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Thromboembolism and hemorrhage related to anticoagulation remain a major concern in elderly patients with mechanical valves. Clinical results following isolated aortic valve replacement (AVR) with tilting disk and bileaflet prostheses in patients aged over 70 years were analyzed and compared with results in patients aged45 years.Between January 1980 and August 2002, 319 consecutive older patients (group A) and 497 young patients AVR. Preoperative clinical data, early and late mortality, valve-related complications and data related to anticoagulation status (including mean INR and mean interval between INR assays) were compared between groups.Hospital mortality was lower in group B (3.4%) than in group A (10.7%; p0.0001). Twelve-year actuarial survival was lower in older patients (54% in group A versus 78% in group B; p0.001). The two groups showed similar 12-year actuarial freedom from hemorrhage (99.6% versus 99.5%; p = 0.69), endocarditis (99.6% versus 98.43%; p = 0.25) and perivalvular leak (99.6% versus 97.9%; p = 0.21). However, actuarial freedom from thromboembolism was lower in older patients (98.8% versus 99.7%; p = 0.041).Despite lower rates of long-term mortality and thromboembolism (the latter because of advanced atherosclerosis) in group A, there were no differences in rates of other valve-related complications. Hence, older age cannot be considered a contraindication to implantation of mechanical valves in the aortic position.

Background Evaluation of the impact of prosthesis-patient mismatch (PPM) on long-term outcome and quality of life (QOL) in elderly patients who underwent implantation of small size bileaflet prostheses for aortic stenosis. Methods Between September 1988 and September 2006, 377 patients aged greater than 70 years underwent aortic valve replacement with a small size bileaflet prosthesis (17, 19, and 21 mm) in one Institution. The study population's survivors (345 patients) were divided into three groups according to the indexed effective orifice area (EOAI): Group A included patients with EOAI less than 0.60 cm 2 /m 2 ; group B included patients with EOAI ranging between 0.61 and 0.84 cm 2 /m 2 ; and group C included patients with EOAI 0.85 cm 2 /m 2 or greater. Cumulative and comparative analyses of long-term outcomes and of left ventricular mass regression were performed. The QOL was evaluated with the 36-Item Short Form Health Survey (SF-36) questionnaire. Results Overall hospital mortality was 8.5% (32 patients). Group A included 33 patients (9.6%), group B 175 (50.7%), and group C 137 (39.7%). Actuarial survival was 88.8% ± 0.016 at 1 year, 82.1% ± 0.022 at 5 years, and 76.7% ± 0.032 at 10 years. No difference emerged among the three groups. A significant reduction in left ventricular mass was observed in all groups and in all patient subsets of prosthetic size. The scores obtained in the SF-36 test were similar in the three groups and significantly higher than those of the general population ( p Conclusions Incidence of severe PPM is low after aortic valve replacement. Presence of severe or moderate PPM, did not influence long-term outcome, left ventricular mass regression and QOL in a population of septuagenarians.

The aim of this study was to determine whether changes in prognosis and quality of life (QOL) after aortic valve replacement (AVR) in octogenarians differ depending on the choice of mechanical (MP) or tissue (BP) valves.Between July 1992 and September 2006, 160 consecutive octogenarians underwent AVR with (18.8%) or without concomitant coronary artery bypass grafting. At follow-up (mean 3.4 +/- 2.8 years, 552 patient-years, 98.3% complete), 121 were still alive and answered the Medical Outcomes Study Short-Form 36 Health Survey (SF-36) QOL questionnaire.Group BP had 62 patients. Group MP had 98 patients. Preoperative risk factors were comparable except group BP was older. Global hospital mortality was 8.8%. There were 21 late deaths, 61.9% of which were not valve- or anticoagulation-related. A significant difference emerged in 1-, 3-, 5- and 8-year actuarial survival rates (BP: 86.4% +/- 0.04%, 76.9% +/- 0.06%, 58.1% +/- 0.1%, 46.5% +/- 0.14%, respectively, vs MP: 91.3% +/- 0.03%, 88.6% +/- 0.03%, 81.6% +/- 0.05%, 70% +/- 0.67%; p = 0.025) but not in terms of 8-year freedom from valve-related complications (82.6% +/- 0.1% vs 87% +/- 0.053%, p = 0.55). One anticoagulant-related hemorrhage occurred in group MP; one stroke occurred in group BP. Survivors had significant improvement in New York Heart Association functional class compared with preoperatively (1.1 vs 2.8, p0.001) Mean QOL scores were satisfactory and substantially comparable between the two groups; in seven domains, scores were higher than those of the age- and sex-matched general Italian population.Long-term survival after AVR in selected octogenarians was similar to that of the general elderly population. The device type exerted no influence on QOL.

Results after isolated aortic valve replacement with bileaflet prostheses in patients over 70 years old were reviewed. One-hundred-twenty-eight elderly patients were operated on between January 1988 and January 2000. Patients with associated heart disease were excluded from the study. Preoperative data, early and late postoperative mortality, all valve related complications and data concerning anticoagulation status were recorded. Hospital mortality was 9.3%. Mean follow-up time was 60.98±2.23 months. Twelve-year actuarial survival was 69.6±0.08%. Valve related and anticoagulation related complication rates (0.8% and 1.6% respectively) and actuarial freedom (99±0.009 both) were low, as well as the mean interval between consecutive INR checks (18.39±1.90 days) and the mean INR value (2.17±0.135). Late echocardiographic results showed low postoperative mean transprosthetic gradients (15.48±0.94). Bileaftlet prostheses in the elderly can achieve excellent results with a low incidence of anticoagulation related complications and low risk of reoperation. Older age can no longer be considered a contraindication to bileaftlet prosthesis implant.

Objectives: Polyamines are organic polycations playing an essential role in cell proliferation and differentiation, as well as in cell contractility, migration and apoptosis. These processes are known to contribute to restenosis, a pathophysiological process often occurring in patients submitted to revascularization procedures. We aimed to test the effect of alpha-difluoromethylornithine (DFMO), an inhibitor of ornithine decarboxylase, on vascular cell pathophysiology in vitro and in a rat model of carotid arteriotomy-induced (re) stenosis. Methods: The effect of DFMO on primary rat smooth muscle cells (SMCs) and mouse microvascular bEnd. 3 endothelial cells (ECs) was evaluated through the analysis of DNA synthesis, polyamine concentration, cell viability, cell cycle phase distribution and by RT-PCR targeting cyclins and genes belonging to the polyamine pathway. The effect of DFMO was then evaluated in arteriotomy-injured rat carotids through the analysis of cell proliferation and apoptosis, RT-PCR and immunohistochemical analysis of differential gene expression. Results: DFMO showed a differential effect on SMCs and on ECs, with a marked, sustained anti-proliferative effect of DFMO at 3 and 8 days of treatment on SMCs and a less pronounced, late effect on bEnd. 3 ECs at 8 days of DFMO treatment. DFMO applied perivascularly in pluronic gel at arteriotomy site reduced subsequent cell proliferation and preserved smooth muscle differentiation without affecting the endothelial coverage. Lumen area in DFMO-treated carotids was 49% greater than in control arteries 4 weeks after injury. Conclusions: Our data support the key role of polyamines in restenosis and suggest a novel therapeutic approach for this pathophysiological process. (C) 2013 Elsevier Ireland Ltd. All rights reserved.

Myocardial ischemia is often associated to aortic valve stenosis in the elderly. Aim of this study was to evaluate the impact on survival and quality of life of CABG associated to aortic valve replacement in the septuagenarians and octogenarians. Between January 1991 and January 2010, 520 patients ageing > 70 years underwent aortic valve replacement with a mechanical prosthesis in two Institutions. They were divided into 2 groups: Group A included 406 patients undergoing isolated aortic valve replacement; Group B 114 patients receiving aortic valve replacement and CABG. A comparative analysis of long-term survival and quality of life (SF-36 test) was performed. Mean age was 74.2 ± 3.6 years (74.3 ± 3.6 in Group A, 74 ± 3.3 in Group B; p = 0.33). Hospital mortality was 9.5% (46 patients). Twenty-nine (7.8%) in Group A and 17 in Group B (15.2%)(p = 0.019). Actuarial survival was 88.5% ± 0.015 at 1 year, 81.9% ± 0.02 at 5 years, 76.6% ± 0.032 at 10 and 57.3 ± 0.1 at 15 years. Ten-year survival was 77% ± 0.034 in Group A and 77.8% ± 0.045 in Group B (p = 0.2). Multivariate analysis did not reveal associated CABG as a predictor of long term mortality. The scores obtained in the SF-36 test were similar in the two groups and significantly higher than those of the general population matched for country, age and sex (p < 0.001 in all domains). Associated CABG determines a significant increase of hospital mortality in the elderly undergoing aortic valve replacement. Survivors did not show differences in long-term outcome and quality of life according to the presence of associated CABG.

AIMS Age over 75 years and logistic Euroscore over 20% have been jointly proposed by European scientific associations as the criteria for aortic valve stenosis patients to be considered 'high-risk' for surgical aortic valve replacement (AVR) and candidates for transcatheter aortic valve implantation (TAVI). We aimed to verify traditional AVR outcomes in the presence of the above criteria. METHODS Between January 2001 and January 2011, 180 patients with severe aortic valve stenosis (mean aortic valve area = 0.4±0.1 cm/m), with age range 75-88 years (mean 78.2±3), logistic Euroscore between 4.5 and 40% (mean 12.6±7.4%), underwent surgical AVR. The patient population was divided into group A (118 patients between 75 and 79 years of age), further divided into subgroups A1 (76 patients) and A2 (42 patients) with logistic Euroscore, respectively, less than 20% and at least 20%; and group B (62 patients between 80 and 88 years of age), subdivided into B1 (34 patients) and B2 (28 patients) with logistic Euroscore, respectively, less than 20% and at least 20%. Hospital outcomes were retrospectively evaluated. Univariate and multivariate analyses, including age and logistic Euroscore, were performed to individuate predictors of hospital mortality. RESULTS Overall observed/expected mortality ratio was 0.4. Hospital mortality was 5.3% in group A1, 4.8% in A2, 5.9% in B1, 3.6% in B2 (P=NS). Mortality with age over 75 and Euroscore at least 20% was 4.3%. As regards postoperative morbidity, atrio-ventricular bock indicating pacemaker implantation occurred in four patients, pneumonia in three, stroke in two, perioperative myocardial infarction in one. Age and Euroscore were not independent predictors of mortality, morbidity or composite endpoint in multivariable analysis. CONCLUSION Age and logistic Euroscore might be inadequate criteria for the identification of patients with severe aortic stenosis unsuitable for AVR and addressable to TAVI.

This study aimed to evaluate our 30-year experience in the treatment of deep sternal wound infection after cardiac surgery. Between 1979 and 2009, deep sternal wound infections occurred in 200 of 22,366 (0.89%) patients who underwent sternotomy. The study population was divided into 3 groups. In group A (62 patients; 1979–1994), an initial attempt at conservative antibiotic therapy was the rule, followed by surgery in case of failure. In group B (83 patients; 1995–2002), the treatment was in 3 steps: wound debridement and closed irrigation for 10 days; in case of failure, open dressing with sugar and hyperbaric treatment; delayed healing and negative wound cultures mandated plastic reconstruction. In group C (2002–2009), the treatment was based on early surgical debridement, vacuum application, and reconstruction using pectoralis muscle flap. Hospital mortality in group A was significantly higher than that in groups B and C. Hospital stay, time for normalization of white blood cell count and C reactive protein, and time for defervescence were significantly shorter in group C. In our experience, early surgical debridement and vacuum application followed by plastic reconstruction provided a satisfactory rate of healing and a good survival rate.

Between January 2002 and January 2009, 39 patients with post-cardiotomy staphylococcal deep sternal wound infection were treated primarily by a vacuum-assisted closure method (group A). Results were compared with those of 30 patients with staphylococcal deep sternal wound infection who received closed mediastinal irrigation with antibiotics (group B). The prevalence of methicillin-resistance was similarly high in both groups (64.1% in A, 56.7% in B). One group B patient died during treatment. The median healing time was significantly shorter at 13 days in group A (mean, 13.5 ± 3.2 days) compared to 18 days (mean, 21.2 ± 16.4 days) in group B. Deep sternal wound infection did not recur after vacuum treatment, while 7 (24%) patients in group B suffered a recurrence. Hospital stay was significantly shorter in group A (median, 30.5 days; mean, 32.2 ± 11.3 days vs. median, 45 days; mean, 49.2 ± 19.3 days). The significantly shorter healing time with vacuum-assisted closure was confirmed in both methicillin-sensitive (12 vs. 17 days) and methicillin-resistant infections (14 vs. 21 days). Hospital stay remained significantly shorter in group A (35 vs. 46 days) when only methicillin-resistant deep sternal wound infection was considered.

Restenosis rates following vascular interventions still limit their long-term success. Oxidative stress plays a relevant role in this pathophysiological phenomenon, but less attention has been devoted to its effects on DNA damage and to the subsequent mechanisms of repair. In the present study, we analysed in a model of arteriotomy-induced stenosis in rat carotid arteries the time-dependent expression of DNA damage markers and of DNA repair genes, together with the assessment of proliferation and apoptosis indexes. The expression of the oxidative DNA damage marker 7,8-dihydro-8-oxo-2′-deoxyguanosine was increased at 3 and 7 days after arteriotomy, with immunostaining distributed in the injured vascular wall and perivascular tissue. Expression of the DNA damage marker phospho-H2A.X was less relevant, but increased from 4 h to 7 days after arteriotomy, with immunostaining prevalently present in the adventitia and, to a lesser extent, in medial smooth muscle cells at the injury site. RT (reverse transcription)–PCR indicated a decrease in eight out of 12 genes involved in the DNA repair machinery we selected from 4 h to 7 days after arteriotomy, with the exception of an increase in the Mutyh and Slk genes (P

Percutaneous transcatheter closure of ASD or PFO has been performed since 1976 as an alternative to conventional surgical repair with various types of mechanical occluder devices.3 The Amplatzer septal occluder is a model of such devices and was approved by the Food and Drug Administration in December 2001. A good rate of successful closure has been reported. Nevertheless, cases of late complications necessitating emergency surgical procedures have been described.4 Our patient had important anatomic injuries. His hemodynamically stabile condition at the time of surgical repair was a fortunate situation. Classic open heart surgery remains the standard of care for ASD repair with excellent outcomes since 1954, providing low operative mortality and morbidity. Percutaneous closure is growing rapidly, principally because of the patient’s, family’s, and pediatric cardiologist’s desire for a less invasive procedure. Considering the increase in the number of procedures, a long-term follow-up is necessary to evaluate the safety of mechanical occluders at long term. Our case report described a complication that occurred 13 months after the percutaneous procedure. The literature includes other authors reporting delayed heart perforation by the occluder device5; hence this patient’s need for long-term echocardiographic follow-up to made an early diagnosis of device failure and prevent emergency surgical intervention. Finally, we conclude that patients should be informed of the actual early and long-term results of surgical repair and percutaneous approach to allow an informed decision.

Background The aim of the study was to examine our experience with the implant of bileaflet mechanical prostheses and with a centralized management of anticoagulation and the related risks in patients aged older than 70 years, focusing on the resulting expectancy and quality of life. Methods Between January 1988 and January 2005, 681 consecutive patients older than 70 years (mean age, 73 ± 3.3 years) underwent bileaflet prostheses implantation in an isolated procedure (77%) or concomitant with other procedures (23%). Data were retrospectively collected, and follow-up was conducted by mean of outpatient chart review and outpatient clinic controls. Follow-up included assessment of perceived quality of life through the Medical Outcomes Trust Short Form 36-Item Health Survey tool (SF-36). The scores obtained by the patients were compared with those of the Italian general population matched for age and sex. Results Hospital mortality was 11.8%, and 74 late deaths (12.3%) occurred. Mean follow-up was 4.38 ± 2.85 years. Actuarial survival was 85.2% ± 0.014% at 1 year, 77.9% ± 0.017% at 5 years, 74.2% ± 0.02% at 10 years, and 71.8% ± 0.031% at 15 years. The mean international normalized ratio variability was 4.5% ± 1.2%. Freedom from bleeding was 98.7% ± 0.005% at 5 years and 98.3% ± 0.007% at 10 and 15 years. Freedom from thromboembolism was 99.1% ± 0.004% at 5 years, and 98.3% ± 0.007% at 10 and 15 years. The mean SF-36 scores in the study patients were significantly higher than those of the general population matched for age and sex ( p Conclusions Septuagenarian patients receiving mechanical valve prostheses did not experience increased rates of anticoagulation-related complications and perceived a satisfactory quality of life.

Background: Prolonged survival in the Western world has increased the number of elderly patients referred for open-heart surgery during the last decade. Aortic valve disease is the most common heart valve disease in aged patients. Which aortic valve substitute is best employed in the elderly is still a debated matter. The main concern is about the thromboembolic and hemorrhagic risks related to mechanical valves and anticoagulation. Objective: The study aimed at reviewing clinical results after isolated aortic valve replacement with bileaflet prostheses in patients over 70 years and at retrospectively comparing them with those of a group of otherwise comparable patients under 50 years of age who underwent isolated aortic valve replacement with a mechanical device. Methods: The study population included 118 consecutive elderly patients (group A) operated on between January 1988 and January 1999 and 122 young patients (group B) who underwent aortic valve replacement during the same time period. Patients with associated coronary artery disease, mitral stenosis or regurgitation, type A aortic dissection, and infective endocarditis were excluded from the study. Preoperative clinical data, early and late postoperative mortality, all valve-related complications, and all data concerning the anticoagulation status – including the mean international normalized ratio (INR) and the mean time interval between each INR assay – were compared between the two groups. Results: The hospital mortality was significantly lower in group B (2.45%) than in group A (9.3%; p = 0.022). The mean follow-up period was 50.98 ± 2.23 months. The 12-year actuarial survival was significantly lower (69.6 ± 0.08%) in group A than in group B (94.4 ± 0.02%; p < 0.001). No significant difference was found in terms of valve-related and anticoagulation-related complication rates and actuarial freedom as well as mean interval between consecutive INR checks (p = 0.219) and mean INR value (p = 0.914). Conclusions: Bileaflet prostheses in elderly patients can achieve excellent early and late clinical results, with a low incidence of anticoagulation-related complications and an extremely low risk of a reoperation. Older age can no longer be considered a contraindication to bileaflet prosthesis implantation in the aortic position.

In 1997 Argenta and Morykwas 1 reported the use of negative pressure to enhance wound granulation and closure. Since then, more studies have reported good results with the application of vacuum in the treatment of deep sternal wound infection after cardiac surgery. 2,3 No study has described the use of negative pressure and the therapeutic intensity of vacuum in the neonatal age group. We report our experience in a 28-day-old female neonate with a thoracotomy wound infection treated with vacuum application. Clinical Summary

Objective: Extubation failure is a serious complication after cardiac surgery. The role of noninvasive positive-pressure ventilation for acute respiratory failure in patients undergoing cardiac surgery is unknown. This study aimed to assess the safety of implementing noninvasive positive-pressure ventilation in this setting and its impact on lung function and operative outcomes. Methods: In a 6-month pilot prospective survey, the study population comprised 43 patients (32were male with a mean age of 65.73 ± 9 years; 3 heart transplantations, 18 coronary artery bypass grafts, 5 aortic dissections, and 17 valvular procedures; 34 active smokers, 25 with medically treated chronic obstructive pulmonary disease, 21 emergency/urgency procedures) who required noninvasive positive-pressure ventilation for acute respiratory failure after initial weaning from a respirator. The cause of acute respiratory failure (classified as post-cardiopulmonary bypass lung injury in 48.8% [21 patients], cardiogenic edema in 30.2% [13 patients], and pneumonia in 21% [9 patients]), length of noninvasive positive-pressure ventilation support, respiratory ratios (arterial oxygen tension/fraction of inspired oxygen assessed immediately before noninvasive positive-pressure ventilation, and every 6 hours after institution of pressure ventilation), and need for reintubation along with a set of predefined safety parameters were recorded. Results: The mean length of noninvasive positive-pressure ventilation support was 33.8 ± 24.04 hours. Plotting respiratory ratios with length of noninvasive positive-pressure ventilation supports a significant improvement was already evident within the first 6-hour frame (133.6 ± 39.5 vs 205 ± 65.7; P < .001) for all causes. Noninvasive positive-pressure ventilation prevented intubation in 74.4% of the patients, with satisfactory recovery for post-cardiopulmonary bypass lung injury and cardiogenic dysfunction (90.5% and 69.2%, respectively) and poor results (55% reintubated) in those treated for pneumonia. Noninvasive positive-pressure ventilation safety approached 97.7%. Conclusion: In appropriate candidates, noninvasive positive-pressure ventilation exerts favorable effects on lung function, preventing reintubation. The cost-effectiveness of its systematic use in this setting should be assessed.