Claudio Muneretto

Endovascular Aortic Repair Versus Open Surgical Repair for Descending Thoracic Aortic Disease A Systematic Review and Meta-Analysis of Comparative Studies

OBJECTIVES The purpose of this study was to determine whether thoracic endovascular aortic repair (TEVAR) reduces death and morbidity compared with open surgical repair for descending thoracic aortic disease. BACKGROUND The role of TEVAR versus open surgery remains unclear. Metaregression can be used to maximally inform adoption of new technologies by utilizing evidence from existing trials. METHODS Data from comparative studies of TEVAR versus open repair of the descending aorta were combined through meta-analysis. Metaregression was performed to account for baseline risk factor imbalances, study design, and thoracic pathology. Due to significant heterogeneity, registry data were analyzed separately from comparative studies. RESULTS Forty-two nonrandomized studies involving 5,888 patients were included (38 comparative studies, 4 registries). Patient characteristics were balanced except for age, as TEVAR patients were usually older than open surgery patients (p = 0.001). Registry data suggested overall perioperative complications were reduced. In comparative studies, all-cause mortality at 30 days (odds ratio [OR]: 0.44, 95% confidence interval [CI]: 0.33 to 0.59) and paraplegia (OR: 0.42, 95% CI: 0.28 to 0.63) were reduced for TEVAR versus open surgery. In addition, cardiac complications, transfusions, reoperation for bleeding, renal dysfunction, pneumonia, and length of stay were reduced. There was no significant difference in stroke, myocardial infarction, aortic reintervention, and mortality beyond 1 year. Metaregression to adjust for age imbalance, study design, and pathology did not materially change the results. CONCLUSIONS Current data from nonrandomized studies suggest that TEVAR may reduce early death, paraplegia, renal insufficiency, transfusions, reoperation for bleeding, cardiac complications, pneumonia, and length of stay compared with open surgery. Sustained benefits on survival have not been proven.

Beta-blocker therapy influences the hemodynamic response to inotropic agents in patients with heart failure: A randomized comparison of dobutamine and enoximone before and after chronic treatment with metoprolol or carvedilol

OBJECTIVE We compared the hemodynamic effects of dobutamine and enoximone administration before and after long-term beta-blocker therapy with metoprolol or carvedilol in patients with chronic heart failure (HF). BACKGROUND Patients with HF on beta-blocker therapy may need hemodynamic support with inotropic agents, and the hemodynamic response may be influenced by both the inotropic agent and the beta-blocker used. METHODS The hemodynamic effects of dobutamine (5 to 20 microg/kg/min intravenously) and enoximone (0.5 to 2 mg/kg intravenously) were assessed by pulmonary artery catheterization in 29 patients with chronic HF before and after 9 to 12 months of treatment with metoprolol or carvedilol at standard target maintenance oral doses. Hemodynamic studies were performed after >/=12 h of wash-out from all cardiovascular medications, except the beta-blockers that were administered 3 h before the second study. RESULTS Compared with before beta-blocker therapy, metoprolol treatment decreased the magnitude of mean pulmonary artery pressure (PAP) and pulmonary wedge pressure (PWP) decline during dobutamine infusion and increased the cardiac index (CI) and stroke volume index (SVI) response to enoximone administration, without any effect on other hemodynamic parameters. Carvedilol treatment abolished the increase in heart rate, SVI, and CI and caused a rise, rather than a decline, in PAP, PWP, systemic vascular resistance, and pulmonary vascular resistance during dobutamine infusion. The hemodynamic response to enoximone, however, was maintained or enhanced in the presence of carvedilol. CONCLUSIONS In contrast with its effects on enoximone, carvedilol and, to a lesser extent, metoprolol treatment may significantly inhibit the favorable hemodynamic response to dobutamine. No such beta-blocker-related attenuation of hemodynamic effects occurs with enoximone.

Isolation and culture of human muscle-derived stem cells able to differentiate into myogenic and neurogenic cell lineages.

BACKGROUND Skeletal-muscle-derived stem cells seem to be a distinct population of immature progenitors of satellite cells, but their functional properties remain unclear, especially in human adult tissue. We investigated their differentiation in samples of skeletal muscle obtained from adults undergoing cardiovascular surgery. METHODS Samples were obtained from the brachioradialis muscle of 12 patients in whom the radial artery was the conduit for myocardial revascularisation. The stem cells were isolated by a procedure similar to that used for rat gastrocnemius and cultured in medium optimised for growth of neural stem cells. Cytometry was used for phenotypic characterisation and immunocytochemistry and RT-PCR to assess differentiation. Immunohistochemistry was used to examine engraftment of skeletal-muscle-derived stem cells into injured rat spinal cord. FINDINGS The skeletal-muscle stem cells consisted of two distinct types: one with the typical spindle morphology of satellite cells, the other of rounded cells. Some cultures could be maintained for longer than 6 months. The cells were mainly positive for desmin and to a lesser extent CD105, vimentin, and AC133/CD133, but negative for FLK-1/KDR, CD34, CD31, CD45, von Willebrand factor, Ve-cadherins, and BCL2. After in-vitro differentiation, the cells were able to organise skeletal-muscle fibres and stained positively for striated-muscle actin, smooth-muscle actin, and desmin. Moreover, they differentiated into astrocytes and neurons, as confirmed by positive staining for characteristic proteins. INTERPRETATION Adult human skeletal muscle includes a population of progenitor stem cells that can generate cells of the same lineage and cells with neurogenic properties. Muscle may therefore be a tissue source for the isolation of pluripotent stem cells for development of cell-based therapies for human myogenic and neurogenic diseases.

Total Arterial Myocardial Revascularization With Composite Grafts Improves Results of Coronary Surgery in Elderly: A Prospective Randomized Comparison With Conventional Coronary Artery Bypass Surgery

BackgroundTotal arterial myocardial revascularization with composite grafts proved to enhance the long-term benefits of coronary surgery. We assessed the hypothesis that full arterial revascularization (FAR) may improve clinical outcome even in elderly and at short term. Methods and ResultsA prospective randomized study was designed to compare FAR with conventional coronary artery bypass grafting (CABG) surgery [left interval thoracic artery (LITA) on left anterior descending (LAD) plus additional saphenous vein grafts] with the following end points: early and late death, graft occlusion, reintervention, angina recurrence, and acute myocardial infarction (AMI). We enrolled 200 consecutive patients >70 years of age; population was equally divided at random in Group 1 (G1, FAR) and Group 2 (G2, Conventional). The groups resulted comparable with respect to all preoperative continuous and discrete variables and risk factors (Euroscore: G1=8.4 versus G2=8.1). No differences between G1 versus G2 were observed in terms of postoperative complications (perioperative AMI:2% versus 3%), mean intensive care unit (ICU) (hours: 39±11 versus 40±9) and hospital stay (days: 6±2 versus 7±3) nor were there any differences in hospital mortality(G1=5% versus G2=4%). At the mean follow-up of 14±5 months the incidence of angina recurrence was 3% in G1 versus 12% in G2. Angiographic controls of grafts showed a superior graft patency rate of all the arterial grafts when compared with saphenous vein grafts. Conventional CABG surgery was identified as incremental risk factor for angina recurrence and as predictor for graft occlusion. ConclusionsTotal arterial myocardial revascularization improved clinical outcome of patients undergoing coronary surgery in the elderly, whereas saphenous vein grafts negatively affected patient prognosis in terms of graft patency and freedom from late cardiac events.

Prospective evaluation of a new sternal closure method with thermoreactive clips

OBJECTIVES The role of the sternal closure techniques on the incidence of sternal dehiscence and wound infection are well defined among a high number of other variables involved. In the various series, the incidence of wound complication in cardiac surgery varies from 2 to 8%. The aim of our study is to evaluate the role of thermal-dependent shape-memory Nitillium clips in reducing the incidence of sternal dehiscence following sternotomy. METHODS We perspectively randomized 1000 consecutive patients requiring cardiac surgery to evaluate the incidence of sternal wound complications (SWC), sternal dehiscence and/or other related complications. We compared Group I (500 patients), in which sternal closure was achieved with standard sternal wires, with Group II (500 patients), in which sternal approximation was carried out by means of thermoreactive Nitillium clips. The two randomized groups were comparable in terms of age, gender, Euroscore and risk factors for sternal/wound complications. RESULTS In our study the overall incidence of SWC was 4.7%. The incidence of SWC was considerably higher in Group I (6.8%) when compared to Group II (2.6%) (P=0.003). Mechanical sternal dehiscence without infection occurred in 14 patients in Group I and in one patient in Group II (P=0.002). Despite sternotomy wound infection occurred similarly in both groups (15 patients in Group I vs. 12 patients in Group II), sternal revision was performed only in patients of Group I (Group I: 9/15 vs. Group II: 0/12; P=0.001). CONCLUSION Thermal shape-memory Nitillium clips provided superior results in sternal osteosynthesis following midline sternotomy, due to a considerable reduction of sternal dehiscence and related complications. The clinical benefit of Nitillium clips was demonstrated even in patients with several risk factors for SWC.

Treating the patients in the ‘grey-zone’ with aortic valve disease: a comparison among conventional surgery, sutureless valves and transcatheter aortic valve replacement

OBJECTIVES Although the use of transcatheter aortic valve replacement (TAVR) has recently become an attractive strategy in extremely high-risk patients undergoing aortic valve replacement (AVR), the most appropriate treatment option in patients with an intermediate- to high-risk profile with conventional surgery (sAVR), TAVR or novel options, such as sutureless valves, has been widely debated. METHODS One hundred and sixty-three consecutive patients with intermediate to high risk were prospectively enrolled and selected to undergo sAVR (Group 1: G1, n = 55), sutureless valve implantation (Group 2: G2, n = 53) or TAVR (Group 3: G3, n = 55) following a multidisciplinary evaluation including frailty, anatomy and degree of atherosclerotic disease of the aorta/peripheral vessels. The mean logistic EuroSCORE (G1 = 21.3 ± 12.7 vs G2 = 16 ± 11.7 vs G3 = 20.4 ± 12.7, P = 0.06) and preoperative demographics, such as age, gender and left ventricular ejection fraction, were similar: of note, chronic obstructive pulmonary disease was more frequent in TAVI patients (G1 = 27.2% vs G2 = 15.1% vs G3 = 47%; P <0.01). The Perceval S sutureless valve was used in Group 2, whereas TAVR was performed with a Corevalve prosthesis. RESULTS Post-procedural pacemaker implantation (G1 = 1.8% vs G2 = 2% vs G3 = 25.5%, P <0.001) and peripheral vascular complications (G1 = 0% vs G2 = 0% vs G3 = 14.5%, P <0.001) occurred more frequently in patients undergoing TAVR. Hospital mortality was similar among the groups (G1 = 0% vs G2 = 0% vs G3 = 1.8%, P = NS). At the 24-month follow-up, overall survival free from major adverse cardiac and cerebrovascular events and prosthetic regurgitation was better in patients who had undergone sAVR and sutureless valves than those who had undergone TAVR (G1 = 95.2 ± 3.3% vs G2 = 91.6 ± 3.8% vs G3 = 70.5 ± 7.6%; P = 0.015). CONCLUSIONS This preliminary study suggests that the use of TAVR in patients with an intermediate- to high-risk profile is associated with a higher rate of perioperative complications and decreased survival at the 24-month follow-up compared with the use of conventional surgery or sutureless valves.

Hybrid approach for the treatment of long-standing persistent atrial fibrillation: electrophysiological findings and clinical results †

OBJECTIVES The sequential, staged hybrid approach has recently emerged as a novel strategy for the treatment of long-standing persistent atrial fibrillation (AF); nevertheless, the potential modifications in terms of electrophysiological findings and their correlation with mid-term results have not been fully elucidated so far. METHODS Forty-five patients with long-standing persistent AF underwent a hybrid procedure combining surgical closed-chest posterior left atrium (LA) and pulmonary veins (PV) isolation (box lesion) first, followed by transcatheter evaluation at least 1 month afterwards. Electrophysiological findings and their correlation with rhythm outcomes were assessed at different time points, i.e. following the surgical ablation (T1), during (T2) and at the end (T3) of the transcatheter evaluation and at 28-month follow-up (T4). RESULTS At T1, exit and entrance blocks were achieved in 100 and 91.1% (41 of 45) of patients, respectively. At T2, the percentage of conduction block was unchanged, while at T3 also entrance block was achieved in all instances. In terms of electrophysiological findings (at T2), PV reconnection occurred in 6.7% (3 of 45) of patients, fractionated electrograms were targeted in 44.4% (20 of 45) while right atrium isthmus lesion was performed in 24.4% (11 of 45) of patients. Sinus rhythm was restored in 75.6% (34 of 45) at T1, at T2 (with AF induction) in 68.9% (31 of 45), at T3 in 93.3% (42 of 45) and at T4 in 88.9% (40 of 45) of patients, respectively. In those patients with a bidirectional block at T1, sinus rhythm restoration steadily improved from 78 (32 of 41) at T1 to 82.9 (34 of 41) at T2 and finally 92.6% (38 of 41) at T4. CONCLUSION Complete posterior LA and PV isolation with the box lesion in a staged hybrid approach is associated with incremental benefits in terms of sinus rhythm maintenance in patients with long-standing persistent AF.

Surgical and interventional management of mitral valve regurgitation: a position statement from the European Society of Cardiology Working Groups on Cardiovascular Surgery and Valvular Heart Disease

Mitral regurgitation (MR) has a prevalence of 2% in the general population and is even more common in the elderly.[1][1] Organic (or primary) MR arises as a result of pathology affecting one or more components of the mitral valve (MV) apparatus, whereas functional (or secondary) MR is a consequence

Hybrid revascularization in multivessel coronary artery disease

OBJECTIVES Minimally invasive hybrid revascularization (MIHR) by means of the left mammary artery on the left anterior descending artery [minimally invasive direct coronary artery bypass (MIDCAB)] combined with percutaneous coronary interventions (PCI) stenting may be an alternative to conventional coronary artery bypass grafting through sternotomy or multiple PCI. The purpose of this study is to retrospectively evaluate the long-term outcomes of this strategy. METHODS Since May 1997 up to January 2011, 810 MIDCAB have been performed as isolated revascularization in 644 patients. Since 2004, MIDCAB, as a part of hybrid revascularization, was associated with PCI in 166 patients. RESULTS In the MIDCAB group, mean age was 64.6 ± 12.0, with 83.8% males. Two-vessel disease was 62.4%, three-vessel disease 37.6%. Overall mortality was 0.24%, perioperative acute myocardial infarction-1.6%, early reoperation-0.74%, reopening for bleeding-1.2%, case rate of haemotrasfusion-3.1%, with a mean hospital postoperative stay of 4 ± 2.5 days. Postoperative angiographic control prior to PCI and in symptomatic patients showed patent left internal mammary artery in 100% of cases. PCI was performed in 166 patients, 64.2% before MIDCAB and 35.8% after surgery (interval 2.2 ± 1.3 months). The mean follow-up in the MIDCAB group was 8.4 ± 3.2 years. In the MIHR group, at the mean follow-up of 4.5 ± 2.3 years, freedom from related cardiac death was 93% with freedom from cardiac reintervention of 83%. CONCLUSIONS Our 13-year experience with MIDCAB demonstrates that the operation is safe and associated with a very low incidence of early and late complications. The hybrid approach provided excellent long-term outcome in terms of freedom from cardiac death and reoperation. Accurate patient selection, as well the timing of the hybrid procedure, is mandatory to optimize surgical and PCI results.

Possible role of F18-FDG-PET/CT in the diagnosis of endocarditis: preliminary evidence from a review of the literature

Infective endocarditis (IE) is a particular disease which presents with a variety of clinical, aetiological forms and is lethal if not aggressively treated with antibiotics alone or in combination with surgery. This review tries to analyse the possible role of F18-FDG-PET/CT in the diagnosis of IE based on the state of art in literature.