterize a fungal endophyte of A. bisulcatus named A2. It is common in seeds from natural seleniferous habitat containing 1,000–10,000 mg kg-1 Se. We identified A2 as Alternaria tenuissima via 18S rRNA sequence analysis and morphological characterization. X-ray microprobe analysis of A. bisulcatus seeds that did or did not harbor Alternaria, showed that both contained >90% organic seleno-compounds with C-Se-C configuration, likely methylselenocysteine and glutamyl-methylselenocysteine. The seed Se was concentrated in the embryo, not the seed coat. X-ray microprobe analysis of A2 in pure culture showed the fungus produced Se0 when supplied with selenite, but accumulated mainly organic C-Se-C compounds when supplied with selenate. A2 was completely resistant to selenate up to 300 mg L-1, moderately resistant to selenite (50% inhibition at ∼50 mg Se L-1), but relatively sensitive to methylselenocysteine and to Se extracted from A. bisulcatus (50% inhibition at 25 mg Se L-1). Four-week old A. bisulcatus seedlings derived from surface-sterilized seeds containing endophytic Alternaria were up to threefold larger than seeds obtained from seeds not showing evidence of fungal colonization. When supplied with Se, the Alternaria-colonized seedlings had lower shoot Se and sulfur levels than seedlings from uncolonized seeds. In conclusion, A. tenuissima may contribute to the Se0 observed earlier in A. bisulcatus, and affect host growth and Se accumulation. A2 is sensitive to the Se levels found in its host’s tissues, but may avoid Se toxicity by occupying low-Se areas (seed coat, apoplast) and converting plant Se to non-toxic Se0. These findings illustrate the potential for hyperaccumulator endophytes to affect plant properties relevant for phytoremediation. Facultative endophytes may also be applicable in bioremediation and biofortification, owing to their capacity to turn toxic inorganic forms of Se into non-toxic or even beneficial, organic forms with anticarcinogenic properties.

Objectives: The aim was to evaluate 16S rDNA sequencing in heart valves in patients with infective endocarditis undergoing surgery., Methods: Fifty-seven patients with infective endocarditis were examined in this prospective study by analysing heart valves with 16S rDNA sequencing and culturing methods and comparing the results to blood cultures. As controls, heart valves from 61 patients without any signs of endocarditis were examined., Results: All together 77% of the endocarditis patients were positive for 16S rDNA, 84% had positive blood cultures and 23% had positive cultures from heart valves, whereas only 16% of the cultures from heart valves were concordant with results from blood cultures or 16S rDNA. Concordant results between 16S rDNA sequencing and blood cultures were found in 75% patients. All controls were negative for 16S rDNA. In 4 out of 9 patients with negative blood cultures, the aetiology was established by 16S rDNA alone, i.e. viridans group streptococci., Conclusion: In this Swedish study, 16S rDNA sequencing of valve material was shown to be a valuable addition in blood culture-negative cases. The value of heart valve culture was low. Molecular diagnosis using 16S rDNA sequencing should be recommended in patients undergoing valve replacement for infective endocarditis., (Copyright © 2011 The British Infection Association. Published by Elsevier Ltd. All rights reserved.)

Background: The clinical outcome in discharged cardiac surgery patients after prolonged postoperative intensive care needs further investigation. The aim was to study survival, functional status, and quality of life in cardiac surgery patients with more than 10 days postoperative intensive care unit stay., Methods: We performed a population-based study including 4,086 cardiac surgery patients and identified 141 patients who had a postoperative intensive care unit stay of more than 10 days. Data regarding patients and outcome were collected, and all discharged patients alive in May 2008, or a family member, were contacted to assemble information regarding functional status and quality of life using the Karnofsky performance scale and the Short Form-36 questionnaire., Results: Early mortality was 33%. Risk factors for early mortality were advanced age and postoperative dialysis. Survival at 1, 3, and 5 years was 62%, 56%, and 52%, respectively. Ninety-five patients were discharged from the hospital, and during a mean follow-up of 1.9 years, 62% were readmitted at least once. In discharged patients, 65% had a Karnofsky score of 80 or more. We found significantly lower physical (39.7 versus 43.6; p = 0.03), and mental (44.1 versus 50.8; p = 0.001) scores in the study group compared with a reference group., Conclusions: Early mortality was high, especially in patients who required dialysis. However, long-term survival and functional status were encouraging. Quality of life was worse compared with the general population in both physical and mental aspects, but the difference was moderate. Extensive efforts in this patient group seem reasonable despite high resource utilization., (2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: The aim was to study the change in cardiac index (CI) and pulmonary artery pressure (PAP) by intra-cardiac measurements after surgical ventricular restoration (SVR) in patients with left ventricular aneurysm and symptoms of heart failure. Aspects of functional improvement were analyzed as secondary outcomes., Design: Mean PAP and CI were obtained before and 6 months postoperatively in 22 patients who underwent SVR., Results: There were no significant changes in CI (2.3 vs. 2.4 L/min/m(2); p=0.91) or mean PAP (22 vs. 22 mmHg; p=0.64) at rest before and six months after surgery. Left ventricular ejection fraction improved from 25 to 38% (p<0.001). Before surgery 15 patients (68%) were in NYHA class III-IV and 6 months after the operation 19 (86%) patients were in NYHA class I-II (p<0.001)., Conclusions: Invasive hemodynamic measurements under resting conditions do not correspond well to the significant clinical improvement noted in these patients. Studies during exercise conditions are necessary to further evaluate this procedure.

Congenital malformations causing mild cyanosis can be overlooked. A large intrapulmonary right pulmonary artery to left atrium connection was the unusual etiology of arterial oxygen desaturation and erythrocytosis in an asymptomatic 30-year-old patient. The shunt was not possible to detect at echocardiography. It was closed via a median sternotomy without the aid of cardiopulmonary bypass. A novel technique was to use an angiographic catheter inserted through the wide shunt into the left atrium before the operation to securely identify it at the surgical dissection.

Objectives: Report long-term freedom from ventricular tachycardia (VT), survival, and causes of death in patients with left ventricular aneurysm and VT, who underwent a combined procedure for VT and surgical ventricular restoration (SVR)., Design: The primary outcome measures VT, survival, and cause of death, were ascertained by review of patients' records, interrogation of implanted cardioverter-defibrillators and use of national registers., Results: Mean follow-up was 5.2 years. Overall survival was 62% at 5 years and 51% at 9 years. Freedom from spontaneous VT was 89%. In 32 patients who were non-inducible at postoperative testing, there was no occurrence of VT during a mean follow-up of 6.0 years. Causes of death were cardiac in 17 patients, and non-cardiac in 6 patients. No patient died from ventricular arrhythmia., Conclusions: Direct surgery for VT combined with SVR resulted in a very low risk of late recurrence of VT and good long-term survival. Implantation of a cardioverter-defibrillator can safely be withheld in patients who are non-inducible on postoperative programmed electrical stimulation.

This article presents a review on the efficacy of surgical ventricular restoration and direct surgery for ventricular tachycardia in patients with left ventricular aneurysm or dilated ischemic cardiomyopathy. The procedure includes a non-electrophysiologically guided subtotal endocardiectomy and cryoablation in addition to endoventricular patch plasty of the left ventricle. Coronary artery bypass surgery and mitral valve repair are performed concomitantly as needed. In our experience, this procedure yielded a 90% success rate in terms of freedom from spontaneous ventricular tachycardia, with an early mortality rate of 3.8%. A practical guide to the pre- and postoperative management of these patients is provided.

Background and Aims: To identify pre-operative risk factors for delirium in patients undergoing elective cardiac surgery, using clearly defined diagnostic criteria for delirium, and a thorough clinical assessment., Methods: The incidence of post-operative delirium in 107 patients >or=60 years undergoing elective cardiac surgery was calculated. None of the patients included suffered from dementia. Pre-operative cognitive function in all patients was assessed using the Mini Mental State Examination (MMSE) and post-operative delirium was diagnosed using the Confusion Assessment Method (CAM). Post-operative clinical and cognitive assessments were carried out for all patients., Results: Twenty-five patients (23.4%) developed delirium post-operatively. Clinical parameters, including age, gender, co-morbidities, medications, and peri-operative parameters, were similar in patients with and without post-operative delirium. Patients with pre-operative subjective memory complaints and lower MMSE scores, undergoing valve operation or valve + coronary artery bypass grafting (CABG), exhibited an increased risk of developing post-operative delirium. Additionally, delirious patients had a significant decline in post-operative MMSE score compared with the non-delirious ones., Conclusions: The main pre-operative risk factors for post-operative delirium after elective cardiac operations were subjective memory complaints, mild cognitive impairment, and type of cardiac surgery, such as valve procedures. This study suggests that cognitive evaluation should be included in pre-operative assessment.

Objective: The aim of this study was to prospectively investigate changes in brain natriuretic peptide (BNP) and amino terminal pro-BNP (NT-pro-BNP) in relation to functional status after surgical ventricular restoration (SVR)., Methods: Between March 2003 and May 2006, 29 patients (20 men and 9 women, mean age 65 years, mean ejection fraction 24%) with post-infarction left ventricular aneurysm and depressed left ventricular function underwent SVR according to the Dor technique at our institution. Twenty-two patients (76%) were in New York heart association (NYHA) functional class III or IV. Multi-vessel disease was present in 26 patients. Natriuretic peptides, functional status, ejection fraction and left ventricular volumes were analyzed at baseline, after 6 months, and late postoperatively., Results: There was no early mortality. Survival at 24 months was 93%. Six months postoperatively 25/29 (86%) patients were in NYHA class I and II (p<0.001) and at late (mean 21 months) follow-up, all patients were in NYHA class I and II. There was a persistent reduction of NT-pro-BNP (2406 pg/ml vs 1510 pg/ml; p=0.03 and 975 pg/ml; p=0.03) and BNP (312 pg/ml vs 228 pg/ml; p=0.12 and 191 pg/ml; p=0.20) 6 months postoperatively and at late follow-up, respectively. Ejection fraction improved from 24% to 37% (p<0.001) at 6 months. End-diastolic (110 ml/m(2) vs 90 ml/m(2), p=0.009) and end-systolic (75 ml/m(2) vs 52 ml/m(2), p=0.006) volume index were reduced at 6 months. Functional improvement correlated significantly with reduction in BNP (r=0.61, p=0.01) and NT-pro-BNP (r=0.58, p=0.003) 6 months after surgery. Ejection fraction correlated inversely with BNP (r=-0.58, p=0.02) and NT-pro-BNP (r=-0.51, p=0.04), and end-systolic volume correlated with BNP (r=0.65, p=0.03) and NT-pro-BNP (r=0.62, p=0.03) 6 months after surgery., Conclusions: Heart failure secondary to post-infarction left ventricular remodeling can be reversed by SVR. Improvement in these patients was associated with reduced levels of B-type natriuretic peptides 6 months after surgery. Clinical improvement was maintained and peptide levels were further reduced at late follow-up.

Background: Surgical ventricular restoration (SVR) has been shown to improve hemodynamics and survival among patients with coronary artery disease, left ventricular aneurysm, and heart failure. The aim of this study was to investigate functional status and health-related quality of life after SVR., Methods: Over a period of 2 years beginning in March 2003, 23 patients with left ventricular aneurysm and depressed left ventricular function were included in a prospective study. Functional status and quality of life was analyzed preoperatively, 6 months postoperatively, and at late follow-up by assessment of New York Heart Association (NYHA) functional class, 6-minute walk test, and the Medical Outcome Study 36-Item Short Form., Results: There was no early mortality. Before surgery, 17 patients (74%) were in NYHA class III to IV; and 6 months after SVR, 20 patients (87%) were in NYHA class I to II (p < 0.001). At late follow-up, (mean, 22 months postoperatively), all patients alive (n = 20) were in NYHA class I to II. Mean 6-minute walk distance increased by 41 meters (p = 0.06) at 6 months postoperatively and by 57 meters (p = 0.03) at late follow-up. Quality of life, assessed by the physical component summary score of the Medical Outcome Study 36-Item Short Form, improved significantly (p = 0.04) at 6 months postoperatively. A significant and clinically relevant improvement in both physical aspects (+25%, p < 0.001) and mental aspects (+37%, p = 0.003) of quality of life was found at late follow-up., Conclusions: Functional status and quality of life improved 6 months after SVR, and the improvement was sustained at late follow-up almost 2 years after surgery.

Background: Functional mitral regurgitation is common in ischemic dilated cardiomyopathy. Edge-to-edge repair is an option for correction and can be performed through the ventriculotomy during surgical ventricular restoration (SVR). This report describes the durability of the edge-to-edge repair without annuloplasty in combination with SVR., Methods: From March 1997 to July 2002, 31 patients with left ventricular aneurysm or ischemic dilated cardiomyopathy and functional ischemic mitral regurgitation grade II (n = 18), III (n = 10), and IV (n = 3) underwent SVR and edge-to-edge repair without annuloplasty with concomitant coronary artery bypass grafting. Long-term valve competence was assessed by echocardiography. Early and late survival and hospital readmission for heart failure were analyzed., Results: Early mortality was 5 (16%) of 31 patients. At 1, 3, and 5 years, actuarial survival was 77%, 55%, and 48%. The cumulative follow-up was 117 patient-years (4.5 years mean follow-up). Late echocardiograms performed at a mean of 3.1 years postoperatively showed patients had mitral regurgitation at grade 0 (n = 4), I (n = 10), II (n = 9), and III (n = 1). Two patients underwent reoperation owing to grade III-IV recurrent mitral regurgitation. Freedom from hospital readmission or cardiac death was 56% at 1 year and 48% at 3 years., Conclusions: Combined mitral valve repair and SVR carries high operative risk and long-term prognosis is worse than after SVR alone. The edge-to-edge repair without annuloplasty for functional ischemic mitral regurgitation seems to be fairly durable in conjunction with SVR. To improve results a transventricular annuloplasty may be added.

This article is a presentation of direct surgery for ventricular tachycardia in patients undergoing surgical ventricular restoration. The procedure includes a non-electrophysiologically guided subtotal endocardiectomy and cryoablation in addition to endoventricular patch plasty of the left ventricle. Coronary artery bypass surgery and mitral valve repair are performed concomitantly as needed. In our experience, this procedure yielded a 90% success rate in terms of freedom from spontaneous ventricular tachycardia, with an early mortality rate of 3.8%. Perioperative considerations and a short overview of the literature are presented.

Background: Surgical ventricular restoration is an option in patients with coronary artery disease, heart failure, postinfarction left ventricular aneurysm or ischemic dilated cardiomyopathy with or without ventricular tachycardia. The aims of this study were to investigate survival and re-admission for heart failure and to identify predictors for early and long-term mortality and re-admission after surgical ventricular restoration., Methods: Pre- and postoperative data were collected for 136 consecutive patients who underwent surgical ventricular restoration for postinfarction left ventricular aneurysm or ischemic dilated cardiomyopathy during 1994-2005. Survival and risk factors for mortality and hospital re-admission were analyzed by using multivariable models., Results: Early mortality was 10/136 (7.4%). At 1, 3, 5 and 9 years overall actuarial survival was 89%, 80%, 68% and 62%. Increasing age, diabetes and mitral regurgitation grade III-IV were associated with an increased risk for late mortality. Freedom from re-hospitalization due to heart failure or cardiac death in operative survivors at 1, 3 and 5 years was 78%, 72% and 58%. Risk factors for re-hospitalization or cardiac death in operative survivors were increasing age and increasing grade of mitral regurgitation., Conclusions: Surgical ventricular restoration by the Dor procedure can achieve good long-term survival and a high degree of freedom from readmission for heart failure in patients with advanced ischemic heart disease. We found a strong association between increasing grade of mitral regurgitation and both long-term mortality and re-admission for heart failure.

A 57-year-old man with dilated cardiomyopathy was referred to our institution to be assessed for heart transplantation. He had symptoms of severe heart failure and left ventricular dysfunction. We proposed surgical ventricular restoration (the Dor procedure) as an alternative to heart transplantation. The patient underwent successful surgery and an uneventful postoperative course. Pre- and postoperative investigations are presented. One year after surgery, the patient is in good clinical and functional condition. This case illustrates that surgical ventricular restoration can be an alternative to heart transplantation.

Background: Surgical ventricular restoration (the Dor procedure) is an option in patients with coronary artery disease and postinfarction left ventricular aneurysm. The procedure can be extended to treat ventricular tachycardia (VT). The aim of this study was to evaluate the Dor procedure including VT surgery in our institution., Methods: From July 1997 to December 2003, 53 consecutive patients with left ventricular aneurysm and VT underwent surgical ventricular restoration including nonguided endocardiectomy and cryoablation. Twenty-four patients had at least one preoperative episode of spontaneous VT, of which 8 were survivors of sudden cardiac death. Twenty-nine patients had inducible-only VT. In 45 patients, who underwent preoperative programmed stimulation, sustained uniform VT could be initiated. Arrhythmia control was evaluated by programmed stimulation or analysis of events registered by implanted defibrillators and by review of patient's records., Results: Early mortality was 2 of 53 (3.8%). Mean follow-up was 3.7 years. At 1, 3, and 5 years overall actuarial survival was 94%, 80%, and 59%, respectively. Surgical success rate in patients with preoperative spontaneous VT was 91%. Inducible VT was found in 5 of 35 patients who underwent postoperative programmed stimulation. There was no arrhythmia-related late death and there was no loss to follow-up., Conclusions: The Dor procedure including VT surgery is an effective treatment for postinfarction left ventricular aneurysm and VT and eliminates the need for an implantable defibrillator in most patients. Early and long-term results are good in terms of survival and arrhythmia control.

Left ventricular (LV) dilatation occurs after myocardial infarction and leads to heart failure. LV reconstruction or surgical ventricular restoration (SVR) by means of the Dor procedure reduces LV volume and restores normal LV shape. Mitral repair and surgery for ventricular tachycardia are performed as needed. SVR improves LV function and early and long-term results are good in terms of survival and arrhythmia control. International results as well as the experience of the procedure at Karolinska University Hospital are presented and illustrated with a case report.

Objective: Surgical ventricular restoration by means of the Dor procedure is a surgical option in patients with coronary artery disease, postinfarction left ventricular aneurysm or ischemic dilated cardiomyopathy with or without ventricular tachycardia. The aim of this study was to evaluate the 10-year clinical experience of this procedure in our institution., Methods: From May 1994 to June 2004, surgical ventricular restoration was performed in 101 patients (77 males), mean age 63.8 (35-80) years. All patients presented with angina and/or heart failure and/or ventricular tachycardia. Postinfarction left ventricular aneurysm was present in 97 patients and ischemic dilated cardiomyopathy with a large akinetic left ventricle in 4. The preoperative left ventricular ejection fraction was 27+/-10 (7-50) %. Multi-vessel disease was present in 80 patients. Ventricular tachycardia was diagnosed in 53 patients (spontaneous VT in 25). Mitral regurgitation more than grade 2 was found in 13 patients. The mean Euroscore was 7.1+/-2.9 (3-17)., Results: All patients underwent the Dor procedure, which in 53 patients included a non-guided endocardectomy and cryoablation for treatment of ventricular tachycardia. Coronary artery bypass grafting was performed in 99 patients and a mitral valve procedure was performed in 29. Intra-aortic balloon pumping was used postoperatively in 14 cases and 24 patients needed inotropic support for more than 24 h. Mean time on the ventilator was 16+/-25 (3-168) hours and mean stay in the intensive care unit was 2.1+/-2.2 (0-13) days. Postoperative stroke occurred in 7 patients. Early mortality was 8/101 (7.9%). Mean follow-up in operative survivors was 4.4+/-2.8 (0.1-10.4) years. Actuarial survival at 1, 3 and 5 years was 88, 79 and 65%., Conclusions: The Dor procedure is a reproducible surgical option for treatment of postinfarction left ventricular aneurysm. Early and long-term results are good in terms of survival.

Objective: It is thought that a patent foramen ovale (PFO) is the crucial mechanism in patients with suspected paradoxical embolism and cryptogenic stroke. It has been hypothesized that closure of the PFO would prevent further cerebrovascular incidents. We describe our early and late experience with surgical closure of the PFO in patients with paradoxical embolism., Patients and Methods: Between May 1994 and December 2001, 33 patients (26 men, 7 women; mean age, 55.2 +/- 8.7 years; range, 37-74) underwent surgical closure of a PFO at our institution. All patients had preoperatively suffered from a stroke and/or a transient ischemic attack, after which echocardiography showed a PFO. Mean follow-up at 99 +/- 30 months (range, 10-111 months) was 100% complete., Results: All patients survived the operative procedure. Early complications occurred in four patients (12%). Actuarial survival at 1, 5 and 8 years was 97 +/- 3%, 97 +/- 5% and 94 +/- 8%, respectively. At long-term follow-up all but two patients were alive. The deaths of these two patients were related to malignancy and ischemic heart disease, respectively. Two patients (6%) had suffered a residual cerebrovascular event after successful surgery., Conclusion: Surgical closure of PFO in patients with paradoxical embolism can safely be performed with a low risk of early mortality. Residual thromboembolic events were rare and in those few it occurred it did so with the interatrial septum being closed, indicating that in those patients the PFO was not the mechanism of the thromboembolic event in the first place.

A potentially serious but rare complication of mediastinoscopy procedures is acute damage to any of the great vessels in the region of the distal trachea and carina. We report a case of serious hemorrhage from a mediastinoscopic biopsy-injury to the posterior aspects of the right pulmonary artery (RPA), which required sternotomy, cardiopulmonary bypass, division and retraction of the ascending aorta, incision of the RPA, intermittent deep hypothermic circulatory arrest, and suturing from the inside of the RPA for a successful repair.

Transient sinus node dysfunction has been demonstrated by noninvasive methods following the maze procedure for atrial fibrillation (AF). However, extensive data from invasive electrophysiological studies have not been previously reported. Thirty-seven patients, mean age 54 +/- 10 years, underwent the maze (III) procedure. Electrophysiological studies with recordings of SNRT, CSNRT, AVN-ERP, point of Wenckebach block, AH, PA, and HV interval, were performed preoperatively and 6 and 15 months postoperatively. Induction of atrial flutter/AF was attempted postoperatively. Based on electrophysiological study evaluation, the maze (III) procedure did not cause permanent damage to the sinus node in any patient with a documented normal sinus node function preoperatively (CSNRT max 541 +/- 210 vs 587 +/- 437 ms, P = 0.26). Postoperative AV node function was normal in all patients with a documented normal AV node function before surgery. One patient had an iatrogenic third degree AV block. There was no difference in PA or HV interval after surgery. Sustained atrial tachyarrhythmias could be induced in 5 patients, of whom 4 developed permanent AF/atrial flutter late after surgery. At late follow-up, (mean 45 months), 27 (73%) patients were in sinus rhythm, 5 (13%) patients had permanent pacing, and 5 patients had recurrent AF requiring His bundle ablation (n = 2) or medical treatment (n = 3). Based on electrophysiological studies, the maze (III) procedure does not cause permanent damage to the sinus or AV nodes or to the right atrial and His-Purkinje conduction systems. Electrophysiological study evaluation may predict the need for postoperative pacemaker. Induction attempts of atrial arrhythmias may predict future recurrences and guide therapeutic efforts.

Objective: To test the safety and bioactivity of phVEGF-A165 after intramyocardial injection during 12-month follow-up., Design: Open-labelled study., Subjects: Inclusion criteria were angina pectoris, Canadian Cardiovascular Society (CCS) class III-IV, unamenable to further revascularization, ejection fraction (EF) >30%, perfusion defects extending over >10% of the anterolateral left ventricle wall detectable with adenosine single photon emission computerized tomography (SPECT) and at least one patent vessel visible by coronary angiography. Seven of 39 patients referred for gene therapy were included., Intervention: Via a mini-thoracotomy under general anaesthesia. phVEGF-A165 was injected directly into the myocardium at four sites in the anterolateral region of the left ventricle., Results: Operative procedures were uneventful. Perioperative release of myocardial markers and electrocardiogram (ECG) changes were detected in two patients. There were no perioperative deaths but one patient died 7 months postoperatively because of myocardial infarction. Plasma vascular endothelial growth factor (VEGF)-A levels increased two to threefold peaking 6 days postoperatively (P < 0.004) and returning to baseline by day 30. A significant reduction in angina pectoris was reported. The CCS class improved from 3.3+/-0.2 to 1.9+/-0.3 (P < 0.01) and nitroglycerine intake decreased from 39+/-15 to 12+/-5 tablets week(-1) (P < 0.001) 2 months after gene transfer. Improvements remained after 12 months when nitroglycerine consumption approached zero. Improved myocardial function in the phVEGF-A165 injection region was documented in all patients (P < 0.016) by tissue velocity imaging (TVI). Reduced reversible ischaemia was detected by adenosine SPECT in four patients. Improved collateralization was detected in four patients with coronary angiography., Conclusion: Intramyocardial injection of phVEGF-A165 is safe and may lead to improved myocardial perfusion and function with longstanding symptomatic relief in end-stage angina pectoris. Based on these results this therapeutic potential is being tested in a double-blind placebo controlled multicentre trial.

Objectives: The aim of the study was to evaluate the risk from calcified atheromas in the ascending aorta, and the extent and topography of the disease in the development of stroke after cardiac surgery., Background: Postoperative stroke constitutes a serious problem in cardiac surgery, and atherosclerosis of the ascending aorta is an important risk factor., Methods: Before surgical manipulation epiaortic echocardiographic ultrasound was performed to evaluate the ascending aorta in 921 consecutive patients undergoing cardiac surgery. The presence of calcification, location of atheroma, extent of the disease and clinical variables including postoperative stroke were recorded prospectively., Results: A total of 26.2% of the patients had atherosclerosis of the ascending aorta, and in 44.4% of them more than one of 12 possible segments was involved. Logistic regression showed that atherosclerotic disease in the ascending aorta was the most important predictive factor for postoperative stroke. The incidence of stroke was 1.8% in patients without atherosclerotic disease of the ascending aorta, and 8.7% in patients with the disease (p < 0.0001). Diabetes mellitus was also a predictive factor (p = 0.04). A new and unique finding of this study was that the middle-lateral segment is an independent predictive factor for postoperative stroke, with a relative risk of 26% (p = 0.04)., Conclusions: Patients with atheromatosis in the ascending aorta had an 8.7% incidence of postoperative stroke, in spite of minor surgical modifications. The risk depended on the presence, location and extent of the disease. Randomized trials evaluating alternative surgical strategies in coronary surgery are urgently needed in high risk patients.