Prevalence of calcification of the mitral valve annulus in patients undergoing surgical repair of mitral valve prolapse

Factors correlating to mitral annulus calcification (MAC) include risk factors predisposing to atherosclerosis. In patients with mitral valve (MV) prolapse (MVP), other anatomic or mechanical factors have been supposed to facilitate MAC. The aims of this study were, in patients with MVP undergoing MV repair, (1) to describe the prevalence and characteristics of MAC, (2) to correlate MAC with clinical risk factors, coronary involvement, and aortic valve disease, and (3) to describe prevalence, site, and extension of MAC in fibroelastic deficiency (FED) versus Barlow's disease (BD) and correlate MAC to surgical outcomes (repair vs replacement). In 410 consecutive patients with MVP suitable for surgical MV repair, detailed clinical and echocardiographic data were collected to characterize MAC in BD and FED. MAC was found in 99 patients (24%). Age, female gender, coronary artery disease, and cardiovascular risk factors were correlated with MAC. MAC was equally distributed in FED and BD groups despite patients with FED being older with more cardiovascular risk factors. The most common localization of MAC was annular involvement adjacent to P2 (75%), P1 (31%), and P3 (35%). The presence of MAC affected surgical outcomes in both groups (8% patients with MAC underwent replacement after a first attempt of repair vs 3% without MAC). MAC is a common finding in patients undergoing MV repair, and several clinical characteristics correlate with MAC either in FED or BD. In conclusion, despite very high percentage of repairability, MAC influences surgical outcomes and very detailed echo evaluation is advocated.

Direct closure of an asymptomatic right coronary sinus of Valsalva aneurysm

A 52-year-old man was referred for evaluation of palpitation. Transthoracic echocardiography revealed an extracardiac aneurysm of the right coronary sinus of Valsalva, and normal anatomy of the aortic valve with no regurgitation. Three-dimensional computed tomography confirmed the aneurysm with a diameter of 21 × 13.7 mm arising from the right coronary sinus of Valsalva under the right coronary artery. Surgical repair was performed without changing the normal anatomy of the aortic valve, preserving the right coronary ostium. Intraoperative and postoperative echocardiography showed complete closure of the aneurysm with normal functioning of the aortic valve.

In-hospital mortality risk assessment in elective and non-elective cardiac surgery: a comparison between EuroSCORE II and age, creatinine, ejection fraction score

OBJECTIVES

Age, creatinine, ejection fraction (ACEF) score is a simplified algorithm for prediction of mortality after elective cardiac surgery. Although mainly conceived for elective cardiac surgery, no information is available on its performance in non-elective surgery and on comparison with the new EuroSCORE II. This study was undertaken to compare the performance of ACEF score and EuroSCORE II within classes of urgency.

METHODS

Complete data on 13 871 consecutive patients who underwent major cardiac surgery in a 6-year period were retrieved from three prospective institutional databases. Discriminatory power was assessed using the c-index and h with Delong, bootstrap and Venkatraman methods. Calibration was evaluated with calibration curves and associated statistics.

RESULTS

The in-hospital mortality rate was 2.5%. The discriminatory power of ACEF score within elective and non-elective surgery was similar (area under the curve (AUC) 0.71, 95% confidence interval (CI) 0.67-0.74 and AUC 0.68, 95% CI 0.62-0.73, respectively) but significantly lower than that of EuroSCORE II (AUC 0.80, 95% CI 0.77-0.83 for elective surgery; AUC 0.82, 95% CI 0.78-0.85 for non-elective surgery). The calibration patterns were different in the two subgroups, but the summary statistics underscored a miscalibration in both of them (U-statistic and Spiegelhalter Z-test P-values <0.05). Even the calibration of EuroSCORE II was insufficient, although it was demonstrated to be well calibrated in the first tertile of predicted risk.

CONCLUSIONS

This study demonstrated that the performance of ACEF score in predicting in-hospital mortality in elective and non-elective cardiac surgery is comparable. Nonetheless, it is not as satisfactory as the new EuroSCORE II, as its discrimination is significantly lower and it is also miscalibrated.

Comparison of accuracy of aortic root annulus assessment with cardiac magnetic resonance versus echocardiography and multidetector computed tomography in patients referred for transcatheter aortic valve implantation

The evaluation of the aortic root in patients referred for transcatheter aortic valve implantation is crucial. The aim of the present study was to compare the accuracy of cardiac magnetic resonance (CMR) evaluation of the aortic annulus (AoA) with transthoracic and transesophageal echocardiography and multidetector computed tomography (MDCT) in patients referred for transcatheter aortic valve implantation. In 50 patients, maximum diameter, minimum diameter and AoA, length of the left coronary, right coronary, and noncoronary aortic leaflets, degree (grades 1 to 4) of aortic leaflet calcification, and distance between AoA and coronary artery ostia were assessed. AoA maximum diameter, minimum diameter, and area by CMR were 26.4 ± 2.8 mm, 20.6 ± 2.3 mm, 449.8 ± 86.2 mm(2), respectively. The length of left coronary, right coronary, and noncoronary leaflets by CMR were 13.9 ± 2.2, 13.3 ± 2.1, and 13.4 ± 1.8 mm, respectively, whereas the score of aortic leaflet calcifications was 2.9 ± 0.8. Finally, the distances between AoA and left main and right coronary artery ostia were 16.1 ± 2.8 and 16.1 ± 4.4 mm, respectively. Regarding AoA area, transthoracic and transesophageal echocardiography showed an underestimation (p <0.01), with a moderate agreement (r: 0.5 and 0.6, respectively, p <0.01) compared with CMR. No differences and excellent correlation were observed between CMR and MDCT for all parameters (r: 0.9, p <0.01), except for aortic leaflet calcifications that were underestimated by CMR. In conclusion, aortic root assessment with CMR including AoA size, aortic leaflet length, and coronary artery ostia height is accurate compared with MDCT. CMR may be a valid imaging alternative in patients unsuitable for MDCT.

Oxidative stress and nitric oxide pathway in adult patients who are candidates for cardiac surgery: patterns and differences

OBJECTIVES

We investigated whether oxidative stress and the arginine/nitric oxide pathway differ in control subjects and in adult patients who are candidates for the three most common cardiac surgical operations: coronary bypass surgery, aortic valve replacement for calcific non-rheumatic aortic stenosis or mitral valve repair for degenerative mitral insufficiency.

METHODS

In this prospective observational study, we studied 165 consecutive patients undergoing surgery from January to June 2011 (coronary bypass surgery, n = 63; aortic valve replacement for calcific non-rheumatic aortic stenosis, n = 51; mitral valve repair for degenerative mitral insufficiency, n = 51). Thirty-three healthy subjects with cardiovascular risk factors similar to surgery patients were also studied (Controls). Oxidative stress (the ratio of reduced and oxidized glutathione and urinary isoprostane), antioxidants (alpha- and gamma tocopherol) and factors involved in nitric oxide synthesis (arginine, symmetric and asymmetric dimethylarginine) were measured before surgery. Analysis of variance general linear models and principal component analysis were used for statistical analysis.

RESULTS

Surgical patients had increased levels of oxidative stress and decreased levels of antioxidants. Increased levels of nitric oxide inhibitor asymmetric dimethylarginine were detected in surgical candidates, suggesting arginine/nitric oxide pathway impairment. Concerning the differences among surgical procedures, higher oxidative stress and a major imbalance of the ratio between substrate and inhibitors of nitric oxide synthesis were evidenced in patients who were candidates for mitral valve repair with respect to coronary bypass surgery patients and patients with calcific non-rheumatic aortic stenosis.

CONCLUSIONS

Patients undergoing cardiac surgery have increased oxidative stress and a trend towards an impaired arginine/nitric oxide pathway with respect to Controls. Patients affected by mitral valve regurgitation show more pronounced perturbations in these pathways. The clinical implications of these findings need to be investigated.

The impact of transcatheter aortic valve implantation on patients' profiles and outcomes of aortic valve surgery programmes: a multi-institutional appraisal

OBJECTIVES

The aim of this retrospective multicenter study was to assess how the development of transcatheter aortic valve implantation (TAVI) influenced the characteristics and outcomes of patients undergoing aortic valve procedures.

METHODS

We reviewed 1395 patients who underwent isolated surgical aortic valve replacement (SAVR) or TAVI in three centres with a high-volume TAVI programme. Patients were divided into two groups: 'Pre-TAVI' (395 patients, 28.3%) and 'Post-TAVI' (1000 patients, 71.7%) operated on before and after the introduction of TAVI into clinical practice. We evaluated age, logistic EuroSCORE I (LES) and hospital mortality according to time periods and the procedure performed, whether SAVR or TAVI.

RESULTS

'Post-TAVI' patients were older (78.2 ± 7.8 vs 76.8 ± 6.7 years; P = 0.002) and with a significantly higher LES (17.8 ± 14.7 vs 9.1 ± 9.2%; P < 0.001) than 'Pre-TAVI' patients. Hospital mortality was not significantly different between groups ('Pre-TAVI' vs 'Post-TAVI': 2 vs 3.4%; P = 0.17). Of the 1000 'Post-TAVI' patients, 605 (60.5%) underwent TAVI and 395 (39.5%), SAVR. Patients undergoing TAVI were older (79.9 ± 7.1 vs 75.5 ± 9.2 years; P < 0.001) and with a higher LES (22.9 ± 15.3 vs 9.7 ± 9.3%; P < 0.001) than 'Post-TAVI' SAVR patients, but their hospital mortality was similar (3.9 vs 2.5%; P = 0.22). LES was similar between 'Pre-TAVI' and 'Post-TAVI' SAVR patients (9.1 ± 9.2 vs 9.7 ± 9.3%; P = 0.26). Furthermore, we did not find significant differences in the overall hospital mortality between SAVR and TAVI patients: 2.3 vs 3.9%, P = 0.08.

CONCLUSIONS

This analysis shows that the development of TAVI has caused an increase in the preoperative risk profile of patients scheduled for aortic valve procedures (SAVR or TAVI) without increasing hospital mortality.

Biological features of thoracic aortic diseases. Where are we now, where are we heading to: established and emerging biomarkers and molecular pathways

Thoracic aortic aneurysms (TAAs) and aortic dissections (ADs) are among the main causes of mortality and morbidity in Western countries. For this reason, the diagnosis, prevention and prediction of TAAs and ADs have become a very active area of research; in fact, it is important to monitor and predict the evolution of these diseases over time. It is also critical, in cases of doubtful diagnosis, to receive some guidance from biochemical assays, particularly in the case of ADs. Although biological testing for disease prediction has already been discussed several times, the role of biomarkers in TAAs and ADs is still under discussion for routine patient screening, periodical follow-up or for prompt diagnosis in emergency conditions. In this review, we update the current knowledge and new trends regarding the role of biomarkers in thoracic aortic diseases, focusing on established and emerging biomarkers in the fields of genetics, inflammation, haemostasis and matrix remodelling as well as on substances released upon cell damage. Other than D-dimer, a sensitive but not a specific marker for the diagnosis of AD that has been widely tested by several authors and currently seems a viable option in ambiguous cases, the remaining markers have been most frequently assessed in limited or mixed patient populations. This currently precludes their widespread adoption as diagnostic or prognostic tools, even if many of these markers are conceptually promising. In years to come, we expect that future studies will further clarify the diagnostic and prognostic features of several established and emerging biomarkers that, to date, are still in the translational limbo separating biological discovery from a practical clinical role.

Patient profile modulates cardiac c-kit(+) progenitor cell availability and amplification potential

Human c-kit(+) cardiac progenitor cells (CPCs) are multipotent and may be used for cardiac repair. The effect of cardiovascular risk factors and medications on CPCs isolation efficiency, c-kit stem cell marker expression, and ex vivo proliferative potential is unknown and was examined in the present work. Cells from human right atrial appendages (n = 50) were expanded in culture; after ∼16 days (T0), it was established the percentage of CPCs and c-kit protein mean fluorescence intensity (MFI) by fluorescence activated cell sorting (FACS). Thereafter, CPCs were isolated by high throughput sorting; after culturing for 4 passages CPCs-derived cells were re-analyzed to assess c-kit(+) cell percentage and enrichment vs T0. The association between 19 demographic and clinical variables to CPCs number and MFI at T0, and CPCs enrichment at P4, was determined by multiple linear regression analysis with stepwise selection procedure. The results revealed that (1) at T0, the number of isolated CPCs directly correlated to β-blocker treatment; (2) at T0, c-kit protein expression directly correlated to pulmonary hypertension (PH); (3) at P4, CPC's enrichment inversely correlated to smoke, atrial fibrillation (AF), a history of myocardial infarction, whereas it directly correlated to PH and statins. Patient clinical profile and medications differently modulate CPCs isolation and amplification potential ex vivo. These results may provide new insights for the understanding of cardiac homeostasis and suggest both limitations and possible enhancing strategies for the therapeutic use of cardiac-resident progenitor cells.

Pulmonary valve papillary fibroelastoma: management of an unusual, tricky pathology

Papillary fibroelastomas are rare benign tumours of the endocardium, accounting for the most common primary valvular tumours of the heart. They typically originate from left-sided heart valves, whereas pulmonary valve involvement is anecdotal. They rarely cause valvular dysfunction, but they can cause turbulent flow and thrombus formation with consequent cerebral, retinal, coronary and pulmonary embolic disease and obstruction. We present here the case of a 56-year old man who was referred to our institution with an accidental finding, at transthoracic echocardiogram, of a mobile, pedunculated mass on the pulmonary valve, confirmed at cardiac magnetic resonance. He underwent surgical removal of the mass through median sternotomy with complete sparing of the valve. The postoperative course was unremarkable. Histopathological examination confirmed that the mass was a papillary fibroelastoma.

Aortic annulus area assessment by multidetector computed tomography for predicting paravalvular regurgitation in patients undergoing balloon-expandable transcatheter aortic valve implantation: a comparison with transthoracic and transesophageal echocardiography

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is a valid alternative to surgery in high-risk patients with severe aortic stenosis. Aortic annulus (AoA) sizing is crucial for TAVI success. The aim of the study was to compare AoA dimensions measured by multidetector computed tomography (MDCT) vs those obtained with transthoracic (TTE) and transesophageal echocardiography (TEE) for predicting paravalvular aortic regurgitation (PVR) after TAVI.

METHODS

Aortic annulus maximum diameter, minimum diameter, and area were assessed using MDCT and compared with TTE and TEE diameter and area for predicting PVR after TAVI in 151 patients (45 men, age 81.2 ± 6.4 years).

RESULTS

Aortic annulus maximum, minimum diameter, and area detected by MDCT were 25.04 ± 2.39 mm, 21.27 ± 2.10 mm, and 420.87 ± 76.10 mm(2), respectively. Aortic annulus diameter and area measured by TTE and TEE were 21.14 ± 1.94 mm and 353.82 ± 64.57 mm(2) and 22.04 ± 1.94 mm and 384.33 ± 67.30 mm(2), respectively. A good correlation was found between AoA diameters and area evaluated by MDCT vs TTE and TEE (0.61, 0.65, and 0.69 and 0.61, 0.65, and 0.70, respectively), with a mean difference of 3.90 ± 1.98 mm, 0.13 ± 1.67 mm, and 67.05 ± 55.87 mm(2) and 3.0 ± 2.0 mm, 0.77 ± 1.70 mm, and 36.54 ± 56.43 mm(2), respectively. Grade ≥2 PVR occurred in 46 patients and was related to male gender, higher body mass index, preprocedural aortic regurgitation, and lower mismatch between the nominal area of the implanted prosthesis and AoA area detected by MDCT.

CONCLUSIONS

Mismatch between prosthesis area and AoA area detected by MDCT is a better predictor of PVR as compared with echocardiography mismatch. Specific MDCT-based sizing recommendations should be developed.