Christos G. Mihos

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 Right Minithoracotomy Mitral Valve Surgery in Patients With Previous Sternotomy

BACKGROUNDnWe evaluated the outcomes of patients with a history of previous sternotomy who underwent minimally invasive mitral valve surgery through a right minithoracotomy approach.nnnMETHODSnWe reviewed all the isolated mitral valve operations performed at our institution between January 1, 2005, and October 8, 2010, and selected for analysis only patients who had had a prior sternotomy. The outcome of patients who underwent a minimally invasive approach was compared with that of patients whose mitral surgery was performed through a standard median sternotomy.nnnRESULTSnThere were 88 patients with prior sternotomy, with 59 having minimally invasive surgery and 29 undergoing a repeat median sternotomy. Significant baseline differences (minimally invasive versus sternotomy, respectively) included the number of male patients (76% versus 45%, p=0.003), prior coronary artery bypass graft surgery (71% versus 45%, p=0.02), prior valve surgery (47% versus 72%, p=0.03), congestive heart failure (46% versus 76%, p=0.008), and diabetes mellitus (34% versus 10%, p=0.02). The in-hospital mortality and composite postoperative complications were 3% versus 14% (p=0.07) and 29% versus 66% (p=0.001) for the minimally invasive versus the median sternotomy group, respectively. The intensive care unit stay and hospital length of stay were 48 hours (interquartile range [IQR], 41 to 90) versus 118 hours (IQR, 67 to 167; p<0.001), and 8 days (IQR, 6 to 12) versus 13 days (IQR, 9 to 18; p=0.001), for the minimally invasive and median sternotomy groups, respectively.nnnCONCLUSIONSnMinimally invasive mitral valve surgery in patients who have had a prior sternotomy is associated with improved postoperative outcomes and reduced resource utilization, when compared with a median sternotomy approach.

The pleiotropic effects and therapeutic potential of the hydroxy-methyl-glutaryl-CoA reductase inhibitors in malignancies: A comprehensive review

The hydroxy-methyl-glutaryl-CoA reductase inhibitors (statins) are used extensively in the treatment of hyperlipidemia. They have also demonstrated a benefit in a variety of other disease processes via actions known as pleiotropic effects. Our paper serves as a focused review of pre-clinical investigations and published clinical data regarding the pleiotropic effects of statins in malignancies and emphasizes the importance of randomized, placebo-controlled trials to further elucidate this interesting phenomenon.

The pleiotropic effects of the hydroxy-methyl-glutaryl-CoA reductase inhibitors in rheumatologic disorders: a comprehensive review

The hydroxy-methyl-glutaryl-CoA reductase inhibitors (statins) are used extensively in the treatment for hyperlipidemia. They have also demonstrated a benefit in a variety of other disease processes, including a wide range of rheumatologic disorders. These secondary actions are known as pleiotropic effects. Our paper serves as a focused and updated discussion on the pleiotropic effects of statins in rheumatologic disorders and emphasizes the importance of randomized, placebo-controlled trials to further elucidate this interesting phenomenon.

Incidence of postoperative atrial fibrillation in patients undergoing minimally invasive versus median sternotomy valve surgery

BACKGROUNDnAtrial fibrillation (AF) after cardiac surgery is associated with increased morbidity and hospital length of stay. Our objective was to determine whether a minimally invasive approach to isolated valve surgery reduced the incidence of postoperative AF.nnnMETHODSnPatients without a history of arrhythmia, who underwent isolated aortic or mitral valve surgery between January 2005 and August 2011, were included. The incidence of postoperative AF in those who underwent a minimally invasive approach was compared with that of patients undergoing median sternotomy surgery. Resource utilization was approximated on the basis of intensive care unit and total hospital lengths of stay.nnnRESULTSnA total of 571 patients were identified (413 minimally invasive and 158 median sternotomy). No significant differences in baseline characteristics existed between groups. The incidence of postoperative AF (25% vs 37%; Pxa0=xa0.002), use of intraoperative blood products (52% vs 83%; Pxa0<xa0.001), and prolonged intubation (≥24 hours) (12% vs 20%; Pxa0=xa0.008) were significantly less in the minimally invasive group. The intensive care unit and hospital lengths of stay were 45 hours (interquartile range [IQR], 28-66 hours) versus 53 hours (IQR, 45-91 hours) (Pxa0<xa0.001), and 5 days (IQR, 4-7 days) versus 8 days (IQR, 6-11 days) (Pxa0<xa0.001) for the minimally invasive and median sternotomy groups, respectively. Multivariable analysis revealed a decreased risk of postoperative AF in patients undergoing minimally invasive surgery (odds ratio, 0.4; 95% confidence intervals, 0.24-0.66; Pxa0<xa0.001).nnnCONCLUSIONSnA minimally invasive approach for isolated valve surgery reduces postoperative AF and resource use when compared with median sternotomy.

Mechanisms and Clinical Evidence of the Pleiotropic Effects of the Hydroxy-Methyl-Glutaryl-CoA Reductase Inhibitors in Central Nervous System Disorders: A Comprehensive Review

ABSTRACT The hydroxy-methyl-glutaryl-CoA reductase inhibitors, better known as statins, are principally used in the treatment of hyperlipidemia and play a pivotal role in the primary and secondary prevention of atherosclerotic heart disease and stroke. Evidence also exists for the potential benefits from statin use in a variety of other disease processes, conferred via their non-lipid lowering properties, which are known as pleiotropic effects. Our paper serves as a focused and updated discussion on the pleiotropic effects of statins in neurological disorders. Emphasis is placed on the discussion of randomized, placebo-controlled trials, and their importance in further elucidating this interesting phenomenon.

Incidence of cerebrovascular accidents in patients undergoing minimally invasive valve surgery

OBJECTIVESnMinimally invasive valve surgery has been associated with increased cerebrovascular complications. Our objective was to evaluate the incidence of cerebrovascular accidents in patients undergoing minimally invasive valve surgery.nnnMETHODSnWe retrospectively reviewed all the minimally invasive valve surgery performed at our institution from January 2009 to June 2012. The operative times, lengths of stay, postoperative complications, and mortality were analyzed.nnnRESULTSnA total of 1501 consecutive patients were identified. The mean age was 73 ± 13 years, and 808 patients (54%) were male. Of the 1501 patients, 206 (13.7%) had a history of a cerebrovascular accident, and 225 (15%) had undergone previous heart surgery. The procedures performed were 617 isolated aortic valve replacements (41.1%), 658 isolated mitral valve operations (43.8%), 6 tricuspid valve repairs (0.4%), 216 double valve surgery (14.4%), and 4 triple valve surgery (0.3%). Femoral cannulation was used in 1359 patients (90.5%) and central cannulation in 142 (9.5%). In 1392 patients (92.7%), the aorta was clamped, and in 109 (7.3%), the surgery was performed with the heart fibrillating. The median aortic crossclamp and cardiopulmonary bypass times were 86 minutes (interquartile range [IQR], 70-107) minutes and 116 minutes (IQR, 96-143), respectively. The median intensive care unit length of stay was 47 hours (IQR, 29-74), and the median postoperative hospital length of stay was 7 days (IQR, 5-10). A total of 23 cerebrovascular accidents (1.53%) and 38 deaths (2.53%) had occurred at 30 days postoperatively.nnnCONCLUSIONSnMinimally invasive valve surgery was associated with an acceptable stroke rate, regardless of the cannulation technique.

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.

Outcomes of transaortic edge-to-edge repair of the mitral valve in patients undergoing minimally invasive aortic valve replacement

Gender Male 16 (67%) Female 8 (33%) Age (y, mean SD) 77.8 9.2 Aortic valve lesion Aortic stenosis 20 (83%) Aortic insufficiency 2 (8.5%) Clinically significant mitral regurgitation (MR) is often found in conjunction with severe aortic valve stenosis. Adding mitral valve surgery to aortic valve replacement (AVR) increases the operative risk. This risk may be reduced by performing a transaortic edge-to-edge repair of the mitral valve during the AVR. We describe how to perform this procedure and report our results of using this approach during minimally invasive valve surgery. Prosthetic valve insufficiency 2 (8.5%) Mitral valve lesion Functional 11 (46%) Degenerative calcification 10 (42%) Rheumatic 3 (12%) Reoperation 8 (33%) Prior CABG surgery 6 (25%) Prior AVR 1 (4%) Prior CABG surgery and AVR 1 (4%) Preoperative MR (grade, median, IQR) 3 (3-4)

Is a minimally invasive approach for mitral valve surgery more cost-effective than median sternotomy?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: is a minimally invasive approach for mitral valve surgery more cost-effective than median sternotomy? Altogether, 51 studies were found using the reported search, of which 7 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. No randomized controlled trials have assessed the cost-effectiveness of less invasive mitral valve surgery compared with median sternotomy, with the best evidence coming from retrospective and propensity-matched analyses. Five studies compared minithoracotomy versus sternotomy, one compared minimally invasive port-access surgery versus sternotomy and one compared video-assisted minithoracotomy versus sternotomy. The use of a minithoracotomy or a minimally invasive port-access approach for mitral valve surgery resulted in significant reductions in costs of cardiac imaging and laboratory tests, lower use of blood products, fewer perioperative infections, faster recovery, shorter hospital length of stay, fewer requirements for rehabilitation and lower readmission rates in the following postoperative year. We conclude that a minimally invasive approach for mitral valve surgery is safe, effective and significantly more cost-effective than median sternotomy.