Long-term treatment with deferiprone enhances left ventricular ejection function when compared to deferoxamine in patients with thalassemia major

Transfusion and iron chelation treatment have significantly reduced morbidity and improved survival of patients with thalassemia major. However, cardiac disease continues to be the most common cause of death. We report the left-ventricular ejection fraction, determined by echocardiography, in one hundred sixtyeight patients with thalassemia major followed for at least 5 years who received continuous monotherapy with deferoxamine (N = 108) or deferiprone (N = 60). The statistical analysis, using the generalized estimating equations model, indicated that the group treated with deferiprone had a significantly better left-ventricular ejection fraction than did those treated with deferoxamine (coefficient 0.97; 95% CI 0.37; 1.6, p = 0.002). The heart may be particularly sensitive to iron-induced mitochondrial damage because of the large number of mitochondria and its low level of antioxidants. Deferiprone, because of its lower molecular weight, might cross into heart mitochondria more efficiently, improving their activity and, thereby, myocardial cell function. Our findings indicate that the long-term administration of deferiprone significantly enhances left-ventricular function over time in comparison with deferoxamine treatment. However, because of limitations related to the design of this study, these findings should be confirmed in a prospective, randomized clinical trial

Skeletonization of radial and gastroepiploic conduits in coronary artery bypass surgery

The use of a skeletonized internal thoracic artery in coronary artery bypass graft surgery has been shown to confer certain advantages over a traditional pedicled technique, particularly in certain patient groups. Recent reports indicate that radial and gastroepiploic arteries can also be harvested using a skeletonized technique. The aim of this study is to systematically review the available evidence regarding the use of skeletonized radial and gastroepiploic arteries within coronary artery bypass surgery, focusing specifically on it's effect on conduit length and flow, levels of endothelial damage, graft patency and clinical outcome. Four electronic databases were systematically searched for studies reporting the utilisation of the skeletonization technique within coronary revascularisation surgery in humans. Reference lists of all identified studies were checked for any missing publications. There appears to be some evidence that skeletonization may improve angiographic patency, when compared with pedicled vessels in the short to mid-term. We have found no suggestion of increased complication rates or increased operating time. Skeletonization may increase the length of the conduit, and the number of sequential graft sites, but no clear clinical benefits are apparent. Our study suggests that there is not enough high quality or consistent evidence to currently advocate the application of this technique to radial or gastroepiploic conduits ahead of a traditional pedicled technique

Surgical ventricular restoration plus mitral valve repair in patients with ischaemic heart failure : risk factors for early and mid-term outcomes

OBJECTIVES: To assess the early and mid-term outcomes and related predictors in a consecutive series of patients who underwent surgical ventricular restoration (SVR) combined with additional mitral valve (MV) repair. METHODS: From January 2001 to October 2014, 626 patients underwent SVR; of these, 175 (28%, median age 65) had an additional MV repair. Anterior, inferior or diffuse remodelling was present in 124 (71%), 41 (23%) and 10 (6%) patients, respectively. The median ejection fraction was 30%, whereas mitral regurgitation grade was 3.3 \ub1 0.8. Multivariable logistic regression and Cox regression analyses were used to identify predictors of early and mid-term mortality. RESULTS: Operative death occurred in 25 patients (14.3%). Independent predictors of early mortality were age, creatinine and ejection fraction score [odds ratio (OR) = 5.1, 95% confidence interval (CI) 2.5-10.3], previous stroke (OR = 8.0, 95% CI 1.5-44), unstable angina (OR = 8.8, 95% CI 1.5-53) and diffuse remodelling (OR = 5.8, 95% CI 1.02-33). Average follow-up was 42 \ub1 37 months. The actuarial survival rate of the whole patient population at 3, 5 and 8 years was 72 \ub1 4, 65 \ub1 4 and 45 \ub1 6%, respectively. Risk factors for late mortality were preoperative creatinine (OR = 2.6, 95% CI 1.5-4.4), previous implantation of cardioverter defibrillator (OR = 4.7, 95% CI 1.6-5.8), whereas the absence of angina at the time of surgery emerged as protective factor (OR = 0.46, 95% CI 0.23-0.89). CONCLUSIONS: MV repair combined with SVR is a complex and challenging procedure that can be performed with acceptable early and mid-term results. Interestingly, angina features predict both early and late outcome, with unstable angina at the time of surgery being a predictor of poor early outcome and the absence of angina at surgery, a predictor of favourable outcome at mid-term follow-up

Surgical excision of cardiac myxomas: twenty years experience at a single institution

Background: Primary cardiac tumors are quite uncommon and myxomas constitute the major proportion among these masses. The present study summarizes our 20-year clinical experience with surgical resection of intracardiac myxomas. Methods: Between January 1990 and December 2007, 98 patients (42 males, mean age 60.4 \ub1 4.1 years) underwent complete excision of primary intracardiac myxoma. In 84 patients the origin site of the tumor was located in the left atrium, and the most common implant site was the interatrial septum. The most common symptom at admission was dyspnea, while systemic embolization was observed in 37 patients. Preoperative diagnosis was established in all patients by transthoracic echocardiography. All patients were operated through median sternotomy. Results: Ninety-five patients (97%) survived the operation. Mean tumor dimension was 2.7 \ub1 1.3 cm in largest diameter. According to the St. John Sutton classification (St. John Sutton MG, Mercier LA, Giuliani ER, et al. Atrial myxomas: a review of clinical experience in 40 patients. Mayo Clin Pro 1980;55:3716), solid tumors were detected in 43 patients (44%), while a papillary myxoma was found in 55 patients (56%). The follow-up was 100% complete, and the mean time to last follow-up was 98 \ub1 60 months. Of the 95 survivors, 3 patients (3%) died at a mean follow-up of 72 \ub1 45 months after surgery. Actuarial survival was 98%, 98%, and 89% at 5, 10, and 15 years, respectively. One patient operated for left atrial myxoma resection showed a recurrence 68 months after the first surgery. Conclusions: Although cardiac myxomas carry the risk of severe systemic and cardiac symptoms, prompt surgical excision gives excellent early and long-term results

Aortic valve replacement in octogenarians: is biologic valve the unique solution?

Background: This study analyzed morbidity, mortality, and quality of life after aortic valve replacement with mechanical and biologic prostheses in octogenarian patients. Methods: A retrospective analysis was performed in 345 consecutive patients, mean age of 82 \ub1 2 years (range, 80 to 92), who had aortic valve replacement from May 1991 to April 2005. A bioprosthesis (group I) was used in 200 patients (58%), and 145 (42%) received a mechanical prosthesis (group II). Associated cardiac procedures were done in 211 patients (61%), of which 71% were coronary artery bypass grafting. Patients had symptomatic aortic stenosis (84.3%) or associated aortic insufficiency; 88% were in New York Heart Association (NYHA) class III or IV. The mean preoperative aortic valve gradient was 62 \ub1 16 mm Hg (range, 25 to 122 mm Hg). The mean left ventricular ejection fraction was good (0.52 \ub1 0.12); 30 patients (8.7%) had an ejection fraction of less than 0.30. Results: The in-hospital mortality rate was 7.5% (26 patients); 17 (8.5%) in group I and 9 (6.2%) in group II (p = 0.536) Significant predictors of operative mortality were preoperative renal insufficiency (blood creatinine > 2.00 mg/mL) and need for urgent operation. Mean follow-up, complete at 100%, was 40 \ub1 33 months (range, 1 to 176 months). Long-term follow-up, using Kaplan-Meier analysis, showed an overall survival of 61% at 5 years and 21% at 10 years; survival by type of prosthesis was significantly higher with mechanical prostheses (log-rank p = 0.03). Freedom from cerebrovascular events (thromboembolic/hemorrhagic) at 5 and 10 years was 89% and 62% in the mechanical group and 92% and 77% in the biologic group (p = 0.76). Postoperative NYHA functional class was I or II in 96% of patients. Quality-of-life scores were excellent considering the age of the patients. No differences were found between the two groups. Conclusions: Surgical treatment for symptomatic aortic stenosis in octogenarians has an acceptable operative risk with excellent long-term results and good quality of life. In this cohort, survival rate is slightly but significantly higher with mechanical prostheses

Tricuspid Valve Replacement with Mechanical Prostheses: Long-Term Results

Background and aim of the study: Historically, tricuspid valve replacement (TVR) has been associated with high mortality and morbidity, and current knowledge in the long-term outcome of TVR is limited. The study aim was to review the authors' experience from a consecutive series of patients. Methods: Between January 1990 and December 2005, a total of 43 patients (seven males, 36 females; mean age 52 14 years) underwent TVR. The etiology was rheumatic in 33 patients (77%) and degenerative disease in 10 (22%). Thirty-six patients (84%) were in NYHA class III or IV. Thirty-four patients (79%) underwent redo procedures; all patients underwent TVR with a mechanical prosthesis. Results: The overall operative mortality was 16% (n = 7). Of the 36 survivors, nine (25%) died during follow up. The Kaplan-Meier survival at 2.5, 5, and 10 years was 78%, 70%, and 58%, respectively. Five patients (14%) underwent reoperation during follow up (three for tricuspid valve thrombosis) and all five survived the reoperation. Freedom from reoperation at five and 10 years was 90% and 74%, respectively. On permutation test analysis, older age, liver congestion and redo surgery were found to be the major determinants of long-term mortality. Conclusion: TVR carries a higher short- and long-term mortality when compared to left-heart valve surgery. A timely referral before the development of end-stage cardiac impairment might determine a further improvement in outcome