Andrés M. Pineda

Cardiovascular effects of statins, beyond lipid-lowering properties.

The 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors, better known as statins, are amongst the most widely used medications in the world. They have become a pivotal component in the primary and secondary prevention of coronary artery and vascular disease. However, a growing amount of evidence has suggested that statins also possess strong pleiotropic effects irrespective of their lipid-lowering properties, which include enhancement of endothelial function, anti-inflammatory and anti-atherothrombotic properties, and immunomodulation. The following provides a comprehensive and updated review of the clinical evidence regarding the pleiotropic effects of statins in cardiovascular disorders and their potential therapeutic benefits.

Outcomes of Minimally Invasive Valve Surgery Versus Median Sternotomy in Patients Age 75 Years or Greater

BACKGROUNDnAdvanced age is a major predictor of poor outcome in patients undergoing valve surgery. We hypothesized that elderly patients who underwent minimally invasive valve surgery for aortic or mitral valve disease would do better when compared with those undergoing the standard median sternotomy.nnnMETHODSnWe retrospectively reviewed 2,107 consecutive heart operations at our institution and identified 203 patients, age 75 years or greater, who underwent isolated mitral or aortic valve surgery. Outcomes of those who had minimally invasive valve surgery through a right minithoracotomy were compared with those who had a median sternotomy.nnnRESULTSnOf the 203 patients, 119 (59%) underwent a minimally invasive approach, while 84 (41%) had a median sternotomy. The median postoperative length of stay was 7 days (interquartile range [IQR] 6 to 10) versus 12 days (IQR 9 to 20), p less than 0.001, and intensive care unit length of stay was 52 hours (IQR 44 to 93) versus 119 hours (IQR 57 to 193), p less than 0.001 for minimally invasive and median sternotomy, respectively. In-hospital mortality was 2 (1.7%) versus 8 (9.5%, p=0.01 and composite postoperative morbidity and mortality occurred in 25 (21%) versus 38 (45.2%), p less than 0.001, in minimally invasive versus median sternotomy, respectively. The difference was driven by the following: a lower incidence of acute renal failure, 1 (0.8%) versus 14 (16.7%), p<0.001; prolonged intubation 23 (19.3%) versus 32 (38.1%), p=0.003; wound infections 1 (0.8%) versus 5 (6%), p=0.034; and death.nnnCONCLUSIONSnMinimally invasive surgery for isolated valve lesions in elderly patients yields a lower morbidity and mortality when compared with median sternotomy and should be considered when such individuals require valve surgery.

A meta-analysis of transcatheter closure of patent foramen ovale versus medical therapy for prevention of recurrent thromboembolic events in patients with cryptogenic cerebrovascular events.

We sought to perform a meta‐analysis of randomized controlled trials (RCTs) comparing percutaneous patent‐foramen‐ovale (PFO) closure with medical therapy for preventing recurrent thromboembolic events after cryptogenic stroke.

The obesity paradox in elderly obese patients undergoing coronary artery bypass surgery.

We sought to determine whether the protective role of the obesity paradox was present among elderly obese patients undergoing coronary artery bypass grafting (CABG) by median sternotomy. We retrospectively analyzed 1909 consecutive patients who underwent heart surgery between January 2006 and June 2009, and identified 396 patients who were ≥ 70 years of age and had isolated CABG. Subjects were divided into three groups according to their body mass index (BMI): obese (BMI ≥ 30 kg/m(2)), overweight (BMI 25-29.99 kg/m(2)) and normal (BMI 18.5-24.99 kg/m(2)). Of the 396 patients, 94 were obese, 167 were overweight, and 135 had a normal BMI. The composite of in-hospital complications and hospital mortality did not differ between the groups. Re-exploration for bleeding was required in none of the obese patients, which was statistically significant (P=0.05) compared to the other groups; otherwise there was no statistical difference for all other complications, including total length hospital stay and length of stay in the intensive care unit. Despite being labeled as higher risk candidates preoperatively, obese elderly patients undergoing CABG did not demonstrate an increased risk of postsurgical complications. We conclude that the obesity paradox is present in this population, and they should not be excluded from receiving the benefits of CABG.

Left Main Coronary Artery Acute Thrombosis Related to Energy Drink Intake

A 24-year-old previously healthy black man presented the emergency department with a 10-hour history of nausea, multiple episodes of emesis, palpitations, and severe retrosternal chest pain, described as constant pressure. His symptoms started 1 or 2 hours after he had 3 drinks of vodka mixed with an energy drink at a local party. He used marijuana in the week before but denied cocaine or other recreational drug use. Two of his friends who shared the drinks had similar symptoms but without chest pain. There was no family history of premature coronary artery disease. The patient smokes no more than 5 cigarettes weekly.nnAt admission, his vital signs were blood pressure 138/94 mm Hg, pulse 63 bpm, breathing rate 18 respirations per minute, temperature 36°C, and 99% oxygen saturation on room air. …

Outcomes of a Minimally Invasive Approach Compared With Median Sternotomy for the Excision of Benign Cardiac Masses

BACKGROUNDnWe hypothesize that for the excision of benign cardiac masses, a minimally invasive approach through a right minithoracotomy is safe and feasible, and has lower resource utilization when compared with a standard median sternotomy.nnnMETHODSnWe retrospectively analyzed 39 consecutive patients who underwent benign cardiac mass excision at our institution between December 1999 and April 2010. The in-hospital outcomes of patients who had a right minithoracotomy were compared with those of patients who underwent a standard median sternotomy.nnnRESULTSnOf the 39 patients, 22 had cardiac masses removed through a minimally invasive approach, and 17 had a median sternotomy. The type of masses resected included 26 myxomas (66.7%), 9 papillary fibroelastomas (23.1%), and 4 thrombi (10.2%). The aortic cross-clamp and cardiopulmonary bypass times were 43 minutes (interquartile range [IQR] 30 to 64) versus 31 minutes (IQR 23 to 47; p=0.20) and 78 minutes (IQR 55 to 88) versus 57 minutes (IQR 33 to 70; p=0.02) for the minimally invasive group and the median sternotomy group, respectively. There were no significant differences in postoperative complications including mortality. The mean intensive care unit and hospital lengths of stay were 27 hours (IQR 24 to 47) versus 60 hours (IQR 48 to 79; p=0.001) and 5 days (IQR 4 to 6) versus 7 days (IQR 6 to 8; p=0.03) for the minimally invasive and the median sternotomy group, respectively.nnnCONCLUSIONSnA minimally invasive approach through a right minithoracotomy for the resection of benign cardiac masses can be performed safely with lower resource utilization, and should be considered for these patients.

Is a minimally invasive approach for re-operative aortic valve replacement superior to standard full resternotomy?

A best-evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was is a minimally invasive approach for re-operative aortic valve replacement (AVR) superior to standard full resternotomy? A total of 193 papers were found using the reported search of which 13 represented the best evidence to answer the clinical question. The authors, country, journal and date of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that minimally invasive re-operative AVR can be performed with an operative morbidity and mortality at least similar to the standard full sternotomy approach. A shorter hospital length of stay and less blood product requirements are the main advantages of this technique. The incidence of prolonged ventilation, bleeding requiring re-operation, sternal wound infections and in-hospital mortality may be reduced with a minimally invasive approach. Prospective studies are required to confirm the potential benefits of minimally invasive surgery and, up to date, conventional full re-sternotomy is still the standard approach for re-operative AVR.

Hybrid approach of percutaneous coronary intervention followed by minimally invasive valve operations.

BACKGROUNDnA subset of patients requiring coronary revascularization and valve operations may benefit from a hybrid approach of percutaneous coronary intervention (PCI) followed by a minimally invasive valve operation, rather than the standard combined median sternotomy coronary artery bypass grafting (CABG) and a valve operation. This study sought to evaluate the outcomes of this approach in a heterogeneous group of patients with concomitant coronary artery and valvular disease.nnnMETHODSnWe retrospectively evaluated 222 consecutive patients with coronary artery and valvular heart disease who underwent PCI followed by elective minimally invasive valve operations at our institution between February 2009 and Augustxa02013.nnnRESULTSnA total of 136 men and 86 women were identified. The mean age was 74.6 ± 8.2 years, with 181 (81.5%) undergoing 1-vessel, 27 (12.2%) undergoing 2-vessel, and 14 (6.3%) undergoing 3-vessel PCI. Within a median of 38 days (interquartile range [IQR] 18-65 days), 182 (82%) patients underwent primary and 34 (15.3%) underwent repeated valve operations, which consisted of 185 (83.3%) single-valve and 37 (16.7%) double-valve procedures. Operative mortality occurred in 8 patients (3.6%). At a mean follow-up of 16.2xa0± 12 months, 6 patients required PCI, with target-vessel revascularization performed in 4 patients (2.1%). Survival at 1 and 4.5 years was 91.9% and 88.3%, respectively.nnnCONCLUSIONSnIn a heterogeneous group of patients, a hybrid approach of PCI followed by minimally invasive valve operations in patients undergoing primary or repeated valve operations can be performed with excellent outcomes.

A Systematic Review of Mitral Valve Repair With Autologous Pericardial Leaflet Augmentation for Rheumatic Mitral Regurgitation

A systematic review was conducted to assess the efficacy of mitral valve repair using glutaraldehyde-treated autologous pericardial leaflet augmentation for rheumatic mitral regurgitation (MR). Five retrospective studies were identified, which included 196 patients with moderate or greater MR. There was 1 operative death (0.5%). At a mean follow-up of 3.2 ± 2.2 years, moderate or greater MR reoccurred in 22 patients (11.2%), reoperation was required in 9 (4.6%), and the cumulative survival was 98.9%. Finally, outcomes were similar between the patients who underwent augmentation of the anterior vs the posterior mitral leaflet. Pericardial leaflet augmentation isxa0a viable technique for the treatment of rheumatic MR.

Minimally invasive papillary muscle sling placement during mitral valve repair in patients with functional mitral regurgitation

BACKGROUNDnWe evaluated the safety and feasibility of minimally invasive mitral valve repair with papillary muscle sling placement via a right anterior thoracotomy approach in patients with severe functional mitral regurgitation (MR).nnnMETHODSnWe retrospectively reviewed all minimally invasive mitral valve repairs with papillary muscle sling placement in patients with severe functional MR performed at our institution between October 2011 and September 2012. The operative times, lengths of stay, postoperative complications, and mortality were analyzed.nnnRESULTSnWe identified a total of 19 consecutive patients. There were 12 men (63%); the mean age was 60xa0±xa013 years. The meanxa0±xa0SD left ventricular ejection fraction was 23%xa0±xa05.5%, and 4 (21%) of the patients underwent previous coronary artery bypass graft surgery. The median aortic cross-clamp and cardiopulmonary bypass times were 106 (interquartile range [IQR], 76-120) and 163 (IQR, 119-170) minutes, respectively. The median intensive care unit length of stay was 64 (IQR, 43-75) hours, and the median postoperative length of stay was 7 (IQR, 5-7.5) days. Postoperatively, 2 patients developed acute kidney injury. There were no reoperations for bleeding or any cerebrovascular accidents. The 30-day mortality was 0. A follow-up echocardiogram, obtained at a median of 3 (IQR, 1-7.5) months, demonstrated none to trivial MR in all patients.nnnCONCLUSIONSnMinimally invasive mitral repair with papillary muscle sling placement for severe functional MR is safe and effective in the short-term. Long-term data are needed to evaluate the effects on left ventricular remodeling and to assess the durability of the repair.