Michael Spartalis

Role of platelet-rich plasma in ischemic heart disease: An update on the latest evidence.

Myocardial infarction is the most common cause of congestive heart failure. Novel strategies such as directly reprogramming cardiac fibroblasts into cardiomyocytes are an exciting area of investigation for repair of injured myocardial tissue. The ultimate goal is to rebuild functional myocardium by transplanting exogenous stem cells or by activating native stem cells to induce endogenous repair. Cell-based myocardial restoration, however, has not penetrated broad clinical practice yet. Platelet-rich plasma, an autologous fractionation of whole blood containing high concentrations of growth factors, has been shown to safely and effectively enhance healing and angiogenesis primarily by reparative cell signaling. In this review, we collected all recent advances in novel therapies as well as experimental evidence demonstrating the role of platelet-rich plasma in ischemic heart disease, focusing on aspects that might be important for future successful clinical application.

Hypertension in patients with type 2 diabetes mellitus: Targets and management

Two-thirds of patients with type 2 diabetes mellitus (T2DM) have arterial hypertension. Hypertension increases the incidence of both micro- and macrovascular complications in these patients, while the co-existence of these two major risk factors leads to a four-fold increased risk for cardiovascular disease (CVD) compared with normotensive non-diabetic controls. The aim of this article is to comprehensively review the literature and present updated information on targets for blood pressure (BP) and on the management of hypertension in patients with T2DM. A BP target of <140/90 mmHg applies to most patients, but individualization is always important. All classes of antihypertensive drugs can be used in the management of hypertension in patients with T2DM, as long as they are effective and safe and after taking co-morbidities into account. Angiotensin-converting-enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) are the ideal choice for initial or early treatment of hypertension in patients with T2DM and albuminuria. Combination of two or more drugs seems to be inevitable as most of these patients demonstrate resistant hypertension. The combination of ACE inhibitors with ARBs should be avoided. Thiazide and thiazide-like diuretics might be beneficial, alone or in a fixed-dose combination with ACE inhibitors or ARBs. Calcium channel blockers (CCBs) constitute an ideal option as a second- or third-line agent. Beta-blockers are not considered as first-line antihypertensive agents, except for those patients with heart failure or previous myocardial infarction. The addition of mineralocorticoid receptor antagonists to a triple-drug therapy seems the next ideal step. Gender-specific characteristics regarding BP, T2DM and CVD should be taken into consideration, even if different recommendations do not exist yet.

Letter by Spartalis et al Regarding Article, “Modifiable Risk Factors and Atrial Fibrillation”

We read with great interest the article by Lau et al.1 The authors present an excellent article focusing on strategies aiming at lowering the risk of atrial fibrillation (AF) development and progression. The authors conclude that targeting modifiable risk factors is an essential fourth pillar of AF care alongside appropriate anticoagulation and rate and rhythm control. We totally agree. However, the authors state that the risk of AF is reduced by weight loss after bariatric surgery.1 A recent self-controlled …

Comment on “Establishing a Porcine Model of Small for Size Syndrome following Liver Resection”

1Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK 2Laboratory of Experimental Surgery and Surgical Research, University of Athens, Medical School, Ag. Thoma 15B, 11527 Athens, Greece 3Department of Surgery, Mercy University Hospital, Grenville Place, Cork, Ireland 4First Surgery Department, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece

Cytokines as biomarkers of inflammatory response after open versus endovascular repair of abdominal aortic aneurysms: a systematic review

The repair of an abdominal aortic aneurysm (AAA) is a high-risk surgical procedure related to hormonal and metabolic stress-related response with an ensuing activation of the inflammatory cascade. In contrast to open repair (OR), endovascular aortic aneurysm repair (EVAR) seems to decrease the postoperative stress by offering less extensive incisions, dissection, and tissue manipulation. However, these beneficial effects may be offset by the release of cytokines and arachidonic acid metabolites during intra-luminal manipulation of the thrombus using catheters in endovascular repair, resulting in systemic inflammatory response (SIR), which is clinically called post-implantation syndrome. In this systematic review we compared OR with EVAR in terms of the post-interventional inflammatory response resulting from alterations in the circulating cytokine levels. We sought to summarize all the latest evidence regarding post-implantation syndrome after EVAR. We searched Medline (PubMed), ClinicalTrials.gov and the Cochrane library for clinical studies reporting on the release of cytokines as part of the inflammatory response after both open/conventional and endovascular repair of the AAA. We identified 17 studies examining the cytokine levels after OR versus EVAR. OR seemed to be associated with a greater SIR than EVAR, as evidenced by the increased cytokine levels, particularly IL-6 and IL-8, whereas IL-1β, IL-10 and TNF-α showed conflicting results or no difference between the two groups. Polyester endografts appear to be positively correlated with the incidence of post-implantation syndrome after EVAR. Future large prospective studies are warranted to delineate the underlying mechanisms of the cytokine interaction in the post-surgical inflammatory response setting.

Mitral valve prolapse: an underestimated cause of sudden cardiac death—a current review of the literature

Mitral valve prolapse (MVP) is a common valve abnormality in general population. Despite the general belief of a benign disorder, several articles since the 1980s report sudden cardiac death (SCD) in MVP patients, with a substantial percentage of asymptomatic young individuals. The problem is to detect those patients at increased risk and implement methods that are suitable to prevent cardiac arrest. This review investigates the correlation between MVP and SCD, the understanding of the pathophysiology, the strategies for detecting those at risk and treatment options. A complete literature survey was performed using PubMed database search to gather available information regarding MVP and SCD. A total of 33 studies met selection criteria for inclusion in the review. MVP is an underrated cause of arrhythmic SCD. The subset of patients with malignant MVP who may be at greater risk for SCD is characterized by young women with bileaflet MVP, biphasic or inverted T waves in the inferior leads, and frequent complex ventricular ectopic activity with documented ventricular bigeminy or ventricular tachycardia (VT) and premature ventricular contractions (PVCs) configurations of outflow tract alternating with fascicular origin or papillary muscle. MVP is a common condition in the general population and is often encountered in asymptomatic individuals. The existing literature continues to generate significant controversy regarding the association of MVP with ventricular arrhythmias and SCD. Early echocardiography and cardiac magnetic resonance (CMR) are essential, as is a greater understanding of the potential electrophysiological processes of primary arrhythmogenesis and the evaluation of the genetic substrate.

Letter by Moris et al Regarding Article, “One-Year Outcomes After Minor Stroke or High-Risk Transient Ischemic Attack: Korean Multicenter Stroke Registry Analysis”

Park et al1 published a large observational study, conducted in a Korean stroke registry, demonstrating lower than expected rates of stroke recurrence, myocardial infarction, vascular death, and all-cause death after a minor ischemic stroke or transient ischemic attack (TIA). This study also highlighted the effect of early medical intervention on outcomes after stroke or TIA. These findings should be taken into consideration among an increasing body of literature highlighting the effect of early surgical intervention of patients with TIA or minor stroke. More specifically, recent evidence favor early carotid endarterectomy in patients with carotid stenosis and neurological symptoms similar to the inclusion criteria of this study because carotid endarterectomy was found safe in …

Safety concerns regarding ablative radiotherapy for ventricular tachycardia

https://doi.org/10.1016/j.radonc.2018.06.009 0167-8140/ 2018 Elsevier B.V. All rights reserved. Dear Editor, We read with great interest the article by Jumeau et al, titled ‘‘Rescue procedure for an electrical storm using robotic non-invasive cardiac radio-ablation” [1]. The authors provide a detailed description of an interesting and unusual clinical scenario and should be applauded for their thoughtful and meticulous workup and treatment of what must have been a challenging case [1]. The authors report that non-invasive stereotactic cardiac radiotherapy as an ablation strategy of ventricular tachycardia (VT) resulted in no complications after four months follow-up [1]. Conclusions should be drawn with caution because early and late effects of chest radiation can lead to radiotherapy-induced cardiovascular damage [2]. These radiation-induced cardiac effects have been observed with doses from 30 to 40 grays [2], and there is still the issue of tissue-specific vulnerability to radiation injury which remains elusive [3]. An obvious challenge of using radiotherapy to attack a cardiac target is motion. Although cardiac contraction is part of the problem, cardiac displacement during respiration results in even more movement of the heart within the chest [3]. How did the authors overcome this challenge? The authors did not observe any cardiac device malfunction after radiotherapy [1]. Bagur et al in a large population of patients with cardiac implantable devices undergoing radiotherapy for cancer treatment showed that the rate of newly diagnosed device malfunction was 7% [4]. Radioablation is an attractive alternative strategy to treat VT [1,5]. However, with longer periods of survival, late effects of chest radiation may become clinically evident years after completion of therapy. As a result, gains could come at a higher cost. Further large studies are required before we can attribute ablative radiotherapy as an alternative ablation strategy. Conflict of interest

Controversy Regarding the Beneficial Effect of Bariatric Surgery on the Incidence of Atrial Fibrillation

Dear Editor, We read with great interest the article by Yılmaz et al. titled BAssessment of Atrial Fibrillation and Ventricular Arrhythmia Risk After Bariatric Surgery by P Wave/QT Interval Dispersion^ [1]. The authors investigated whether weight reduction by bariatric surgery has an effect on P wave dispersion (PWD), a predictor of atrial fibrillation (AF), and corrected QT interval dispersion (CQTD) [1]. The authors concluded that PWD values of patients were attenuated after bariatric surgery, suggesting an indirect reduction in the risk of AF [1]. We congratulate the authors for this excellent study. However, the study supports an electrophysiological benefit for bariatric surgery in the non-AF population only [1]. The study by Yılmaz et al. has certain methodological flaws, and the results should be considered with caution [1]. The primary concern is that the results are drawn from a highly selected population, where patients are free from AF and known AF risk factors such as coronary artery disease, heart failure, cardiomyopathies, renal failure, and chronic obstructive pulmonary disease (COPD) [1]. The study group is young, and there is no advanced atrial remodeling that we would expect in obese patients [1]. Consequently, this may reflect a selection bias as well. The beneficial effect of weight loss regarding AF is well established in the literature [2–5].Weight loss directly impacts AF risk factors such as hypertension, diabetes, hypercholesterolemia, inflammation, and COPD andmediates reverse atrial remodeling [2–5]. New evidence by Shimada et al. regarding the beneficial effect of bariatric surgery on the incidence of AF contradicts current knowledge though [2, 3]. Shimada et al. showed that bariatric surgery was associated with an increased risk of AF burden [2, 3]. Bariatric surgery is correlated with impaired nutrient absorption, anemia, higher sympathetic tone, higher catecholamine concentration, and inflammation [2, 3, 6–8]. All of the above are possible mechanisms that could explain the increased risk of AF after bariatric surgery [2, 3, 6–8]. Further large-scale prospective randomized clinical studies with incident AF as a predefined endpoint are required before we can actually correlate bariatric surgery with a reduced AF burden.

Platelets-to-lymphocyte ratio and esophageal cancer

We read with great interest the recent publication by Deng et al . (1) published in the March 2018 issue of Journal of Thoracic Disease . The authors have performed a meta-analysis in order to examine the role of platelet to lymphocyte ratio (PLR) in the prognosis of esophageal cancer and also to evaluate the relationship with tumor pathological characteristics.