Tiberio Santoro

Percutaneous versus surgical closure of secundum atrial septal defects: a systematic review and meta-analysis of currently available clinical evidence

AIMS To summarise data from studies comparing surgical (SC) versus percutaneous closure (PC) of atrial septal defects (ASDs). METHODS AND RESULTS Electronic databases, journals and major international conference proceedings were systematically searched for pertinent clinical studies comparing the two methods of closure (percutaneous and surgical) published up to December 2008, including only those reporting on more than 20 patients. Primary endpoints: occurrence of death and of total and major early complications. Thirteen original studies (3,082 patients) were included. All studies were non-randomised. One death was reported in the surgical group (0.08%; 95% C.I. 0-0.23%). Analysis of postprocedural complications showed a 31% rate (95% CI 21-41%) in SC patients and a 6.6% rate (95% CI 3.9-9.2%) in PC subjects. The adjusted OR for SC vs. PC total complications was 5.4 (95% CI 2.96-9.84; p<0.0001), significantly in favour of PC. The postprocedural major complication rate was 6.8% (95% CI 4-9.5%) in SC patients and 1.9% (95% CI 0.9-2.9%) in PC patients. The adjusted OR for SC vs. PC major complications was 3.81 (95% CI 2.7-5.36; p=0.006), again favouring PC. CONCLUSIONS The largest cohort to date of patients with secundum ASD shows that treatment by a percutaneous approach has a significantly lower rate of either total or major early postprocedural complications compared to surgery.

Aortic Valve Replacement With 17-mm Mechanical Prostheses: Is Patient–Prosthesis Mismatch a Relevant Phenomenon?

BACKGROUND We sought to evaluate the long-term performance of a consecutive cohort of patients implanted with a 17-mm bileaflet mechanical prosthesis. METHODS Between January 1995 and December 2005, 78 patients (74 women, mean age=71±12 years) underwent aortic valve replacement with a 17-mm mechanical bileaflet prosthesis (Sorin Bicarbon-Slim and St. Jude Medical-HP). Preoperative mean body surface area and New York Heart Association class were 1.6±0.2 m2 and 2.6±0.8, respectively. Preoperative mean aortic annulus, indexed aortic valve area, and peak and mean gradients were 18±1.6 mm, 0.42 cm2/m2, 89±32 mm Hg, and 56±21 mm Hg, respectively. Patients were divided into two groups, according to the presence (group A, 29 patients) or absence of patient-prosthesis mismatch (group B, 49 patients). Patient-prosthesis mismatch was defined by an indexed effective orifice area less than 0.85 cm2/m2. RESULTS Overall hospital mortality was 8.8%. Follow-up time averaged 86±44 months. Actuarial 5-year and 10-year survival rates were 83.7% and 65.3%, respectively. The mean postoperative New York Heart Association class was 1.3±0.6 (p<0.001). Overall indexed left ventricular mass decreased from 163±48 to 120±42 g/m2 (p<0.001), whereas average peak and mean prosthesis gradients were 28±9 mm Hg and 15±6 mm Hg, respectively (p<0.001). Early and long-term mortality were similar between the two groups as well as long-term hemodynamic performance (mean peak gradient was 28 mm Hg and 27 mm Hg in group A and B, respectively, not significant); left ventricular mass regression occurred similarly in both groups (indexed left ventricular mass at follow-up was 136±48 and 113±40 in group A and B, respectively; not significant). CONCLUSIONS Selected patients with aortic stenosis experience satisfactory clinical improvement after aortic valve replacement with modern small-diameter bileaflet prostheses.

Prevalence of Tako-Tsubo Syndrome among patients with suspicion of acute coronary syndrome referred to our centre

BACKGROUND The Tako-Tsubo Syndrome is a clinical entity characterized by acute but rapidly reversible left ventricular systolic dysfunction and triggered by emotional or psychological stress. The aim of our study was to determine the prevalence and characteristics of this syndrome among the patients presenting to our Centre with suspicion of acute coronary syndrome. METHODS AND RESULTS Over a 12-month period (May 2006 to April 2007), among 82 patients referred to our catheterization laboratory with suspicion of acute coronary syndrome, 4 confirmed Tako-Tsubo Syndrome (prevalence 4.87%). The patients referred to our Centre came from Foggias province above all. The mean age of the population was 65.5 +/- 18.48 years (range 49 to 82), with a ratio of men to women of 1:3. The syndrome characterized by acute chest pain with ST-segment elevation, absence of significant lesions in each of the 3 epicardial coronary arteries by angiography, systolic dysfunction (ejection fraction 35 +/- 9.12%) with abnormal wall motion of the mid and distal LV and hyperkinesia of the basal LV, and emotional or psychological stress immediately preceding the cardiac events. Among markers of cardiac necrosis, only serum Troponin-I increased in each patients without significant elevation of CPK and with mild elevation of CK-mb and LDH. 2 patients developed hemodynamic instability. Each patient survived with normalized ejection fraction (54.25 +/- 5.05%) and rapid restoration to previous functional cardiovascular status within 4 weeks. CONCLUSIONS A reversible cardiomyopathy triggered by emotional or psychological stress occurs in elderly women above all and mimic acute coronary syndrome. The diagnosis of Tako-Tsubo Syndrome is based mainly on coronary and left ventricular angiography, which excludes the diagnosis of coronary artery disease and recognizes the pattern of wall-motion abnormalities. The different epidemiology of this Syndrome reported in literature demonstrates which this cardiomyopathy is underdiagnosed.

Clinical and Brain Magnetic Resonance Imaging Follow-up After Percutaneous Closure of Patent Foramen Ovale in Patients With Cryptogenic Stroke

Patent foramen ovale (PFO) closure is reported to result in fewer episodes of clinically manifest recurrent cerebral ischemia than medical treatment. We evaluated by means of magnetic resonance imaging (MRI) whether silent cerebral ischemic episodes are also decreased by PFO closure. Seventy-one patients with PFO were selected for percutaneous closure of PFO at our center. All had PFO with large right-to-left shunt documented by transcranial Doppler ultrasound and transesophageal echocardiography, > or =1 previous stroke or transient ischemic attack with MRI documentation at the index event, and no alternative cause for cerebral ischemia. MRI studies were performed in all patients 24 hours before the procedure and at 1-year follow-up (or before in the case of a suspected new neurologic event). Eight patients (11%) had >1 clinical event before the procedure. Comparing the 2 MRI studies before the procedure, silent ischemic lesions were observed in 14 other patients (20%). Thus, considering clinical and silent events together, >1 event was present at baseline in 22 patients (31%). After PFO closure (follow-up 16 +/- 7 months), 1 recurrent neurologic event occurred (1%, p = 0.02 vs preprocedural clinical events); however, urgent brain MRI results were negative. Moreover, only 1 patient showed 1 new silent lesion at brain MRI at follow-up (1%, p <0.001 vs preprocedural silent brain lesions). Considering clinical and silent events, relapses occurred in 2 patients only (p <0.001 vs before procedure). Recurrent events were limited to those with incomplete PFO closure at postprocedural transcranial Doppler ultrasound (p = 0.02). In conclusion, percutaneous PFO closure results in few clinical or silent events after 1-year follow-up, especially when complete PFO closure is successfully accomplished.

Cardiac Arrest caused by Barlow's Syndrome or by Stress Cardiomyopathy?

We describe a case of out-of-hospital Cardiac Arrest (CA) in a patient with Barlows Syndrome (BS) and features of Stress Cardiomyopathy (SC) (or Apical Ballooning Syndrome or Tako-Tsubo). The patient experienced CA during physical stress and was resuscitated thanks to DC-Shock. The Electrocardiogram (ECG) after resuscitation was unremarkable. In the reported case the documented severe hypokalemia, with the physical stress, could have triggered the CA, probably of tachyarrhythmic origin. However, in the reported case, the echocardiographic, coronarographic and ventriculographic features, were surprisingly indistinguishable from those of the SC. In conclusion it is impossible to say if, in our patient, the CA has been caused by BS or by SC. However, even if CA has been probably caused by the BS, we hypothesize that the CA, in its turn determined, might have caused the SC via stress mechanisms. In few words, the CA is a complication of SC, but should probably be regarded also as a cause of SC.

Anomalous origin of the left coronary artery from the pulmonary artery in an elderly patient, football player in youth.

Anomalous origin of the left coronary artery from the pulmonary artery is a rare congenital defect. Without surgical treatment, approximately 90% of infants die within the first year of life. Late presentation in the adult or elderly is rare. Factors that may lead to survival in advanced age include the development of intercoronary collaterals. Furthermore, the risk of sudden cardiac death due to ischaemic malignant ventricular dysrhythmias exists even in asymptomatic adult patients and, classically, is precipitated by exercise. We report the case of a 67-year-old man, a football player in his youth, always asymptomatic until presentation at our centre for symptomatic sustained ventricular tachycardia and shortness of breath on exertion. We show the features of the ECG, transthoracic echocardiography, angiography study of the coronary and the pulmonary system, myocardial basal and stress gated single photon emission computed tomography with Tc-tetrofosmin and cardiac CT 64 slices. The patient was referred to cardiac surgery. We believe that this patients favourable course may be ascribed to the large network of collaterals from the right coronary artery supplying the entire heart. However, the exact reason why these favourable evolutions (both vascular and clinical) occur only in some individuals remains largely unknown.

Aortocaval fistula mimicking an acute coronary syndrome.

A 75-year-old man complained of episodes of chest pain and dyspnea. An acute coronary syndrome was suspected but coronary angiography showed only mild stenosis (less than 50% reduction of vessel diameter) of the left anterior descending artery. We performed an aortography that showed a large infrarenal aneurysm with direct communication from the aorta to the inferior vena cava, forming an aortocaval fistula (ACF). The patient was immediately brought to the operating room where he underwent a successful surgical repair. The interesting aspect of our case is the clinical presentation mimicking an acute coronary syndrome with shock and bradyarrhythmias. The prompt diagnosis of ACF is very difficult because this rare pathology may present with several signs and symptoms. Surgery, or endovascular treatment in selected cases, is the only chance of survival.

Pulmonary embolism: a late complication of a correctly positioned occluder device for patent foramen ovale.

We describe a patient with pulmonary embolism originating from right atrial thrombosis that developed at least 18 months after patent foramen ovale (PFO) device implantation. On surgical inspection, the PFO device was found to be correctly positioned, stable and well endothelialized. We then hypothesize that current smoker status, double antiplatelet regimen discontinuation and mild hyperhomocysteinaemia may have had a role in determining this severe, unexpected and late complication in this patient.

Aortic valve decalcification for severe aortic valve stenosis in the elderly: medium-term results.

Aims To present the results of a novel technique of aortic valve decalcification (AVD) in a consecutive population of elderly patients with severe aortic valve stenosis (AVS) and small aortic annulus. Methods Between January 2008 and December 2012, a consecutive series of 34 patients (mean age 80 ± 13 years) with severe AVS were operated on using AVD. They were compared with a matched population of 68 patients (mean age 82 ± 7 years) submitted to aortic valve replacement (AVR) with bioprosthesis. The two groups were comparable for cardiac risk factors and admission symptoms. Preoperatively, all patients presented with severe AVS, small aortic annulus (19 mm) and preserved left ventricular function. Results Thirty-day mortality was 8.8 vs. 7.5% in the AVD and AVR groups, respectively (P = 0.88). Actuarial 2 and 5-year survival rates were 80 vs. 82% and 64 vs. 78% in the AVD and AVR groups, respectively (P = 0.27). Long-term valve-related events incidence was significantly higher in the AVD group (12%) compared with that in the AVR group (4%; P = 0.01). However, in the AVD group, patients with no or mild residual AR experienced 2 and 5 years of freedom from valve-related events, which is not significantly different from the patients submitted to the AVR group (P = 0.76). After AVD, a significant increase in the aortic valve area (from 0.8 to 1.9 cm2) and a parallel reduction in the mean gradient (from 40 to 12 mmHg) was observed in all patients (P = 0.01). Postoperative aortic valve area (1.9 vs. 1.26 cm2), as well as mean gradient (12 vs. 21 mmHg), were significantly better in the AVD group compared with that in the AVR group (P = 0.01). Conclusion In this preliminary experience, AVD seems a good therapeutic option for elderly patients with severe AVS. Further studies with longer follow-up are needed in order to confirm these preliminary results and to ascertain the valve durability over time.