An alternative technique for aortic root remodeling in patients with bicuspid aortic valve.
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Adult↗
Biomedical subjects
Sabino Iliceto
Publications and source records attributed to Sabino Iliceto.
Modulations of autonomic activity leading to tilt-mediated syncope.
BACKGROUND: Vasovagal syncope (VVS) results from a complex interaction among afferent vagal and sympathetic signals, cortical modulation and bulbar integration. The aim of our study was to evaluate the modifications of autonomic activity during Upright Tilt Test (UTT) in patients with unexplained syncope, and to correlate these changes with the specific cardiovascular reactions induced. METHODS AND RESULTS: We studied 90 patients with a mean age of 44+/-17 yrs. Frequency domain analysis of heart rate variability (HRV) (normalized units) was performed on 2 periods of 300 beats: at baseline and after 5 min of 60 degrees tilt. UTT was positive in 56 patients (62%). The responses were cardioinhibitory in 8, vasodepressive in 15, mixed in 33. Baseline LF and HF components did not show significant difference between subjects with positive or negative test (HF: 39+/-21 versus 41+/-22; LF: 50+/-22 versus 49+/-23). HRV during UTT showed similar changes in patients with positive or negative test. However, subjects with mixed or cardioinhibitory reactions were characterized by a relevant increase of LF during UTT (from 47+/-23 to 66+/-21), whereas the others by a non-significant decrease of the same component (from 57+/-19 to 51+/-31). CONCLUSIONS: Patients developing a reflex cardioinhibitory reaction during UTT were characterized by an increase of sympathetic activity during the test, that might represent an essential factor to induce a stronger vagal reaction on the sinus node. On the contrary, in subjects with vasodepressive reactions an inadequate enhancement of the sympathetic drive, probably causing a failure of peripheral vasoconstriction, was evidenced.
Adult↗
Relation of patient age to outcome of percutaneous mitral valvuloplasty.
The aim of this study was to evaluate the impact of age on immediate- and long-term outcomes of percutaneous mitral balloon valvuloplasty (PMV). PMV is the first-line treatment for patients with symptomatic mitral stenosis. However, long-term results in large series of patients from Europe and the United States have been found less favorable than those from Asia and South America involving younger patients. Six hundred ten patients who underwent 626 PMV procedures were prospectively followed for 6.1 +/- 4.10 years using clinical and echocardiographic evaluation. Patients were divided in quartiles according to age: < or =41 years (n = 163), 42 to 53 years (n = 163), 54 to 63 years (n = 142), and >63 years (n = 158). The success of PMV was defined as valve area > or =1.5 cm(2) without severe regurgitation; restenosis was defined as a loss > or =50% of initial gain, with a valve area of <1.5 cm(2). PMV success was significantly more prevalent in younger patients: 95.7% in group 1, 91.4% in group 2, 86.4% in group 3, and 83.4% in group 4 (p = 0.002). No significant differences in complications were found among all age groups, including death, cardiac tamponade, emergency mitral replacement, and any embolic events (p = NS). Event-free survival was greater in younger patients (p <0.0001), but on multivariate analysis, age was not an independent predictor of events (p = NS). Restenosis occurred in 27.9% of patients, throughout all groups (p = NS). In conclusion, PMV may be safely and effectively performed in younger and older patients. Although event-free survival was greater in younger groups, multivariate analysis did not find that age was an independent predictor of events.
Adult↗
Influence of transmurality, infarct size, and severe microvascular obstruction on left ventricular remodeling and function after primary coronary angioplasty.
Infarct size has been considered an established marker of left ventricular (LV) remodeling. We assessed the predictive value of myocardial/microvascular injury assessed by delayed enhanced magnetic resonance imaging (MRI) on LV remodeling and LV ejection fraction after primary coronary intervention (PCI) compared with peak troponin levels, an established index of myocardial infarct size. We performed MRI in 76 patients with first acute myocardial infarction 6 +/- 2 days after successful PCI. Necrosis was judged as transmural when delayed enhancement was extended to >or=75% of LV segment thickness. Severe microvascular obstruction was identified as areas of late hypoenhancement surrounded by delayed enhancement. Infarct size was expressed as an index by dividing the total percentage of delayed enhancement involvement by the number of LV segments. LV end-diastolic volume index and function were quantified by 2-dimensional echocardiography at 6 +/- 1 months after acute myocardial infarction. Remodeling was evaluated as a change in LV end-diastolic volume index at follow-up compared with baseline. At univariate analyses, transmural necrosis, severe microvascular obstruction, infarct size, and troponin level were correlated directly with remodeling and inversely with LV function at follow-up (p <0.001). At multiple regression, only transmural necrosis and troponin level remained independent predictors of LV remodeling and function. With respect to troponin, transmural necrosis improved the predictive power of LV remodeling (R2 for change = 0.19) and function (R2 for change = 0.16). In conclusion, in patients with acute myocardial infarction undergoing PCI, the amount of transmural necrosis as assessed by MRI is a major determinant of LV remodeling and function, with significant additional predictive value to infarct size and severe microvascular obstruction.
Angiography↗
Interaction among risk-time and benefit of primary angioplasty.
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Angioplasty, Balloon, Coronary↗
Coronary flow velocity pattern and coronary flow reserve by contrast-enhanced transthoracic echocardiography predict long-term outcome in heart transplantation.
BACKGROUND: We assessed coronary flow velocity pattern and coronary flow reserve (CFR) by contrast-enhanced transthoracic echocardiography (CE-TTE) as markers of major adverse cardiac events (MACE) related to cardiac allograft vasculopathy (CAV) after heart transplantation (HT). METHODS AND RESULTS: Deceleration time of diastolic flow velocity (DDT) and CFR were measured in the left anterior descending coronary artery (LAD) by CE-TTE in 66 consecutive HT patients (follow-up 19+/-5 months). CFR was calculated as the ratio of hyperemic to basal diastolic flow velocity. Angiographies were analyzed by a qualitative grading system; CAV was defined as changes grade II or higher. MACE were cardiac death, stent implantation, and heart failure. Patients with MACE had higher CAV incidence (P=0.004) and grade (P=0.008), shorter DDT (P=0.006), and lower CFR (P=0.008). A receiver-operating characteristic-derived DDT cutpoint < or = 840 ms (area under the curve 0.793; P=0.01) was 75% specific and 86% sensitive for predicting MACE, with positive predictive value (PPV) and negative predictive value (NPV) of 33% and 97%, respectively (P=0.002). A CFR cutpoint of < or =2.6 (area under the curve 0.746; P=0.01) was 62% specific and 91% sensitive for predicting MACE (PPV =32%, NPV =97%) (P=0.001). Patients with CFR < or = 2.6 and patients with DDT < or = 840 ms had a lower survival free from MACE (P=0.006 and P=0.009, respectively). By Cox regression, only a lower CFR predicted the risk of MACE (relative risk 3.1; 95% CI, 1.26 to 7.9; P=0.01). CONCLUSIONS: In HT patients, shorter DDT and lower CFR by CE-TTE are reliable markers for CAV-related MACE. CFR is the main independent predictor of MACE.
Adolescent↗
Metabolic treatment with L-carnitine in acute anterior ST segment elevation myocardial infarction. A randomized controlled trial.
BACKGROUND: Administration of L-carnitine in patients with anterior acute myocardial infarction (AMI) prevents left ventricular remodeling. Current study was aimed to assess the effect of L-carnitine administration on mortality and heart failure in patients with anterior AMI. METHODS: CEDIM 2 trial was a randomized, double-blind, multicenter, placebo-controlled trial planned to enroll 4,000 patients with acute anterior AMI. The trial was interrupted after the enrolment of 2,330 patients because of the lower than expected enrolment rate. The primary end point was a composite of death and heart failure at 6 months; 5-day mortality was the secondary end point. RESULTS: During the 6-month follow-up, the primary end-point was not significantly different between the L-carnitine and placebo group (9.2 vs. 10.5%, p = 0.27). A reduction in mortality was seen in the L-carnitine arm on day 5 (secondary end-point) from randomization (HR = 0.61, 95% CI 0.37-0.98, p = 0.041). CONCLUSIONS: In CEDIM 2 trial L-carnitine therapy led to a reduction in early mortality (secondary end-point) without affecting the risk of death and heart failure at 6 months in patients with anterior AMI, leading to a non-significant finding with respect to the primary end-point.
Carnitine↗
Contribution of decreased atrial function in the pathogenesis of neurally mediated syncope.
One of the most important mechanisms proposed in the pathogenesis of neurally mediated syncope considers the stimulation of myocardial mechanoreceptors as the final trigger leading to reflex hypotension and bradycardia. The aim of our study was to analyze the modifications of systolic and diastolic velocities of the left ventricle by tissue Doppler echocardiography, during the upright tilt test, to confirm the presence of an increased ventricular contractility before syncope. We evaluated 47 patients (mean age 43 years) with unexplained syncope and 13 healthy subjects. Three echocardiographic recordings were collected: at baseline, during the initial 5 minutes of the test, and after 15 minutes of tilt. The upright tilt test was positive in 28 patients. During the test, all of them had a similar, significant, progressive reduction of left ventricular end-diastolic volume, left atrial area, and left atrial volume. In contrast, the left ventricular ejection fraction showed an early, more pronounced decrease in those with positive tests. By tissue Doppler echocardiography, the systolic waves remained almost unchanged, and the early filling waves decreased similarly in those with positive or negative findings and the controls. In contrast, the atrial filling waves showed a significant decrease only in patients with positive tests. In conclusion, our study did not find increased ventricular contractility before syncope. In contrast, a decreased atrial contribution to ventricular filling characterized patients with positive upright tilt test results, which, we postulate, may be an important contributory factor to vasovagal syncope.
Adult↗
Positive stress test in a patient with patent coronary artery grafts.
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Aged↗
Worldwide management of oral anticoagulant therapy: the ISAM study.
A multicenter, observational, retrospective, cross-sectional study of patients, receiving oral anticoagulation therapy (OAT) for stroke prophylaxis in chronic non-valvular atrial fibrillation (NVAF) was conducted in the US, Canada, France, Italy and Spain according to their predominant model of care [routine medical care (RMC) or Anticoagulation Clinic care (ACC)]. The study objectives were to assess anticoagulation control (time in target range), and to describe the features of the local model of care. Consecutive patients were recruited on the basis of a minimum of 60 days of oral anticoagulant treatment over a 12 month period, and clinic and physician details were captured by means of a structured face-to-face or telephone interview. Time in therapeutic range (TTR) was calculated by using linear interpolation between INR values. A total of 1511 patients were recruited, of whom 1445 were included in the analysis of TTR. TTR was higher in ACC (69.5% and 64.9% for Italy and Spain, respectively) with respect to RMC (58.1%, 62.8% and 59.3% for the US, Canada and France, respectively). Mean intervals between INR determinations were between 3 and 4 weeks. Dose changes in case of INR outside therapeutic range were more frequent in Spain and less frequent in France. Striking differences were observed in type of VKA used, specialists involved in patient management, and dosage instructions. Studying of anticoagulation management based on local models of care highlights important discrepancies among countries and suggests further standardization of the management of this important therapy is necessary.
Administration, Oral↗
How to deal with recipients of valves prone to structural failure in the 2000s: Padua experience with the TRI Technologies valve.
BACKGROUND: TRI Technologies (TT) valves evidenced a propensity to structural failure, consisting in fracture of the pivoting system, leading to leaflet escape. At our institution, between 2000 and 2002, 36 TT valves were implanted in 34 patients. Here we report the final results of the Tritech survey program. METHODS: In February 2002, the first valve-related death occurred. After the event, patients were enrolled in the TT valve survey program and strictly followed up. The option of a reintervention was advised to each patient and weighed against the redo operative risk. The prophylactic TT valve replacement program took place in two time frames, dependent on each patient's personal choice: between September 2002 and October 2003 (first phase), and between September 2004 and October 2004 (second phase). Overall, 22 (10 women, 12 men) patients underwent reoperation. Mean time interval between TT valve implantation and replacement was 23 +/- 11 months. Patients' mean age was 59 +/- 11 years (median age, 64 years). RESULTS: All recipients adhering to the program successfully underwent reoperation. Operative mortality was 0%. CONCLUSIONS: We believe that the timing of the second surgery was fundamental for the favorable outcome of each patient and the absence of operative mortality. We are convinced that the tailored programming of the reintervention, together with the strong motivation of each patient, contributed in minimizing the risks related to surgery. The circumscribed cohort of patients involved was compatible with a tailored therapeutic plan. We strongly advise prophylactic reoperation of recipients of TT valves.
Aged↗
The diagnosis of the antiphospholipid syndrome.
The concurrence of antiphospholipid (aPL) antibodies and thrombosis or pregnancy loss defines the 'antiphospholipid syndrome' (APS). The Sydney update of the classification criteria for definite APS diagnosis introduced numerous ameliorations to the previous preliminary consensus statement. Clinical criteria are now better defined as vascular thrombosis must be diagnosed on the basis of objective criteria. Moreover,additional risk factors for thrombosis or pregnancy loss must be taken into account before the diagnosis is made and should be described in detail in scientific reports. As far as laboratory criteria are concerned,the lack of standardization and the misinterpretation of results remain major problems often leading to overdiagnosis. A single positive test result out of the possible assays determining aPL antibodies (Lupus Anticoagulant, LAC, anticardiolipin, aCL and anti. beta2-Glycoprotein I, beta2-GPI, antibodies) is still sufficient,according to the Sydney criteria, to justify a diagnosis of APS. Nevertheless single test positivity may result in overdiagnosis or identification of low risk patients and use of all three tests seems more reasonable. Multiple positivity or (better) triple positivity in our experience allows for the identification of high risk patients for possible recurrence. In the near future, coagulation tests discriminating between a beta2-GPI and anti-prothrombin LAC may be useful in identifying high risk patients.
Antibodies, Anticardiolipin↗
Antibody profile and clinical course in primary antiphospholipid syndrome with pregnancy morbidity.
In women diagnosed as having category I primary obstetric antiphospholipid syndrome, clinical characteristics and the risk of subsequent thromboembolic events and further unsuccessful pregnancy has not been clearly documented. Women with unexplained obstetric complications and no definite autoimmune systemic diseases were tested for lupus anticoagulant (LA), IgG/IgM anticardiolipin (aCL) and IgG/IgM anti-human beta2-Glycoprotein I (abeta2GPI) antibodies and diagnosed as having primary antiphospholipid syndrome (APS) in classification category I on the basis of more than one laboratory criteria present in any combination. Characteristics at the time of diagnosis and risk factors for subsequent clinical events during a mean follow-up of 6.3 years were evaluated. Fifty-three of 600 women studied were found to fulfil obstetric criteria and had more than one positive laboratory test at the time of diagnosis. All the women were aCL and abeta2GPI positive, and 16 were also LA positive. This latter group (triple positivity) had distinct features and had more frequently experienced previous thromboembolism (OR = 122.5, 95% CI 16-957, p < 0.001). They also had an increased rate of late pregnancy loss (OR = 16.2, 95%CI 0.9-292, p = 0.01), and a higher IgG abeta2GPI titer at diagnosis (median, 25(th) and 75(th) percentile were 118, 37-962, vs. 23, 18-32, respectively, p < 0.0001). During follow-up, the rate of thromboembolic events was significantly higher in the group of women with triple positivity and/ or previous thromboembolism (OR = 57.5, 95% CI 2.7-1160, p = 0.0004) which were the only independent predictors of TE in the multivariate model. Recurrent pregnancy loss took place in seven out of 47 women who had a new pregnancy. Triple positivity and/or previous thromboembolism were again the only independent markers (OR = 34.4, 95% CI 3.5-335.1, p = 0.003) of an unsuccessful new pregnancy. In conclusion, in primary APS with pregnancy morbidity in classification category I, quite different groups of patients may be identified on the basis of laboratory tests. Triple positivity and/or a history of thromboembolism predict new TE events and new unsuccessful pregnancies.
Adult↗
Analytical and clinical evaluation of a new heart-type fatty acid-binding protein automated assay.
BACKGROUND: The accurate and rapid recognition of myocardial injury in patients presenting in the emergency department (ED) with chest pain continues to be a clinical challenge. Heart-type fatty acid-binding protein (H-FABP) appears to be one of the best candidates among the new early cardiac markers studied. METHODS: We evaluated the analytical characteristics of a new quantitative and fully automated H-FABP assay (Randox Laboratories Ltd., Crumlin, UK) and compared its clinical performance with respect to the myoglobin (Myo) assay (Dade Behring, Milan, Italy). A precision study was carried out by testing three levels of quality control (QC) material and two in-house pool (P) samples. To test the accuracy of H-FABP determinations in plasma (lithium-heparin) samples, H-FABP concentrations measured in a set of matched sera and plasma samples were compared. A total of 77 non-consecutive patients (51 males and 26 females; 62+/-16 years) who presented to the ED with chest pain suggesting myocardial ischemia were enrolled. The patients were classified into two groups (acute myocardial infarction, n=22; non-acute myocardial infarction, n=55) on the basis of the discharge diagnosis. RESULTS: The between-day imprecision for three levels of control material and serum pool samples was 6.26%-8.04% (range 2.32-44.03 microg/L) and 9.03%-12.63% (range 11.85-65.13 microg/L), respectively. In the serum vs. plasma study, bias was +0.178 (95% CI -0.033 to +0.389). The best cut-off and the associated diagnostic efficacy were 95 microg/L and 89.47% for Myo and 5.09 microg/L and 98.70% for H-FABP, respectively. CONCLUSIONS: H-FABP determination in patients with ischemic symptoms may be a more reliable early indication of cardiac damage than myoglobin.
Aged↗
High-risk percutaneous coronary intervention using the intracardiac microaxial pump 'Impella recover'.
Patients with multivessel coronary artery disease and severe left ventricular dysfunction are considered to be at high risk for percutaneous coronary intervention, and often are poor surgical candidates because of severe comorbidity. We report a case of high-risk percutaneous coronary intervention in a 67-year-old man with a severe left ventricular dysfunction and three-vessel coronary artery disease using a novel left ventricular assist device.
Aged↗
Management of acute coronary syndromes.
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Acute Disease↗
Letter regarding article by Pellikka et al, "Severe asymptomatic aortic stenosis".
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Aortic Valve Stenosis↗
Explanation for the survival benefit of primary angioplasty over thrombolytic therapy in patients with ST-elevation acute myocardial infarction.
Our study evaluated the interaction across mortality risk, time delay related to percutaneous coronary intervention (PCI), and survival benefit of PCI over thrombolytic therapy (risk-time benefit analysis). Mortality risk and angioplasty-related time delay were independently correlated to 30-day survival benefit of primary angioplasty over lytic therapy. A PCI-related delay>60 minutes could be justified for high-risk patients.
Angioplasty, Balloon, Coronary↗