Surgery for severe aortic stenosis with low transvalvular gradient and poor left ventricular function – a single centre experience and review of the literature

BACKGROUND: A retrospective comparative study was designed to determine whether the transvalvular gradient has a predictive value in the assessment of operative outcome in patients with severe aortic stenosis and poor left ventricular function. METHODS: From a surgical database, a series of 30 consecutive patients, who underwent isolated aortic valve replacement for severe aortic stenosis with depressed left ventricular (LV) function (EF < 40%), were enrolled in the study and divided into two groups according to the mean transvalvular gradient (TVG): LG(low gradient)-Group < 40 mmHg (n = 13), and HG(high gradient)-Group > 40 mmHg (n = 17). Both groups were then comparatively assessed with respect to perioperative organ functions and mortality. RESULTS: Both groups were well matched with respect to the preoperative clinical status. LG-Group had a larger aortic valve area, higher LVEDP, larger LVESD and LVEDD, and higher mean pulmonary pressures. The immediate postoperative outcome, hospital morbidity and mortality did not differ significantly among the groups. CONCLUSION: In patients with severe aortic stenosis and poor LV function, the mean transvalvular gradient, although corresponds to reduced LV performance, has a limited prognostic value in the assessment of surgical outcome. Generally, operating on this select group of patients is safe

Gene expression in acute Stanford type A dissection: a comparative microarray study

BACKGROUND: We compared gene expression profiles in acutely dissected aorta with those in normal control aorta. MATERIALS AND METHODS: Ascending aorta specimen from patients with an acute Stanford A-dissection were taken during surgery and compared with those from normal ascending aorta from multiorgan donors using the BD Atlas™ Human1.2 Array I, BD Atlas™ Human Cardiovascular Array and the Affymetrix HG-U133A GeneChip(®). For analysis only genes with strong signals of more than 70 percent of the mean signal of all spots on the array were accepted as being expressed. Quantitative real-time polymerase chain reaction (RT-PCR) was used to confirm regulation of expression of a subset of 24 genes known to be involved in aortic structure and function. RESULTS: According to our definition expression profiling of aorta tissue specimens revealed an expression of 19.1% to 23.5% of the genes listed on the arrays. Of those 15.7% to 28.9% were differently expressed in dissected and control aorta specimens. Several genes that encode for extracellular matrix components such as collagen IV α2 and -α5, collagen VI α3, collagen XIV α1, collagen XVIII α1 and elastin were down-regulated in aortic dissection, whereas levels of matrix metalloproteinases-11, -14 and -19 were increased. Some genes coding for cell to cell adhesion, cell to matrix signaling (e.g., polycystin1 and -2), cytoskeleton, as well as several myofibrillar genes (e.g., α-actinin, tropomyosin, gelsolin) were found to be down-regulated. Not surprisingly, some genes associated with chronic inflammation such as interleukin -2, -6 and -8, were up-regulated in dissection. CONCLUSION: Our results demonstrate the complexity of the dissecting process on a molecular level. Genes coding for the integrity and strength of the aortic wall were down-regulated whereas components of inflammatory response were up-regulated. Altered patterns of gene expression indicate a pre-existing structural failure, which is probably a consequence of insufficient remodeling of the aortic wall resulting in further aortic dissection

Recurrent embolism in the course of marantic endocarditis

Marantic or nonbacterial thrombotic endocarditis (NBTE) associated with systemic embolism is usually a complication of advanced or terminal malignancies. We report on the case of a 46-year-old woman in whom nonbacterial thrombotic endocarditis (NBTE)-related cerebral embolism was the first clinical sign of ovarian neoplasm, which was diagnosed after cardiac surgery. Marantic endocarditis should alert the physician to make every effort to diagnose the possible background of this clinical phenomenon. Early identification of NBTE, treatment of the underlying disease, and the associated coagulopathy could possibly prevent cardiac surgery

Coronary artery disease progression in patients who need repeat surgical revascularisation: the surgeon's point of view

Objective The purpose of this study was to evaluate changes in native coronary arteries in patients undergoing repeat myocardial revascularisation late (>3 years) after primary coronary artery bypass grafting (CABG). Methods The angiographic images of 30 patients obtained at first and redo CABG were assessed for significant (>75%), short (1 cm) stenosis or total occlusion in native coronary arteries. Bypass grafts were also evaluated for significant stenosis (>50%) or occlusion. Results At first CABG, a mean number of 3.3 grafts/patient (range 1-5) were implanted. The mean time interval from first CABG to reoperation was 11.4 years (range 3-21 years). All patients showed disease progression in the native coronary arteries. At redo CABG, 3 (3.5%) grafts were non-stenotic, 27 (31%) stenotic, and 57 (65.5%) occluded. In native coronary vessels, five patients developed a new left main coronary artery stenosis, and there was a four-to-sixfold increase in total occlusions. Indications for redo CABG were disease progression in non-bypassed vessels (n = 3), bypass lesions (n = 19), and both bypass lesions and disease progression in the distal segments of native coronary arteries (n = 8). Conclusions Late after CABG, coronary artery disease is highly progressive, mainly affecting the proximal segments of native coronary arteries, with a high incidence of coronary occlusion. Conversely, a low incidence of disease progression is observed in the distal segments of native coronary arteries, except in diabetic patients. Total arterial revascularisation as a primary strategy for CABG should be highly recommended, and more aggressive risk factor management is desirable

Rupture of a Saphenous Vein Coronary Artery Bypass Graft Due to Aspergillus Necrotizing Vasculitis

We present the first, unusual case of a lethal mediastinal hemorrhage caused by rupture of a saphenous vein aortic coronary bypass graft due to Aspergillus species necrotizing vasculitis in an immunocompetent patient 18 days after redo coronary artery bypass surgery. The patient had neither signs for mediastinitis nor for another source of Aspergillus infection

Rezerwa przepływu wieńcowego w kardiomiopatii przerostowej. Ocena przy pomocy wewnątrzwieńcowego Dopplera

Background: In spite of progress in diagnosis and treatment, hypertrophic obstructive cardiomyopathy (HOCM) remains a serious medical problem. Among many issues, the pathophysiology of the coronary circulation in HOCM has not yet been fully examined.Aim: To assess coronary flow reserve in HOCM.Methods: The study group consisted of 15 patients (6 males, 9 females, mean age 51&#177;15 years) with typical echocardiographic signs of HOCM and without stenosis of the coronary arteries. Using an intracoronary Doppler catheter, the average peak velocity and the absolute coronary flow reserve were determined in the proximal, medial and distal parts of the left anterior descending (LAD) and the circumflex coronary artery (Cx) following administration of papaverine, substance P, and during pacing. The coronary square plane was calculated angiographically after substance P injection. The retrograde coronary flow and the relationship between the increase of the coronary square plane and the coronary flow reserve were also examined.Results: Under pharmacological stimulation, higher values of the average peak velocity were observed compared to pacing. A retrograde flow was observed in 8 of 10 patients in the LAD and in 3 of 8 patients in the Cx. The coronary flow reserve was higher under pharmacological stress than during pacing. No relationship was found between the increase of the coronary square plane and the coronary flow reserve.Conclusions: No decrease in the coronary flow reserve was observed in our patients with HOCM which, however, does not exclude the possibility of ischaemia based on subordinate vessels and microcirculation changes. In the majority of patients a retrograde flow was detected

Review paper <br>Postconditioning: a brief review

Preconditioning represents the most effective form of cardioprotection that can be induced to attenuate the injury accompanying a longer lasting ischemia (=index ischemia) of sufficient duration and severity to cause myocardial necrosis. Preconditioning can be induced by short bouts of ischemia, several pharmaceuticals (e.g. adenosine), and volatile anesthetics all imposed before the index ischemia. A brief ischemia of an organ other than the heart can likewise initiate protection of the heart, which has been called “preconditioning at a distance” or “remote preconditioning”. According to the more recent literature, short bouts of ischemia after an index ischemia can also initiate cardioprotection, e.g. improved post-ischemic endothelial function, reduced infarct size and less apoptosis; this protective maneuver has been called “postconditioning”. Postconditioning can also be elicited at a distant organ, termed “remote postconditioning”. It is the aim of this short review to (1) characterize preconditioning and in particular postconditioning, (2) describe possible mechanisms, and (3) call attention to the clinical relevance of this cardioprotective strategy