Yanai Ben-Gal

Comparison of early and late outcomes of TAVI alone compared to TAVI plus PCI in aortic stenosis patients with and without coronary artery disease

To assess the safety and effectiveness of performing percutaneous coronary intervention (PCI) before transcatheter aortic valve implantation (TAVI).

New evidence for the role of TNF-α in liver ischaemic/reperfusion injury

Background  Tumour necrosis factor‐alpha (TNF‐α) plays a key role in causing ischaemia/reperfusion (I/R) injury. I/R also causes activation of xanthine oxidase and dehydrogenase (XDH + XO) system that, via generated free radicals, causes organ damage. We investigated the effect of ischaemia, reperfusion and non‐ischaemic prolonged perfusion (NIP) on TNF‐α and XDH + XO production in an isolated perfused rat liver model.

Surgical Versus Percutaneous Coronary Revascularization for Multivessel Disease in Diabetic Patients With Non–ST-Segment–Elevation Acute Coronary Syndrome Analysis From the Acute Catheterization and Early Intervention Triage Strategy Trial

Background—The preferred revascularization strategy for diabetic patients with acute coronary syndromes and multivessel coronary artery disease is uncertain. We evaluated the outcomes of diabetic patients with moderate and high-risk acute coronary syndrome and multivessel disease managed with percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG). Methods and Results—Among 13 819 moderate and high-risk acute coronary syndrome patients enrolled in the Acute Catheterization and Early Intervention Triage Strategy (ACUITY) trial, 1772 diabetic patients had multivessel disease with left anterior descending artery involvement and were managed by PCI (n=1349) or CABG (n=423). Propensity scoring was applied to adjust for differences in baseline clinical and angiographic characteristics, yielding a total of 326 matched patients (163 managed by PCI and 163 managed by CABG). At 30 days, treatment with PCI compared with CABG was associated with lower rates of major bleeding (15.3% versus 55.6%; P<0.0001), blood transfusions (9.2% versus 43.2%; P<0.0001), and acute kidney injury (13.4% versus 33.6%; P<0.0001), but more unplanned revascularization procedures (6.9% versus 1.9%; P=0.03). At 1 year PCI was associated with higher rates of repeat revascularization procedures (19.5% versus 5.2%; P=0.0001), with nonsignificantly different rates of myocardial infarction, stroke, and death at either 30 days or 1 year. Conclusions—In the large-scale ACUITY trial, diabetic patients with acute coronary syndrome and multivessel disease treated with PCI rather than CABG had less bleeding and acute kidney injury, greater need for repeat revascularization procedures, and comparable rates of myocardial infarction, stroke, and death through 1-year follow-up. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT00093158.

Surgical Myocardial Revascularization versus Percutaneous Coronary Intervention with Drug-Eluting Stents in Octogenarian Patients

OBJECTIVE Our goal was to compare the clinical outcomes of octogenarian (or older) patients who are referred for either surgical or percutaneous coronary revascularization. METHODS We retrospectively evaluated the outcomes of all patients 80 years of age who had undergone coronary artery bypass grafting (CABG) with an internal mammary artery or had undergone a percutaneous coronary intervention (PCI) with a sirolimus-eluting stent to the left anterior descending artery in our center between May 2002 and December 2006. RESULTS Of the 301 patients, 120 underwent a PCI, and 181 underwent CABG. Surgical patients had higher rates of left main disease, triple-vessel disease, peripheral vascular disease, emergent procedures, and previous myocardial infarctions (39.7% versus 3.3% [P = .001], 76.1% versus 28.3% [P = .0001], 19.6% versus 7.5% [P = .004], 15.8% versus 2.5% [P = .0001], and 35.9% versus 25% [P = .04], respectively). CABG patients had a higher early mortality rate (9.9% versus 2.5%, P = .01). There were no differences in 1- and 4-year actuarial survival rates, with rates of 90% and 68%, respectively, for the PCI group and 85% and 71% for the CABG group (P = .85). The rates of actuarial freedom from major adverse cardiac events (MACEs) at 1 and 4 years were 83% and 75%, respectively, for the PCI group, and 86% and 78% for the CABG group (P = .33). The respective rates of freedom from reintervention were 87% and 83% for the PCI group, versus 99% and 97% for the CABG group (P < .001). The 4-year rate of freedom from recurring angina was 58% for the PCI group, versus 88% for CABG patients (P < .001). Revascularization strategy was not a predictor of adverse outcome in a multivariable analysis. CONCLUSION Octogenarian CABG patients were sicker and experienced a higher rate of early mortality. The 2 strategies had similar rates of late mortality and MACEs, with fewer reinterventions and recurring angina occurring following surgery.

Pulmonary Hypertension: A Nomogram Based on CT Pulmonary Angiographic Data for Prediction in Patients without Pulmonary Embolism

PURPOSE To use cardiovascular data from computerized tomographic (CT) pulmonary angiography for facilitating the identification of pulmonary hypertension (PH) in patients without acute pulmonary embolism. MATERIALS AND METHODS The institutional human research committee approved this retrospective study; informed consent was waived. Patients without pulmonary embolism who underwent CT pulmonary angiography and echocardiography within 24 hours of each other between December 2008 and October 2012 were retrospectively identified. The diameters of the pulmonary artery, aorta, and right and left ventricles and the severity of reflux of contrast material were assessed. The volumes of each cardiac compartment were calculated. Doppler echocardiography served as a reference standard for PH. A prediction model for PH was built by using backward logistic regression and was presented on a nomogram. The prediction model was evaluated with 10-fold cross-validation, and a test group of patients was studied between November 2012 and June 2014. RESULTS The final study group included 182 patients, of whom 98 (54%) were given a diagnosis of PH on the basis echocardiographic results. Age of 67 years or older (odds ratio [OR] = 4.46), reflux grade of 3 or higher (OR = 2.63), right atrial volume of greater than or equal to 106 cm(3) (OR = 3.59), pulmonary artery diameter greater than or equal to 28 mm (OR = 2.52) and pulmonary artery diameter to aorta diameter ratio of greater than or equal to 0.86 (OR = 2.17) were independently associated with PH. The logistic model showed good discrimination ability (area under the curve = 0.844, discrimination slope = 0.359). Tenfold cross-validation showed 85.7% sensitivity, 60.7% specificity, 71.3% positive predictive value, and 76.1% negative predictive value for identification of PH, while the test group showed similar results (84.1%, 60.5%, 71.2%, and 76.7%, respectively). CONCLUSION Cardiovascular data derived from CT pulmonary angiography are associated with PH, and a nomogram can be created that may facilitate identification of PH after exclusion of acute pulmonary embolism.

Revascularization of the left anterior descending artery with drug-eluting stents: comparison with arterial off-pump surgery.

BACKGROUND This study compared early results of left anterior descending artery (LAD) stenting using drug-eluting stents (Cypher) with off-pump bilateral internal thoracic arterial (BITA) grafting. METHODS From June 2002 to June 2003, 200 consecutive patients underwent myocardial revascularization of the LAD territory, 100 by Cypher and 100 by BITA. The 2 groups were similar; however, left main disease and triple-vessel disease (20% and 75% versus 2% and 28%), age >70 (36% versus 17%) and intraaortic balloon pump (7% versus 0%) were more prevalent in the BITA group, and prior percutaneous coronary angiogplasty to the LAD was more prevalent in the Cypher group (28% versus 16%). RESULTS The number of coronary vessels treated per patient in the BITA group was higher (2.7 versus 1.45, P < .01). Thirty-day mortality was 1% in the BITA group and 0% in the Cypher group. Mean follow-up was 12 months. There was 1 late death in each group. Angina returned in 32% of the Cypher group and in 1% of the BITA group. There were 9 reinterventions in the Cypher group: 7 coronary angioplasties (including 2 to the LAD) and 2 surgical interventions. There was neither recurrent angina nor reintervention in the surgical group. CONCLUSIONS Despite a higher risk profile of patients treated with BITA, their clinical outcome is better. A longer and more complete angiographic follow-up is required to determine the role of drug-eluting stents in LAD revascularization.

l-Arginine improves endothelial function, independently of arginine uptake, in aortas from chronic renal failure female rats

Endothelial cell dysfunction (ECD) is a common feature of chronic renal failure (CRF). Defective nitric oxide (NO) generation due to decreased endothelial nitric oxide synthase (eNOS) activity is a crucial parameter characterizing ECD. Decreased activity of cationic amino acid transporter-1 (CAT-1), the selective arginine transporter of eNOS, has been shown to inhibit eNOS in uremia. Recently, we failed to demonstrate a decrease in glomerular arginine transport in uremic female rats (Schwartz IF, Grupper A, Soetendorp H, Hillel O, Laron I, Chernichovski T, Ingbir M, Shtabski A, Weinstein T, Chernin G, Shashar M, Hershkoviz R, Schwartz D. Am J Physiol Renal Physiol 303: F396-F404, 2012). The current experiments were designed to determine whether sexual dimorphism which characterizes glomerular arginine transport system in uremia involves the systemic vasculature as well and to assess the effect of L-arginine in such conditions. Contractile and vasodilatory responses, ultrastructural changes, and measures of the L-arginine-NO system were performed in thoracic aortas of female rats subjected to 5/6 nephrectomy. The contractile response to KCl was significantly reduced, and acetylcholine-induced vasodilation was significantly impaired in aortas from CRF dames compared with healthy rats. Both of these findings were prevented by the administration of arginine in the drinking water. The decrease in both cGMP generation, a measure of eNOS activity, and aortic eNOS and phosphorylated eNOS abundance observed in CRF rats was completely abolished by l-arginine, while arginine transport and CAT-1 protein were unchanged in all experimental groups. Arginine decreased both serum levels of advanced glycation end products and the asymmetrical dimethylarginine/arginine ratio and restored the endothelial ultrastructure in CRF rats. In conclusion. arginine administration has a profound beneficial effect on ECD, independently of cellular arginine uptake, in CRF female rats.

Comparison between multivessel stenting with drug eluting to the LAD and bilateral internal thoracic artery grafting.

BACKGROUND Reduction of restenosis and reinterventions was reported with drug-eluting stents (Cypher). This study compares results of multivessel Cypher stenting with bilateral internal thoracic artery (BITA) grafting. METHODS From January 2002 to June 2004, 725 consecutive patients underwent multivessel myocardial revascularization, 95 by 2 or more Cypher stents and 630 by BITA. After matching for age, sex, and extent of coronary artery disease, 2 groups (87 patients each) were used to compare the 2 revascularization modalities. RESULTS The 2 groups were similar; however, left main and the use of an intra-aortic balloon pump were more prevalent in the BITA group. The number of coronary vessels treated per patient was higher in the BITA group (2.71 versus 2.24 for BITA and Cypher, respectively; P = .001). Mean follow-up was 12 months. Thirty-day mortality was 0 in both groups. There were no late deaths in the BITA group and 2 (2.3%) in the Cypher group (P value was not significant). Angina returned in 29.9% of the Cypher group and 12.6% of the BITA group (P = .005). Multivariable Cox analysis revealed percutaneous intervention (PCI) (Cypher group) to be the only independent predictor of angina recurrence (Odds Ratio 2.62, 95% Confidence Interval 1.11-6.17). There were 10 reinterventions (PCI) in the Cypher group compared to 5 in the BITA group. One-year reintervention-free survival (Kaplan-Meier) of the BITA group was 96% compared to 88% in the Cypher group (P = .015). CONCLUSIONS Midterm clinical outcome of surgically treated patients is still better. However, the reintervention gap between surgery and percutaneous interventions was reduced by treating 2 or more coronary vessels with Cypher stents.

The right internal thoracic artery and right gastroepiploic artery: alternative sites for proximal anastomosis in patients with atherosclerotic calcified aorta.

BACKGROUND Atherosclerotic or calcified ascending aorta is an important predictor of adverse cerebrovascular events. Using off-pump coronary artery bypass (OPCAB) with composite and in situ arterial grafting to avoid aortic manipulation and clamping may reduce the risk of stroke related to aortic atheroembolism. When the aorta is calcified and cannot serve as a safe site for proximal anastomosis, this anastomosis can be performed on the proximal segment of the right internal thoracic artery (ITA) and right gastroepiploic artery (RGEA). Four such cases are described. METHODS In 2 patients, the proximal right ITA was used as the site for proximal saphenous vein graft (SVG) anastomosis. Chronic obstructive lung disease in one patient and insulin-dependent diabetes in the other precluded performance of OPCAB with bilateral ITA. In addition, positive Allen test precluded performance of composite T-graft with radial artery (RA) on ITA. Both SVGs were anastomosed distally to the posterior descending artery. In 2 other patients, RA was connected end-to-side to the proximal segment of the RGEA. Both of these patients had repeat operations. The distal end of the RGEA was too small, and concerns regarding the future flow to a very large coronary bed precluded its use as an in situ graft. RESULTS All patients underwent the operative procedures without any neurological or cardiovascular adverse effects, and all are midterm, symptom-free survivors. Postoperative graft patency was confirmed intraoperatively with flow measurements and postoperatively with control angiography or coronary imaging computed tomography. CONCLUSIONS The RITA and proximal RGEA can serve safely as sites for proximal anastomosis in patients with atherosclerotic calcified aorta undergoing OPCAB.

Radiation dose of patients undergoing transcatheter aortic valve implantation: A comparison between edwards SAPIEN XT and medtronic corevalve aortic valve prostheses

The relative radiation dose (RD) of patients undergoing transcatheter aortic valve implantation (TAVI) with either the Edwards Sapien XT (ESX) or the Medtronic CoreValve (MCV) prostheses has not been studied in depth. Our aim was to quantify RD in uncomplicated transfemoral TAVI with either prosthesis.