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Perioperative Red Blood Cell Transfusion and Outcome in Stable Patients after Elective Major Vascular Surgery

OBJECTIVESnDefinitive evidence that red blood cell transfusion improves outcome after vascular surgery is lacking. The aims of the study were to determine, among stable consecutive patients who underwent elective major vascular surgery, (1) the association between postoperative transfusion and 30-day death, myocardial infarction, and both, and (2) and if this association differs according to the presence of postoperative anaemia (haemoglobin value less than 9.0 g/dL within 7 days after surgery).nnnMETHODSnA retrospective observational study was conducted on 359 patients prospectively screened according to the ACC/AHA guidelines for preoperative risk in non-cardiac surgery. Main outcome was 30-day death; secondary outcomes 30-day myocardial infarction, and composite of 30-day myocardial infarction or death.nnnRESULTSnOf the patients included, 95 (26.5%) received at least one unit of red blood cells. Patients who received transfusion had a significantly increased hazard of 30-day death (hazard ratio [HR] 11.72, 95% confidence interval [CI] 3.92-35.10; p<0.0001), myocardial infarction (HR 3.3, 95% CI 1.7-6.1; p=0.0003), and both (HR 4.0 95% CI 2.2-7.3; p<0.0001). Such associations held even after adjusting for baseline characteristics, surgical risk, bleeding, and propensity to receive transfusion. There was a significant interaction between transfusion and postoperative anaemia (p=0.012). In patients without anaemia, transfusion was associated with higher risk of 30-day death (HR 19.20, 95% CI 3.99-92.45; p=0.007), myocardial infarction (HR 5.05, 95% CI 2.23-11.44; p=0.0001), and both. Conversely, in patients with anaemia this association was not significant.nnnCONCLUSIONSnIn patients who underwent elective major vascular surgery, perioperative transfusion was associated with a significantly increased risk of 30-day events which was more attributable to patients with lesser degree of anaemia. Our data caution against the use of liberal transfusion in stable vascular surgery patients.

Menopause and cardiovascular risk.

Menopause is not a disease, but a physiologic phase of a womans life, due to the changes of their hormonal status. Fastidious symptoms may be associated with changes in the metabolism together with new cardiovascular risk factors, particularly aggressive for the female cardiovascular system, unprepared because of the protection due to the fertile period. Changes of the lipid profile, obesity, hypertension, glucose intolerance and diabetes mellitus may intervene as severe risk factors. Cardiovascular disease represents therefore the most frequent cause of mortality and morbidity also in the female gender more than cancer either in the United States as in Europe. The risks related to post-menopause are mainly due to the abrupt interruption of estrogen, which has indirect protective effects on lipid, glycidic metabolism and direct effects on vessel function. They have, in fact, vasodilator action due to nitric oxide release, calcium-antagonist like action and an antiproliferative effect on smooth muscle cells. Post-menopause is also frequently associated with hypertension, the most frequent related factor to coronary artery disease. Hypertension is due to increased body mass index, with insulin-resistance, sodium retention, increased blood viscosity and estrogen deficiency with increased smooth muscle cell proliferation which determines an increase in systemic vascular resistance. Age and estrogen deficiency are together the most important cause of cardiovascular risk in post-menopause. The discovery of alpha and recently beta estrogen receptors on coronary female vessels unaffected by atherosclerosis either during pre and post-menopause phase are possible key of interpretation of pathophysiology of coronary artery disease in women, with important therapeutic consequence.

Chronic total coronary occlusion in patients with intermediate viability: value of low-dose dobutamine and contrast-enhanced 3-T MRI in predicting functional recovery in patients undergoing percutaneous revascularisation with drug-eluting stent

PurposeMyocardial viability was evaluated by magnetic resonance imaging (MRI) in patients with chronic total coronary occlusion (CTO) treated with a drug-eluting stent. Change in left ventricular ejection fraction (LVEF) was analysed.Materials and methodsTwenty-three patients with CTO underwent delayed-enhancement (DE) and low-dose dobutamine MRI (LD). Diastolic wall thickness (DWT), dobutamine-induced systolic wall thickening (SWT) and DE transmural extension were quantitatively assessed in vessel-related segments, calculating the contribution of viable tissue to SWT, expressed as viability index (VI)=[SWT×(100 − DE)]/100. Patients with transmural enhancement were excluded from revascularisation. At 6 months follow-up, patients underwent coronary angiography (CA) and MRI. Functional recovery was defined as a 2-mm increase in SWT.ResultsTransmural enhancement (mean DE 62.88±37.18] was present in three patients. Mean DWT, SWT, VI and DE of recanalised patients were 8.03±2.35, 2.64±1.56, 1.77±1.48 mm and 41.97±30.32. Revascularisation was successful in 14/16. Follow-up CA showed patency of treated vessels. Functional recovery was achieved in 13 patients. Functional recovery showed significant correlation with SWT (β 1,779, p=0.015), and even higher correlation with VI (β 2.032, p=0.011). LVEF improved significantly [Delta 95% confidence interval (CI) −4.47, p=0.0203).ConclusionsInvasive CTO treatment has beneficial effects on myocardial contractility that can be predicted by VI, and on LVEF.RiassuntoObiettiviValutazione mediante risonanza magnetica (RM) della vitalità miocardica in pazienti con occlusione coronarica cronica (CTO) trattati mediante stent medicati. Valutare la modificazione della frazione di eiezione (FE).Materiali e metodiVentitré pazienti con CTO sono stati sottoposti RM con contrasto e dobutamina a bassa dose. Sono stati valutati quantitativamente spessore telediastolico (DWT), telesistolico (SWT) e enhancement tardivo (DE) nei segmenti relativi al vaso occluso, calcolando il contributo del tessuto vitale a SWT, espresso come viability index (VI)=[SWT×(100−DE)]/100. Pazienti con infarto transmurale sono stati esclusi dalla rivascolarizzazione. A 6 mesi si esegue follow-up angiografico e RM. Recupero funzionale (RF) è definito come incremento di 2 mm di SWT.RisultatiEnhancement transmurale (62,88±37,18) era presente in 3 pazienti. DWT, SWT, VI e DE medi dei pazienti rivascolarizzati erano 8,03±2,35, 2,64±1,56, 1,77±1,48 mm e 41,97±30,32. Rivascolarizzazione efficace era presente in 14/16. La CA di follow-up ha mostrato pervietà di tutti i vasi trattati. Il RF è stato ottenuto in 13 pazienti. Il RF ha correlazione significativa con SWT (β 1,779, p=0,015) e VI (β 2,032, p=0,011). EF è migliorata significativamente (delta 95% CI −4,47, p=0,0203).ConclusioniIl trattamento percutaneo delle CTO ha effetti positivi sulla contrattilità miocardica, che possono essere predetti dal VI, e sulla FE.

3-Tesla MRI for the evaluation of myocardial viability: a comparative study with 1.5-Tesla MRI

Purpose . We compared 3-Tesla (3-T) and 1.5-Tesla (1.5-T) cardiac magnetic resonance imaging (MRI) for the assessment of myocardial viability in nearly identical experimental conditionsMaterials and methods . Thirty-five patients (mean age 63±11; 94.2% men) submitted to primary coronary angioplasty underwent both 3-T and 1.5-T cardiac MRI, which was considered the gold standard. Comparison was performed on the basis of the same viability imaging protocol, which included resting cine-MR [balanced fastfield echo (b-FFE) sequence] followed by contrastenhanced MR to evaluate perfusion and delayed enhancement (DE). We then performed functional index measurements and visual estimation of kinesis, perfusion and DE referring to a 5-point scale. Image quality was assessed on the basis of signal to noise ratio (SNR) and contrast to noise ratio (CNR)Results . We found nonsignificant differences between the two scanners ( p =NS) in measuring the functional and viability parameters. Myocardial SNR was significantly higher with 3-T MRI compared with 1.5-T MRI (61.3% gain). Even though a loss of CNR was recorded in b-FFE and in first-pass perfusion sequences (12.4% and 23.7%, respectively), on DE images, we quantified the increase of SNR and CNR of infarction of 387.8% and 330%, respectivelyConclusions . We found that 3-T MRI showed high concordance with 1.5-T MRI in the evaluation of functional and viability parameters and provided better evidence of damaged myocardiumRiassuntoObiettivo . Confrontare la risonanza magnetica (RM) cardiaca a 3 Tesla (3 T) con quella a 1,5 Tesla (1,5 T) per la valutazione della vitalità miocardica in condizioni sperimentali essenzialmente identicheMateriali e metodi . Trentacinque pazienti (età media di 63±11; 94,2% maschi) dopo essere stati sottoposti ad angioplastica primaria sono stati esaminati sia con RM cardiaca a 3 T che RM cardiaca a 1,5 T, che è stata considerata il gold standard. Il confronto è stato effettuato basandosi sullo stesso protocollo di imaging di vitalità che includeva: cine-MR a riposo (sequenza b-FFE) seguito da somministrazione di contrasto per la valutazione della perfusione e dell’enhancement tardivo (DE). È stata poi eseguita la misura degli indici funzionali e l’analisi visuale della cinesi, perfusione e dell’enhancement tardivo basandosi su una scala a 5 punti. La qualità di immagine è stata valutata sulla base del rapporto segnale-rumore (SNR) e del rapporto contrasto-rumore (CNR)Risultati . Abbiamo trovato una differenza statisticamente non significativa tra le due apparecchiature RM (p=NS) nella misurazione dei parametri funzionali e di vitalità. Il SNR miocardico è risultato significativamente più alto con lo scanner a 3 T MR rispetto a quello a 1,5 T (61,3% guadagno). Nonostante sia stata apprezzata una perdita di CNR nelle sequenze b-FFE e di perfusione al primo passaggio (12,4% e 23,7% rispettivamente), nelle immagini di enhancement tardivo abbiamo quantificato un aumento del SNR e CNR del tessuto infartuato del 387,8% e 330% rispettivamenteConclusioni . La RM a 3 Tesla ha dimostrato una alta concordanza con quella a 1,5 Tesla riguardo alla valutazione dei parametri funzionali e di vitalità con una più cospicua evidenza del miocardio danneggiato

Impairment of functional integrity of the vasculature is not changed in patients starting abacavir

Abstracts of the Ninth International Congress on Drug Therapy in HIV Infection Meeting abstracts – A single PDF containing all abstracts in this Supplement is available here . http://www.biomedcentral.com/content/pdf/1758-2652-11-S1-info.pdf