Daniele Marinelli

Mechanisms, Consequences, and Prevention of Coronary Graft Failure

Graft failure occurs in a sizeable proportion of coronary artery bypass conduits. We herein review relevant current evidence to give an overview of the incidence, pathophysiology, and clinical consequences of this multifactorial phenomenon. Thrombosis, endothelial dysfunction, vasospasm, and oxidative stress are different mechanisms associated with graft failure. Intrinsic morphological and functional features of the bypass conduits play a role in determining failure. Similarly, characteristics of the target coronary vessel, such as the severity of stenosis, the diameter, the extent of atherosclerotic burden, and previous endovascular interventions, are important determinants of graft outcome and must be taken into consideration at the time of surgery. Technical factors, such as the method used to harvest the conduits, the vasodilatory protocol, the storage solution, and the anastomotic technique, also play a major role in determining graft success. Furthermore, systemic atherosclerotic risk factors, such as age, sex, diabetes mellitus, hypertension, and dyslipidemia, have been variably associated with graft failure. The failure of a coronary graft is not always correlated with adverse clinical events, which vary according to the type, location, and reason for failed graft. Intraoperative flow verification and secondary prevention using antiplatelet and lipid-lowering agents can help reducing the incidence of graft failure.

Antiplatelet versus oral anticoagulant therapy as antithrombotic prophylaxis after mitral valve repair

OBJECTIVE To verify the rate of thromboembolic and hemorrhagic complications during the first 6 months after mitral valve repair and to assess whether the type of antithrombotic therapy influenced clinical outcome. METHODS Retrospective data were retrieved from 19 centers. Inclusion criteria were isolated mitral valve repair with ring implantation. Exclusion criteria were ongoing or past atrial fibrillation and any combined intraoperative surgical procedures. The study cohort consisted of 1882 patients (aged 58 ± 15 years; 36% women), and included 1517 treated with an oral anticoagulant (VKA group) and 365 with antiplatelet drugs (APLT group). Primary efficacy outcome was the incidence of arterial thromboembolic events within 6 months and primary safety outcome was the incidence of major bleeding within 6 months. Propensity matching was performed to obtain 2 comparable cohorts (858 vs 286). RESULTS No differences were detected for arterial embolic complications in matched cohort (1.6% VKA vs 2.1% APLT; P = .50). Conversely, patients in the APLT group showed lower incidence of major bleeding complications (3.9% vs 0.7%; P = .01). Six-month mortality rate was significantly higher in the VKA group (2.7% vs 0.3%; P = .02). Multivariable analysis in the matched cohort found VKA as independent predictor of major bleeding complications and mortality at 6 months. CONCLUSIONS Vitamin K antagonist therapy was not superior to antiplatelet therapy to prevent thromboembolic complications after mitral valve repair. Our data suggest that oral anticoagulation may carry a higher bleeding risk compared with antiplatelet therapy, although these results should be confirmed in an adequately powered randomized controlled trial.

From bench to bedside: Can the improvements in left ventricular assist device design mitigate adverse events and increase survival?

OBJECTIVE In vitro tests demonstrated that the new cone-bearing configuration of the Jarvik 2000 (Jarvik Heart Inc, New York, NY) left ventricular assist device exhibits better hydraulic efficiency than the previous pin-bearing design. We investigated the long-term outcomes of patients who received the Jarvik 2000 left ventricular assist device, depending on bearing design. METHODS A retrospective review of prospectively collected data from 18 centers included in the Italian Registry was performed. From May 2008 to September 2013, 99 patients with end-stage heart failure were enrolled. Patients were divided into 2 groups according to their Jarvik 2000 suspending mechanism: Group pin included patients with pin bearings (May 2008 to June 2010), and group cone included patients with newer cone bearings (July 2010 to September 2013). The 2 groups did not differ significantly in terms of baseline characteristics. RESULTS A total of 30 of 39 patients (group pin) and 46 of 60 patients (group cone) were discharged. During follow-up, 6 patients underwent transplantation, and in 1 patient the left ventricular assist device was explanted. The cumulative incidence competing risk of the entire cohort for noncardiovascular-related death was 28% (20%-40%); the cumulative incidence competing risk for cardiovascular-related death was 56% (42%-73%): 71% in group pin versus 26% in group cone (P = .034). The multivariate analyses confirmed that the pin-bearing design was a risk factor for cardiovascular death, along with Interagency Registry for Mechanically Assisted Circulatory Support class. Right ventricular failures and ischemic and hemorrhagic strokes were significantly higher in group pin. CONCLUSIONS Patients with the new pump configuration showed a better freedom from cardiovascular death and lower incidence of fatal stroke and right ventricular failure. Further studies are needed to prove the favorable impact of pump-enhanced fluid dynamics on long-term results.

Aortic valve bypass surgery in severe aortic valve stenosis: Insights from cardiac and brain magnetic resonance imaging

Objective To investigate and describe the distribution of aortic and cerebral blood flow (CBF) in patients with severe valvular aortic stenosis (AS) before and after aortic valve bypass (AVB) surgery. Methods We enrolled 10 consecutive patients who underwent AVB surgery for severe AS. Cardiovascular magnetic resonance imaging (CMR) and brain magnetic resonance imaging were performed as baseline before surgery and twice after surgery. Quantitative flow measurements were obtained using 1.5‐T magnetic resonance imaging (MRI) scanner phase‐contrast images of the ascending aorta, descending thoracic aorta (3 cm proximally and distally from the conduit‐to‐aorta anastomosis), and ventricular outflow portion of the conduit. The evaluation of CBF was performed using 3.0‐T MRI scanner arterial spin labeling (ASL) through sequences acquired at the gray matter, dorsal default‐mode network, and sensorimotor levels. Results Conduit flow, expressed as the percentage of total antegrade flow through the conduit, was 63.5 ± 8% and 67.8 ± 7% on early and mid‐term postoperative CMR, respectively (P < .05). Retrograde perfusion from the level of the conduit insertion in the descending thoracic aorta toward the aortic arch accounted for 6.9% of total cardiac output and 11% of total conduit flow. We did not observe any significant reduction in left ventricular stroke volume at postoperative evaluation compared with preoperative evaluation (P = .435). No differences were observed between preoperative and postoperative CBF at the gray matter, dorsal default‐mode network, and sensorimotor levels (P = .394). Conclusions After AVB surgery in patients with severe AS, cardiac output is split between the native left ventricular outflow tract and the apico‐aortic bypass, with two‐thirds of the total antegrade flow passing through the latter and one‐third passing through the former. In our experience, CBF assessment confirms that the flow redistribution does not jeopardize cerebral blood supply.

Intraoperative graft verification in coronary surgery.

Transit-time flow measurement (TTFM) is a reliable method to check the graft function intraoperatively in coronary surgery. The given parameters are: Mean Graft Flow (MGF); Pulsatility Index (PI) and Insufficiency Ratio (%BF). Some cutoffs of these parameters have been identified as predictors for unfair 1-y clinical outcome: mean graft flow (MGF) less than 20 ml/min and high pulsatility index greater than 5. Other cutoffs have been found as related to postoperative angiography: MGF 15 ml/min or less and pulsatility index at least 3 (sensitivity 94%; specificity 61%); MGF less than 15 ml/min and pulsatility index greater than 3 for left coronary artery or pulsatility index greater than 5 for right coronary artery (sensitivity 96%; specificity 77%); MGF 15 ml/min or less and pulsatility index at least 5.1 left coronary artery (sensitivity 98%; specificity 26%). Hence, with the need to improve the diagnostic accuracy of TTFM, high-resolution epicardic coronary ultrasound module has been added to graft flow evaluation providing 2D ultrasound imaging (either in short-axis or long-axis) and color-flow mapping, allowing an accurate morphological evaluation of body graft and anastomosis. An intraoperative method aimed to verify coronary grafts should be easy to handle, not time consuming, minimally invasive, easily meaningful and relatively cheap; in addition, it should offer objective parameters more than qualitative criteria. We herein report the results of our experience with intraoperative graft verification with TTFM and high-resolution imaging along with a systematic review of the literature in this field with the aim to provide a road map to be followed.

Surgery for prosthetic valve endocarditis: a retrospective study of a national registry

OBJECTIVES We described clinical-epidemiological features of prosthetic valve endocarditis (PVE) and assessed the determinants of early surgical outcomes in multicentre design. METHODS Data regarding 2823 patients undergoing surgery for endocarditis at 19 Italian Centers between 1979 and 2015 were collected in a database. Of them, 582 had PVE: in this group, the determinants of early mortality and complications were assessed, also taking into account the different chronological eras encompassed by the study. RESULTS Overall hospital (30-day) mortality was 19.2% (112 patients). Postoperative complications of any type occurred in 256 patients (44%). Across 3 eras (1980-2000, 2001-08 and 2009-14), early mortality did not significantly change (20.4%, 17.1%, 20.5%, respectively, P  = 0.60), whereas complication rate increased (18.5%, 38.2%, 52.8%, P  < 0.001), consistent with increasing mean patient age (56 ± 14, 64 ± 15, 65 ± 14 years, respectively, P  < 0.001) and median logistic EuroSCORE (14%, 21%, 23%, P  = 0.025). Older age, female sex, preoperative serum creatinine >-2 mg/dl, chronic pulmonary disease, low ejection fraction, non-streptococcal aetiology, active endocarditis, preoperative intubation, preoperative shock and triple valve surgery were significantly associated with mortality. In multivariable analysis, age (OR = 1.02; P  = 0.03), renal insufficiency (OR = 2.1; P  = 0.05), triple valve surgery (OR = 6.9; P  = 0.004) and shock (OR = 4.5; P  < 0.001) were independently associated with mortality, while streptococcal aetiology, healed endocarditis and ejection fraction with survival. Adjusting for study era, preoperative shock (OR = 3; P  < 0.001), Enterococcus (OR = 2.3; P  = 0.01) and female sex (OR = 1.5; P  = 0.03) independently predicted complications, whereas ejection fraction was protective. CONCLUSIONS PVE surgery remains a high-risk one. The strongest predictors of early outcome of PVE surgery are related to patients haemodynamic status and microbiological factors.

Intraoperative imaging to detect coronary stenosis in no-angiography patients

Sometimes, patients scheduled for cardiac operations other than coronary artery bypass may be unsuitable for preoperative coronary angiography. We routinely use intraoperative high-resolution epicardial ultrasound to select the proper target for the graft and to check graft anastomosis integrity. We describe 3 patients who could not undergo preoperative coronary angiography for different reasons. In all cases, we discovered significant stenosis in the left anterior descending coronary artery, which required bypass grafting. Intraoperative verification by transit-time flow measurements confirmed the significant stenosis detected by imaging.

Corticosteroid prophylaxis for fetal immaturity in a pregnant patient with atrial myxoma

We report a case of a woman at 32nd gestational week, admitted for resting dyspnea, showing left atrial (LA) myxoma. Cardiac myxomas are the most common primary benign tumors of the heart. The incidence of cardiac myxomas diagnosed in pregnancy is extremely low. In the present case, cesarean delivery and concomitant surgical resection of LA myxoma were both delayed after corticosteroid prophylaxis in order to reduce neonatal cerebral, intestinal, and pulmonary complications. <Learning objective: The rarity of these cases makes the management more related to anecdotal experiences. In our case, the gestational age was lower than 34th week, but the fetus was sufficiently large to be delivered before heart surgery with low risk of prematurity complications after an adequate corticosteroid prophylaxis. A waiting approach with several days of corticosteroid prophylaxis was successfully adopted. When the pregnant hemodynamics are stable with low risk of complications, heart surgery should be delayed after corticosteroid prophylaxis.>.

We are what we eat

the old adage that pregnant women eat for two might be more true than ever before in the light of recent research into diet and the control of gene expression. the link between the diet of pregnant women—and, to some extent, men—during pre-conception and the health of the fetus has been viewed mostly in terms of major risk factors such as smoking or substance abuse. However, epidemiological and molecular research is revealing a more complex and subtle picture of how a pregnant woman’s eating behaviour influences the expression of her own—and possibly her fetus’s—genes, and thus the long-term health of her children. “type ii diabetes, heart disease due to obesity, insulin resistance, and hypertension are the diseases most strongly associated with maternal diet during pregnancy,” said Karen lillycrop, who specializes in perinatal nutrition at the university of Southampton in the uK. in addition, there is growing evidence that dietary effects, which can alter the expression and control of genes, might even have been a driving force for human evolution. a recent study revealed that the greatest divergence between the genomes of humans and chimpanzees is found among genes that control metabolism and are closely associated with diet (Somel et al, 2008).

Corrigendum to “A predictive model for early mortality after surgical treatment of heart valve or prosthesis infective endocarditis. The EndoSCORE”. [Int. J. Cardiol. Aug 15 2017;241:97-102.]

Michele Di Mauro ⁎, Guglielmo Mario Actis Dato , Fabio Barili , Sandro Gelsomino , Pasquale Santè , Alessandro Della Corte , Antonio Carrozza , Ester Della Ratta , Diego Cugola , Lorenzo Galletti , Roger Devotini , Riccardo Casabona , Francesco Santini , Antonio Salsano , Roberto Scrofani , Carlo Antona , Luca Botta , Claudio Russo , Samuel Mancuso , Mauro Rinaldi , Carlo De Vincentiis , Andrea Biondi , Cesare Beghi , Giangiuseppe Cappabianca , Vincenzo Tarzia , Gino Gerosa , Michele De Bonis , Alberto Pozzoli , Francesco Nicolini , Filippo Benassi , Francesco Rosato , Elena Grasso , Ugolino Livi , Sandro Sponga , Davide Pacini , Roberto Di Bartolomeo , Andrea DeMartino , Uberto Bortolotti , Francesco Onorati , Giuseppe Faggian , Roberto Lorusso , Enrico Vizzardi , Gabriele Di Giammarco , Daniele Marinelli , Emmanuel Villa , Giovanni Troise , Marco Picichè , Francesco Musumeci , Domenico Paparella , Vito Margari , Francesco Tritto , Girolamo Damiani , Giuseppe Scrascia , Salvatore Zaccaria , Attilio Renzulli , Giuseppe Serraino , Giovanni Mariscalco , Daniele Maselli , Massimiliano Foschi , Alessandro Parolari , Giannantonio Nappi ,