Mario Monaco

Aortic Valve Replacement: A Prospective Randomized Evaluation of Mechanical Versus Biological Valves in Patients Ages 55 to 70 Years

OBJECTIVES The aim of this study was to determine long-term results between bioprosthetic (BP) and mechanical (MP) aortic valves in middle-aged patients. BACKGROUND It has not been established which is the best aortic valve substitute in patients ages 55 to 70 years. We conducted a randomized study to compare long-term outcomes between BP and MP aortic valves. METHODS Between January 1995 and June 2003, 310 patients were randomized to receive a BP or an MP aortic valve. Primary end points of the study were survival, valve failure, and reoperation. RESULTS One hundred fifty-five patients received a BP valve, and 155 patients received an MP valve. Four patients died, perioperatively, in the MP group (2.6%), and 6 patients died in the BP group (3.9%, p = 0.4). At late follow-up (mean 106 +/- 28 months) 41 patients died in the MP group and 45 patients died in the BP group (p = 0.6). There was no difference in the survival rate at 13 years between the MP and BP groups. Valve failures and reoperations were more frequent in the BP group compared with the MP group (p = 0.0001 and p = 0.0003, respectively). There were no differences in the linearized rate of thromboembolism, bleeding, endocarditis, and major adverse prosthesis-related events (MAPE) between the MP and BP valve groups. CONCLUSIONS At 13 years, patients undergoing aortic valve replacement either with MP or BP valves had a similar survival rate as well the same rate of occurrence of thromboembolism, bleeding, endocarditis, and MAPE, but patients who had undergone aortic valve replacement with BP valves faced a significantly higher risk of valve failure and reoperation.

Thoracic aortic emergencies: impact of endovascular surgery.

BACKGROUND Conventional surgery for thoracic aortic emergencies, such as contained or free rupture of thoracic aortic aneurysms, acute type B dissections, and traumatic rupture of the thoracic aorta, is frequently associated with a high rate of mortality and morbidity. To obviate this risk, endovascular surgery is considered to be a valid alternative procedure. METHODS From March 2001 to July 2002, 15 of 22 patients with acute thoracic aortic syndromes were submitted to endovascular surgery: 3 patients (20%) for traumatic rupture, 4 patients (26.7%) for contained or free rupture of thoracic aortic aneurysm, and 8 patients (53.3%) for acute type B dissection evolving to rupture. Computed tomographic scan was diagnostic in all patients. The stent grafts were introduced through the femoral artery. RESULTS In the endovascular group there were no perioperative deaths or open conversions. The intraoperative angiography and computed tomographic scan performed on discharge showed no significant endoleaks and successful sealing of the aortic dissection. Average intensive care unit and hospital stay was 1.7 +/- 0.8 and 5.9 +/- 3.0 days. Follow-up ranged between 4 and 23 months and included clinical examinations and serial computed tomographic scan at 3, 6, and 12 months, and every 6 months thereafter. One 84-year-old patient with thoracic aortic aneurysm died of pneumonia 78 days after endovascular surgery. Only one type 1 endoleak was noted in the first patient with traumatic rupture, 3 months after the procedure. CONCLUSIONS Endovascular surgery is a safe technique, showing encouraging early and midterm results and allowing for prompt treatment of associated lesions in complex multitrauma patients.

Combination therapy with warfarin plus clopidogrel improves outcomes in femoropopliteal bypass surgery patients

BACKGROUND Patients having undergone femoropopliteal bypass surgery remain at significant risk of graft failure. Although antithrombotic therapy is of paramount importance in these patients, the effect of oral anticoagulation therapy (OAT) on outcomes remains unresolved. We performed a randomized, prospective study to assess the impact of OAT plus clopidogrel vs dual antiplatelet therapy on peripheral vascular and systemic cardiovascular outcomes in patients who had undergone femoropopliteal bypass surgery. METHODS Three hundred forty-one patients who had undergone femoropopliteal surgery were enrolled and randomized: 173 patients received clopidogrel 75 mg/d plus OAT with warfarin (C + OAT), and 168 patients received dual antiplatelet therapy with clopidogrel 75 mg/d plus aspirin 100 mg/d (C + acetylsalicylic acid [ASA]). Study end points were graft patency and the occurrence of severe peripheral arterial ischemia, and the incidence of bleeding episodes. RESULTS Follow-up ranged from 4 to 9 years. The graft patency rate and the freedom from severe peripheral arterial ischemia was significantly higher in C + OAT group than in C + ASA group (P = .026 and .044, respectively, Cox-Mantel test). The linearized incidence of minor bleeding complications was significantly higher in C + OAT group than in C + ASA group (2.85% patient-years vs 1.37% patient-years; P = .03). The incidence of major adverse cardiovascular events, including mortality, was found to be similar (P = .34) for both study groups. CONCLUSIONS In patients who have undergone femoropopliteal vascular surgery, combination therapy with clopidogrel plus warfarin is more effective than dual antiplatelet therapy in increasing graft patency and in reducing severe peripheral ischemia. These improvements are obtained at the expenses of an increase in the rate of minor anticoagulation-related complications.

Aortomesenteric Fat Thickness With Ultrasound Predicts Metabolic Diseases in Obese Patients

Background:The relation between visceral fat accumulation and development of cardiovascular and metabolic disorders has been demonstrated. The aim of this study was to determine the relationship between a new ultrasound visceral fat thickness (VFT) measurement and clinical and anthropometric data in a consecutive series of obese patients. Methods:Fifty-five consecutive male obese patients underwent ultrasound evaluation and metabolic and anthropometric parameters determination at baseline and after 3 weeks of a very low–calorie diet (VLCD) therapy. The new ultrasound measurement, the thickness of the fat between the aorta and the superior mesenteric artery (AMFT), was determined along with the maximum thickness of preperitoneal fat and the global VFT. Results:AMFT showed a better correlation than VFT and preperitoneal fat with all anthropometric and metabolic parameters, both at baseline and after VLCD regimen. At baseline, patients in the middle and high AMFT and VFT tertiles had a significantly higher prevalence of metabolic diseases with respect to AMFT and VFT low tertile patients, whereas after VLCD period, AMFT only showed significant difference within tertiles. The odds ratios for the various metabolic diseases were higher in the middle and high AMFT tertiles than those in the middle and high VFT tertiles, remaining significant after adjustment for age, body mass index and VLCD regimen only in the middle and high AMFT tertiles. Conclusions:The ultrasonographic AMFT evaluation is strongly correlated to the presence of metabolic syndrome and could be a valuable tool to predict metabolic diseases and associated cardiovascular risks in men.

Left heart pump-assisted beating heart coronary surgery in high-risk patients.

A simple technique of left ventricular assistance, offering the advantages of both cardiopulmonary bypass and off-pump revascularization, was adopted for high-risk patients. It was used in 56 patients with critical left main stenosis and occluded right coronary artery, severely reduced ejection fraction and/or unstable angina. All patients underwent complete and successful myocardial revascularization (3.4 grafts per patient). Weaning from the pump was uncomplicated, and none required conversion to full cardiopulmonary bypass.

Combined endoscopic approach in the treatment of benign broncho-oesophageal fistula

The treatment of benign broncho-oesophageal fistula is usually surgical but sometimes other methods of treatment are preferred. The case history is described of an adult in poor general condition in which an endoscopic approach combined with the use of fibrin glue on the bronchial side and metallic clips on the oesophageal side was used to close the fistula.

Complicated acute type B aortic dissection involving the arch: Treatment by simultaneous hybrid approach under local anesthesia

We herein report the case of a high-risk patient with complicated acute type B aortic dissection (B-AD) involving the arch up to both common iliac arteries. The patient was treated by a simultaneous hybrid approach accomplished with local anesthesia.

Atorvastatin Sensitises Vascular Smooth Muscle Cells, but not Endothelial Cells, to TNF-α-induced Cell Death

OBJECTIVE Stimuli activating vascular smooth muscle cell death can constrain the neointimal response to arterial damage and prevent vascular thickening. Conversely, endothelial cell death increases endothelial dysfunction and thrombosis risk. We investigated the combined effect of atorvastatin and TNF-α on vascular cell death. METHODS AND RESULTS Cell death was investigated in cultures of human aortic smooth muscle cells (VSMCs) and human umbilical vein endothelial cells (HUVECs). Atorvastatin downregulated NF-κB and enhanced JNK activity and cell death in VSMC cultured with TNF- α. In the absence of TNF-α, percentages (mean and StDev) of annexin V positive cells were 17.4 ± 6.6%, 19.3 ± 5.9%, 22.9 ± 9.4% and 35.0 ± 20.0 % with 0, 1, 3 and 10 µM atorvastatin, respectively. The cytotoxic effect of statin was significant at the highest dose of 10 μM (p=0.001). In the presence of TNF-α, percentages of annexin V positive cells were 27.1 ± 10.6%, 34.2 ± 8.5%, 37.4 ± 14.6, and 54.1 ± 20.0% with 0, 1, 3 and 10 µM atorvastatin, respectively. The cytotoxic effect of statin was significant at each dose used (p≤0.02), in the presence of TNF-α. The cell death sensitising effect of atorvastatin was apparently mediated by down modulation of PKCβ activity, because it was reproduced by the specific PKCβ inhibitor LY317615 and prevented by the PKC activator phorbol-12-myristate-13-acetate (PMA). This effect was cell context dependent because it was not observed in HUVECs. PKCβ was found to be constitutively active in VSMCs but not in HUVECs, thereby explaining the differential effect among the two cell types. Measurement of phosphoPKCβ protein levels in arterial specimens confirmed increased activation of this kinase in the smooth muscle layer, in comparison with endothelium. We show that PKCβ provides survival signals to vascular smooth muscle cells and not the endothelium. CONCLUSION Our study suggests that atorvastatin enhances TNF-α-induced cell death in vascular smooth muscle- but not endothelial - cells; by a cell-context-dependent mechanism, involving PKCβ inhibition.

Left Heart Pump-Assisted Myocardial Revascularization Favorably Affects Neutrophil Apoptosis

ObjectivesGranulocyte apoptosis is a key control process in the clearance of neutrophils from inflammatory sites, and its rate is modulated by a number of inflammatory mediators. In this study, we investigated whether the use of left ventricular-assisted technique (LVA) in beating heart myocardial revascularization would exert less impact on neutrophil apoptosis compared with conventional cardiopulmonary bypass (CPB).MethodsForty consecutive patients who underwent myocardial revascularization were randomly assigned to LVA (group A, 21 patients) or CPB (group B, 19 patients). Blood samples for detection of interleukin-6, interleukin-8, and tumor necrosis factor-α were measured at baseline and at various time points postoperatively. Neutrophil apoptosis was detected by light microscopy as well as by the annexin-V assays together with the activity of caspase 3 on postoperative samples.ResultsPreoperative clinical and demographic data did not differ between the two groups. The two groups also were similar with respect to mortality, number of grafts performed, duration of extracorporeal circulation, and need for inotropes. However postoperatively, spontaneous apoptosis was significantly delayed in neutrophils from CPB patients compared with LVA patients. Neutrophils were activated, as indicated by increased surface expression of CD11b. Caspase 3 activity was found to be significantly reduced in neutrophils from CPB patients after 18 and 24 hours of culture.ConclusionsPatients who underwent beating heart myocardial revascularization with LVA show a better preserved neutrophil apoptosis than patients treated with the CPB.

Left ventricular-assisted myocardial revascularization favorably affects levels of circulating adhesion molecules and lung function

BACKGROUND We investigated whether the use of left ventricular-assisted (LVA) technique in beating heart myocardial revascularization would exert less impact on patients adhesion molecules and oxygenation index as compared with conventional cardiopulmonary bypass (CPB). METHODS Sixty-six consecutive patients undergoing myocardial revascularization were randomly assigned either to LVA (group A, 34 patients) or CPB (group B, 32 patients). Adhesion molecules and oxygenation indexes were measured at baseline and at various time points postoperatively. RESULTS Pre-operative clinical and demographic data did not differ between the 2 groups. The 2 groups were also similar with respect to mortality, number of grafts performed, duration of extracorporeal circulation, and need for inotropes. However, postoperatively patients treated with LVA had a reduced levels of adhesion molecules compared with patients treated with CPB, as indicated by a significant difference in endothelial leukocyte adhesion molecule-1 (P = .002), intercellullar adhesion molecule-1 (P = .0001), and vascular cell adhesion molecule-1 (P = .004). The oxygenation index at 1 (P = .04) and 3 hours (P = .03) postoperatively was better in the LVA group than in the CPB group. CONCLUSION Patients undergoing beating heart myocardial revascularization with LVA show reduced levels of adhesion molecules and better oxygenation index than patients treated with CPB.