Left internal mammary elongation with inferior epigastric artery in minimally invasive coronary surgery

OBJECTIVE

Sometimes the left internal mammary artery (LIMA) is not long enough to reach a too lateral LAD when a left anterior small thoracotomy (LAST operation) is the surgical approach to graft the LAD. LIMA elongation with an inferior epigastric artery (IEA) can be an useful surgical option.

METHODS

From November 1994 to June 30, 1996, out of 289 patients who underwent LAST operation; 28 patients had a LIMA elongation with an IEA, 20 patients had single vessel disease, 4 had two vessel disease, and 4 three vessel disease. Mean age was 62 +/- 22 (48-84) and mean EF was 57 +/- 86. The IEA was used only when the LAD was totally or nearly occluded with no transmural myocardial infarction (high expected run off).

RESULTS

All patients had an uneventful recovery. After 315 +/- 104 days from surgery all were asymptomatic. A late doppler flow assessment, performed in 28 patients, showed a high velocity diastolic flow in 27. One patient was reoperated on because of graft occlusion 84 days after surgery. An angiography was performed after 87.5 +/- 23.3 days in 22 patients. All conduit and anastomoses were patent but one, (patency rate 21/22, 95.4%); another showed mild anastomotical stenosis at the LIMA-IEA junction without clinical signs (perfect patency rate 20/22, 90.9%).

CONCLUSIONS

IEA elongation of LIMA is an alternative strategy to reach a lateral LAD in selected cases; a satisfying patency rate can be expected, when correct surgical indications are used.

[Ventricular remodeling after myocardial revascularization with venous grafts]

Left ventricular remodeling, through long-term left ventricular chamber dilation and increased wall stress can result in alteration of ventricular architecture and impairment of systolic and diastolic performance. Most of the studies regard post acute myocardial infarction remodeling, knowledge is still lacking about preoperative and postoperative factors which predict the long-term prognosis of patients who underwent venous coronary artery bypass graft surgery. We evaluated 243 patients (225 males, 18 females, mean age 65 +/- 7.3 years) submitted to venous coronary artery bypass graft surgery and 10-year follow-up (123 +/- 20 months). Global mortality was 17.6% (n = 43), significantly higher in patients with ejection fraction (EF) < 50% (log-rank test p < 0.001). The survivors (n = 200) were subdivided into two groups according to postoperative EF: patients with EF > or = 50% (n = 160) and patients with EF < 50% (n = 40). Multivariate analysis revealed that cardiovascular risk factors (hypertension, diabetes, hypercholesterolemia, smoking), number of grafts and infarct location were not associated with EF reduction. Only multivessel disease was significantly associated with EF reduction (p = 0.008). Preoperative echocardiographic parameter analysis evidenced that regional ventricular wall motion score was significantly higher in patients with reduced EF (EF < 50% 11 +/- 7.5; EF > or = 50% 6 +/- 4.1, p < 0.001) and left ventricular dilation (p < 0.001). Multivariate analysis revealed that the strongest correlates of EF < 50% were left ventricular wall motion score index > 10 (odds ratio 5.8, 95% confidence interval 2.8-11.7) and multivessel disease (odds ratio 9.0, 95% confidence interval 2.6-31.08). This study revealed that echocardiographic detection of preoperative ventricular wall motion score may be useful to assess patients at high risk of ventricular remodeling after venous coronary artery bypass graft surgery.

Minimally invasive coronary artery bypass grafting on a beating heart

BACKGROUND

We reviewed our experience with left internal mammary artery (LIMA)-to-left anterior descending artery (LAD) anastomosis on a beating heart through a left anterior small thoracotomy.

METHODS

This procedure was performed in 343 of 358 scheduled patients; in 15 (4.2%) the LAD was not suitable or was too small. The chest was opened in the fourth (127, 37.0%) or fifth (197, 57.4%) intercostal space, or both (19, 5.6%); the length of the harvested LIMA was 4-15 cm. The LAD was occluded by means of two 4-0 Prolene (Ethicon, Somerville, NJ) sutures, both snared on a small piece of silicone tubing. The anastomosis was performed with two 8-0 Prolene sutures. In the early postoperative period all patients underwent angiography or a doppler flow assessment of the LIMA or both.

RESULTS

In 310 patients the LIMA was connected directly to the LAD; to elongate the LIMA, in 30 patients an inferior epigastric artery and in 3 patients a saphenous vein was used. In 2 patients the diagonal branch was also grafted using an inferior epigastric artery from the LIMA. Three patients (0.9%) died during the first 30 days after the operation, and 4 other patients (1.2%) died after the first month. Twenty-five patients (7.3%) were reoperated on because of anastomotic or conduit failure, 18 (5.2%) early and 7 (2.1%) late; one additional patient had a late percutaneous transluminal coronary angioplasty for anastomotic stenosis. At a mean of 9.5 +/- 5.7 months of follow-up, 336 patients (98.0%) were alive, asymptomatic with or without medical treatment, and without cardiac events.

COMMENT

Left internal mammary artery-to-LAD anastomosis performed on a beating heart through a left anterior small thoracotomy is a procedure that can be performed with low risk and acceptable midterm results in selected patients.

Persistence of mammary artery branches and blood supply to the left anterior descending artery

BACKGROUND

Partial harvesting of the left internal mammary artery (LIMA) is a widespread technique used during minimally invasive coronary operations performed through a left anterior small thoracotomy. The influence of persisting LIMA branches was investigated to evaluate their effect on the blood flow of the left anterior descending artery.

METHODS

Thirty patients, 15 with totally (group A) and 15 with partially (group B) harvested LIMAs, were evaluated. All the patients underwent postoperative angiography, during which a flow map of the LIMA was performed. The average peak velocity and the diastolic-to-systolic peak velocity ratio were recorded. The LIMA graft flow pattern was recorded in the proximal and distal thirds of the artery. Intramammary adenosine (12 to 14 microg) was injected and the average peak velocities before and after injection were calculated.

RESULTS

The average peak velocity was similar in both groups in the proximal and distal thirds of the LIMA (25 +/- 7 and 26 +/- 5 cm/sec, respectively, in group A versus 27 +/- 5 and 25 +/- 5 cm/sec, respectively in group B; p = NS). The diastolic-to-systolic peak velocity ratio was similar proximally (0.78 +/- 0.3 in group A versus 0.69 +/- 0.3 cm/s in group B; p = NS), but not distally (1.72 +/- 0.1 in group A versus 0.97 +/- 0.3 in group B; p < 0.0005). The LIMA graft flow reserve was similar both proximally and distally (2.6 +/- 0.6 and 2.5 +/- 0.3 cm/s, respectively, in group A versus 2.6 +/- 0.5 and 2.6 +/- 0.3 cm/s, respectively, in group B; p = NS).

CONCLUSIONS

The persistence of LIMA branches does not influence the blood flow of the left anterior descending artery after acute adenosine-induced myocardial hyperemia. If a left anterior small thoracotomy is used in left anterior descending artery direct revascularization, complete LIMA harvesting is not mandatory and depends on the personal preference of the surgeon.

[The prognostic value of activation of the hypophyseal and adrenal cortical systems in severe heart failure]

The aim of this study was to evaluate changes of pituitary and adrenal cortex hormones in patients with congestive heart failure according to NYHA functional classes and to detect possible prognostic effects of these changes. We studied 101 patients: 60 with congestive heart failure, in absence of clinical, anamnestic signs of endocrine diseases (Group I, 37 males, 23 females; mean age 62 +/- 7.2 years) and 41 patients with cardiac diseases without signs of congestive heart failure, homogeneous for age and sex (Group II, 23 males, 18 females; mean age 61 +/- 8.5 years). All patients were submitted to a 12 month follow-up in order to evaluate hormonal changes. Hormonal study was performed through radioimmunoassay technique. Plasma levels of insulin, growth hormone (GH), adrenocorticotropine (ACTH), cortisol and prolactin (PRL) were evaluated. We observed in Group I a significant increase of cortisol and GH with respect to Group II. No significant difference occurred in plasma levels of insulin, PRL and ACTH. Subdividing Group I patients on the basis of NYHA classification, significant increase (p < 0.05) in cortisol and GH was observed in IV NYHA functional class with respect to II and III NYHA ones. Moreover a significant reduction (p < 0.02) of ACTH in IV NYHA functional class was also detected. Plasma levels of cortisol and GH were also significantly higher in patients dead during the follow-up with respect to survivors. Statistical analysis showed a linear negative correlation between cortisol and ACTH in III NYHA functional class (p < 0.03), a negative correlation between cortisol and radius/thickness ratio (p < 0.03) and between cortisol and serum glutamic oxalacetic transaminase (p < 0.05). In IV NYHA functional class a significant negative correlation between cortisol and shortening fraction (p < 0.05) also occurred. Plasma levels of cortisol and GH were significantly higher (p < 0.05) in IV NYHA functional class with respect to II and III classes, with associated significant reduction of shortening fraction (p < 0.05). Our data confirm that, besides catecholamines and renin-angiotensin-aldosterone system, in the presence of severe congestive heart failure (IV NYHA functional class), a significant activation of pituitary and adrenal cortex hormones occurs. It is still an open question whether this activation plays a pathogenetic role in the evolution of heart failure, but the significant increase of these hormones (GH and cortisol) seems to be significant negative prognostic markers.

[Ischemic preconditioning of the myocardium: the role of changes in the permeability of the coronary microcirculation]

In isolated working rat hearts we have evaluated the effects of preconditioning on postischemic coronary endothelial permeability. Isolated Wistar male rat hearts were used and subdivided into three groups: Group A, control hearts submitted to 20 min global normothermic ischemia; Group B, hearts subjected, before ischemia, to preconditioning (three phases of 3 min ischemia, each one followed to 2 min Langendorff reperfusion; Group C, hearts submitted to preconditioning and hypertonic reperfusion (by adding 80 mM sucrose to normal perfusion buffer), in order to increase the effects on postischemic interstitial fluid accumulation (osmotic forces balance). A 65 min working heart reperfusion was also performed to assess functional response. We have evaluate the hemodynamic changes (coronary and aortic flows, systolic aortic pressure, work minute), reperfusion arrhythmias, heart weight changes (ww/dw), myocardial enzyme release (creatine phosphokinase and lactic dehydrogenase) and microcirculation permeability changes (FITC.albumin diffusion), as an index of endothelial function. In Group B, a significant reduction of ischemia-reperfusion damage (functional recovery, enzyme release and arrhythmias) was detected with respect to Group A. In Group C this reduction was significantly more evident with respect to groups A and B. In Groups B and C, a significant reduction in myocardial reperfusion (ww/dw: A: 5.9 +/- 0.5, B: 4.9 +/- 1.1, p < 0.02 vs A, C: 4.4 +/- 0.6, p < 0.01 vs A) edema and FITC-albumin diffusion (A: 32.8 +/- 5.9% area; B: 16.3 +/- 6.1% area, p < 0.01 vs A; C: 13.3 +/- 4.5% area, p < 0.01 vs A), especially in perimyocytic space was also observed. Data show that preconditioning may exert a cardioprotective effect by reducing endothelial postischemic functional alterations (vascular permeability) and reperfusion edema. The importance of fluid diffusion within the interstitium in the development of reperfusion damage is supported by better postischemic recovery in Group C, in which an interference on osmotic load was performed.

Sarcoplasmic reticulum calcium uptake in human myocardium subjected to ischemia and reperfusion during cardiac surgery

We evaluated the effect of ischemia and reperfusion on sarcoplasmic reticulum Ca uptake in patients subjected to cardiac surgery. Our series included 16 patients (seven female, nine male, age 63 +/- 2 years): five were subjected to aortic valve replacement, five to aortic and mitral valve replacement, six to coronary artery bypass graft. In each case no clinical, electrocardiographic or echocardiographic evidence of perioperative infarction was observed. Biopsies were obtained from the right atrium of each patient before starting extracorporeal circulation, and after the recovery of spontaneous contractile activity, i.e. after cardioplegia-ischemia-reperfusion. The tissue was homogenized, and oxalate-supported Ca uptake, which represents sarcoplasmic reticulum Ca uptake, was measured in the unfractionated homogenate. The assay was performed under basal conditions and in the presence of 900 microM ryanodine, in order to block sarcoplasmic reticulum Ca release channels. Under basal conditions at pCa = 5.85 the rate of sarcoplasmic reticulum Ca uptake averaged 4.76 +/- 0.37 nmol/min per mg of protein in the pre-ischemic samples, and decreased significantly in the post-ischemic samples (3.09 +/- 0.29 nmol/min per mg, P < 0.01). A significant decrease of Ca uptake after ischemia and reperfusion was observed also in the presence of ryanodine (3.53 +/- 0.48 nmol/min per mg) compared to pre-ischemic values (5.98 +/- 0.56 nmol/min per mg, P < 0.01). Additional experiments showed no change in the Ca sensitivity of Ca uptake in the postischemic samples (Kca = 0.48 +/- 0.02 microM, no significant difference after ischemia and reperfusion). In conclusion, active sarcoplasmic reticulum Ca transport was impaired in human atrial myocardium after reversible ischemia and reperfusion.

Respiration in NREM and REM sleep after upper airway surgery for obstructive sleep apnoea

To verify whether upper airway surgery in obstructive sleep apnoea syndrome affects differently respiration in NREM and REM sleep, 22 patients were studied by polysomnography before and three months after surgical treatment. On the average, treatment improved respiration during both sleep states, but no significant interaction was found between sleep state and effect of surgical treatment. According to the response to treatment, three groups of patients were identified: the first group (N = 6), with an improvement in apnoea-hypopnoea index (AHI), percentage of sleep time spent in apnoea and hypopnoea (time in AH) and mean oxyhaemoglobin saturation (SaO2) in both NREM and REM sleep; the second group (N = 5), with an improvement in AHI only in NREM sleep, associated with improvement in mean SaO2 in both sleep states; the third group (N = 11), without any improvement in AHI and time in AH, either associated (N = 5) or not (N = 6) with an improvement in mean SaO2 in both sleep states. An increase in the percentage of hypopnoeas out of the total AHI after treatment could partly account for the apparent discrepancy between AHI and mean SaO2 behaviour in the subjects of the second group, but not in the patients of the third group who improved their mean SaO2. Mixed apnoeas occurred before surgery in six subjects; they remained numerous after surgery only in two subjects who did not show any SaO2 improvement. In conclusion, the degree of improvement in respiration after upper airway surgery was similar in every patient in NREM and REM sleep.

[The surgical treatment of obstructive sleep apnea syndrome]

Studies concerning the anatomical abnormalities of upper airways in patients affected by Obstructive Sleep Apnea Syndrome (OSAS) allowed the corrective surgical treatments in this syndrome. To provide an improvement or a definitive recovery of OSAS, various surgical treatments, i.e. functional nasal surgery, palatal surgery [Partial resection of palate (RPP), Uvulopalatopharingoplasty (UPPP), Palatopharingoplasty (PPP), modified Palatopharingoplasty (modified PPP)], mandibular and base tongue surgery, have been performed in order to obtain an enlargement of upper airways. It has been reported that in RPP, UPPP, PPP and modified PPP partial or total uvula and soft palate resection is conduct; in our research we performed modified PPP. 44 OSAS patients, severe or moderately severe form (polisomnographic diagnosis), underwent surgical treatment: 5 patients underwent functional nasal surgery; 9 patients underwent modified PPP; 29 patients underwent nasal and palatal surgery; only 1 patient underwent base tongue surgery. 32 patients underwent polisomnographic records after surgery (two months later) and we evaluated Apnea Index (I.A.) and a SaO2 low (nadir) with statistic tests. The results have been positive. Therefore, we have now 7 normal, 2 mild form, 7 moderate form, 3 moderately severe form and 13 severe form OSAS patients. If, on the one hand, all these surgical treatments can be considered a good way of therapy, on the other, only tracheostomy represents today the unfailing surgical therapy.

[Brain stem auditory evoked potentials in obstructive sleep apnea syndrome]

To evaluate a possible brainstem role in pathogenesis of obstructive sleep apnea syndrome, a study on brainstem auditory evoked potentials (BAEP), has been conducted. 15 OSAS patients, medium and severe form, with organic pathologies of the upper respiratory tract have been evaluated. 15 normal subjects were compared as control. All the patients were subjected to audiometry, including total liminal audiometry, timpanometry, acustic reflex, and BAEP study. BAEP evoked with trains of cliks at 11 and 51 periods/sec., showed morphological alterations and a longer central conductance of time interval (I-V interval) in only four patients. BAEP alterations noted in the OSAS-affected patients are neither constant nor specific. Therefore, the observed BAEP alterations might be due to apneas, as a consequence of the chronic hypoxic- hypercapnic status occurring in the brain-stem.

[Morphologic and ultrastructural changes of soft palate in patients who underwent palatopharyngoplasty]

In order to clarify pathogenesis of Obstructive Sleep Apnea Syndrome (OSAS) in patients with anatomic abnormalities of upper airways, we studied soft palate and uvula of OSAS patients by means of histological and ultrastructural techniques. 38 OSAS patients, severe and moderately severe form, underwent modified Palatopharingoplasty. We evaluated only 16 OSAS patients' soft palate and uvula and observed histological changes in all of them: submucosal edema and minor salivary glandes ipertrophy and iperplasy are present. On the contrary, ultramicroscope showed normal muscle fibers. Strie Z alterations and sarcomeres disorganization, although present, have no statistical value. Very probably, ronflement and apneas determined the observed alterations through trauma on pharingeal wall. Therefore, they are not OSAS primary cause.

[Characteristics and clinical course of degenerative aortic stenosis in the elderly]

Degenerative aortic stenosis represents the most common form of aortic stenosis. The aim of this study was to evaluate the relationship between symptoms, valvular disease severity and prognosis. We studied the evolution of valvular aortic stenosis in 65 patients (39 males and 26 females, mean age 77.78 +/- 6.2 years) for a period of 7 years. All patients were submitted to accurate anamnestic examination, ECG, color Doppler echocardiography. Sixteen patients (26%) underwent cardiac catheterization. Associated diseases were: hypertension (45%), diabetes (40%), dyslipidemia (29%), chronic obstructive lung disease (6%). In 64% patients, the diagnosis of aortic stenosis was made after symptoms onset, and in 36% was occasional. Mean age at symptoms onset was 70 +/- 17 years: dispnoea was present in 81%, chest pain in 32%, and syncope in 8%. At the beginning of the follow-up, echocardiography showed, aortic stenosis to be mild in 21.73%, moderate in 60.8% and severe in 17.4%. At the end of the follow-up, mild stenosis was present in 9.5%, moderate in 38.7%, and severe in 51.8%. At entry, 56.6% had pure aortic stenosis, 34.78% had steno-insufficiency and 8.7 had an associated mitral valve insufficiency. At the end of the follow-up pure aortic stenosis was present in 17%, steno-insufficiency in 40%, and associated mitral valve insufficiency in 4.3%. Surgery was performed in 21% of the patients (77% valve replacement and 23% valve replacement and aortocoronary bypass). The mortality, at the end of the follow-up, was 31%. Causes of death were: heart failure (61%), arrhythmias (23%), and surgical complications (16%).(ABSTRACT TRUNCATED AT 250 WORDS)

[Role of interstitial myocardium in ischemia-reperfusion injury: experimental data and clinical implications]

Myocardial interstitium plays an important role in the regulation of cardiac function compared with myocytes and it is actively involved in ischemia-reperfusion damage and in the acute and chronic remodelling during ischemic heart diseases. Myocardial post-ischemic oedema seems to interfere in this process. Myocardial oedema is able to induce structural alterations, to reduce myocardial function and to activate the renin-angiotensin-aldosterone system. Angiotensin II and aldosterone seem to be the cause of myocardial fibrosis that is detected during ischemic heart disease. Post-ischemic vascular permeability alterations have a similar role. In clinical conditions, ACE-inhibitors have important effects on cardioreparation and are able to improve cardiac function and reduce early and late mortality. The effects of myocardial oedema reduction (i.e. hypertonic reperfusion) on ischemia-reperfusion damage and myocardial fibrosis are still to clarify. A reduction in myocardial fibrosis may improve cardioreparation and prevent congestive heart failure, following ischemic heart disease.

[Prevention of reinfarction: a global strategy]

Reinfarction occurs in approximately 10-20% of patients with acute myocardial infarction with an year incidence of about 3% for males and 9% for females. The reinfarction induces a worsen prognosis by producing arrhythmias and a new ventricular "remodelling" with an increase in sudden death and cardiogenic shock. The new event may occur, early or later, in regions either adjacent to or remote from the initial myocardial infarction. Among all the patients admitted to our coronary care unit (1181) during the last 6 years, the overall reinfarction rate was 11.4%; among these, 46% were in the same side (SSMI), while 54% in the distant side (DSMI). The SSMI occurred more often during early months after infarction, while the DSMI occurred significantly later. Cigarettes smoking has been shown to be a common and often the only risk factor in patients with early reinfarction; while arterial hypertension, mostly associated with diabetes and hypercholesterolemia, was found the most important risk factor in later reinfarctions. SSMI was strongly related to one coronary vessel disease or to a double vessel disease (especially with interventricular artery and right coronary artery); while DSMI occurred in presence of triple coronary vessel disease involving secondary branches. The later SSMI is related to serious impairment of left ventricular function in 30% of patients, with cardiogenic shock and death evolution in 25%. The clinical trials for prevention of reinfarction showed that the correction of risk factors and the use of anticoagulation and/or antiaggregation therapy, beta-blockers or Ca(++)-antagonist drugs, must be chosen in relation to the myocardial damage related to previous infarct. In all the patients follow-up during the acute, subacute and chronic phases, must be performed by clinical and instrumental controls able to evidence the developing new cardiovascular events in order to decision making.

[From myocardial hypertrophy to heart failure: role of the interstitium]

In the progression from myocardial hypertrophy to heart failure, abnormalities in the interstitial space of the heart seem to play a critical role. The formation of an extracellular oedema and the alterations in coronary subendocardial perfusion are associated with the development of interstitial fibrosis. Cardiac experimental studies documented the presence of augmented interstitial fluid volume and pressure and a subsequent remodelling of the fibrillar network of the extracellular space of the myocardium during the phases of the cardiovascular response to a sudden overload. Variations of the Starling's forces balance caused by enhanced endothelial permeability or due to an impairment of cardiac lymphatic drainage may contribute to the development of an acute heart failure. During stable hyperfunction, the organization of a chronic oedema should account for interstitial changes in the hypertrophic myocardium. Reactive fibrosis seems to be under hormonal control. The activation of the renin-angiotensin-aldosterone system is responsible for interfascicular and intercellular accumulation of fibrillar collagen within the cardiac interstitium. Perivascular fibrosis in the subendocardium may impair intramyocardial distribution of coronary flow. When an inadequate hypertrophy occurs, because of an elevation in ventricular wall stress, myocardial oxygen consumption rises and this may lead to the exhaustion of coronary blood flow reserve in the subendocardial layers. This underperfusion may be responsible for the development of myocardial ischemia. Coronary hemodynamic changes in the microcirculation as those prompted by interstitial alterations may contribute to the onset of myocyte necrosis and to the formation of restorative fibrosis. The progressive mechanical overload of the spared hypertrophied myocytes could explain the initiation of a positive feedback mechanism which perpetuates endomyocardial perfusion impairment, interstitial oedema and remodelling, finally, causing myocyte deaths and fibrous tissue proliferation. These structural alterations and their pathophysiological counterparts appear to be closely related to the evolution from compensatory hypertrophy to chronic myocardial failure in hypertrophic heart disease.

[The clinical and echocardiographic parameters at rest and during mental arithmetic stress in preadolescent subjects with a hypertensive parent]

Previous studies have showed that a genetic predisposition and/or a family history of essential hypertension may play a significant role in the development of cardiovascular changes in borderline hypertensive patients. Moreover, mental stress has been identified as contributing to the development of cardiovascular disease. The aim of this study was to compare the possible changes in blood pressure and Doppler echocardiographic parameters in resting and during mental arithmetic stress in 21 children with a hypertensive parent (Group I) and 21 age-matched children with normotensive parents (Group II), similar for body mass index, alimentary and life habits, and not differing in resting blood pressure, heart rate and Doppler echocardiographic parameters. Mass index was slightly but not significantly high in Group I with respect to controls. During mental stress only in the children with a family history of hypertension there was a significant increase (p < 0.02) in systolic blood pressure. A positive relation between the increase in systolic blood pressure and end-diastolic thickness of interventricular septum and posterior wall was observed in the same group. In addition a close relation (p < 0.05) between mass index and end-systolic left ventricular stress at rest was evidenced, whereas a negative relation (p < 0.03) between the increase in systolic blood pressure on one side and the early peak diastolic filling velocity (Vmax E) and the ratio of early to atrial peak diastolic filling velocity (Vmax E/Vmax A), on the other side, were found.(ABSTRACT TRUNCATED AT 250 WORDS)

Chemotherapeutic treatment of recurrent and/or metastatic nasopharyngeal carcinoma: a retrospective analysis of 40 cases

Authors carried out a review of 40 cases of recurrent and/or metastatic nasopharyngeal carcinoma (NPC) treated with cisplatin-based chemotherapy at the Division of Othorhinolaryngology and the Service of Chemotherapy of the University of Palermo between July 1984 and July 1992. All patients were treated with regimens comprising high dose cisplatin (80-100 mg m-2). Histologically there were 29 squamous cell and 11 undifferentiated NPC. Thirty-nine patients were evaluable for response and toxicity. The overall response rate was 64%, with a 20.5% complete response rate and a 43.5% partial response rate. The mean duration of complete responses was 10.2+months, while that of partial responses was 8.6+months. The mean survival of the whole group was 11.4+months, with four patients alive after 2 years of follow-up. No statistically significant difference in response rate and survival was found between patients with metastatic disease and those with locoregional recurrency, and between patients with squamous cell NPC and those with undifferentiated histology. The employed regimens have been generally well tolerated. These data confirm that NPC is a neoplasm highly responsive to chemotherapy. However, duration of objective response and survival are still largely unsatisfactory.

[The myocardial protective effects of cardiac tissue ACE inhibition in experimental ischemia-reperfusion in isolated rat hearts]

The protective effects of captopril were evaluated in vitro on isolated perfused rat hearts after a global ischemia of 20 min. The hearts were randomly allocated in 2 groups. In the first one (n = 6) captopril was added at a concentration of 270 microM. The second one was utilized as control (n = 6). Aortic flow and minute work respectively decreased on reperfusion by 35% and 49% in captopril group and by 65% and 71% in controls (p < 0.001). No changes occurred in heart rate. Aortic systolic pressure and coronary flow decreased in the 2 groups, but not significantly. Myocardial enzyme release during reperfusion showed significant lower levels of CPK and LDH in the captopril group as compared to controls (p < 0.001 after 41 min). The occurrence of serious ventricular arrhythmias was considerably higher in controls with respect to the captopril group. Irreversible ventricular fibrillation occurred only in control hearts (50%). These data indicate that captopril exerts a protective effect during myocardial ischemia and reperfusion by preventing serious ventricular arrhythmias, reducing enzymatic release and a lower decrease in cardiac performance, without an increase in heart rate.