Quantitative analysis of myocardial blood flow in surgically revascularized and not revascularized myocardial segments. A pilot PET study

PURPOSE

To prospectively compare changes in myocardial blood flow (MBF) and myocardial flow reserve (MFR) in multivessel coronary artery disease (MVCAD) patients undergoing incomplete revascularization (IR) versus complete revascularization (CR) by coronary artery bypass grafting (CABG).

METHODS

Seven male patients (age 68 ± 9 years) with MVCAD underwent myocardial perfusion PET/CT with [13N]ammonia before and at least 4 months after CABG. Segmental resting and stress MBF as well as MFR were measured. Resting and during stress left ventricle ejection fraction (LVEF) were also calculated.

RESULTS

Three patients (43%) underwent CR and four (57%) IR. Among 119 myocardial segments, 101 (85%) were revascularized, and 18 (15%) were not. After CABG, stress MBF (mL/min/gr) and MFR are significantly increased in all myocardial segments, with a greater increase in the revascularized segments (p = 0.013). In both groups, LVEF significantly decreased during stress at baseline PET (p = 0.04), but not after CABG.

CONCLUSION

Stress MBF and MFR significantly improve after CABG in both revascularized and not directly revascularized myocardial segments. IR strategy may be considered in patients with high surgical risk for CR.

Outcomes of Minimally Invasive Aortic Valve Replacement in Obese Patients: A Propensity-Matched Study

INTRODUCTION

Obese patients are at risk of complications after cardiac surgery. The aim of this study is to investigate safety and efficacy of a minimally invasive approach via upper sternotomy in this setting.

METHODS

We retrospectively reviewed 203 obese patients who underwent isolated, elective aortic valve replacement between January 2014 and January 2023 - 106 with minimally invasive aortic valve replacement (MIAVR) and 97 with conventional aortic valve replacement (CAVR). To account for baseline differences, a propensity-matching analysis was performed obtaining two balanced groups of 91 patients each.

RESULTS

The 30-day mortality rate was comparable between groups (1.1% MIAVR vs. 0% CAVR, P=0.99). MIAVR patients had faster extubation than CAVR patients (6 ± 2 vs. 9 ± 2 hours, P<0.01). Continuous positive airway pressure therapy was less common in the MIAVR than in the CAVR group (3.3% vs. 13.2%, P=0.03). Other postoperative complications did not differ significantly. Intensive care unit stay (1.8 ± 1.2 vs. 3.2 ± 1.4 days, P<0.01), but not hospital stay (6.7 ± 2.1 vs. 7.2 ± 1.9 days, P=0.09), was shorter for MIAVR than for CAVR patients. Follow-up survival was comparable (logrank P-value = 0.58).

CONCLUSION

MIAVR via upper sternotomy has been shown to be a safe and effective option for obese patients. Respiratory outcome was promising with shorter mechanical ventilation time and reduced need for post-extubation support. The length of stay in the intensive care unit was reduced. These advantages might be important for the obese patient to whom minimally invasive surgery should not be denied.

Comparison of De-Kay repair versus De Vega suture for functional tricuspid regurgitation: a preliminary experience

BACKGROUND

In patients undergoing mitral valve surgery, restrictive suture annuloplasty (De Vega) for less-than-severe functional tricuspid regurgitation has been proven to be safe and effective. The aim of this study is to determine whether the adjunct of the plication of the posterior tricuspid leaflet with the same running suture (bicuspidized De Vega or "De Kay") is equally safe and effective.

METHODS

Single center, retrospective study on patients submitted to suture repair of the tricuspid valve during mitral valve surgery, with either conventional or De Kay, between January 2014 and December 2020. Comparison was based on degree of residual tricuspid valve regurgitation and right ventricular assessment at discharge.

RESULTS

Over the course of the study period, 255 patients undergoing mitral valve surgery had a dilated (>40 mm or >20 mm/m²) tricuspid valve annulus, with less-than-severe tricuspid regurgitation. Conventional De Vega was employed in 166 patients (65.1%) and De Kay in the remaining 89 (34.9%). At discharge the adjunct of postero-septal commissure plication has similar outcomes to the classic De Vega repair. It seems to preserve right ventricular function.

CONCLUSIONS

De Kay repair guarantees the same tricuspidal regurgitation reduction as compared with conventional De Vega early after surgery.

Right ventricular strain in Fabry disease: Prognostic implications

INTRODUCTION

Left ventricular (LV) hypertrophy is the main feature of cardiac involvement in Anderson-Fabry disease (FD), but the right ventricle (RV) is also frequently affected. Previous studies failed to demonstrate an independent association between conventional parameters of RV performance and outcomes in FD. Nevertheless, if RV free wall strain (RV-FWS), assessed by 2D speckle tracking analysis, may provide a better prognostication is currently unknown.

METHODS

We retrospectively evaluated the association between RV-FWS and the occurrence of cardiovascular events in a cohort of 56 patients with FD. The study endpoint comprises cardiovascular mortality, severe heart failure symptoms, new-onset atrial fibrillation and major arrhythmias requiring device implantation.

RESULTS

Reduced RV-FWS, defined by values lower than 23%, was found in 25 (45%) patients. During a median follow-up of 47 months, 16 (29%) patients met the study endpoint. A ROC-curve analysis confirmed the threshold of reduced RV-FWS (<23%) as the best cut-off for predicting cardiovascular events, but with a lower power compared to left-sided parameters. On univariable Cox regression analysis, RV-FWS, expressed as continuous variable, was significantly associated with the study endpoint (HR: 0.795, 95% CI: 0.710-0.889, p < 0.001). However, RV-FWS did not retain a significant association with outcomes, after adjustment for LV global longitudinal strain or indexed left atrial volume (p = 0.340 and p = 0.289 respectively).

CONCLUSIONS

RV-FWS was not independently associated with the occurrence of cardiovascular events in FD, confirming previous observations that prognosis is mainly driven by the severity of LV cardiomyopathy.

332 RIGHT VENTRICULAR STRAIN IN FABRY CARDIOMYOPATHY: PROGNOSTIC IMPLICATIONS

Left ventricular (LV) hypertrophy is the main feature of Fabry cardiomyopathy (FC), but the right ventricle (RV) is also frequently affected. Previous studies failed to demonstrate an independent association between RV hypertrophy or conventional parameters of RV function and the occurrence of adverse outcomes in patients with FC. Nevertheless, if RV free wall strain (RV-FWS), assessed by 2D speckle tracking analysis, may provide a better prognostication is currently unexplored.

We retrospectively evaluated the association between RV-FWS and the occurrence of cardiovascular events in a cohort of 28 patients with FC. The study endpoint comprises the occurrence of cardiovascular mortality, severe heart failure symptoms, new-onset atrial fibrillation, bradyarrhythmias requiring pacemaker implantation and sustained ventricular tachyarrhythmias.

The median value of RV-FWS was 21.4% (interquartile range:17.1-23.9%) and a total of 18 (64%) patients showed reduced RV-FWS (&lt;23%). During a median follow-up of 49 (IQR: 37-51) months, 17 (61%) patients met the study endpoint. A ROC-curve analysis confirmed the previously defined threshold of reduced RV-FWS (23%) as the best cut-off for predicting cardiovascular outcomes at 4 years (area under curve: 0.76; p-value=0.018), but with a lower predictive value in comparison to left-sided parameters (Panel A). Kaplan-Meier survival curves showed significantly lower event-free survival at 4 years in patients with impaired RV-FWS as compared to patients with preserved RV-FWS (log rank p=0.013) (Panel B). On univariable Cox regression analysis, RV-FWS expressed as continuous variable was significantly associated with the study endpoint (Hazard ratio [HR]: 0.85, 95% CI: 0.75-0.96, p=0.009). RV-FWS retained an independent association with outcomes after alternative adjustment for age (p=0.048) or indexed LV mass (p=0.036). Conversely, RV-FWS was not significantly associated with cardiovascular events, after correcting for LV global longitudinal strain or indexed left atrial volume (p=0.401 and p=0.208; respectively).

In Conclusion, impaired RV-FWS was not independently associated with the occurrence of cardiovascular events in FC, confirming previous observations that prognosis is mainly driven by the severity of LV cardiomyopathy.

626 CARDIOVASCULAR DISEASE PHENOTYPES IN PREGNANCY: GESTATION, PERIPARTUM, AND LONG-TERM OUTCOMES

Background

Maternal cardiovascular physiology is affected by changes that may be impaired in women with cardiovascular disease. Management of these pregnancies is challenging, as prevalence of late childbearing and of women with congenital heart disease achieving pregnancy is increasing.

Objective

This single-center prospective study sought to evaluate the effects of maternal cardiovascular disease (CVD) on pregnancy outcome and, after birth, on maternal and fetal morbidity and mortality.

Methods

140 patients with cardiovascular disease prior to pregnancy (congenital or acquired) or cardiovascular disease developed during pregnancy were enrolled at our tertiary referral hospital between 2011 and 2021. Baseline data included cardiovascular risk factors, cardiological therapy, mWHO class in pregnancy, 12-lead EKG, and transthoracic echocardiography. Birth-related data included gestational age at delivery; neonatal weight, Apgar score at 1 and 5 minutes from birth; admission to neonatal ICU. A medium-to-long term follow-up of these patients was carried out by telemedicine. The primary endpoint was pregnancy outcome in terms of live births, week of delivery and fetal growth. Secondary endpoints included neonatal complications, maternal adverse cardiovascular events (death from cardiovascular causes, sustained arrhythmia, acute heart failure, postpartum cardiac surgery) and adverse obstetric events (spontaneous abortion, fetal loss, intrauterine death, neonatal death, SGA, prematurity, frequency of caesarean sections).

Results

Six cohorts were identified: adult congenital heart disease (ACHD); arrhythmias; valvular heart disease (VHD); ischemic CVD; cardiomyopathies and myopericarditis (CM/MYO); aortic disease. Heart disease prior to pregnancy was the most common setting (88%), mainly including ACHD (54%), followed by VHD (15%) and arrhythmias (11%). The pregnancy-onset cardiovascular diseases (12%) were predominantly CM/MYO (53%), mainly peripartum dilated cardiomyopathy, followed by arrhythmias (35%). Intermediate and high-risk classes (mWHO II-III, III and IV) were observed in 94 patients (67%). There were no maternal deaths; acute heart failure occurred in 6% of patients with no significant difference between groups. Sustained arrhythmias were found in 7% of the total cases, with a significantly higher prevalence in the cohort with preexisting arrhythmia (p &lt;0.05). Cardiac surgery was performed in 4% of the patients, all in the ACHD cohort. Live births were 135 (94%); fetal deaths were 5 (one spontaneous abortion, 3 fetal losses and one neonatal death). Caesarean section was performed in 74% of patients. The mean gestational age at birth was low in all groups (36.6 ± 4.6 weeks), as well as the neonatal weight in grams (2676.9 ± 698.3) and the percentile of neonatal weight (37.8 ± 25.2). Reduced LVEF was significantly associated with low neonatal weight in the mWHO risk class IV patients (p = 0.04). At a mean follow-up of 26 months, cardiac surgery was significantly higher in the group of aortic disease (50% in diseases of the aorta, 8% in the ACHD group, 7% in the CM/MYO group, no events in other groups; p = 0.007), despite the small sample under investigation.

Conclusions

We provide insights of how, by strict and timely follow-up and a multidisciplinary approach implemented before pregnancy and throughout gestation, good outcomes can be achieved in pregnancies with congenital or acquired cardiovascular disease, despite the high prevalence of intermediate and high-risk patients.

255 IMPACT OF SEVERE VALVULAR HEART DISEASE IN ADULT CONGENITAL HEART DISEASE PATIENTS

Background

The clinical impact of valvular heart disease (VHD) in adult congenital heart disease (ACHD) patients is unascertained. Aim of our study was to assess the prevalence and clinical impact of severe VHD (S-VHD) in a real-world contemporary cohort of ACHD patients.

Methods

Patients followed-up at our ACHD Outpatient Clinic were enrolled. Clinical characteristics and echocardiographic data were prospectively entered into a digitalized medical records database. VHD at the first access was evaluated and graded according to VHD guidelines. Clinical data at follow-up were collected.

Results

A total of 390 patients were included and S-VHD was present in 101 (25.9%) patients. Over a median follow-up time of 26 months (IQR: 12-48), the primary composite endpoint occurred in 76 patients (19.5%). The cumulative primary endpoint-free survival was significantly lower in patients with S-VHD vs patients with non-severe VHD (Log rank p &lt;0.001). At multivariable analysis, age and atrial fibrillation at first visit (p=0.029 and p=0.006 respectively), lower %Sat O2, higher NYHA class (p=0.005 for both), lower LVEF (p=0.008) and S-VHD (p=0.015) were independently associated to the primary endpoint. The likelihood ratio test demonstrated that S-VHD added significant prognostic value (p=0.017) to a multivariate model including age, severe CHD, atrial fibrillation, Sat O2, NYHA, LVEF and right ventricle systolic pressure&gt;45 mmHg.

Conclusion

In ACHD patients, the presence of S-VHD is independently associated with the occurrence of cardiovascular mortality and hospitalization. The prognostic value of S-VHD is incremental above other established prognostic markers.

687 RIGHT VENTRICULAR DISFUNCTION IN A PATIENT WITH CCTGA TREATED WITH ARNI

Congenitally Corrected Transposition of Great Arteries is a unique condition in which atrio-ventricular discrepancy e ventricular-arteriosus discrepancy are mutually balanced, so that there is the normal oxygenation and distribution of the blood to the tissues, but the morphologically right ventricle and the tricuspid valve have to deal with systemic pressures, developing severe ventricular disfunction and valve regurgitation along the years.

We presented the case of a young male patient from India with Congenitally Corrected Transposition of Great Arteries, Ventricular Septum Defect and Pulmonary Artery Stenosis, for which he was treated surgically by positioning a valved conduit between the morphologically left ventricle and the pulmonary artery; he developed worsening dyspnoea years after the operation and further investigations in our centre demonstrated the patency of the conduit and right (systemic) ventricular disfunction that we decided, in a pioneering manner, to treat with Sacubitril/Valsartan.

Impact of severe valvular heart disease in adult congenital heart disease patients

Background

The clinical impact of valvular heart disease (VHD) in adult congenital heart disease (ACHD) patients is unascertained. Aim of our study was to assess the prevalence and clinical impact of severe VHD (S-VHD) in a real-world contemporary cohort of ACHD patients.

Materials and methods

Consecutive patients followed-up at our ACHD Outpatient Clinic from September 2014 to February 2021 were enrolled. Clinical characteristics and echocardiographic data were prospectively entered into a digitalized medical records database. VHD at the first evaluation was assessed and graded according to VHD guidelines. Clinical data at follow-up were collected. The study endpoint was the occurrence of cardiac mortality and/or unplanned cardiac hospitalization during follow-up.

Results

A total of 390 patients (median age 34 years, 49% males) were included and S-VHD was present in 101 (25.9%) patients. Over a median follow-up time of 26 months (IQR: 12–48), the study composite endpoint occurred in 76 patients (19.5%). The cumulative endpoint-free survival was significantly lower in patients with S-VHD vs. patients with non-severe VHD (Log rank p &lt; 0.001). At multivariable analysis, age and atrial fibrillation at first visit (p = 0.029 and p = 0.006 respectively), lower %Sat O2, higher NYHA class (p = 0.005 for both), lower LVEF (p = 0.008), and S-VHD (p = 0.015) were independently associated to the study endpoint. The likelihood ratio test demonstrated that S-VHD added significant prognostic value (p = 0.017) to a multivariate model including age, severe CHD, atrial fibrillation, %Sat O2, NYHA, LVEF, and right ventricle systolic pressure &gt; 45 mmHg.

Conclusion

In ACHD patients, the presence of S-VHD is independently associated with the occurrence of cardiovascular mortality and hospitalization. The prognostic value of S-VHD is incremental above other established prognostic markers.

Performance, clinical outcomes and implementation of an original heart valve clinic model

BACKGROUND

Valvular heart disease (VHD) requires optimized outpatient management that is generally considered to be best delivered by a dedicated, multidisciplinary team (Heart Valve Clinic [HVC]). Although HVC is promoted by clinical guidelines and organized in many centers, real world outcome assessments are limited. Thus, we evaluated the performance, clinical and management outcomes during a 6-year experience with an original HVC model.

METHODS

By interrogating the local database, 1047 consecutive patients admitted to the HVC from January 2015 to October 2020 were found. Management and mortality were checked for all patients. After 3 years of HVC activity, in order to improve appropriateness and efficiency, access priority criteria were introduced. Thus, the study population was divided in two period subgroups (before and after access criteria introduction) that were compared.

RESULTS

A total of 1047 consecutive patients admitted to the HVC constituted the study population; 346 patients (33%) were recommended for invasive treatment. After a mean follow-up of 25.7±3.1 months, 37 patients (3.5%) died. When comparing study periods, statistically significant increase inpatients' complexity and VHD severity was noticed in Period 2, also translating into higher rate of referral to intervention (39.0% vs. 29.4% in Period 1; P=0.001). Finally, despite higher rate of elderly and frail patients, operative mortality was not jeopardized.

CONCLUSIONS

The present study reports a comprehensive assessment of the characteristics and outcomes achieved through an original HVC model. Standardization of access criteria supports the HVC improvement.

Right ventricle-pulmonary artery coupling in repaired tetralogy of fallot with pulmonary regurgitation: clinical implications

Funding Acknowledgements

Type of funding sources: None.

Background

The right ventricle-pulmonary artery (RV-PA) coupling is a strong prognostic marker in

several clinical settings, but only few studies focused on its role in repaired Tetralogy of

Fallot (rToF) with pulmonary regurgitation (PR). Aim of this study was to assess

whether differences exist in RV-PA coupling, estimated as by echocardiography,

between patients with rToF and PR with (i-PVR) or without (ni-PVR) indication for

pulmonary valve replacement (PVR).

3

Materials and Methods

The study population included 40 rToF patients allocated to two groups: 20 i-PVR and

20 ni-PVR; 40 healthy controls were also included. All subjects underwent

echocardiogram, while Cardiac magnetic resonance (CMR) was available in 27/40

rToF patients. RV-PA coupling was assessed by echocardiographic TAPSE/PASP and

RV stroke volume/RV end systolic volume (RVSV/RVESV) by CMR.

Results

TAPSE was similar in i-PVR vs ni-PVR (19.0 ± 3.4 vs 18.8 ± 2.7 mm, p = 0.85) while RV-PA coupling

was significantly worse in i-PVR vs ni-PVR (TAPSE/PASP 0.8 ± 0.3 vs 1.1 ± 0.5

mm/mmHg, p = 0.009) as well as in i-PVR vs controls (p = 0.02) while there was no

difference between ni-PVR and controls (p = 0.29). CMR data confirmed the echo

results, with a significant difference in RV-PA coupling between i-PVR and ni-PVR

(RVSV/RVESV 0.9 ± 0.2 vs 1.2 ± 0.3 mL/min/mL, p = 0.01).

Conclusions

This study shows the presence of worse RV-PA uncoupling, despite normal RV systolic

function, in rToF patients with indication to PVR. RV-PA coupling could be a sensitive

marker of a progressive maladaptive RV response to long-standing volume overload in

rToF prior to the onset of clinical symptoms and RV systolic dysfunction. Abstract Figure. example of an i-PVR patient

Early Right Heart Chambers Reverse Remodeling in Patients Operated in Adulthood for Congenital Lesions Associated with Right Heart Chambers Enlargement

BACKGROUND

Progressive right heart chambers dilatation is frequent in the adult congenital heart disease (ACHD) population. We evaluated the immediate and mid-term response of right heart chambers to surgery performed in adulthood for lesions associated with right heart chambers enlargement.

METHODS

Thirty-six adult patients with lesions associated with right heart chambers enlargement submitted to surgery were studied. We collected echocardiographic data of right ventricle (RV) mid-diameter, right atrial volume indexed, RV systolic pressure, and tricuspid annular plane systolic excursion (TAPSE) prior to surgery (T0), at 2 to 5 days (T1), and 3 to 6 months (T2) after surgery.

RESULTS

At T1, we observed a significant decrease of RV mid-diameter (47.2 ± 8.4 vs. 39.6 ± 7.4 mm, P < .001), right atrial volume indexed (45.6 ± 26.6 vs. 27.2 ± 11 ml/m2, P < .001), and RV systolic pressure (39 ± 14.8 vs. 32.8 ± 11.3 mm Hg, P = .03). At T2, a further significant deviation in the rate of RV diameter (39.6 ± 7.4 vs. 34.5 ± 5.1 mm, P < .001), in RV systolic pressure (32.8 ± 11.3 vs. 25.3 ± 5 mm Hg, P = .03) and TAPSE (13.9 ± 3.2 vs. 15.8 ± 2.6 mm, P < .001) was observed.

CONCLUSIONS

Positive right heart chambers remodeling occurs as early as in the immediate post-operative period in most ACHD patients operated for lesions associated with right heart chambers enlargement.

Heart Valve Critical Pathway and Heart Valve Clinic: Novel Benchmarks for Modern Management of Valvular Heart Disease

The growing burden of valvular heart disease in Western countries represents a challenge for the daily clinical practice, especially in the light of the ever-increasing number of therapeutic options. The Euro Heart Survey showed that, among elderly subjects with severe, symptomatic valve dysfunction, surgery is denied for 33% of patients with aortic stenosis and for 50% of patients with mitral regurgitation. Current management (from diagnosis to follow-up) is often fragmented in multiple-sometimes unnecessary-steps. Such a "patchy" approach may translate into a suboptimal management, especially in the geriatric population. New healthcare models exist that can coordinate care, reduce fragmentation, limit costs and, ultimately, improve outcomes: the clinical pathways.

Telemedicine for adult congenital heart disease patients during the first wave of COVID-19 era: a single center experience

AIM

To summarize our experience on the implementation of a telemedicine service dedicated to adult congenital heart disease (ACHD) patients during the lockdown for the first wave of Coronavirus disease 2019 (COVID-19).

METHODS

This is a prospective study enrolling all ACHD patients who answered a questionnaire dedicated telematic cardiovascular examination.

RESULTS

A total of 289 patients were enrolled, 133 (47%) were male, 25 (9%) were affected by a genetic syndrome. The median age was 38 (29-51) years, whereas the median time interval between the last visit and the telematic follow-up was 9.5 (7.5-11.5) months. Overall, 35 patients (12%) reported a worsening of fatigue in daily life activity, 17 (6%) experienced chest pain, 42 (15%) had presyncope and 2 (1%) syncope; in addition, 28 patients (10%) presented peripheral edema and 14 (5%) were orthopneic. A total of 116 (40%) patients reported palpitations and 12 had at least one episode of atrial fibrillation and underwent successful electrical (8) or pharmacological (4) cardioversion. One patient was admitted to the emergency department for uncontrolled arterial hypertension, five for chest pain, and one for heart failure. Two patients presented fever but both had negative COVID-19 nasal swab.

CONCLUSION

During the COVID-19 pandemic, the use of telemedicine dramatically increased and here we report a positive experience in ACHD patients. The postpandemic role of telemedicine will depend on permanent regulatory solutions and this early study might encourage a more systematic telematic approach for ACHD patients.

Duchenne Dilated Cardiomyopathy: Cardiac Management from Prevention to Advanced Cardiovascular Therapies

Duchenne muscular dystrophy (DMD) cardiomyopathy (DCM) is characterized by a hypokinetic, dilated phenotype progressively increasing with age. Regular cardiac care is crucial in DMD care. Early recognition and prophylactic use of angiotensin converting enzyme inhibitors (ACEi) are the main stay therapeutic strategy to delay incidence of DMD-DCM. Pharmacological treatment to improve symptoms and left ventricle (LV) systolic function, have been widely implemented in the past years. Because of lack of DMD specific drugs, actual indications for established DCM include current treatment for heart failure (HF). This review focuses on current HF strategies to identify, characterize, and treat DMD-DCM.

P722 Unrepaired complex severe aortic coarctation determining restrictive cardiomyopathy with pulmonary hypertension in adulthood

A 54-year-old female presented to our Emergency Department with acute pulmonary edema. On physical examination she was tachypneic with arterial oxygen saturation of 91% and a grade 3/6 systolic murmur in the apex and left second intercostal space that was irradiated to the intrascapular area. Bilateral femoral and pedal pulses were quite faint on palpation. The blood pressure was 260/120 mmHg. Results of routine blood chemistry were normal with the exception of increased NT-proBNP (2746 pg/mL). Twelve-lead electrocardiogram revealed left ventricular hypertrophy with repolarization abnormalities and left atrial enlargement. The two dimensional (2D) echocardiography showed significant left ventricular hypertrophy (RWT 0.6; LVmass index 150 g/m2), no wall-motion abnormalities and normal left ventricular ejection fraction (EF 60%) but with reduced longitudinal components at TDI evaluation (6 cm/s). Severe ventricular diastolic dysfunction was detected with E/A 2,11 and E/e" 26 with a significant left atrial dilatation (LAVi 73 ml/m2) and severe pulmonary arterial hypertension ( PASP of 85 mmHg) . We were unable to visualize the aortic arch but reduced/absent pulsatile wall motion of abdominal aorta was identified. The patient reported to be affected by unrepaired aortic coarctation diagnosed at the age of 32 during pregnancy. She refused the surgical treatment twice and the she did not undergo any specific follow up but she had several admissions in emergency department for uncontrolled arterial hypertension. Our further evaluation with CT angiography showed a severe narrowing of the post isthmic aortic lumen with significant development collateral vessels (Figure 1). The patient was discharged after resolution of pulmonary edema and titration of hypertension treatment with a planning of hybrid approach to treat the aortic coarctation. The case shows a restrictive cardiomyopathy with post-capillary pulmonary hypertension due to severe unrepaired aortic coarctation.

Abstract P722 Figure. CT angiography,echo, right heart cath

Results for tricuspid valve surgery in adults with congenital heart disease other than Ebstein's anomaly†

OBJECTIVES

Tricuspid valve (TV) surgery in the adult with congenital heart disease (ACHD) is a frequently performed procedure. The aim of this study was to analyse postoperative and medium-term outcomes.

METHODS

We conducted a single-centre retrospective study of patients with ACHD who underwent TV surgery (January 2000-December 2016); patients with Ebstein's anomalies were excluded. Operative and clinical records were reviewed. Outcomes considered were survival, grade of insufficiency/stenosis and TV reoperation at follow-up.

RESULTS

A total of 128 patients with ACHD had TV surgery for functional regurgitation (n = 95), dysplasia (n = 23) and systemic TV (n = 10). Median age was 40.8 years [interquartile range (IQR) 25.3]; 55.5% were men. Preoperative regurgitation was classified as mild (n = 8), moderate (n = 47) and severe (n = 70). The TV was repaired in 109 as follows: ring annuloplasty (n = 43), de Vega annuloplasty (n = 29), Wooler annuloplasty (n = 13), commissural plasty (n = 9), Kay annuloplasty (n = 7) and others (n = 8). The TV was replaced in 19 patients with biological (n = 10) and mechanical (n = 9) prostheses. The median hospital stay was 12 days (IQR 10). The overall mortality rate was 8.6% (n = 11): 2 hospital deaths (1.6%) and 9 late deaths. Survival was 93% [95% confidence interval (CI) 85-97%] at 5 years and 83% (95% CI 70-91%) at 10 years. The median follow-up period was 4.95 years (IQR 7.7) with 1 TV reoperation. Echocardiographic assessment showed ≥moderate regurgitation in 34 (34.3%) patients. Suture plasty had a significantly higher incidence of TV regurgitation ≥moderate compared to ring annuloplasty (48.9% vs 26.3%; P = 0.033).

CONCLUSIONS

TV surgery in the ACHD is frequently associated with other main procedures. Stabilizing the TV annulus with a prosthetic ring guarantees lower recurrence of moderate to severe regurgitation compared to suture plasty repair.

First Surgical Melody Valve-In-Valve Implantation for Early Degeneration in Mitral Position

Congenital mitral valve disease is a real challenge in infants and small children. The implantation of expandable stented valves in mitral position has become one of the options of choice in consideration of their acceptable short-term expandable durability and subsequent feasibility of balloon expansion of these devices. We report the first case of a surgical Melody valve-in-valve procedure for early Melody valve degeneration in the mitral position. The result was good, and the procedure safe, rapid, and without an increased risk when a mechanical valve implantation will be necessary.

Apoptosis in the dorsal lateral geniculate nucleus after monocular deprivation involves glutamate signaling, NO production, and PARP activation

In mammals, visual experience during early postnatal life is critical for normal development of the visual system. Here we report that monocular deprivation for 2, 7, and 14 consecutive days causes p53 accumulation, cell death, and progressive loss of neurones in the dorsal lateral geniculate nucleus (dLGN) of newborn rats and these are prevented by NMDA and non-NMDA glutamate receptor antagonists, and by L-NAME, an inhibitor of nitric oxide synthesis. Monocular deprivation also increases dLGN levels of citrulline, the coproduct of nitric oxide synthesis, and this, as well as cell death and neuronal loss, is abolished by antagonists of glutamate receptors and by L-NAME. Finally, poly-(ADP-ribose) polymerase (PARP) knock-out mice appear to be protected from monocular deprivation-induced cell death. In conclusion, during early postnatal development of the rat visual system monocular deprivation causes excitotoxic, nitric oxide-mediated, cell death in the dLGN that appears to be apoptotic and also requires activation of PARP.

Blood antioxidant status and urinary levels of catecholamine metabolites in beta-thalassemia

It has been reported that iron overload in beta-thalassemia leads to an enhanced generation of reactive oxygen species and to oxidative stress. We have studied the oxidant/antioxidant imbalance in the blood of 48 transfusion-dependent beta-thalassemic patients (TLP) (17 males, 31 females, 11-22 year), under chelation therapy, and in 40 sex and age matched healthy controls (CTR). Plasma and lymphocyte levels of vitamin E (Vit E), ubiquinol (CoQ10H2), ubiquinone (CoQ10), plasma concentrations of vitamin A (Vit A), beta-carotene, lycopene, vitamin C (Vit C), total thiols, fatty acid patterns of phospholipids (PL-FA), and plasma and urinary markers of lipoperoxidation (TBA-RM, conjugated dienes, and azelaic acid (AZA), as well as the urinary levels of catecholamine and serotonin metabolites, were evaluated by gas chromatography-mass spectrometry (GC-MS), HPLC and spectrophotometry. Routine laboratory blood analyses were performed on the same samples; 39/48 TLP were HCV positive. Blood samples were collected just before transfusion, the 24 h urine samples the day before. Our results clearly showed that a severe oxidative stress occurs in the plasma of TLP in comparison with CTR. In fact, the levels of lipophilic antioxidants and ascorbate were severely depleted: CoQ10H2 (-62.5%), total CoQ10 (-35.1%), Vit E (-43.8%), beta-carotene (-31.1%), lycopene (-63.7%), Vit A (-35.9%), Vit C (-23.1%). The impairment of the antioxidant status was associated with elevated plasma levels of by-products of lipoperoxidation and urinary concentrations of catecholamine metabolites and of AZA, indicating a high degree of both neurological stress and lipoperoxidation. A significant positive correlation was found between vitamin E and non-transferrin-bound iron (NTBI) (r = -0.81; p < 0.001), while no correlation was found between antioxidant depletion and ferritin serum levels, average blood consumption, or the presence of clinical complications. The administration of selective antioxidants along with an appropriate diet might represent a promising way of counteracting oxidative damage and its deleterious effects on the progression of the disease.

Epidermal oxidative stress in vitiligo

Epidermal levels of enzymatic and non-enzymatic antioxidants such as superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GSH-Px), vitamin E (Vit E), ubiquinol (CoQ10H2), and reduced glutathione (GSH), as well as polyunsaturated fatty acids of phospholipids (PL-PUFA), were evaluated in the affected epidermis of 15 patients with active vitiligo (AVP) and in the corresponding epidermis of 15 healthy phototype matched controls. The epidermal levels of CoQ10H2, Vit E, GSH, and CAT activity were significantly reduced in AVP and were associated with a marked increase of oxidized glutathione, whereas SODs and GSH-Px activities and ubiquinone concentration remained similar to control values. Antioxidant deficiency, in particular the decline of lipophilic antioxidants, i.e., CoQ10H2 and Vit E, accounts well for PL-PUFA reduction observed in vitiligo epidermis, mainly affecting C18:3 n-3, C20:3 n-6, C20:4 n-6, and C22:6 n-3 fatty acids and suggesting the occurrence of a lipoperoxidative process. In conclusion, both an imbalance of the intracellular redox status and a significant depletion of enzymatic and non-enzymatic antioxidants feature the epidermis of AVP, and represent a fingerprint of an abnormal oxidative stress leading to epidermal cell injury.

Imbalance in the antioxidant pool in melanoma cells and normal melanocytes from patients with melanoma

In order to evaluate the free radical defense systems of melanocytes and their possible correlation with melanoma, we have studied in cultured normal human melanocytes (20), normal melanocytes from melanoma patients (15), and melanoma cells (40) the fatty acid pattern of membrane phospholipids as a target of peroxidative damage and the superoxide dismutase and catalase activities, vitamin E, and ubiquinone levels as intracellular antioxidants. Cells were cultured in the same medium and analyzed at III or IV passage. Compared to the values obtained in normal human melanocytes, melanoma cells showed on average: a) higher levels of polyunsaturated fatty acids, b) increased superoxide dismutase and decreased catalase activities, higher vitamin E, and lower ubiquinone levels. Among the normal melanocytes from melanoma patients studied, two groups were differentiated: a) cultures (7) with enzymatic and non-enzymatic antioxidants level similar to those of normal human melanocytes; b) cultures (8) with antioxidant patterns similar to those observed in melanoma cells. Polyunsaturated fatty acids were also increased in the latter group. The results indicate that in melanoma cells and in a percentage of normal melanocytes from melanoma patients, an imbalance in the antioxidant system can be detected that can lead to endogenous generation of reactive oxygen species and to cellular incapability of coping with exogenous peroxidative attacks. These alterations could be correlated with the malignant transformation of cells and with the progression of the disease.

Paraphenylene diamine, a contact allergen, induces oxidative stress in normal human keratinocytes in culture

During the course of evaluating the interaction between allergens and keratinocytes in the pre-immunological phase of contact sensitization, we have studied the effects of paraphenylene diamine (pPD) on membrane lipid peroxidation and on intracellular antioxidant levels in cultured human keratinocytes. pPD is an aromatic amine which undergoes spontaneous oxidation in culture medium, generating short-lived free radical species including oxyradicals. Following exposure to non-toxic concentrations of pPD (0.5-10 micrograms/ml), we have evaluated the fatty acid pattern of membrane phospholipids as a target of peroxidative damage, and the intracellular level of reduced glutathione (GSH), the activity of superoxide dismutase (SOD), and that of catalase (CAT) as parameters of the antioxidant system. Depending on pPD concentration and the period of exposure, peroxidative damage with a significant decrease in membrane polyunsaturated fatty acids, was detected. Concentrations between 0.5 and 2 micrograms/ml produced an initial increase and then a decrease in both SOD and CAT activities, and in the oxidation of GSH, up to 12 h. After 24 h, when all the pPD had decomposed, recovery of the initial levels of the antioxidants was detected. Concentrations over 5 micrograms/ml induced a progressive decrease in both the enzymatic activities and the GSH concentrations. These results are consistent with the view that oxidative stress can be an essential event in the pre-immunological phase of contact sensitization.

Antioxidant status in the blood of patients with active vitiligo

We have previously reported that patients with active vitiligo (AVP) have elevated urinary levels of catecholamine metabolites, such as homovanillic and vanilmandelic acids, irrespective of the form of the disease (acrofacial, segmental, generalized). We have suggested that abnormal release of catecholamines from autonomic nerve endings might play an etiological role in the onset and development of vitiligo through an overproduction of toxic (oxy)radicals in the microenvironment of melanocytes in the affected areas. In the present study we have investigated whether this suggested increase in radicals might be associated with an oxidative stress in the blood of AVP. We have analyzed by gas-chromatography mass-spectrometry, by high pressure liquid chromatography, by spectrophotometry plasma levels of vitamin E (Vit E), lipoperoxides (LIP), and polyunsaturated fatty acids of phospholipids (PL-FA), erythrocyte reduced glutathione (GSH), glutathione peroxidase (GSH-Px), and superoxide dismutase (SOD) activities in 62 patients affected with different forms of active vitiligo (acrofacial, segmental, generalized) and in 60 age-matched controls. Our results show that blood levels of Vit E, SOD, GSH, GSH-Px activity, LIP and PL-FA in AVP were not significantly different from those of healthy age matched controls, indicating that melanocyte damage in vitiligo is not linked with a generalized oxidative stress.