Salvatore Di Stefano

Association between self-replicating calcifying nanoparticles and aortic stenosis: a possible link to valve calcification.

AIMS Among various hypotheses proposed for pathological tissue calcification, recent evidence supports the possibility that self-replicating calcifying nanoparticles (CNPs) can contribute to such calcification. These CNPs have been detected and isolated from calcified human tissues, including blood vessels and kidney stones, and are referred to as nanobacteria. We evaluated calcific aortic valves for the presence of CNP. METHODS AND RESULTS Calcific aortic valves were obtained from 75 patients undergoing surgical valve replacement. The control group was formed by eight aortic valves corresponding to patients with heart transplants. In the microbiology laboratory, valves were screened for CNP using a 4-6 weeks specific culture method. The culture for CNP was positive in 48 of the 75 valves with aortic stenosis (64.0%) in comparison with zero of eight (0%) for the control group (P = 0.0005). The observation of cultures by way of scanning electron microscopy highlighted the resemblance in size and morphology of CNP. CONCLUSION Self-replicating calcific nanometer-scale particles, similar to those described as CNP from other calcific human tissues, can be cultured and visualized from calcific human aortic valves. This finding raises the question as to whether CNP contribute to the pathogenesis of the disease or whether they are only innocent bystanders.

Building a New Annulus: A Technique for Mitral Valve Replacement in Heavily Calcified Annulus

We describe the rationale, methodology, and our preliminary experience with a new surgical technique for mitral valve replacement in patients with severe calcification of the mitral annulus in which the conventional techniques can not be applied. In contrast with other procedures published in the literature for these patients, in which the placement of the prosthesis is supra-annular, we plicate both mitral leaflets and the atrial wall creating a new annulus that allows the intra-annular placement of the prosthesis.

Risk score for cardiac surgery in active left-sided infective endocarditis

Objective To develop and validate a calculator to predict the risk of in-hospital mortality in patients with active infective endocarditis (IE) undergoing cardiac surgery. Methods Thousand two hundred and ninety-nine consecutive patients with IE were prospectively recruited (1996–2014) and retrospectively analysed. Left-sided patients who underwent cardiac surgery (n=671) form our study population and were randomised into development (n=424) and validation (n=247) samples. Variables statistically significant to predict in-mortality were integrated in a multivariable prediction model, the Risk-Endocarditis Score (RISK-E). The predictive performance of the score and four existing surgical scores (European System for Cardiac Operative Risk Evaluation (EuroSCORE) I and II), Prosthesis, Age ≥70, Large Intracardiac Destruction, Staphylococcus, Urgent Surgery, Sex (Female) (PALSUSE), EuroSCORE ≥10) and Society of Thoracic Surgeons’s Infective endocarditis score (STS-IE)) were assessed and compared in our cohort. Finally, an external validation of the RISK-E in a separate population was done. Results Variables included in the final model were age, prosthetic infection, periannular complications, Staphylococcus aureus or fungi infection, acute renal failure, septic shock, cardiogenic shock and thrombocytopaenia. Area under the receiver operating characteristic curve in the validation sample was 0.82 (95% CI 0.75 to 0.88). The accuracy of the other surgical scores when compared with the RISK-E was inferior (p=0.010). Our score also obtained a good predictive performance, area under the curve 0.76 (95% CI 0.64 to 0.88), in the external validation. Conclusions IE-specific factors (microorganisms, periannular complications and sepsis) beside classical variables in heart surgery (age, haemodynamic condition and renal failure) independently predicted perioperative mortality in IE. The RISK-E had better ability to predict surgical mortality in patients with IE when compared with other surgical scores.

Cardiac Surgery With Extracorporeal Circulation in Cancer Patients: Influence on Surgical Morbidity and Mortality, and on Survival

INTRODUCTION AND OBJECTIVES Morbimortality related to cardiac surgery may be superior in patients with malignant neoplastic disease. Inflammatory phenomena and immunologic changes secondary to extracorporeal circulation use can also increase tumor recurrence. We evaluate characteristics and results of cardiac surgery in our neoplastic patients. METHODS Out of 2146 consecutive patients who underwent cardiac surgery with extracorporeal circulation, 89 (4.2%) had been previously affected by cancer. Cancer was active (recent diagnosis or under treatment) in 33 patients (group A) and 56 (group B) were in remission. Both groups were matched with 165 patients with no tumor, according to age, gender, type of surgery, and comorbidity (group C). We retrospectively evaluated incremental risk factors for surgical morbimortality, survival and tumor recurrence. RESULTS Median interval between cancer diagnosis and surgery was 60 months and mortality and morbidity were 4.5% and 36%, respectively, vs 5,4% and 32,7% in group C. During follow-up, 12 patients died (8 due to cancer), 16 suffered cancer recurrence and 2 new tumors were diagnosed. Statistical analysis did not permit us to identify any incremental risk factor for mortality. Postoperative morbidity was increased in case of preoperative renal failure. During follow-up, survival was significantly decreased in group A, in case of preoperative left ventricular dysfunction or pulmonary obstructive disease, and when interval between cancer diagnosis and cardiac surgery was under 2 years. CONCLUSIONS We have not observed an increase in cardiac surgery morbimortality in cancer patients. Anyway, survival is decreased in case of active or recently diagnosed cancer.

Cirugía cardiaca con circulación extracorpórea en pacientes oncológicos: influencia en la morbimortalidad quirúrgica y la supervivencia

Introduccion y objetivos La morbimortalidad de la cirugia cardiaca parece ser mayor en los pacientes neoplasicos. Los fenomenos inflamatorios y las reacciones inmunitarias secundarias a la circulacion extracorporea pueden favorecer la recidiva tumoral. Evaluamos las caracteristicas y los resultados de la cirugia cardiaca en nuestros pacientes oncologicos. Metodos De 2.146 pacientes consecutivos sometidos a circulacion extracorporea, 89 (4,2%) presentaban una neoplasia. El cancer estaba activo (recientemente diagnosticado o en tratamiento) en 33 pacientes (grupo A) y en remision completa en 56 (grupo B). Se pareo ambos grupos con 165 pacientes sin tumor similares en edad, sexo, tipo de cirugia y comorbilidad (grupo C). Evaluamos retrospectivamente los factores de riesgo de morbimortalidad quirurgica, supervivencia y recidiva tumoral. Resultados La mediana del intervalo entre diagnostico del cancer y cirugia fue de 60 meses, con mortalidad y morbilidad hospitalarias del 4,5 y el 36%, respectivamente, frente al 5,4 y el 32,7% en el grupo C. Durante el seguimiento, fallecieron 12 pacientes (8 por causa tumoral), 16 sufrieron recidiva y 2, tumores nuevos. El analisis estadistico no permitio identificar ningun factor de riesgo de mortalidad. La morbilidad postoperatoria aumento en pacientes con insuficiencia renal. Durante el seguimiento, la supervivencia disminuyo significativamente en el grupo A en caso de disfuncion ventricular izquierda preoperatoria y enfermedad pulmonar obstructiva cronica y cuando el intervalo entre diagnostico de cancer y cirugia fue Conclusiones No hemos observado un incremento en la morbimortalidad de la cirugia cardiaca en pacientes oncologicos. No obstante, la supervivencia disminuye en neoplasias activas o de diagnostico reciente.

Propensity score matched comparison of transcatheter aortic valve implantation versus conventional surgery in intermediate and low risk aortic stenosis patients: A hint of real-world

BACKGROUND Recently, the use of transcatheter aortic valve implantation (TAVI) in inter-mediate-low risk patients has been evaluated in the PARTNER II randomized trial. However, in the last years, this therapy has been employed in this scenario with underreported results, as compared to surgical aortic valve replacement (SAVR). METHODS We enrolled 362 consecutive patients with severe symptomatic aortic stenosis and intermediate-low surgical risk (logEuroSCORE < 20%), treated in our center with TAVI (103 patients) or single SAVR (259 patients) between 2009 and 2014. Patients were matched according to age, gender, logEuroSCORE, and use of bioprosthesis. RESULTS Mean age of the patients was 73 ± 10.4 years, and 40.3% were women. LogEuroSCORE and Society Thoracic Surgeons score were 7.0 ± 4.4% and 4.2 ± 2.5%, respectively, with mean left ventricular ejection fraction of 52 ± 9%. There were no differences regarding other comorbidities. The length-of-hospitalization was 11 ± 5 days after TAVI vs. 17 ± 9 days after SAVR (p = 0.003). After matched comparison, no differences in terms of in-hospital mortality (5.7% after TAVI vs. 2.9% after SAVR, p = 0.687) and 1-year mortality (11.4% vs. 7.1%, p = 0.381) were found. The combined endpoint of stroke and mortality at 1-year was also similar between both groups (15.7% in TAVI patients vs. 14.4% after SAVR, p = 0.136). Multivariate analysis determined that aortic regurgitation (AR) was an independent predictor of mortality (OR = 3.623, 95% CI: 1.267-10.358, p = 0.016). Although the rate of AR was higher after TAVI, none of the patients treated with the newest generation devices (10.7%) presented more than a mild degree of AR. CONCLUSIONS TAVI is feasible and shows comparable results to surgery in terms of early, 1-year mortality, as well as cerebrovascular events in patients with severe aortic stenosis and intermediate-low operative risk. Better transvalvular gradients, yet higher rates of AR were found, however, newer devices presented comparable rate of AR.

Efecto de la simvastatina en la concentración de las proteínas de fase aguda después de la cirugía cardíaca

Fundamento y objetivo Existe informacion contradictoria referente a que los efectos pleiotropicos de las estatinas mejoran la morbimortalidad de las intervenciones con circulacion extracorporea, ya que reducen las concentraciones plasmaticas de proteinas de fase aguda. Pacientes y metodo Se ha realizado un estudio prospectivo y aleatorizado que incluyo a 44 pacientes a los que se efectuo derivacion aortocoronaria con circulacion extracorporea. Se dividieron en 2 grupos: A (n = 22), formado por pacientes que tomaron simvastatina, y B (n = 22), que fue el grupo control. Se determinaron las concentraciones plasmaticas de proteinas de fase aguda (interleucina 6, fraccion C4 del complemento y proteina C reactiva). Resultados No se observaron diferencias significativas entre ambos grupos en las concentraciones de proteinas de fase aguda ni en las complicaciones postoperatorias. En ambos grupos, las concentraciones maximas de interleucina 6 se observaron a las 6 h de la cirugia y las de proteina C reactiva a las 48 h. Las concentraciones de C4 descendieron al inicio de la derivacion cardiopulmonar y volvieron a la normalidad a las 48 h. Conclusiones La administracion de simvastatina a pacientes intervenidos de revascularizacion miocardica con circulacion extracorporea no modifica las concentraciones plasmaticas de proteinas de fase aguda.

Cirugía cardíaca en octogenarios: situación actual y perspectivas de futuro

Fundamento y objetivo La mayor esperanza de vida incrementa la probabilidad de la cirugia cardiaca en octogenarios. Evaluamos las caracteristicas, la evolucion temporal, la comorbilidad asociada, los factores de riesgo y los resultados de estas intervenciones. Pacientes y metodo Analizamos retrospectivamente los factores de riesgo de morbimortalidad y la supervivencia de 120 pacientes de 80 anos de edad o mas –media (desviacion estandar) de 81,53 (1,83) anos– intervenidos entre 2000 y 2005, comparando la comorbilidad preoperatoria y la mortalidad hospitalaria con las de un grupo de 2.425 pacientes de edad inferior a 80 anos intervenidos en el mismo periodo. Resultados Preoperatoriamente los octogenarios presentaron mayor incidencia de hipertension arterial, insuficiencia renal, angina inestable, afectacion de tronco de coronaria izquierda y peor grado funcional. La cirugia combinada (valvular mas coronaria) fue significativamente mayor (el 20 frente al 9,85%) y un 45% presento alguna complicacion postoperatoria. La mortalidad (15,8%) se duplico con respecto a la poblacion de menor edad y las estancias hospitalarias y en la unidad de cuidados intensivos se prolongaron. En el analisis multivariante la cirugia urgente, la cirugia mitral y la presencia de alguna complicacion postoperatoria fueron factores de riesgo de mortalidad. El sexo femenino fue factor de riesgo de morbilidad. La supervivencia a 1, 3 y 5 anos fue del 91,2, el 80,73 y el 69,2%, respectivamente. Un 98,7% se hallaba en clase funcional I-II de la New York Heart Association (NYHA). El 92,5% de los pacientes se ratifico en su decision de operarse. Conclusiones A pesar de una mayor comorbilidad y peor clase funcional, la mortalidad de la cirugia cardiaca en octogenarios es aceptable y la calidad de vida es muy satisfactoria. Son aconsejables medidas para la reduccion de la alta morbilidad asociada.

Evolution of Prognosis in Left-Sided Infective Endocarditis: A Propensity Score Analysis of 2 Decades.

Left-sided infective endocarditis (LSIE) bears a high in-hospital mortality rate that has remained unchanged over the past 2 decades [(1)][1]. Our objectives were to investigate whether the clinical profile of patients with LSIE has worsened in this time period and to test the hypothesis that this

Troca de valva com a prótese valvar modelo Omnicarbon: seguimento clínico de 10 anos

OBJECTIVE We retrospectively examined the outcomes of 264 patients who underwent consecutive Omnicarbon valve implantation surgery between April 1985 and May 1995. METHODS At the time of surgery, patients who received this mechanical prosthesis averaged 57+/-11 years of age. Omnicarbon valves were placed in the aortic position in 36% of the cases, in the mitral position in 44%, and in both positions in 20%. Follow-up was carefully performed, with most patients undergoing physical examination at our clinic. While taking the case history, cardiac physicians specifically questioned the patient about valve-related complications. RESULTS Accumulated total patient-years is 1291, with a mean follow-up time of 5.4 years. Survival at 10 years is 79.4+/-3.9%, including all causes of death and early mortality. Complications recorded during the 11-year study include: thromboembolism (0.1%), hemorrhage (0.4%), endocarditis (0.2%), and nonstructural failure (1.2%). No hemolytic anemia, valve thrombosis, or structural failure was detected during this long-term experience. Functional capability of these patients was subjectively assessed by the NYHA classification system. With follow-up time averaging over 5 years, 97% of our Omnicarbon valve patients are in NYHA I or II. CONCLUSION The Omnicarbon mechanical prosthesis provides a good clinical performance for up to 10 years in both the aortic and mitral positions. Results indicated a low incidence of thromboembolism and of hemorrhagic complications.