Petar Otasevic

Percutaneous left ventricular partitioning in patients with chronic heart failure and a prior anterior myocardial infarction: Results of the PercutAneous Ventricular RestorAtion in Chronic Heart failUre PaTiEnts Trial

OBJECTIVESnThe aim of this study was to assess the feasibility, safety, and preliminary efficacy of a novel percutaneous left ventricular partitioning device (VPD) in patients with chronic heart failure (HF) and a prior anterior myocardial infarction.nnnBACKGROUNDnAnterior myocardial infarction is frequently followed by left ventricular remodeling, HF, and increased long-term morbidity and mortality.nnnMETHODSnThirty-nine patients were enrolled in a multinational, nonrandomized, longitudinal investigation. The primary end point was an assessment of safety, defined as the successful delivery and deployment of the VPD and absence of device-related major adverse cardiac events over 6 months. Secondary (exploratory) efficacy end points included changes in hemodynamics and functional status and were assessed serially throughout the study.nnnRESULTSnVentricular partitioning device placement was not attempted in 5 (13%) of 39 subjects. The device was safely and successfully implanted in 31 (91%) of the remaining 34 patients or 79% of all enrolled patients. The 6-month rate of device-related major adverse cardiac event occurred in 5 (13%) of 39 enrolled subjects and 5 (15%) of 34 treated subjects, with 1 additional event occurring between 6 and 12 months. For patients discharged with the device to 12 months (n = 28), New York Heart Association class (2.5 ± 0.6 to 1.3 ± 0.6, P < .001) and quality-of-life scores (38.6 ± 6.1 to 28.4 ± 4.4, P < .002) improved significantly; however, the 6-minute hall walk distance (358.5 ± 20.4 m to 374.7 ± 25.6 m, P nonsignificant) only trended toward improvement.nnnCONCLUSIONSnThe left VPD appears to be relatively safe and potentially effective in the treatment for patients with HF and a prior anterior myocardial infarction. However, these limited results suggest the need for further evaluation in a larger randomized controlled trial.

Initial and Long-Term Results of Endovascular Therapy for Chronic Total Occlusion of the Subclavian Artery

PurposeTo study the initial and long-term results of angioplasty and primary stenting for the treatment of chronic total occlusion (CTO) of the subclavian artery (SA).Materials and MethodsFrom January 1999 to February 2010, 56 patients (25 men with a mean age of 58xa0±xa08xa0years) underwent endovascular treatment for CTO of the SA. Duplex scans and arteriograms confirmed occlusion in all cases. Indications for recanalization were subclavian steal syndrome in 33 patients (58.1%), arm claudication in 13 patients (23.2%), and coronary ischemia in 7 patients (12.5%) who had a history of previous coronary artery bypass grafting that included left internal thoracic artery graft. Three patients (5.4%) were treated before the scheduled coronary artery bypass surgery, which included left internal thoracic artery graft. After successful recanalization, all arteries were stented, and all of the patients were followed-up at 1, 3, 6, and 12xa0months after surgery and annually thereafter.ResultsSuccessful recanalization of the SA was achieved in 46 patients (82.1%), and the complication rate was 7.1%. During follow-up (mean 40xa0±xa026xa0months; range 2 to 125), the primary patency rates after 1 and 3xa0years were 97.9% and 82.7%, respectively. At the end of follow-up, 76% of the arteries showed no evidence of restenosis. Univariate analysis failed to identify any variable predictive of long-term patency of successfully recanalized SA.ConclusionPercutaneous transluminal angioplasty with stenting of the complete total occlusion of the SA is a safe and effective procedure associated with low risks and good long-term results.

Comparison of Valve Annuloplasty and Replacement for Ischemic Mitral Valve Incompetence

OBJECTIVEnMitral incompetence is a chronic sequela of myocardial infarction. It is caused by apical displacement and tethering of the mitral valve leaflets after myocardial infarction, resulting in incomplete coaptation. The consensus is for mitral valve surgery in the presence of significant ischemic mitral regurgitation (IMR). Previously, the only option was mitral valve replacement (MVR) with a mechanical or tissue valve. The suboptimal results obtained prompted the development of several methods of mitral valve repair. Today, the most commonly used repair is undersized annuloplasty.nnnMETHODSnWe conducted a retrospective nonrandomized study of all patients who underwent operation for coronary artery disease and IMR between 2000 and 2006. The surgeon chose the surgical method used for the mitral valve procedure. The most commonly used procedures were restrictive mitral valve annuloplasty (MVP) and MVR with a mechanical prosthesis. We collected all pertinent preoperative, intraoperative, and early-postoperative data. We followed up with phone interviews of the patients and their relatives and with complete clinical and echocardiography examinations.nnnRESULTSnWe carried out operations on 138 patients during the study period (MVR, 52 patients; MVP, 86 patients). The 2 groups had comparable demographic data and risk factors. The 2 groups were significantly different with respect to mean (+/-SD) New York Heart Association (NYHA) class (MVP, 2.72 +/- 0.62; MVR, 2.48 +/- 0.70; P < .01) and ejection fraction (MVP, 29.01% +/- 11.00%; MVR, 35.87% +/- 11.00%; P </= .01). The 30-day mortality rates for the MVR and MVP groups were significantly different (9.61% and 5.81%, respectively; P < .01). Our follow-up included 83% of the patients and continued for up to 84 months. The 2 groups showed no significant difference in mortality by the end of follow-up; however, the MVR patients had a better ejection fraction (37.79% versus 29.86%) and NYHA functional class (1.88 +/- 0.498 versus 2.36 +/- 0.564; P < .01).nnnCONCLUSIONnCorrecting chronic IMR with either repair or replacement produces a good mid-term survival rate (approximately 75%) for survivors in NYHA classes I and II. In our study, mortality rates for the MVP and MVR groups were similar, even though the repair group had a lower mean ejection fraction and a higher NYHA class before and after the operation. We therefore conclude that repair is superior to replacement in treating ischemic mitral insufficiency. A prospective randomized study is needed to better compare these 2 approaches.

Color Doppler sonographic evaluation of flow volume of the internal carotid and vertebral arteries after carotid endarterectomy

To measure by Doppler sonography the blood flow volume (BFV) of the ipsilateral and contralateral extracranial internal carotid arteries (ICAs) and both vertebral arteries (VAs) before and after a carotid endarterectomy (CEA) of the ICA. We correlated the result with the degree of stenosis of the ICA.

Endovascular treatment of symptomatic high-grade vertebral artery stenosis.

BACKGROUNDnThe purpose of this study was to evaluate the initial and long-term results of endovascular treatment (EVT) in patients with symptomatic high-grade extracranial vertebral artery (VA) origin stenosis.nnnMETHODSnFrom February 2001 to March 2013, 73 consecutive patients (33 men with a mean age of 61.7xa0± 8.8xa0years) underwent EVT for symptomatic high-grade VA stenosis. Preoperative evaluation included Duplex ultrasonography and arteriography. After successful treatment, all patients were followed up at 1, 3, 6, and 12xa0months after the procedure and every 6xa0months thereafter.nnnRESULTSnSuccessful EVT of the VA stenosis was achieved in 68 patients (93.2%). All procedures were performed without use of cerebral protection. The early complication rate was 5.5%, which included one periprocedural transient ischemic attack, two hematomas at the puncture site, and one allergic reaction to the contrast agent. No in-hospital deaths occurred. During follow-up (mean, 44.3xa0± 31.2xa0months; range, 2-144xa0months), the primary patency rates at 1, 3, 5, and 7xa0years were 98.4%, 87.3%, 87.3%, and 87.3%, respectively. Ultrasound Doppler controls during follow-up detected seven VA restenoses (10.3%). Univariate analysis failed to identify any variable predictive of long-term patency of successfully treated VA stenosis.nnnCONCLUSIONSnEVT of symptomatic VA origin stenosis is a safe and effective procedure associated with low risk and good long-term results, even without use of cerebral protection devices.

Color duplex sonography in the detection of internal carotid artery restenosis after carotid endarterectomy: comparison with computed tomographic angiography.

Internal carotid artery restenosis after carotid endarterectomy is a major postoperative event, but the clinically best suited means for diagnosis of restenosis are still debated. The objective of this study was to evaluate the sensitivity and specificity of color duplex sonography for detection of substantial internal carotid artery restenosis, verified by computed tomographic (CT) angiography.

Distribution of Risk Factors in Patients with Premature Coronary, Supra-Aortic Branches and Peripheral Atherosclerotic Disease

Objective: The aim of this study was to determine the distribution of major risk factors among patients with atherosclerotic disease aged ≤50 years. Subjects and Methods: The study population comprised 944 patients aged ≤50 years with clinically significant manifestations of atherosclerotic disease compared with 350 consecutive (control) older patients (age >50 years). Results: The most significant risk factors for atherosclerotic disease of the supra-aortic branches were: smoking (87.5%, p < 0.001), family history of atherosclerosis (52.3%, p < 0.001), diabetes mellitus (28.5%) and being male (56.9%) (p < 0.05 for both). In patients with coronary artery disease, there was considerable disparity in the prevalence of smoking (85.4%), hyperlipoproteinemia (67.4%), and family history of atherosclerosis (68%) (p < 0.001). For peripheral artery disease, the most significant risk factors were smoking (97%, p < 0.001), hyperlipidemia (p < 0.01), and family history of atherosclerotic disease (p < 0.01). When compared to controls, patients with premature atherosclerosis smoked more frequently, had hyperlipidemia, had a family history of atherosclerosis, and were more frequently of male sex. Conclusion: Premature atherosclerosis was most frequently associated with smoking, hyperlipidemia, family history of atherosclerotic disease, and male sex.

Frequency and characteristics of metabolic syndrome in patients with symptomatic carotid atherosclerosis

BACKGROUNDnMetabolic syndrome (MetS) is associated with increased risk of carotid atherosclerosis.nnnAIMnTo estimate the frequency of MetS in patients with symptomatic carotid atherosclerotic disease, and to compare clinical, biochemical and ultrasonographic characteristics of patients with and without MetS.nnnMATERIAL AND METHODSnCross-sectional study of 657 consecutive patients (412 males) with symptomatic carotid atherosclerotic disease. Carotid atherosclerosis was estimated by high resolution B-mode ultrasonography. National Cholesterol Education Program (NCEP) M criteria were used for estimation of MetS.nnnRESULTSnMetabolic syndrome was present in 55.6% of studied patients. Among patients with metabolic syndrome there was a significantly higher proportion of women, and mean values of body weight, body mass index, waist circumference, percentage of body fat, systolic and diastolic blood pressure, serum triglycerides, total cholesterol and glucose were significantly higher. Mean values of high density lipoprotein cholesterol and alcohol consumption were significantly lower in patients with MetS. No differences between patients with or without MetS, were observed for age, smoking, mean values of low density lipoprotein cholesterol, high sensitive C-reactive protein and fibrinogen, and for degree of carotidstenosis or severity of clinical manifestations.nnnCONCLUSIONnHalf of these patients with carotid stenosis have features of the metabolic syndrome.

Copper and zinc concentrations in atherosclerotic plaque and serum in relation to lipid metabolism in patients with carotid atherosclerosis.

BACKGROUND/AIMnSome oligoelements are now investigated as possibly having a role in atherosclerosis. The aim of this study was to compare the concentrations of copper and zinc in the serum and carotid plaque and parameters of lipid metabolism in patients with different morphology of carotid atherosclerotic plaque.nnnMETHODSnCarotid endarterectomy due to the significant atherosclerotic stenosis was performed in 91 patients (mean age 64 ± 7). The control group consisted of 27 patients (mean age 58 ± 9), without carotid atherosclerosis. Atheroscletoric plaques were divided into four morphological groups, according to ultrasonic and intraoperative characteristics. Copper and zinc concentrations in the plaque, carotid artery and serum were measured by atomic absorption spectrophotometry.nnnRESULTSnSerum copper concentrations were statistically significantly higher in the patients with hemorrhagic in comparison to those with calcified plaque (1.2 ± 0.9 µmol/L vs 0.7 ± 0.2 µmol/L, respectively; p = 0.021). Zinc concentrations were statistically significantly lower in plaques of the patients with fibrolipid in comparison to those with calcified plaques (22.1 ± 16.3 g/g vs 38.4 ± 25.8 µg/g, respectively; p = 0.024). A negative significant correlation was found for zinc and triglycerides in the serum in all the patients (r = -0.52, p = 0.025). In the control group we also demonstrated a positive significant correlation for low-density lipoprotein cholesterol and copper in the serum (r = 0.54, p = 0.04).nnnCONCLUSIONnThe data obtained in the current study are consistent with the hypothesis that high copper and lower zinc levels may contribute to atherosclerosis and its sequelae as factors in a multifactorial disease. Further studies are necessary in order to conclude whether high concentration of copper and zinc in the serum could be risk factors for atherosclesrosis.

Effect of Elective Bentall Procedure on Left Ventricular Systolic Function and Functional Status: Long-Term Follow-Up in 90 patients

Because there are so few data on the long-term effects on left ventricular systolic function and functional status in patients who electively undergo Bentall procedures, we established a retrospective study group of 90 consecutive patients. This group consisted of 71 male and 19 female patients (mean age, 54 ± 10 yr) who had undergone the Bentall procedure to correct aortic valve disease and aneurysm of the ascending aorta, from 1997 through 2003 in a single tertiary-care center. We monitored these patients for a mean period of 117 ± 41 months for death, left ventricular ejection fraction and volume indices, and functional capacity as determined by New York Heart Association (NYHA) class. There were no operative deaths. The survival rate was 73.3% during follow-up. There were 10 cardiac and 13 noncardiac deaths, and 1 death of unknown cause. Echocardiography was performed before the index procedure and again after 117 ± 41 months. In surviving patients, statistically significant improvement in left ventricular ejection fraction, in comparison with preoperative values (0.49 ± 0.11 vs 0.41 ± 0.11; P <0.0001), was noted at follow-up. Similarly, we observed statistically significant reductions in left ventricular end-systolic (39.24 ± 28.7 vs 48.77 ± 28.62 mL/m(2)) and end-diastolic volumes (54.63 ± 6.97 vs 59.17 ± 8.92 mL/m(2); both P <0.0001). Most patients (53/66 [80.3%]) progressed from a higher to a lower NYHA class during the follow-up period. The Bentall procedure significantly improved long-term left ventricular systolic function and functional status in surviving patients who underwent operation on a nonemergency basis.