Oreste Fabio Triolo

Associations of rs3918242 and rs2285053 MMP-9 and MMP-2 polymorphisms with the risk, severity, and short- and long-term complications of degenerative mitral valve diseases: a 4.8-year prospective cohort study

BACKGROUND Degenerative forms of mitral valve diseases (MVDs) are very complex pathologies. Thus, it is difficult to make generalizations about the disease pathways or genetic risk factors contributing to these diseases. However, a key role of metalloproteinases (MMPs) in their pathophysiology is emerging. Thus, we performed for the first time a perspective study to assess eventual associations of some functional single nucleotide polymorphisms (SNPs) in MMP-2 and MMP-9 genes with the MVD risk, symptom severity, and short- and long-term (4.8 years) complications. MATERIALS AND METHODS For this purpose, 90 patients and two control groups were genotyped for rs3918242, rs243865, and rs2285053 MMP-2 and MMP-9 gene SNPs, and systemic levels of pro-atrial natriuretic peptide (pro-ANP) and two enzymes were quantified and correlated to genotypes of MMP-2 and MMP-9 SNPs studied. In addition, associations between these SNPs and symptom severity and short- and long-term (4.8 years) complications were evaluated. RESULTS Interestingly, rs3918242 MMP-9 and rs2285053 MMP-2 SNPs were significantly represented in cases than two control groups and were associated with a higher MVD risk, as demonstrated using dominant/recessive models. Cases stratified for NYHA symptoms and particularly those NYHA III+IV with rs3918242 CT+TT MMP-9 and rs2285053CT+TT genotypes also showed higher severity related to significant higher systemic levels of MMP enzymes and pro-ANP at enrolment and 4.8 follow-up times. In addition, cases with these genotypes and particularly those NYHA III+IV had a very significant percentage of complications, particularly at the 4.8 follow-up. Surprisingly, 20% of patient controls developed MVD at 4.8-year follow-up and were carriers of these genotypes. CONCLUSION Thus, the associations observed seem to suggest that the two SNPs might represent useful biomarkers and targets for preventing and monitoring MVDs and developing personalized treatments, consenting a more appropriate management and outcome.

Advantages of Minimal Access Versus Conventional Aortic Valve Replacement in Elderly or Severely Obese Patients

Objective The aim of our study was to investigate potential clinical advantages of minimal access versus conventional surgical approach in older and severely obese patients undergoing isolated aortic valve replacement (AVR). Methods One hundred thirty-five patients undergoing isolated primary AVR were enrolled. Propensity score matching was used to compare 42 selected patients operated on ministernotomy (MS, group B) with 42 selected patients operated on full sternotomy (FS, group A). Results After propensity score matching, the two groups were comparable in terms of preoperative characteristics. Cardiopulmonary bypass time was significantly longer in MS group compared with the FS group [median (95% confidence level or CL), 103 (98.7–106.4) vs 94 (83.6–99) minutes, respectively; P = 0.0019]. No significant difference was observed in aortic cross-clamp time [median (95% CL), 73 (71.1–78.2) vs 69.5 (62.7–83) minutes; P = 0.4]. Significantly shorter ventilation time [median (95% CL), 13 (12–16.4) vs 24 (22–25) hours; P = 0.00018], intensive care unit stay [median (95% CL), 1 vs 2 days; P = 0.00017], and hospital stay [median (95% CL), 8.5 (8–10.8) vs 13.5 (11.1–14) days; P = 0.00030] were shown in the MS group. The age subgroup analysis showed that statistical significance for mechanical ventilation, intensive care unit, and hospital stay was specific for patients older than 75 years. The analysis of body mass index quartile showed that statistical significance for mechanical ventilation was specific for patients in the fourth quartile. Conclusions Minimal access AVR is a reproducible, safe, and effective surgical option in patients candidate for isolated AVR, and our study suggests a faster recovery when used in severely obese or older patients.

Microvascular angina in diabetic patients with uninjured coronary arteries

AimsThe study aims at the evaluation, of patients with chest pain and uninjured coronary arteries, and the impact of diabetes mellitus on coronary microcirculation. Moreover we want to verify whether a correlation between myocardial scintigraphy results and coronary angiography or not.MethodsThe study population included 316 patients (173 males,143 females) with uninjured coronary arteries. Patients with chest pain (208) were divided into two populations: diabetics (72) and non-diabetics (136).We compared 66 patients with a myocardial scintigraphy with results of angiographic indexes. On angiographic images we evaluated, on the three major epicardial, Gibson’s indexes (TFC, MBG), the Yusuf’s index(TMBS) and a new index: Total Timi Frame Count (TTFC).ResultsPatients with positive scintigraphy had a worse TMBS than patients with negative scintigraphy (p=0.003) and a lower TFC of healthy vessels than diseased vessels (p=0.0001). We found a worse coronary microcirculation in diabetic patients with lower values of MBG and TMBS (p=0.02),compared with non- diabetics. New index TTFC is usually higher in diabetics than non-diabetic patients.ConclusionThe study of microcirculation by coronary angiography and myocardial scintigraphy shows a good correlation between two methods. The analysis of diabetic patients and non-diabetic with chest pain and uninjured coronary arteries has led to assess that diabetic population has a major microcirculation disease.

Early structural degeneration of Mitroflow aortic valve: another issue in addition to the mismatch?

We reported two cases of early structural valve degeneration (SVD) with Mitroflow prosthesis in aortic position in patients above the age of 65 years. Microscopic aspects have been analysed to investigate the intrinsic mechanism of SVD. New techniques to improve the structure and the preservation of this prosthesis are needed in order to reduce potential dangerous early complications.

Assessment of No-Reflow Phenomenon by Myocardial Blush Grade and Pulsed Wave Tissue Doppler Imaging in Patients with Acute Coronary Syndrome.

Background: No-reflow phenomenon is a complication of myocardial revascularization and it is associated with a worse prognosis. Materials and Methods: A prospective study was carried out enrolling patients with acute myocardial infarction (64 patients, 49 male and 15 female, median age 64.9 ± 10.61 years), both STEMI and NSTEMI, who underwent myocardial revascularization with percutaneous coronary intervention (PCI). TIMI flow and Myocardial Blush Grade (MBG) were assessed at baseline (T0), in addition to tissue Doppler imaging (TDI) and electrocardiogram. Cardiological evaluation was also performed at T1 (one month after PCI) and T2 (every year after revascularization for a mean follow-up of 24.9 months ± 6.93 months). Patients were divided into two groups on the basis of MBG. Results: In the present study, we found at T1 a significant association between MBG and dyslipidemia (P = 0,038) and NYHA class and MBG (P = 0,040), among clinical variables and cardiovascular risk factors. Moreover, a statistically significant relationship was observed between MBG and a new echocardiographic index of systolic and diastolic dysfunction, the EAS index measured with tissue Doppler imaging (P = 0,013). At T2, the EAS parameter was also significantly impaired in patients with reduced MBG, compared to patients with normal MBG (P = 0,003). Conclusions: This study demonstrates that the combined evaluation of systolic and diastolic dysfunction by EAS index, according to the literature, could detect a subclinical ventricular dysfunction due to a perfusion defect. Therefore, EAS index could be a useful parameter to be measured in the follow-up of patients undergoing revascularization.

Effects of Essential Hypertension on coronary Microcirculation: Focus on a Population of Hypertensives Affected by Microvascular Angina

A correlation between essential hypertension and the establishment of myocardial ischemia is nowadays universally accepted [1-3]. Coronary atherosclerosis is deemed to be the most important process through which the capability of coronary district to supply a blood flow consistent with myocardial needs can be impaired, until the onset of an anginal syndrome [4,5]. Hypertension is one of the most widespread cardiovascular risk factors underlying the establishment of an atherosclerotic deterioration of arterial walls; furthermore high blood pressure levels determine a higher risk to incur in a major cardiovascular event, by destabilizing atherosclerotic plaques and boosting platelets tendency to aggregate [6]. Nevertheless, when a cardiac catheterism is performed, in order to unveil the causes of an anginal syndrome according to the positivity of exertional tests and/ or myocardial perfusion scintigraphies, showing up the presence of an ischemic territory, the angiographic visualization of unharmed coronary trees is not infrequent, occurring in an overall percentage of cases settled around 30% [7]: in this context, a microvascular angina should be hypothesized. In some of these cases, however, the reason for the ischemia is still to be found within epicardial vessels (coronary spasms, myocardial bridges, endothelial dysfunction), whereas in some others none of these suitable causes can be found. In these patients, ischemia can derive from microvascular district, physiological venue of the 80% of flow resistance. A microvascular dysfunction can be assessed when its regulatory mechanisms are altered, and such abnormality leads to a decrease of coronary flow reserve, without any macroscopic impairment of macroscopic coronary vessels [8]. Nevertheless, its diagnostic definition is usually achieved by a process of exclusion, when an anginal syndrome substained by exertional tests positivity cannot be ascribed to a narrowing of subepicardial vessels’ lumen. Such situation has often been associated to the relief of essential hypertension: a considerable percentage of hypertensives, indeed, copes with the experience of chest pain, without any underlying coronary stenosis. The absence of a macrovascular impairment, in these cases, seems to deny the presence of an hypoperfused territory notwithstanding the results of the nuclear imaging tests, having been coronarographies considered, so far, unable to visualize microvascular district. In this study, we verified whether hypertensives’ coronaries, seen by performing an angiographic study, are properly definable as normal, even in presence of an overt exertional angina, or if they should rather be barely defined as “macroscopically unharmed”, through the clues of a microvascular alteration.