Calcific patterns in atherosclerotic aortic walls versus stenotic aortic valves. Modified histochemical reactions and immunohistochemical localizations

A relevant issue in the study of ectopic calcification affecting different vascular tissues is to elucidate whether and how much common pathogenetic mechanisms, calcific factors and degenerative events are shared mineralization hallmarks1. Previously, in calcifying subdermally implanted aortic valves, modified Cuprolinic Blue reactions revealed a distinct cell degenerative pattern culminating in clustering of acidic lipids at cell surfaces with subsequent blebbing of matrix-vesicle-like bodies, acting as major apatite nucleators2. Additional co-localization of calcium-binding sites, as ultrastructurally revealed by von Kossa reactions, and of immunogold labelled Annexin-V was also found. In the present work, the above procedures, in situ terminal deoxynucleotidyl transferase-mediated dUTP nick-end labelling (TUNEL) method, and immunohistochemical reactions for calcium-binding proteins annexin-V, osteopontin, osteonectin and tenascin-C were used to study calcifying aortic wall and stenotic valve samples. Peculiar CB- and von-Kossa-reactive lipidic layers comparable with those in the experimental model actually resulted as degenerative forms also characterizing these two calcification types. In addition, the whole calcification patterns showed some similarities but also distinct dissimilarities to exist by comparing experimental model, vascular wall atherosclerosis and aortic valve disease. 1. Demer L 2001. Circulation 104, 1881-1883. 2. Ortolani F et al. 2003 Histol. Histopathol. 18, 1131-1140. 3. Ortolani F et al. 2007 Histol. Histopathol. 22, 261-272

Bicuspid aortic valve disease and ascending aortic aneurysm: Should an aortic root replacement be mandatory?

OBJECTIVES: The higher risk of adverse aortic events in patients with bicuspid aortic valve (BAV) disease and ascending aorta aneurysm is known, but the management of moderate aortic root dilatation in younger patients is a controversial issue. The aim of the study was to compare survival in patients with or without root replacement. METHODS: We reviewed 166 consecutive patients with BAV disease and concomitant ascending aorta aneurysm (mean ascending aorta diameter: 51.4 \ub1 7.2 mm) undergoing cardiac surgery from 1994 to 2010. A total of 77 patients underwent Bentall procedure (90.9% male, mean age: 55.7 \ub1 12.7 years, Bentall group), whereas the remaining 89 patients underwent aortic valve replacement with supracoronary ascending aorta replacement (SAAR 71.9% male, mean age: 60.5 \ub1 11.2 years, SAAR group, P = 0.002). The preoperative mean diameter of the root was 44.0 \ub1 7.2 mm in the Bentall, and 38.5 \ub1 4.8 mm in the SAAR group (P < 0.0001). RESULTS: In-hospital mortality was 2.6% in the Bentall, and 2.3% in the SAAR groups. Overall survival was 84 and 81% in the Bentall (median follow-up: 105 months) versus 89 and 88% in the SAAR (median follow-up: 73 months) groups at 10 and 15 years (P = 0.36), respectively. The mean cardiopulmonary bypass (CPB) time was 201 \ub1 56 min and 174 \ub1 58 min (P = 0.0016), the mean cross-clamp time 156 \ub1 42 min and 132 \ub1 38 min (P = 0.0008) in the Bentall and SAAR groups, respectively. Four sudden deaths have occurred in the Bentall group and in 2 in the SAAR group. Progressive dilatation of the aortic root in the SAAR group was not significat (postoperative mean diameter: 36.3 \ub1 4.4 mm). Neither subgroup of patients in the SAAR with preoperative moderate dilatation of aortic root had significat aortic dilatation at the mean follow-up of 73 \ub1 39 months (preoperative diameter: 43.5 \ub1 2.3 mm versus postoperative: 39.1 \ub1 4.2 mm). One patient in Bentall and 1 in the SAAR groups were reoperated for tubular graft infection. CONCLUSIONS: In patients with BAV disease, ascending aorta aneurysm and moderate dilatation of the root, the significat reduction of CPB and cross-clamp times, the stability of the residual root at long term and the low risk of adverse aortic events associated with SAAR compared with the Bentall procedure have led us to consider the isolated aortic valve replacement with supracoronary aorta replacement an alternative strategy to the Bentall procedure, especially in high-risk and older patients

Surgical management of destructive aortic endocarditis: Left ventricular outflow reconstruction with the Sorin Pericarbon Freedom stentless bioprosthesis

OBJECTIVES: The treatment of complicated aortic endocarditis with periannular abscesses and root disarrangement is a surgical challenge, and includes left ventricular outflow tract (LVOT) reconstruction with the patch technique or homograft implantation. The results of a simplified technique to reconstruct the LVOT in destructive endocarditis of either the aortic native valve or valve prosthesis with the Sorin Pericarbon Freedom stentless valve are reported. METHODS: Since August 2007, 40 patients with destructive endocarditis (mean age: 69 \ub1 12, 75% males, European System for Cardiac Operative Risk Evaluation II (EuroSCORE II): 19 \ub1 13, New York Heart Association (NYHA) class: 653 in all cases) have undergone LVOT reconstruction with a Sorin Pericarbon Freedom stentless bioprosthesis. Seven patients (17.5%) were in septic or cardiogenic shock preoperatively, and 18 patients (45%) suffered from moderate or severe aortic regurgitation. Eleven patients (27.5%) experienced preoperative systemic embolizations. Thirty-six cases (90%) were valve redos and 9 patients (22.5%) had concomitant procedures. The mean follow-up was 26 \ub1 25 months. RESULTS: One patient (2.5%) died early (<30 days) and another 3 patients never discharged died due to multiorgan failure and septic shock. Actuarial survival rate was 85 \ub1 6% at 1 year, and 76 \ub1 8% at 3 and 5 years, respectively. Twelve patients (30%) required pacemaker implantation because of atrioventricular block and 20 patients (50%) developed or showed a progression of renal failure. One patient (2.5%) had an endocarditis relapse, and 1 (2.5%) showed a mild paraprosthetic aortic leak. No patient needed reoperation. At the last echocardiographic evaluation, mean gradient, peak gradient and left ventricular ejection fraction were 7.9 \ub1 5.0 mmHg, 15.1 \ub1 7.2 mmHg and 63.3 \ub1 9.3%, respectively. CONCLUSIONS: The Sorin Pericarbon Freedom stentless prosthesis, with the modified technique herein described, seems to be a good option in most of cases of destructive aortic valve endocarditis. It is promptly available in different sizes, easy to implant and, due to its pericardial inflow skirt, ideal for extensive reconstruction of the LVOT with good haemodynamic performance and low risk of relapse

The impact of the distance between patient residency and heart transplant center on outcomes after heart transplantation

Introduction: Heart transplant (HTx) recipients require continuous monitoring and care in order to prevent and treat possible complications related to the graft function or to the immunosuppressive treatment promptly. Since heart transplantation centers (HTC) are more experienced in managing HTx recipients than other healthcare facilities, the distance between patient residency and HTC could negatively affect the outcomes. Methods: Data of patients discharged after receiving HTx between 2000 and 2021, collected into our institutional database, were retrospectively analyzed. The population was divided into three groups: A (n = 180), B (n = 157), and C (n = 134), according to the distance tertiles between patient residency and HTC. The primary end-point was survival, secondary end-points were incidences of complications. Results: Recipient and donor characteristics did not differ between the three groups. Survival at 10 years was 66 ± 4%, 66 ± 4%, and 65 ± 5%, respectively, for groups A, B, and C (p =.34). Immunosuppressive regimen and rate of complications did not differ between groups. However, the rates of outpatient visits and of hospitalization performed at HTC were higher in group A than others. Conclusion: Distance from the HTC does not represent a barrier to a successful outcome for HTx recipients, as long as regular and continuous follow-up is provided

Fish oil and postoperative atrial fibrillation : the Omega-3 Fatty Acids for Prevention of Post-operative Atrial Fibrillation (OPERA) randomized trial

Context: Postoperative atrial fibrillation or flutter (AF) is one of the most common complications of cardiac surgery and significantly increases morbidity and health care utilization. A few small trials have evaluated whether long-chain n-3-polyunsaturated fatty acids (PUFAs) reduce postoperative AF, with mixed results. Objective: To determine whether perioperative n-3-PUFA supplementation reduces postoperative AF. Design, Setting, and Patients: The Omega-3 Fatty Acids for Prevention of Postoperative Atrial Fibrillation (OPERA) double-blind, placebo-controlled, randomized clinical trial. A total of 1516 patients scheduled for cardiac surgery in 28 centers in the United States, Italy, and Argentina were enrolled between August 2010 and June 2012. Inclusion criteria were broad; the main exclusions were regular use of fish oil or absence of sinus rhythm at enrollment. Intervention: Patients were randomized to receive fish oil (1-g capsules containing 65840 mg n-3-PUFAs as ethyl esters) or placebo, with preoperative loading of 10 g over 3 to 5 days (or 8 g over 2 days) followed postoperatively by 2 g/d until hospital discharge or postoperative day 10, whichever came first. Main Outcome Measure: Occurrence of postoperative AF lasting longer than 30 seconds. Secondary end points were postoperative AF lasting longer than 1 hour, resulting in symptoms, or treated with cardioversion; postoperative AF excluding atrial flutter; time to first postoperative AF; number of AF episodes per patient; hospital utilization; and major adverse cardiovascular events, 30-day mortality, bleeding, and other adverse events. Results: At enrollment, mean age was 64 (SD, 13) years; 72.2% of patients were men, and 51.8% had planned valvular surgery. The primary end point occurred in 233 (30.7%) patients assigned to placebo and 227 (30.0%) assigned to n-3-PUFAs (odds ratio, 0.96 [95% CI, 0.77-1.20]; P=.74). None of the secondary end points were significantly different between the placebo and fish oil groups, including postoperative AF that was sustained, symptomatic, or treated (231 [30.5%] vs 224 [29.6%], P=.70) or number of postoperative AF episodes per patient (1 episode: 156 [20.6%] vs 157 [20.7%]; 2 episodes: 59 [7.8%] vs 49 [6.5%]; 653 episodes: 18 [2.4%] vs 21 [2.8%]) (P=.73). Supplementation with n-3-PUFAs was generally well tolerated, with no evidence for increased risk of bleeding or serious adverse events. Conclusion: In this large multinational trial among patients undergoing cardiac surgery, perioperative supplementation with n-3-PUFAs, compared with placebo, did not reduce the risk of postoperative AF. Trial Registration: clinicaltrials.gov Identifier: NCT0097048