Nicola Berlinghieri

Long-term Effects of Arteriovenous Fistula Closure on Echocardiographic Functional and Structural Findings in Hemodialysis Patients: A Prospective Study

BACKGROUND The arteriovenous fistula (AVF) provides an effective vascular access for hemodialysis; however, the associated hemodynamic effects may alter cardiac structure and function. The objective of this study is to evaluate the effect of AVF closure on functional and structural echocardiographic findings. STUDY DESIGN Prospective observational study. SETTING & PARTICIPANTS In a single center between 2003 and 2006, we enrolled 25 consecutive hemodialysis patients with AVF malfunction who underwent AVF closure and conversion to a tunneled central venous catheter because of exhaustion of alternative vascular sites and 36 matched controls with a well-functioning AVF. PREDICTOR AVF closure. OUTCOMES & MEASUREMENTS Outcomes were changes in findings on echocardiograms obtained before and 6 months after AVF closure for patients in the AVF-closure group and at baseline and 6 months later for controls. Echocardiographic measurements included left ventricular (LV) internal diastolic diameter, interventricular septum thickness, diastolic posterior wall thickness, LV mass (LVM), LVM index (LVMi), and LV ejection fraction (LVEF). Dialysis modality and scheme were unchanged. RESULTS In the AVF-closure group, LVM decreased from 225 +/- 55 to 206 +/- 51 g (P < 0.001) and LVMi decreased from 135 +/- 40 to 123 +/- 35 g/m(2) (P < 0.001). LV internal diastolic diameter, interventricular septum thickness, and diastolic posterior wall thickness decreased significantly, whereas LVEF increased from 56% +/- 7% to 59% +/- 6% (P < 0.001). No significant changes were observed in controls. In patients with AVF closure, LV morphologic characteristics showed a decrease in both eccentric and concentric hypertrophy in favor of normalization or a pattern of concentric remodeling. No significant changes were observed in controls. LIMITATIONS Use of matched rather than randomized controls. CONCLUSIONS Closure of an AVF determines a significant decrease in LV internal diastolic diameter, interventricular septum thickness, and diastolic posterior wall thickness. This is associated with significant improvement in LVEF, a significant decrease in LVM and LVMi, and a more favorable shift of cardiac geometry toward normality.

Aortic valve sclerosis as a marker of coronary artery atherosclerosis; a multicenter study of a large population with a low prevalence of coronary artery disease

UNLABELLED There are no studies analyzing the association between aortic valve sclerosis (AVS) and coronary artery disease (CAD) in a large and multicenter patient population with an overall low prevalence of CAD. We hypothesized that AVS could predict the presence and degree of CAD in patients with severe organic mitral regurgitation. METHODS We retrospectively analyzed consecutive patients with flail mitral leaflet who had coronary angiography for pre-surgical screening and not because suspect of CAD. End-points were considered: 1) any degree of CAD (stenosis>20%) and 2) obstructive CAD (stenosis>75% of at least one coronary artery). AVS was defined as focal areas of increased echogenicity and thickening of the leaflets. Traditional clinical risk factors were considered: age, male gender, hypertension (>140/90 mmHg or medical therapy), hypercholesterolemia (total cholesterol>200 mg/dl or statin), diabetes, family history of CAD and smoking habit. RESULTS 675 patients (mean age: 64±12; 27% female) formed the study population. Among patients with AVS, 60% and 39% had any-CAD and ob-CAD respectively, on the opposite among patients without AVS 12% and 7% had any-CAD and ob-cad. After adjustment for clinical risk factors, AVS was associated with a 22.7 fold increased risk of any degree of CAD (95% CI 8.1 63.6 p<0.0001) and with a 21.8 fold increased risk of obstructive-CAD (95% CI 6.6 71.9; p<0.0001). CONCLUSION In a large and multicenter sample of patient with flail mitral leaflet, AVS was strongly associated with the presence and degree of CAD independently of clinical risk factors.

Results of minimally invasive, video-assisted mitral valve repair in advanced Barlow's disease with bileaflet prolapse

OBJECTIVES Minimally invasive mitral valve (MV) surgery has recently gained popularity as the standard approach for MV repair, albeit there could be potential concerns about the feasibility of complex repair in the presence of extreme Barlows disease via a minimally invasive route. METHODS Fifty consecutive patients with advanced Barlows disease and bileaflet prolapse underwent minimally invasive, video-assisted MV repair via a 5 cm right antero-lateral thoracotomy with peripheral cannulation and external aortic clamping. Mean age, left ventricular ejection fraction and New York Heart Association class were 53±11 years, 62±7% and 3.1±0.8, respectively. Logistic EuroSCORE (mean) was 3.1. Either Custodiol (36 patients; 72%) or crystalloid (14 patients; 28%) cardioplegia were utilized. Complete rings (CE Classic or Physio) were implanted. Chordal reimplantation was carried out by means of polytetrafluoroethylene (PTFE) chordae. RESULTS All procedures were successfully performed with null/mild residual mitral regurgitation (MR) intraoperatively. A repair strategy of posterior leaflet resection and PTFE chordae implant (for anterior leaflet) or no-resect approach (only PTFE chordae on both leaflets) was performed in 62% (31 patients) and 38% (19 patients) of cases, respectively. Mean aortic cross-clamp and cardiopulmonary bypass times were 98±23 and 131±41 min, respectively. Hospital mortality was 0%. At a median follow-up of 761 days, 2 patients (4%) required reoperation (infective endocarditis: 1 patient; partial ring detachment: 1 patient) and valve rerepair was achieved in both. All patients are alive with a freedom from ≥2+ degree of MR of 100% at the latest echocardiographic evaluation. CONCLUSIONS Minimally invasive approach for complex MV repair is feasible and safe and provided excellent early and mid-term results.

USE OF N-3 POLYUNSATURATED FATTY ACIDS TO MAINTAIN SINUS RHYTHM AFTER CONVERSION FROM PERSISTENT ATRIAL FIBRILLATION. A PROSPECTIVE RANDOMIZED STUDY

Background: The risk of atrial fibrillation recurrences (AFR) after cardioversion(CV) is one of the most important problems in the treatment of this arrhythmia. Literature data showed that amiodarone is the most effective antiarrhythmic drug in sinus rhythm maintenance.Several studies have recently demonstrated that also non-antiarrhythmic drugs as RAS inhibitors (RASi) and n-3 PUFAs can prevent atrial remodeling and reduce AF occurrence or recurrences. At present only few evidences suggested the beneficial effect of n-3PUFAS in AF. This study has evaluated the role of n-3 PUFAs in addition to amiodarone and RASi on maintaining sinus rhythm (SR) after conversion from persistent AF.

Jugular pacing lead extraction with laser sheath: a case report

Over the past 20 years, the number of patients with pacemakers (PM) or implantable cardioverter defibrillators has risen markedly; consequently, an increasing number of lead-removal procedures have become necessary. A 64-year-old woman presenting with an infected device pocket and positive bacterial cultures (Staphylococcus aureus) was admitted to our department for lead removal; in 1991, she underwent VVI PM implantation for atrioventricular II degree Mobitz 1 block, and a unipolar lead was introduced via the left jugular vein. The procedure was performed in our Electrophysiology Lab with a cardiac surgeon on standby, using an excimer laser system emitting the energy at the tip of a flexible, fibre-optic 12 F sheath, developed by Spectranetics, Inc., Colorado Springs, CO, USA.

PROGNOSTIC ROLE OF ATRIAL FIBRILLATION AND HEART RATE CONTROL IN CHRONIC HEART FAILURE PATIENTS

methods: we performed a retrospective analysis of pts with reduced Left Ventricular Ejection Fraction (LVEF<45%) and stable clinical condition (neither events nor therapeutic changes in the previous 3 months) followed in our HF clinic. Demographic, clinical, echocardiographic and laboratory parameters were recorded. We considered as composite endpoint the occurrence of cardiovascular (CV) death and HF or CV hospitalization at 1 year follow-up. We analyzed clinical characteristics and events in sinus rhythm (SR) pts and in AF pts, stratified according to median baseline HR value (70 bpm).

BETA-1 ADRENERGIC RECEPTOR GENE POLIMORPHISM IN HEART FAILURE: A GENDER SPECIFIC CLINICAL AND PROGNOSTIC ROLE?

Results: No significant differences according to gender were observed in distribution of genotypes and demographic or clinical characteristics. Females (Fs) (n=105) vs males (Ms) (n=367) had a lower prevalence of ischemic disease (31 vs 199, p=0.04) and a higher EF (36.6±10.5 vs32.2±10.6%, p=0.001). Fs with the Arg389Arg homozygosis (n=35), compared to Fs with Arg389Gly+Gly389Gly (n=40) genotype, showed a worse NYHA class (2.5±0.6 vs 2.2±0.5, p=0.0247) and a trend towards a lower EF, a higher total (22.9% vs 7.5%, p=0.05) and CV (14.3% vs7.5%, p=0.05) mortality. On the contrary, there were no differences among gene polymorphisms in Ms pts. Arg389Arg and Arg389Gly Fs had a higher EF vs Arg389Arg and Arg389Gly Ms (respectively 35.6±9.9 vs 31.6±10.9% p=0.04, 38.3±11.1 vs 33.1±9.8%, p=0.009). Moreover, Arg389Arg Fs vs Arg389Arg Ms showed a trend towards a higher total and CV mortality (22.9% vs 16.1% and 14.3% vs12.5%). In pts with idiopathic dilated cardiomyopathy (IDC) (n=212), Arg389Arg Fs (n=20) showed a trend towards a worse NYHA class, a lower EF and a worse peak VO2, compared to Arg389Gly+Gly389Gly Fs (n=24). Moreover, Arg389Arg Fs vs Arg389Gly+Gly389Gly showed a greater prevalence of CV (30%vs25%) and HF hospitalizations (20%vs16%) and a significant higher total (25% vs 4.2%, p=0.006) and CV (10% vs 4.17%, p=0.046) mortality.

OP-001 PROGNOSTIC STRATIFICATION IN DIABETIC PATIENTS ADMITTED FOR ACUTE CORONARY SYNDROME

Objective: To assess the different prognostic role of clinical, angiographic and metabolic parameters on prognosis in diabetic pts with preserved (EF >45%) or impaired LV systolic function (EF 75 years, presence of smoke, hypercholesterolemia, renal insufficiency, Insulin therapy, previous CAD, CABG, PAD, EPA at admission) dichotomized on basis of EF impaired or preserved. Differently from pts with preserved LV function, in pts with LV systolic dysfunction (EF 7%) and smoking at the time of admission and history of CAD had a negative prognostic value, while previous CABG and hypercholesterolemia favourably affected the survival. Moreover Renal Insufficiency, age and insulin therapy didn’t show any predictive value when EF was <45%. Conclusions: The different predictive role of many important prognostic variables between pts with and without LV systolic dysfunction underline the importance of risk stratification considering this parameter. This may allow to better finalize our preventive interventions.