Duality theorems and Kolyvagin systems for elliptic curves

After developing the theory of arithmetic duality for Galois cohomology with a particular focus on the cohomology of an elliptic curve over a local field or a number field, we use these results to define Kolyvagin systems and show how they provide bounds for the Selmer groups of the elliptic curve.ope

Extensive cardiac infiltrative melanoma

We report an unusual clinical case of a 66-year-old patient with cardiac involvement from a metastatic melanoma, causing the formation of a large right atrial mass with extensive infiltration of the right atrial free wall, the interatrial septum, the coronary sinus, and up to the mitral annulus and posterior wall of the right ventricle, unamendable to complete surgical excision. As secondary cardiac tumors are not part of routine daily clinical practice, we thought that this clinical case would be a good educational opportunity for the practicing clinicians, both specialists and nonspecialists

Routine use of bilateral internal thoracic artery grafting in women: A risk factor analysis for poor outcomes

Background: Concerns about increased risk of postoperative complications, primarily deep sternal wound infection (DSWI), prevent liberal use of bilateral internal thoracic artery (BITA) grafting inwomen. Consequently, outcomes after routine BITA grafting remain largely unexplored in female gender. Methods: Of 786 consecutivewomenwithmultivessel coronary diseasewho underwent isolated coronary bypass surgery at the authors' institution from 1999 throughout 2014, 477 (60.7%; mean age: 70 +/- 7.7 years) had skeletonized BITA grafts; their risk profiles, operative data, hospital mortality and postoperative complications were reviewed retrospectively. Risk factor analysis for hospital death, DSWI and poor late outcomes were performed by means of multivariable models. Results: There were 19 (4%) hospital deaths (mean EuroSCORE II: 5.2 +/- 6.1%); glomerular filtration rate b 50 ml/min was an independent risk factor (p = 0.035). Prolonged invasive ventilation (11.3%), multiple blood transfusion (12.1%) and DSWI (10.7%) were most frequent major postoperative complications. Predictors of DSWI were body mass index N35 kg/m2 (p = 0.0094), diabetes (p =0.005), non-elective surgical priority (p = 0.0087) and multiple blood transfusions (p = 0.016). The mean follow-up was 6.8 +/- 4.5 years. The nonparametric estimates of the 13-year freedom from cardiac and cerebrovascular deaths, major adverse cardiac and cerebrovascular events, and repeat myocardial revascularization were 76.1 [95% confidence interval (CI): 73.1-79.1], 59.5 (95% CI: 55.9-63.1) and 91.9% (95% CI: 90.1-93.7), respectively. Preoperative congestive heart failure (p = 0.04) and left main coronary artery disease (p = 0.0095) were predictors of major adverse cardiac and cerebrovascular events. Conclusions: BITA grafting could be performed routinely even in women. The increased rates of early postoperative complications do not prevent excellent late outcomes

Exercise performance, haemodynamics, and respiratory pattern do not identify heart failure patients who end exercise with dyspnoea from those with fatigue

AIMS: The two main symptoms referred by chronic heart failure (HF) patients as the causes of exercise termination during maximal cardiopulmonary exercise testing (CPET) are muscular fatigue and dyspnoea. So far, a physiological explanation why some HF patients end exercise because of dyspnoea and others because of fatigue is not available. We assessed whether patients referring dyspnoea or muscular fatigue may be distinguished by different ventilator or haemodynamic behaviours during exercise. METHODS AND RESULTS: We analysed exercise data of 170 consecutive HF patients with reduced left ventricular ejection fraction in stable clinical condition. All patients underwent maximal CPET and a second maximal CPET with measurement of cardiac output by inert gas rebreathing at peak exercise. Thirty-eight (age 65.0 \ub1 11.1 years) and 132 (65.1 \ub1 11.4 years) patients terminated CPET because of dyspnoea and fatigue, respectively. Haemodynamic and cardiorespiratory parameters were the same in fatigue and dyspnoea patients. VO2 was 10.4 \ub1 3.2 and 10.5 \ub1 3.3 mL/min/kg at the anaerobic threshold and 15.5 \ub1 4.8 and 15.4 \ub1 4.3 at peak, in fatigue and dyspnoea patients, respectively. In fatigue and dyspnoea patients, peak heart rate was 110 \ub1 22 and 114 \ub1 22 beats/min, and VE/VCO2 and VO2 /work relationship slopes were 31.2 \ub1 6.8 and 30.6 \ub1 8.2 and 10.6 \ub1 4.2 and 11.4 \ub1 5.5 L/min/W, respectively. Peak cardiac output was 6.68 \ub1 2.51 and 6.21 \ub1 2.55 L/min (P = NS for all). CONCLUSIONS: In chronic HF patients in stable clinical condition, fatigue and dyspnoea as reasons of exercise termination do not highlight different ventilatory or haemodynamic patterns during effort

Cardiac decompression by pericardiectomy for constrictive pericarditis : multimodality imaging to identify patients at risk for prolonged inotropic support

BACKGROUND: Post-pericardiectomy right ventricular (RV) failure has been reported but it remains not well-studied. To investigate imaging parameters that could predict RV function and the outcome of patients post-pericardiectomy. METHODS: We analysed data from a total of 53 CP patients undergoing pericardiectomy. Preoperative, early and at 6 months postoperative echocardiographic (echo) imaging datasets were analysed and correlated with preoperative cardiac magnetic resonance (CMR), cardiac computed tomography scans and histology. The primary endpoint of the study was RV functional status early postoperatively and at 6 months. Secondary endpoint was the need for prolonged inotropic support. RESULTS: A cause of CP was identified in 26 patients (49%). Inotropic support ≥ 48 hours was required in n = 28 (53%) of patients and was correlated with lower preoperative RV areas by echo or RV volumes by CMR (p < 0.05 for all). A pericardial score based on pericardial thickness/calcification and epicardial fat thickness had good diagnostic accuracy to identify patients requiring prolonged use of inotropes (area under the curve, 0.825; 95% confidence interval, 0.674–0.976). Pericardiectomy resulted in RV decompression and impaired RV function early postoperatively (fractional area change: 40.5% ± 8.8% preoperatively vs. 31.4% ± 10.4% early postoperatively vs. 42.5% ± 10.2% at 6 months, p < 0.001). CONCLUSIONS: We show that a smaller RV cavity size and a pericardial scoring system are associated with prolonged inotropic support in CP patients undergoing pericardiectomy. RV systolic impairment post decompression is present in most patients, but it is only transient

Prognostic significance of atrial fibrillation and severity of symptoms of heart failure in patients with low gradient aortic stenosis and preserved left ventricular ejection fraction

The aims of this study were to investigate the clinical outcomes of patients with low-gradient aortic stenosis despite preserved left ventricular ejection fraction and to assess reliable prognostic clinical-instrumental features in patients experiencing or not experiencing aortic valve replacement (AVR). Clinical-laboratory and echocardiographic data from 167 patients (median age 78 years, interquartile range 69 to 83) with aortic valve areas 70 years showed a trend toward being a prognostic predictor (p = 0.082). In conclusion, in patients with low-gradient aortic stenosis despite a preserved left ventricular ejection fraction, AVR was strongly correlated with a better prognosis. Patients with atrial fibrillation associated with advanced New York Heart Association class had the worst prognosis if treated medically but at the same time a relative better benefit from surgical intervention

Double versus single source left-sided coronary revascularization using bilateral internal thoracic artery graft alone

Left-sided coronary revascularization with bilateral internal thoracic artery (BITA) graft is performed usually either with an in situ (double source) or Y-graft configuration (single source). Two hundred fifty-three (mean age, 67.1\ua0\ub1\ua09.5\ua0years) patients underwent isolated left-sided coronary revascularization with BITA graft alone at the present authors' institution (2000-2015). Skeletonized BITA grafts were used either in an in situ (n\ua0=\ua0199) or Y-graft configuration (n\ua0=\ua054). Forty pairs were identified with the propensity score-matching. Outcomes of the two groups were compared both in unmatched and matched series. Cardiopulmonary exercise testing was performed in five pairs of selected, asymptomatic matched patients having patent BITA grafts at coronary computed tomography angiography. BITA in situ patients had lower risk profiles than BITA Y-graft patients (median EuroSCORE II, 1.9 vs. 2.9%, p\ua0=\ua00.051). In-hospital mortality (5.6 vs. 0, p\ua0=\ua00.0093) and the rates of postoperative complications except deep sternal wound infection were higher in BITA Y-graft patients. However, these differences were not confirmed in matched groups. During the follow-up period (mean, 5.9\ua0\ub1\ua04.3\ua0years), between BITA in situ and BITA Y-graft matched patients, there were no differences in non-parametric estimates of freedom from cardiac death (p\ua0=\ua00.6), major adverse cardiac and cerebrovascular events (MACCEs, p\ua0=\ua00.65), and repeat coronary revascularization (p\ua0=\ua00.44). Adjusted risk estimates of MACCEs according to BITA configuration confirmed no superiority of the one configuration over the other (p\ua0 65\ua00.44). No significant differences were found at the cardiopulmonary exercise testing. Results of left-sided coronary revascularization with BITA graft alone are independent from BITA configuration, even after stress testing