Coronary artery reconstruction for extensive coronary disease: 108 patients and two year follow-up

BACKGROUND: Surgical coronary artery reconstruction for diffuse coronary disease is described and assessed. METHODS: A long arteriotomy, internal thoracic artery graft, and exclusion of atheromatous plaques from the coronary lumen are the bases of the technique. One hundred eighteen reconstructions were performed in 108 patients with a mean age of 59 years. Stable angina was present in 62% of patients and unstable angina in 22%. Sixteen percent had had a recent myocardial infarction. The reconstructions involved 94 left anterior descending coronary arteries, 17 marginal, 5 diagonal, and 2 right coronary arteries. RESULTS: The perioperative mortality rate was 3.7% (4 patients). The rate of perioperative myocardial infarction was 6.3%. Mean follow-up was 29 months (standard deviation, 10 months). Two patients were lost to follow-up. Ninety patients were free from angina and cardiac-related events. Five patients sustained a myocardial infarction, 3 were in congestive heart failure, 3 had class II angina, and 1 died of stroke. Seventy-four of the surgical coronary artery reconstructions have been angiographically evaluated (29 months): 94.6% of the internal thoracic artery grafts were completely patent, and 70 of the reconstructions were patent without restenosis. String signs and occlusions were present in two internal thoracic arteries each. CONCLUSIONS: This technique allows revascularization of severely and diffusely diseased coronary arteries with encouraging results.     

Hipertensão arterial na grávida: o atual estado da arte

Hypertension complicates 6-8% of pregnancies and includes the following four conditions: hypertension preceding pregnancy or documented before the 20th week of gestation; pre-eclampsia (PE) / eclampsia; chronic hypertension with superimposed pre-eclampsia; and gestational hypertension. The latter is defined as a significant rise in blood pressure after the 20th week of pregnancy in previously normotensive women, to over 140/90 mmHg. When blood pressure remains above 160/110 mmHg, it is considered severe. PE is defined as the presence of proteinuria (≥300 mg/24 h) in pregnant women with hypertension. The hypertensive syndromes of pregnancy are among the leading causes of maternal and fetal morbidity and mortality and anti-hypertensive treatment is part of the therapeutic arsenal used to prevent serious complications. Although the role of utero-placental insufficiency due to deficient migration of trophoblasts to the spiral arteries is universally accepted, the pathophysiology of PE remains largely unknown and is the subject of debate. No effective ways of predicting or preventing PE have been found, which highlights the need for further research in this field. This review aims primarily to evaluate recent advances in our understanding of the pathophysiology of gestational hypertension and especially PE, and new ways of predicting PE. Additionally, we present a brief review on the diagnosis, prevention and treatment of PE.     

Objective assessment of gastroesophageal reflux after extended Heller myotomy and total fundoplication for achalasia with the use of 24‐hour combined multichannel intraluminal impedance and pH monitoring (MII‐pH)

SUMMARY. This study aims to evaluate by the use of 24‐hour combined multichannel intraluminal impedance and pH monitoring (MII‐pH) the efficacy of the Nissen fundoplication in controlling both acid and nonacid gastroesophageal reflux (GER) in patients that underwent Heller myotomy for achalasia. It has been demonstrated that fundoplication prevents the pathologic acid GER after Heller myotomy, but no objective data exists on the efficacy of this antireflux surgery in controlling all types of reflux events. The study population consisted of 20 patients that underwent laparoscopic Heller myotomy and Nissen fundoplication for achalasia. All patients were investigated with manometry and MII‐pH. MII‐pH showed no evidence of postoperative pathologic GER. The overall number of GER episodes was normal in both the upright and recumbent position. This reduction was obtained because of the postoperative control of both the acid and nonacid reflux episodes. The Nissen fundoplication adequately controls both acid and nonacid GER after extended Heller myotomy. Further controls with MII‐pH are warranted to check at a longer follow‐up for the efficacy of this antireflux procedure in achalasic patients.     

Effects of colchicine on tissue factor in oxLDL-activated T-lymphocytes

Journal of Thrombosis and Thrombolysis - Several studies have shown that T-cells might be involved in pathophysiology of acute coronary syndromes (ACS). Tissue factor (TF) plays a key role in ACS....     

Non-vitamin K antagonist oral anticoagulation versus left atrial appendage occlusion for primary and secondary stroke prevention after cardioembolic stroke

IntroductionThis study aimed to evaluate the performance of non-vitamin K antagonist oral anticoagulation (NOAC) in patients with previous stroke and non-valvular atrial fibrillation (AF) compared with left atrial appendage occlusion (LAAO) in primary and secondary stroke prevention settings.MethodsThis was a prospective, single-center, non-randomized cohort study of 302 consecutive patients with non-valvular AF and at high risk for stroke. Two treatment strategies were compared: LAAO (n=91) and long-term treatment with NOAC (n=149). The primary outcome was the composite endpoint of death, stroke and major bleeding. Propensity score and cause-of-death analyses were performed to compare outcomes.ResultsIn a mean follow-up of 13 months, there were 30 deaths (LAAO 8.8% vs. NOAC 14.8%), five strokes (LAAO 1.1% vs. NOAC 2.7%) and six major bleeds (LAAO 1.1% vs. NOAC 3.4%). There was a non-significant trend for a lower incidence of the primary endpoint in the LAAO group (11.0% vs. 20.9%; HR 0.42, 95% CI 0.17-1.05, p=0.064). Considering only secondary prevention LAAO patients (34.1% of the LAAO group), there was also a non-significant lower incidence of the primary endpoint (LAAO 6.5% vs. 20.9%; HR 0.30, 95% CI 0.07-1.39, p=0.12). While about a fifth of LAAO patients stopped antiplatelet treatment six months after device implantation due to recurrent minor bleeding, no adverse cardiovascular event or major bleeding occurred in this subset of patients.ConclusionIn this registry-based study, LAAO was a reasonable alternative to NOAC for the prevention of a composite endpoint of all-cause mortality, stroke and major bleeding in patients at high risk for stroke.     

Evaluation of direct thrombin inhibitors during a critical heparin shortage

Journal of Thrombosis and Thrombolysis - A recent heparin shortage related to an outbreak of African Swine Flu in China led to substantial increase in the use of direct thrombin inhibitors (DTI) as...     

Extended early meets late for assessment of conduction block along an ablation line

Journal of Interventional Cardiac Electrophysiology - The purpose of the study was to investigate the usefulness of the extended early meets late (EEML) feature of the HD Coloring software for...     

The use of atrial pacing to induce atrial fibrillation and flutter

We studied the clinical and electrophysiological significance of induction of atrial fibrillation or atrial flutter by atrial electrical stimulation. Our atrial fibrillation/flutter induction protocol included incremental atrial pacing up to a rate of 200 beats/min, ramp up to 250 and 300 beats/min, and bursts up to 600 beats/min. The end point was sustained atrial fibrillation/flutter induction (30 sec). We performed a provocative study on 72 subjects previously divided into three groups: the first was the control group; the second comprised patients with spontaneous paroxysmal atrial fibrillation/flutter; the third comprised patients without spontaneous atrial fibrillation/flutter, but with pathologies assumed to put them at risk for atrial fibrillation/flutter. We were unable to induce sustained atrial fibrillation/flutter in the control group, but were able to induce these arrhythmias in 95% of the subjects with spontaneous atrial fibrillation/flutter. Thus the methods have a sensitivity of 95% and a specificity of 100%. We were also able to induce atrial fibrillation/flutter in 57% of patients at risk for atrial fibrillation/flutter, that is a lower incidence than patients with spontaneous episodes. When sustained atrial fibrillation/flutter could be induced, it was well tolerated and stopped spontaneously in less than 24 hours without treatment. The technique thus involves no risk and demonstrates that antiarrhythmic therapy is usually superfluous in interrupting induced atrial fibrillation/flutter.