Pekka Keto

Relation of aortic stiffness to factors modifying the risk of atherosclerosis in healthy people.

To identify factors predicting aortic stiffness, we studied the modulus of elasticity of the thoracic aorta in relation to sex, obesity, blood pressure, physical activity, smoking, ethanol consumption, salt intake, and serum lipid and insulin levels in 55 healthy people born in 1954. A transverse cine magnetic resonance image of the thoracic aorta was made, and the modulus of elasticity was determined as brachial artery cuff pulse pressure/aortic strain, where strain was determined as the ratio of pulsatile aortic luminal area change to the diastolic luminal area. The average of measurements made in the ascending and descending aorta was used as the elastic modulus of the thoracic aorta. Habitual physical activity, smoking, and alcohol use were quantified by 2-month prospective daily recording and salt intake by 7-day food records. The aortic elastic modulus ranged from 100 to 2091 10(3) dyne/cm2 (median, 390 10(3) dyne/cm2). In multiple regression analyses, log10 aortic elastic modulus was related directly to mean blood pressure (standardized coefficient [beta] = .37, P = .002), serum high-density lipoprotein cholesterol (beta = .36, P = .012), square root of daily energy expenditure in physical activity (beta = .33, P = .005), and log10 serum insulin (beta = .27, P = .047) and inversely to serum low-density lipoprotein cholesterol (beta = -.26, P = .035). A relation to salt intake was also observed, but the regression slope was dependent on mean blood pressure (P = .005 for interaction). These data suggest that many modifiable constitutional and lifestyle characteristics may contribute to the stiffness of the thoracic aorta.

Angiographic 5-year follow-up study of right gastroepiploic artery grafts

BACKGROUND The right gastroepiploic artery (RGEA) has been used from 1987 in coronary artery bypass grafting in several clinical studies. However, the published 1- to 5-year patency rates have been dependent on the selection of patients for angiography. METHODS In our study, the RGEA was used from March 1987 to May 1990 for coronary artery bypass grafting in 31 consecutive patients, 25 male and 6 female. All but 1 patient had triple-vessel disease, and the mean number of distal anastomoses was 3.9 (range, 2 to 5). Internal thoracic artery grafts were used concomitantly in all patients. RESULTS One early and two late deaths occurred. All but 1 of the 28 surviving patients underwent clinical and angiographic follow-up examinations 3 months and 5 years after the operation. The 5-year patency of RGEA grafts was 82.1%, with a 95% confidence interval of 63.1% to 93.9%. In 4 of the 5 nonvisualized cases, the recipient coronary artery showed proximal stenosis of up to 70%, allowing substantial competitive flow. The 5-year patency of the RGEA graft was near that of the left internal thoracic artery, at 90.3%, and the right internal thoracic artery, at 94.4%; and superior to the 66.7% patency of venous grafts. CONCLUSIONS At 5-year follow-up, angiography of RGEA grafts showed good function and a smooth lumen, especially if the proximal stenosis was more than 70%.

Aortic distensibility in children with the Marfan syndrome

The Marfan syndrome is a heritable disease of connective tissue, which predominantly affects the skeletal, ocular and cardiovascular systems.1 Recent immunohistochemical and genetic findings suggest that the ultimate defect is in fibrillin, a microfibrillar protein abundant in tissues involved in Marfan syndrome.2 Clinically and in terms of prognosis, dilatation of the aortic root is the key manifestation of the syndrome, because it predisposes the subject to the risk of aortic dissection and fatal rupture, or severe regurgitation and heart failure.3 Although the structural abnormalities of the Marfan aorta have been well described,1 its conduit function was poorly known until Hirata et al4 recently reported on impaired aortic distensibility in adults with the Marfan syndrome. In the present investigation we expanded this approach by studying aortic distensibility with magnetic resonance imaging (MRI)5 in children and adolescents with this disease.

Right gastroepiploic artery as a coronary bypass graft

Between November 1987 and April 1988, the right gastroepiploic artery (GEA) was used as a coronary artery bypass graft in 11 patients, 9 men and 2 women. In 1 of them, the GEA was used because no veins were available; in the others, the GEA was used to avoid the use of vein grafts. The GEA was anastomosed to the right coronary artery in all patients, and internal mammary artery grafts were used to bypass the left anterior descending and circumflex coronary arteries. All patients survived the operation. There were no early and, to date, there have been no late complications of the abdominal component of the operation. Postoperative coronary angiography showed a patent right GEA in 9 patients (82%). In 1 patient the GEA was occluded, probably because of an enlarged liver. If the long-term patency of right GEA grafts is similar to that of internal mammary artery grafts, wider use of this viable graft is indicated.

Effects of Angiotensin-Converting Enzyme Inhibition Versus β-Adrenergic Blockade on Aortic Stiffness in Essential Hypertension

We assessed the effects of 6 months of treatment with an angiotensin-converting enzyme (ACE) inhibitor (cilazapril) or a beta 1-adrenergic blocker (atenolol) on aortic stiffness in essential hypertension. Forty patients (16 women) aged 47 +/- 9 years (mean +/- SD) with baseline systolic and diastolic blood pressures of 162 +/- 15 and 105 +/- 5 mm Hg, respectively, were entered into a double-blind, parallel-group study with cilazapril, 5 mg once daily, or atenolol, 100 mg once daily. The treatment period was preceded by a 4-week placebo washout phase. Aortic elastic modulus (Ep) was determined by cine magnetic resonance imaging (MRI) and indirect brachial artery blood pressure measurements prior to and after 3 weeks and 6 months of therapy. The reductions in systolic and diastolic blood pressures from baseline to 6 months averaged -17 +/- 13 and -10 +/- 6 mm Hg, respectively, with cilazapril and -23 +/- 16 and -14 +/- 6 mm Hg with atenolol. Concomitantly, Ep of the ascending aorta decreased with cilazapril from a median of 2,234 10(3)dyn/cm2 (interquartile range, 866-3,740) to 868 10(3)dyn/cm2 (515-1,486) and with atenolol from a median of 1,611 10(3)dyn/cm2 (895-2,790) to 1,054 10(3)dyn/cm2 (616-1,860). In repeated-measurements analysis of variance, the change in Ep with time was statistically significant (p < 0.001) but the group x time interaction was not. We conclude that 6 months of treatment with either cilazapril or atenolol reduces the stiffness of the ascending aorta in essential hypertension. No statistically significant differences between the effects of the two drugs were observed. The mechanisms and clinical significance of improved aortic distensibility with antihypertensive therapy deserve further study.

Overview of systematic reviews on invasive treatment of stable coronary artery disease.

OBJECTIVES The aim of the study was to evaluate the validity of the systematic reviews as a source of best evidence and to present and interpret the evidence of the systematic reviews on effectiveness of surgery and percutaneous interventions for stable coronary artery disease. METHODS Electronic databases were searched without language restriction from January 1966 to March 2004. The databases used included the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, DARE, the Health Technology Assessment Database, MEDLINE(R), MEDLINE(R) In-Process & Other Non-Indexed Citations. We included systematic reviews of randomized clinical trials on patients with stable coronary heart disease undergoing percutaneous coronary intervention or coronary artery bypass surgery in comparison with medical treatment or a comparison between invasive techniques. At least one of the following outcomes had to be reported: death, myocardial infarction, angina pectoris, revascularization. The methodological quality was assessed using a modified version of the scale devised by Oxman and Guyatt (1991). A standardized data-extraction form was used. The method used to evaluate clinical relevance was carried out with updated method guidelines from the Cochrane Back Research Group. Quantitative synthesis of the effectiveness data is presented. RESULTS We found nineteen systematic reviews. The median score of validity was 13 points (range, 6-17 points), with a maximum of 18 points. Coronary artery bypass surgery gives better relief of angina, and the need for repeated procedures is reduced after bypass surgery compared with percutaneous interventions. There is inconsistent evidence as to whether bypass surgery improves survival compared with percutaneous intervention. A smaller need for repeated procedures exists after bare metal stent and even more so after drug-eluting stent placement than after percutaneous intervention without stent placement. However, according to the current evidence, these treatment alternatives do not differ in terms of mortality or myocardial infarction. CONCLUSIONS We found some high-quality systematic reviews. There was evidence on the potential of invasive treatments to provide symptomatic relief. Surgery seems to provide a longer-lasting effect than percutaneous interventions with bare metal stents or without stents. Evidence in favor of drug-eluting stents so far is based on short-term follow-up and mostly on patients with single-vessel disease.

Prevalence and predictors of audible physiological third heart sound in a population sample aged 36 to 37 years.

BACKGROUND A physiological third heart sound (S3) is common in youth but allegedly very rare after the age of 40 years. The mechanism of its disappearance is not known. The aim of this work was to study the prevalence and predictors of physiological S3 in a population-based sample of persons approaching 40 years of age. METHODS AND RESULTS A random sample of 120 persons born in 1954 was invited; 93 (42 men) entered the study. Their physical activity, alcohol and tobacco consumption, and salt intake were quantified by diary follow-up. The presence of an S3 was determined by auscultation and confirmed by phonocardiography. Left ventricular (LV) size, mass, and systolic function were assessed by M-mode echocardiography and LV filling by Doppler velocimetry of transmitral flow. An audible S3 was detected in 22 subjects, 1 of whom had heart disease. The prevalence of physiological S3 was 23.1%. Subjects with physiological S3 had a lower body mass index (22.3 +/- 2.8 versus 24.6 +/- 4.1 kg/m2 [mean +/- SD], P = .005), lower heart rate (63 +/- 7 versus 68 +/- 10 beats per minute, P = .015), higher peak early diastolic transmitral velocity (67 +/- 10 versus 58 +/- 8 cm/s, P = .002), and higher acceleration of early diastolic velocity (717 +/- 148 versus 622 +/- 122 cm/s2, P = .012) than those without S3. No differences were noted in the lifestyle characteristics, blood pressure, or LV mass and systolic function. Body mass index and peak early diastolic transmitral velocity were independent predictors of physiological S3 in logistic regression analysis. CONCLUSIONS Nearly one fourth of persons approaching their forties still have an audible physiological S3. The presence of S3 is predicted by leanness and a high early diastolic LV inflow velocity; the disappearance of S3 is unlikely to be secondary to increasing blood pressure and relative LV hypertrophy, as is widely presented, but reflects a more primary age-related alteration of LV early diastolic function.

Nonfluoroscopic localization of an amagnetic stimulation catheter by multichannel magnetocardiography.

This study was performed to: (1) evaluate the accuracy of noninvasive magnetocardiographic (MCG) localization of an amagnetic stimulation catheter; (2) validate the feasibility of this multipurpose catheter; and (3) study the characteristics of cardiac evoked fields. A stimulation catheter specially designed to produce no magnetic disturbances was inserted into the heart of five patients after routine electrophysiological studies. The catheter position was documented on biplane cine x‐ray images. MCG signals were then recorded in a magnetically shielded room during cardiac pacing. Noninvasive localization of the catheters tip and stimulated depolarization was computed from measured MCG data using a moving equivalent current‐dipole source in patient‐specific boundary element torso models. In all five patients, the MCG localizations were anatomically in good agreement with the catheter positions defined from the x‐ray images. The mean distance between the position of the tip of the catheter defined from x‐ray fluoroscopy and the MCG localization was 11 ± 4 mm. The mean three‐dimensional difference between the MCG localization at the peak stimulus and the MCG localization, during the ventricular evoked response about 3 ms later, was 4 ± 1 mm calculated from signal‐averaged data. The 95% confidence interval of beat‐to‐beat localization of the tip of the stimulation catheter from ten consecutive beats in the patients was 4 ± 2 mm. The propagation velocity of the equivalent current dipole between 5 and 10 ms after the peak stimulus was 0.9 ± 0.2 m/s. The results show that the use of the amagnetic catheter is technically feasible and reliable in clinical studies. The accurate three‐dimensional localization of this multipurpose catheter by multichannel MCG suggests that the method could be developed toward a useful clinical tool during electrophysiological studies.

Bronchial Artery Revascularization Improves Tracheal Anastomotic Healing after Lung Transplantation

The study aimed to clarify the role of direct bronchial artery revascularization (BAR) after en bloc double-lung (DLT) and heart-lung transplantation (HLT). Group I comprised eight patients with en bloc DLT or HLT and successful BAR, while group II included 14 DLT or HLT cases without BAR or with failed BAR. From these groups, 2 subgroups were extracted: group III, including 6 cases of en bloc DLT with successful BAR and group IV 10 HLT cases without or with failed BAR. Airway healing was evaluated at bronchoscopy and patency of BAR with angiography. Pulmonary viral, bacterial and fungal infections, rejections and bronchiolitis obliterans syndrome (BOS) were registered. Tracheal healing at 2 weeks and 3 months was better in group I than in group II (p = 0.003 and p = 0.05, respectively). Compared with group IV, tracheal anastomotic healing at 2 weeks was better in group III (p = 0.007) and tended to be better also after 3 months (p = 0.07). The incidence of infections, rejection or BOS did not differ between groups I and II. BAR thus improved healing of tracheal anastomosis.The study aimed to clarify the role of direct bronchial artery revascularization (BAR) after en bloc double-lung (DLT) and heart-lung transplantation (HLT). Group I comprised eight patients with en bloc DLT or HLT and successful BAR, while group II included 14 DLT or HLT cases without BAR or with failed BAR. From these groups, 2 subgroups were extracted: group III, including 6 cases of en bloc DLT with successful BAR and group IV 10 HLT cases without or with failed BAR. Airway healing was evaluated at bronchoscopy and patency of BAR with angiography. Pulmonary viral, bacterial and fungal infections, rejections and bronchiolitis obliterans syndrome (BOS) were registered. Tracheal healing at 2 weeks and 3 months was better in group I than in group 1 (p = 0.003 and p = 0.05, respectively). Compared with group IV, tracheal anastomotic healing at 2 weeks was better in group III (p = 0.007) and tended to be better also after 3 months (p = 0.07). The incidence of infections, rejection or BOS did not differ between groups I and II. BAR thus improved healing of tracheal anastomosis.

Heart transplantation in repaired transposition of the great arteries.

Cardiac transplantation was carried out in a 40-year-old man with the diagnosis of repaired transposition of the great arteries and right-sided aortic arch who had end-stage cardiac failure due to myopathy of the ventricles. Because of several previous surgical repairs and the orientation of the great vessels, the operation presented some technical problems. Therefore, modifications of operative procedures were used, including recipient hypothermia, circulatory arrest, and changes in the donor heart implantation. The removal of the donor heart was modified in such a way that the graft included the aortic arch and both pulmonary arteries. With the extra length of ascending aorta and transverse arch, the innominate, left carotid, and left subclavian vessels were excised as a button, thereby leaving the distal orifice of the aorta in the superior portion of the transverse arch. For the recipient, the operation was performed using hypothermic total circulatory arrest to dissect free the huge pulmonary artery and the short right-sided aortic arch to place the clamp. Implantation of the donor heart was modified accordingly. The technical results were confirmed one and a half months later on a control digital angiogram. Thirty-five days postoperatively the patient was discharged. Six months after operation, the patient is doing better than ever before in his life. Our findings suggest that a complicated conotruncal development does not preclude cardiac transplantation.