Sabina Caciolli

Insights on left ventricular and valvular mechanisms of recurrent ischemic mitral regurgitation after restrictive annuloplasty and coronary artery bypass grafting

BACKGROUND We investigated leaflet and subvalvular configurations to identify mechanisms leading to recurrent mitral regurgitation after combined undersized mitral annuloplasty and coronary artery bypass and to preoperatively recognize patients who are unlikely to benefit from this approach. METHODS Among 261 subjects with chronic ischemic mitral regurgitation undergoing undersized annuloplasty and coronary bypass surgery at one institution between September 2001 and September 2007, 31 were excluded: 4 had intraoperative annuloplasty failure, 12 showed residual regurgitation, and 15 had incomplete echocardiograms available. The study population consisted of 230 patients who were divided into 2 groups: patients without (group 1, n = 176) or with (group 2, n = 54) late recurrent mitral regurgitation. Fifty healthy subjects were used as control subjects. Serial echocardiographic analysis was performed preoperatively, at discharge, and at follow-up appointments (early: median, 6 months [interquartile range, 5-6 months; late: median, 33 months [interquartile range, 17-51 months]). RESULTS Subjects with late regurgitation had preoperatively more symmetric tethering (P < .001), more accentuated anterior mitral leaflet tethering (P < .001), and more restricted anterior leaflet excursion (P = .003) than patients in group 1. Postoperatively, tethering of the posterior leaflet increased (P < .001) and was predominant in both groups, whereas tethering of the anterior leaflet was reduced at discharge (P = .01 and P = .03, respectively), remaining constant afterward. Multivariable analysis showed an anterior tethering angle of 39.5 degrees or greater (P < .001), an anterior/posterior tethering angle ratio of 0.76 or greater (P < .001), an anterior leaflet excursion angle of 35 degrees or less (P = .001), and a coaptation height of 11 mm or greater (P = .04) to be predictors of recurrent mitral regurgitation. CONCLUSIONS Preoperative symmetric tethering with anterior mitral leaflet predominance was strongly associated with recurrence of mitral regurgitation. Measures of leaflet tethering resulted in fundamental findings to identify ischemic patients who can really benefit from restrictive annuloplasty. Further larger studies are necessary to confirm our results.

Decreased Baroreflex Sensitivity Assessed from Phase IV of Valsalva Maneuver in Mild Congestive Heart Failure

Decreased sensitivity of cardiopulmonary and arterial baroreceptors has been hypothe sized to sustain sympathetic activation in patients with heart failure. In the present inves tigation the relationship between the impairment of baroreflex sensitivity and clinical severity of congestive heart failure was investigated. The authors studied 58 patients with heart failure (14 in NYHA class I, 22 in NYHA class II, and 22 in NYHA class III), 38 women and 20 men, age range 28-65 years. Thirty-two patients suffered from idiopathic dilated cardiomyopathy and 26 from coronary heart disease. As control group they examined 21 age-matched subjects. Baroreceptor sensitivity was studied by using the Valsalva maneuver as stimulus. Arterial pressure and heart rate were measured nonin vasively by Finapres instrument (Ohmeda) and signals were recorded and elaborated with a personal computer. A decrease of baroreflex sensitivity was already demonstrable in NYHA class I patients (4.72 ±3.31 vs 9.25 ±5.05 msec/mm Hg in control group) (p < 0.005). A further impairment of baroreceptor response was found in patients in NYHA class II (1.94 ±2.88 msec/mm Hg, p < 0.001) and class III (1.78 ±1.52 msec/mm Hg, p < 0.001). Baroreceptor response showed a significant correlation with functional NYHA class (r = 0.61, p < 0.001) and anaerobic threshold (r = 0.57, p < 0.001) while the correlation was less tight with left ventricular end-diastolic diameter, fractional short ening, left ventricular ejection fraction, pulmonary mean arterial blood pressure, cardiac index, distance at 6 minutes walk corridor test, and maximal oxygen consumption (VO 2max). These results suggest that baroreceptor function may be impaired early in the clinical course of heart failure and may contribute to sympathetic activation.

Severe Hypoplasia of the Posterior Mitral Leaflet

A rare case of a 14-year-old child with congenital mitral insufficiency secondary to hypoplasia of the posterior leaflet is reported. Echocardiography revealed the almost complete absence of the posterior mitral leaflet, which determined massive regurgitation. At surgical inspection the posterior leaflet was almost completely absent, represented only by tags of fibrous tissue that strictly adhered to the posterior annulus with a total absence of chordae inserting into the hypoplastic leaflet. The mitral valve was successfully repaired by restrictive annuloplasty, which gained a satisfactory surface of coaptation between the anterior leaflet and the primordial posterior structure, resulting in stable valve continence.

Prognostic value of baroreflex sensitivity assessed by phase IV of Valsalva manoeuvre in patients with mild‐to‐moderate heart failure

In patients with heart failure, impairment of baroreflex function occurs early and contributes to sympathetic activation, however, at present its prognostic role has not been definitively established.

An alternative technique for surgical repair of pulmonary dissection.

DISCUSSION Suture annuloplasty can maintain the physiologic motion and spatial structure of the mitral annulus without prosthetic ring. Commissural suture, a type of suture annuloplasty, can effectively recover the mitral valve function by decreasing the length of the posterior annulus. Our data showed good results of the commissural suture for moderate FMR.We could get excellent mitral valve exposure through the transaortic approach when the diameter of aortic annulus was enlarged. A retractor was used to withdraw

Relationship between Depressed Baroreflex Function and Exaggerated Sympathetic Response to Exercise in Patients with Heart Failure

The relationship between impaired baroreflex sensitivity (BS) and the degree of sympathetic activation during exercise in patients with heart failure (HF) has not been studied in detail. For this purpose, we studied BS and measured plasma norepinephrine (NE) at rest, and during and after treadmill exercise in 15 patients and 10 controls. HF patients showed lower BS in comparison to controls (3.51 ± 3.62 vs. 9.74 ± 4.56 ms/mm Hg; p < 0.001), and higher levels of plasma NE at rest (449.3 ± 147.1 vs. 261.1 ± 82.48 pg/ml; p < 0.001) and during exercise (1,542 ± 361.2 vs. 524.6 ± 92.61 pg/ml; p < 0.001). BS was directly related to pVO2 (r = 0.62; p = 0.0008) and inversely related to NE at peak exercise and to the increase in NE during exercise (r = 0.59, p = 0.005, and r = 0.53; p = 0.0058). Thus, during exercise, a marked sympathetic activation exists in patients with moderate HF. The relationship between increased plasma NE during exercise and decreased BS suggests that impaired baroreceptor function may be present in sympathetic activation in HF patients.

Coronary embolism following valve surgery.

A 55-year-old man experienced chest pain on the seventh day after valve surgery. Coronary angiography showed embolic occlusion of the left anterior descending coronary artery. The lesion was treated successfully with thrombectomy using the angiojet rheolytic thrombectomy system, resulting in rapid mechanical thrombolysis and removal via the effluent lumen of the catheter. Thrombolysis in Myocardial Infarction 3 flow was restored.

Prognostic value of Doppler-derived mitral deceleration time on left ventricular reverse remodelling after undersized mitral annuloplasty

AIMS This study was aimed at exploring the predictive value of Doppler-Derived Mitral Deceleration Time (DT) on left ventricular reverse remodelling (LVRR) in patients with chronic ischaemic mitral regurgitation (CIMR) undergoing combined undersized mitral annuloplasty (UMRA) and coronary artery bypass grafting (CABG). METHODS AND RESULTS Two hundred and fifteen patients undergoing combined UMRA and CABG for CIMR between September 2001 and September 2007 in our Institution were divided into four groups on the basis of baseline DT: Group 1, normal (n = 48), Group 2, impaired relaxation (n = 61), Group 3, pseudonormal (n = 50), and Group 4, restrictive (n = 56). Echocardiograms were performed, pre-operatively, at discharge and at follow-up appointments (100% complete, early, median 6 months [interquartile range 4-8 months]) and late, median 38 months (17-61 months). Left ventricular reverse remodelling, defined as a reduction in ESV > 15%, occurred in 95.7, 96.3, 88.3, and 0% in Groups 1, 2, 3, and 4, respectively (P < 0.001). Logistic regression analysis showed that DT <or= 125 (P < 0.001) was a strong predictor of LVRR after annuloplasty. CONCLUSION Pre-operative assessment of DT adds significant information to commonly used indexes of global and regional function, and represent a very easy and cost-effective tool to accurately identify CIMR patients who can really benefit from annuloplasty.

Impact of renal function impairment assessed by CKDEPI estimated glomerular filtration rate on early and late outcomes after coronary artery bypass grafting

BACKGROUND We explore the association between short- and long- term adverse outcomes following coronary artery bypass grafting (CABG) and the degree of preoperative renal dysfunction classified on glomerular fraction estimated with Chronic Kidney Disease-Epidemiology Collaboration equation (eGFRCKD-EPI). We also try to identify cut-off values of eGFRCKD-EPI able to predict post-CABG unfavorable events and assess whether a reclassification with new thresholds is necessary. METHODS One-thousand-one-hundred-eighty-six consecutive patients undergoing CABG between 2005 and 2014 were categorized in 4 groups according to the eGFRCKD-EPI: Group 1 (≥60ml/min/1.73m2; n=1199), Group 2 (45-59ml/min/1.73m2; n=358), Group 3 (30-44ml/min/1.73m2; n=171) and Group 4 (≤29ml/min/1.73m2; n=126). Median follow-up was 66months [IQR 46-84]. RESULTS eGFRCKD-EPI ≤30ml/min/1.73m2, ≤41ml/min/1.73m2, ≤27ml/min/1.73m2 and ≤29ml/min/1.73m2 were strong predictors of early mortality (OR 5.88 [95% CI 2.59-11.25]), stroke (2.59 [1.43-3.71]), prolonged length of stay (3.49 [1.24-5.92]) and postoperative dialysis (3.68 [1.34-4.91]), respectively. In addition, eGFRCKD-EPI ≤26ml/min/1.73m2, ≤25ml/min/1.73m2, ≤35ml/min/1.73m2 and ≤29ml/min/1.73m2 predicted all-cause death (hazard ratio 2.74 [95% CI 2.10-3.92] cardiovascular death (sub-hazard ratio 2.11 [95% CI 1.42-3.90]), myocardial infarction (2.01 [1.32-3.70]) and heart failure (2.24 [1.41-3.93]), respectively. Analyses corrected by age and left ventricular ejection fraction confirmed these findings. CONCLUSIONS In our experience, the use of the eGFRCKD-EPI equation led to categorization with a significantly lower number of patients at risk for post-CABG complications. This might have important clinical repercussions on allocation of healthcare resources and more targeted prevention and management of CABG complications.

State-of-the-Art Review : Sex and Cardiovascular Risk Factors

Manuscript received May 15, 1995; accepted July 19, 1995. Address correspondence and reprint requests to Dr. D. Prisco, Istituto di Clinica Medica Generale e Cardiologia, Viale Morgagni 85, 50134 Florence, Italy. It is well known that the incidence of coronary heart disease (CHD) is lower in women than in men, especially in those younger than 50 years of age (1). During the past 20 years, there has been a significant reduction of CHD in western countries attrib-