A unique case of lymphoepithelioma-like HCC with osteoclast-like giant cells: CT imaging features with pathologic correlations

Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver, with several histological variants being reported in literature. Hereby, we describe a case of a 77-year-old man with chronic liver disease referred to our department for performing a computed tomography (CT) due to a liver mass discovered at an abdominal ultrasound follow-up. At CT, a large, ill-defined lesion in the third hepatic segment was detected, characterized by progressive and delayed enhancement with minimal retraction of the hepatic capsule, associated with perihepatic adipose tissue inhomogeneity, mimicking a cholangiocarcinoma. At histopathological evaluation, the lesion turned out to be an HCC with lymphoepithelioma-like component and osteoclastic-like giant cells. This report focuses on the clinicopathological and radiological features of this unique case.

A quantitative evaluation of aerosol generation during cardiopulmonary resuscitation

It is unclear if cardiopulmonary resuscitation is an aerosol-generating procedure and whether this poses a risk of airborne disease transmission to healthcare workers and bystanders. Use of airborne transmission precautions during cardiopulmonary resuscitation may confer rescuer protection but risks patient harm due to delays in commencing treatment. To quantify the risk of respiratory aerosol generation during cardiopulmonary resuscitation in humans, we conducted an aerosol monitoring study during out-of-hospital cardiac arrests. Exhaled aerosol was recorded using an optical particle sizer spectrometer connected to the breathing system. Aerosol produced during resuscitation was compared with that produced by control participants under general anaesthesia ventilated with an equivalent respiratory pattern to cardiopulmonary resuscitation. A porcine cardiac arrest model was used to determine the independent contributions of ventilatory breaths, chest compressions and external cardiac defibrillation to aerosol generation. Time-series analysis of participants with cardiac arrest (n = 18) demonstrated a repeating waveform of respiratory aerosol that mapped to specific components of resuscitation. Very high peak aerosol concentrations were generated during ventilation of participants with cardiac arrest with median (IQR [range]) 17,926 (5546-59,209 [1523-242,648]) particles.l-1 , which were 24-fold greater than in control participants under general anaesthesia (744 (309-2106 [23-9099]) particles.l-1 , p < 0.001, n = 16). A substantial rise in aerosol also occurred with cardiac defibrillation and chest compressions. In a complimentary porcine model of cardiac arrest, aerosol recordings showed a strikingly similar profile to the human data. Time-averaged aerosol concentrations during ventilation were approximately 270-fold higher than before cardiac arrest (19,410 (2307-41,017 [104-136,025]) vs. 72 (41-136 [23-268]) particles.l-1 , p = 0.008). The porcine model also confirmed that both defibrillation and chest compressions generate high concentrations of aerosol independent of, but synergistic with, ventilation. In conclusion, multiple components of cardiopulmonary resuscitation generate high concentrations of respiratory aerosol. We recommend that airborne transmission precautions are warranted in the setting of high-risk pathogens, until the airway is secured with an airway device and breathing system with a filter.

CT Coronary Angiography: Technical Approach and Atherosclerotic Plaque Characterization

Coronary computed tomography angiography (CCTA) currently represents a robust imaging technique for the detection, quantification and characterization of coronary atherosclerosis. However, CCTA remains a challenging task requiring both high spatial and temporal resolution to provide motion-free images of the coronary arteries. Several CCTA features, such as low attenuation, positive remodeling, spotty calcification, napkin-ring and high pericoronary fat attenuation index have been proved as associated to high-risk plaques. This review aims to explore the role of CCTA in the characterization of high-risk atherosclerotic plaque and the recent advancements in CCTA technologies with a focus on radiomics plaque analysis.

Advanced CMR Techniques in Anderson-Fabry Disease: State of the Art

Anderson-Fabry disease (AFD) is a rare multisystem X-linked lysosomal storage disorder caused by α-galactosidase A enzyme deficiency. Long-term cardiac involvement in AFD results in left ventricular hypertrophy and myocardial fibrosis, inducing several complications, mainly arrhythmias, valvular dysfunction, and coronary artery disease. Cardiac magnetic resonance (CMR) represents the predominant noninvasive imaging modality for the assessment of cardiac involvement in the AFD, being able to comprehensively assess cardiac regional anatomy, ventricular function as well as to provide tissue characterization. This review aims to explore the role of the most advanced CMR techniques, such as myocardial strain, T1 and T2 mapping, perfusion and hybrid imaging, as diagnostic and prognostic biomarkers.

Artificial intelligence and radiomics in magnetic resonance imaging of rectal cancer: a review

Rectal cancer (RC) is one of the most common tumours worldwide in both males and females, with significant morbidity and mortality rates, and it accounts for approximately one-third of colorectal cancers (CRCs). Magnetic resonance imaging (MRI) has been demonstrated to be accurate in evaluating the tumour location and stage, mucin content, invasion depth, lymph node (LN) metastasis, extramural vascular invasion (EMVI), and involvement of the mesorectal fascia (MRF). However, these features alone remain insufficient to precisely guide treatment decisions. Therefore, new imaging biomarkers are necessary to define tumour characteristics for staging and restaging patients with RC. During the last decades, RC evaluation via MRI-based radiomics and artificial intelligence (AI) tools has been a research hotspot. The aim of this review was to summarise the achievement of MRI-based radiomics and AI for the evaluation of staging, response to therapy, genotyping, prediction of high-risk factors, and prognosis in the field of RC. Moreover, future challenges and limitations of these tools that need to be solved to favour the transition from academic research to the clinical setting will be discussed.

Dual-Energy CT of the Heart: A Review

Dual-energy computed tomography (DECT) represents an emerging imaging technique which consists of the acquisition of two separate datasets utilizing two different X-ray spectra energies. Several cardiac DECT applications have been assessed, such as virtual monoenergetic images, virtual non-contrast reconstructions, and iodine myocardial perfusion maps, which are demonstrated to improve diagnostic accuracy and image quality while reducing both radiation and contrast media administration. This review will summarize the technical basis of DECT and review the principal cardiac applications currently adopted in clinical practice, exploring possible future applications.

Cardiovascular magnetic resonance native T1 mapping in Anderson-Fabry disease: a systematic review and meta-analysis

BACKGROUND

T1 mapping is an established cardiovascular magnetic resonance (CMR) technique that can characterize myocardial tissue. We aimed to determine the weighted mean native T1 values of Anderson-Fabry disease (AFD) patients and the standardized mean differences (SMD) as compared to healthy control subjects.

METHODS

A comprehensive literature search of the PubMed, Scopus and Web of Science databases was conducted according to the PRISMA statement to retrieve original studies reporting myocardial native T1 values in AFD patients and healthy controls. A random effects model was used to calculate SMD, and meta-regression analysis was conducted to explore heterogeneity sources. Subgroup analysis was also performed according to scanner field strength and sequence type.

RESULTS

From a total of 151 items, 14 articles were included in the final analysis accounting for a total population of 982 subjects. Overall, the weighted mean native T1 values was 984 ± 47 ms in AFD patients and 1016 ± 26 ms in controls (P < 0.0001) with a pooled SMD of - 2.38. In AFD patients there was an inverse correlation between native T1 values and male gender (P = 0.002) and left ventricular hypertrophy (LVH) (P < 0.001). Subgroup analyses confirmed lower T1 values in AFD patients compared to controls with a pooled SMD of -  2.54,  -  2.28, -   2.46 for studies performed on 1.5T with modified Look-Locker inversion recovery (MOLLI), shortened MOLLI and saturation-recovery single-shot acquisition, respectively and of -  2.41 for studies conducted on 3T.

CONCLUSIONS

Our findings confirm a reduction of native T1 values in AFD patients compared to healthy controls and point out that the degree of T1 shortening in AFD is influenced by gender and LVH. Although T1 mapping is useful in proving cardiac involvement in AFD patients, there is need to standardize shreshold values according to imaging equipment and protocols.

Cardiac CT and MRI radiomics: systematic review of the literature and radiomics quality score assessment

OBJECTIVE

To systematically review and evaluate the methodological quality of studies using magnetic resonance imaging (MRI) and computed tomography (CT) radiomics for cardiac applications.

METHODS

Multiple medical literature archives (PubMed, Web of Science, and EMBASE) were systematically searched to retrieve original studies focused on cardiac MRI and CT radiomics applications. Two researchers in consensus assessed each investigation using the radiomics quality score (RQS). Subgroup analyses were performed to assess whether the total RQS varied according to study aim, journal quartile, imaging modality, and first author category.

RESULTS

From a total of 1961 items, 53 articles were finally included in the analysis. Overall, the studies reached a median total RQS of 7 (IQR, 4-12), corresponding to a percentage score of 19.4% (IQR, 11.1-33.3%). Item scores were particularly low due to lack of prospective design, cost-effectiveness analysis, and open science. Median RQS percentage score was significantly higher in papers where the first author was a medical doctor and in those published on first quartile journals.

CONCLUSIONS

The overall methodological quality of radiomics studies in cardiac MRI and CT is still lacking. A higher degree of standardization of the radiomics workflow and higher publication standards for studies are required to allow its translation into clinical practice.

KEY POINTS

• RQS has been recently proposed for the overall assessment of the methodological quality of radiomics-based studies. • The 53 included studies on cardiac MRI and CT radiomics applications reached a median total RQS of 7 (IQR, 4-12), corresponding to a percentage of 19.4% (IQR, 11.1-33.3%). • A more standardized methodology in the radiomics workflow is needed, especially in terms of study design, validation, and open science, in order to translate the results to clinical applications.

Global Left Ventricular Myocardial Work Efficiency in Heart Failure Patients with Cardiac Amyloidosis: Pathophysiological Implications and Role in Differential Diagnosis

Introduction

Cardiac amyloidosis (CA) is an infiltrative cardiomyopathy and a common cause of heart failure with preserved and mid-range ejection fraction (HFpEF and HFmrEF). Left ventricular (LV) systolic assessment is pivotal in differential diagnostic and prognostic stratification in CA. However, nondeformation and deformation-based parameters classically implied had many limitations. Myocardial work (MW) has been recently introduced for the evaluation of myocardial performance, in a load-independent fashion, in patients with cardiomyopathies.

Aims

This study aimed to evaluate MW parameters in LV performance assessment in CA and their possible role in differential diagnosis between AL and ATTR forms, compared with other echocardiographic parameters, also exploring the possible association between MW parameters and blood biomarkers.

Materials and Methods

The study population consisted of 25 patients with CA (10 with AL amyloidosis and 15 with wild-type ATTR [ATTRwt] form) and HFpEF or HFmrHF, enrolled between March 2018 and December 2019, undergoing a comprehensive clinical, biochemical, and imaging evaluation. Ten healthy individuals were studied as controls. ATTR patients had a noninvasive diagnosis of wtATTR-CA (positive ^99mTc-hydroxy methylene-diphosphonate scintigraphy with a negative hematological screening), while AL patients underwent endomyocardial biopsy. All patients underwent standard transthoracic echocardiography. MW and related indices were estimated using a vendor-specific module.

Results

Compared to the ATTRwt group, patients in the AL group showed a more pronounced myocardial performance impairment assessed by Global Word Efficiency (GWE: 83.5% ± 6.3% vs. 88.2% ± 3.6%; P = 0.026). In multiple linear regression analysis, cardiac troponin I (Β = -0.55; P < 0.0001), global longitudinal strain (Β =0.35; P < 0.008), and regional relative strain ratio (Β = -0.30; P < 0.016) were significant predictors of GWE reduction in CA patients. At receiver operating characteristics curve analysis, among all other deformation-based and nondeformation-based echocardiographic parameters, GWE showed the highest area under the curve (AUC) (AUC 0.74; 95% CI: 0.55-0.96; P < 0.04). The optimal cutoff was determined by sensitivity/specificity analysis: a GWE < 86.5% identified patients with AL amyloidosis with a sensitivity and specificity, respectively, of 80.0% and 66.7%.

Conclusions

The results of our pivotal study seem to highlight the importance of new deformation parameters to study myocardial performance in patients with CA, and to differentiate between AL CA and ATTR CA.

The Role of New Imaging Technologies in the Diagnosis of Cardiac Amyloidosis

Cardiac amyloidosis is an infiltrative disorder caused by transthyretin or immunoglobulin free light-chain deposition, which determines clinical disease with similar phenotype but different time course, prognosis and therapy. Multimodality imaging is the cornerstone for disease diagnosis and management. Multimodality imaging has revolutionized the approach to the disease favoring its awareness and simplifying its diagnosis, especially in ATTR cardiac amyloidosis. This describes the different imaging tools, from the traditional to the more novel ones, and highlights the different approach in each different setting (prognosis, subtyping, prognosis, monitoring disease progression, and response to therapy).

Metastatic choriocarcinoma with hemorrhagic complications and spontaneous ovarian hyperstimulation syndrome: A case report

Gestational choriocarcinoma is a malignant trophoblastic tumor arising from any gestational event, even with a long latency period, generally in the reproductive female. It is associated with a high level of beta-human chorionic gonadotropin. Its primary site is usually the uterus but not all patients have a detectable lesion in this site. Regression of the primary tumor after it has metastasized is not uncommon, and one-third of cases manifest as complications of metastatic disease. In this report we present an uncommon case of gestational choriocarcinoma with lung, liver and jejunal metastases at the time of diagnosis without evidence of pelvic disease, in 34-year-old woman. The main points of interest of our case were the development of the ovarian hyperstimulation syndrome with massive multicystic ovarian enlargement induced by high level of beta-human chorionic gonadotropin and the bleeding of jejunal and liver metastases, due to the high vascularity of the tumor tissue, a condition known as "Choriocarcinoma Syndrome". We will focus on the radiological findings of metastases, bleeding complications and ovarian hyperstimulation syndrome.

Quantitative evaluation of coronary artery occlusion by 3D coronary volume reconstruction in a large animal model of acute myocardial infarction

Background

Large animal models of acute myocardial infarction (MI) offer an important platform to test novel therapies. Consistency of infarct size between animals is critical to ensure an accurate assessment of therapies against control. However, anatomical variation challenges the ability to achieve a consistent infarct size and care must be taken to respect the principles of the 3Rs through minimisation of interventional fatalities.

Purpose

To standardise the approach of a closed chest model of balloon occlusion-facilitated MI. Novel 3-dimensional quantitative coronary angiography (3DQCA) software has been used retrospectively to identify a correlation between coronary volume occlusion and the extension of the myocardial scar.

Methods

Twenty-four Yorkshire pigs (mean weight 63.1±3 kg) underwent a closed chest MI model via percutaneous occlusion of the mid portion of the left anterior descending artery (LAD) for 60 minutes. The evaluation of the myocardial damage was obtained via cardiac magnetic resonance imaging (CMR) between 24 and 48 hours after the MI model (Acute) and at 4–5 weeks after MI (Chronic). Troponin I was also measured at multiple timepoints. 3DQCA reconstruction (QAngio XA 3D, Medis medical imaging systems NL) was generated from 2 angiographic projections with segmental analysis of all 3 major epicardial vessels including lumen volume, reference diameters, and segment length. The occlusive volume and vessel length was identified through co-registration of balloon position.

Results

At the short term timepoint, a significant correlation was found between the LAD volume occluded and the scar size as percentage of the LV mass (Spearman correlation 0.72, p value &lt;0.01, Fig. 1). Using Youden index analysis we identified a cut-off point of 32.8% of the LAD volume to determine a scar volume &gt;20% (Fig. 2). At chronic phase the correlation between these two variables was not significant, although there was a trend towards significance (p value = 0.06, Cor = 0.54). No significant correlation was found with serum Troponin I.

Conclusions

There is a significant correlation between the LAD volume occluded and the overall scar size in the acute phase and at least 32.8% of the LAD volume should be occluded to determine a scar volume &gt;20% of the entire LV. This indicates that a prospective measure of occluded LAD volume might minimise the intra-experimental variability in studies aiming to reduce infarct size and acute myocardial injury.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): This research work was supported by grants awarded to Professor Ascione: the British Heart Foundation (BHF) (BHF IG/14/2/30991, BHF RM/13/2/30158), and the Medical Research Council (MRC) (MRC MR/L012723/1).

Impaired transcriptional compensation for oxidative damage in a porcine model of ischaemic cardiomyopathy

Background

The prognosis of heart failure remains poor. Energetic imbalances related to mitochondrial dysfunction, impaired oxidative phosphorylation and oxidative damage have been implicated in the pathogenesis or worsening of heart failure (1,2). Improved understanding of the metabolic alterations in heart failure may provide new biomarkers or therapeutic targets.

Purpose

We explored mutation rate, mitochondrial copy number and regional mitochondrial gene transcription in a porcine model of ischaemic cardiomyopathy. Specifically, we investigated the Dloop region – a promotor for mitochondrial DNA- in which mutations have been implicated in many cancers. We hypothesised that there may be differences in mutation rate and oxidative damage within the mitochondrial genome.

Methods

15 female Yorkshire pigs were studied. 7 animals underwent percutaneous balloon catheter myocardial infarction followed by termination at 4 weeks. A group of 8 healthy animals served as controls. Reverse transcription quantitative PCR (RT-qPCR) assays were performed to determine the gene expression levels of mitochondrial DNA codified genes (ND1, ND2, ND4, ATP6 and ND6). Quantitative PCR (qPCR) methodology was modified to obtain the relative mitochondrial copy number, mutation rate, and oxidative damage according to established methods (3–5).

Results

Significant mitochondrial transcriptional activity of the genes studied was seen in both groups (see Table 1 and 2). When examining the ND2-ND6 region (excluding the Dloop) in control animals, we note an inverse correlation with increased oxidative damage corresponding to a significantly lower mutation rate (p=0.017). There was no correlation between the mutation rate and oxidative damage in the ND6-ND2- including Dloop- region. However, when examining the Dloop specifically, there was a marked inverse correlation between oxidative damage and mutation rate (p=0.007). This suggests that in controls, there is regional variation in the susceptibility to damage within the mitochondrial genome which may trigger repair mechanisms. Indeed, the relative mitochondrial copy number was inversely associated to the mutation rate (p=0.08) in controls.

In contrast, in the chronic animals, we noted no correlation with the level of oxidative damage in the ND2-ND6, D-loop, or ND6–2 regions compared to mutation rate (p=0.52, p=0.53 and p=0.17 respectively). This indicates that there is a loss in the ability to instigate repair mechanisms in the setting of ischaemic cardiomyopathy.

Conclusions

This study demonstrates that in control animals, there appears to be regional variation in the ability to mitigate against mutations in response to oxidative damage within the mitochondrial genome. In contrast, this protection and/or the effectiveness of repair mechanisms appear to be impaired in the setting of ischaemic cardiomyopathy. This may be a driver, and in turn a therapeutic target, for adverse remodelling in this setting.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): This research work was supported by grants awarded to Professor Ascione: the British Heart Foundation (BHF) (BHF IG/14/2/30991, BHF RM/13/2/30158), and the Medical Research Council (MRC) (MRC MR/L012723/1).

Predictors of in-hospital mortality, 20-year survival and reflection on risk scoring in patients with impaired left ventricular function undergoing isolated coronary artery bypass grafting

Background

Impaired left ventricular ejection fraction (LVEF) is a risk factor for mortality in patients undergoing coronary artery bypass grafting (CABG). Limited data is available on survival after 5 years and sensitivity of preoperative risk scoring systems in this high-risk population.

Purpose

To investigate in-hospital mortality, 20-year survival, predictors of early and late mortality and sensitivity of available risk-scoring systems in a large population with moderate to poor baseline LVEF and undergoing isolated CABG.

Methods

Patients presenting with moderate to poor LVEF and undergoing isolated CABG between 1996 and 2015 were selected for the purpose of this study. LVEF was defined moderate if between 30–39% and poor if &lt;30%. Data collection was prospective and retrospectively analysed. Early and long-term mortality was derived from the NHS National Mortality Tracking system. Exclusion criteria included reoperations and combined procedures only. Patients undergoing urgent and emergency CABG procedures were included. Key outcome measures included 30-day health outcome, long-term survival, impact of incomplete revascularization (IC) and off-pump coronary artery bypass (OPCAB) surgery, independent predictors of poor in-hospital outcome and long-term mortality and reliability of Euroscore in predicting mortality in this high-risk population. Comparative analysis was conducted with Student t-test or Mann-whithney test fro numerical variable and Chi-Square for categorical variables. Survival were compared and reported using Log rank test and Kaplan Meier methods. A Cox Proportional Hazard model was developed to identify risk factors for long term mortality.

Results

5016 patients with reduced LVEF were identifiedL1024 (20.4%) with poor and 3992 (79.6%) with moderate LVEF. After excluding reoperations and combined procedures, the final sample consisted of 3867 patients. Average age was68 years, 83% were male, 40% had NYHA IV; 12.5% of patients received IC and 44% underwent OPCAB surgery. 30-day mortality was 4.4%, stroke 1.4% and renal failure requiring dialysis of 2.9%. Survival at 1, 5, 10 and 20 years was 91.1%, 76.7%, 55.1% and 22.1% respectively (Figure). OPCAB surgery was not associated with long-term mortality. Independent predictors of late mortality as shown in Table. Additive Euroscore and Logistic Euroscore appeared to overestimate mortality in this patient population (AUC 0.78).

Conclusions

In patients with reduced LVEF the use of CABG is associated with low rates of in-hospital mortality, key post-operative complications and excellent long-term survival. Incomplete revascularization but not OPCAB surgery are surgical predictors of long-term mortality. Euroscore appears to overestimate the risk of mortality in this population.

Funding Acknowledgement

Type of funding sources: None. Cox Hazard Ratio Table

Distinct metabolic transcriptional patterns and Warburg effect in porcine model of ischaemic cardiomyopathy

Background

Despite improvements in therapy for heart failure, the prognosis remains poor. Energetic imbalances related to mitochondrial dysfunction, impaired oxidative phosphorylation and oxidative damage have been implicated in the pathogenesis or worsening of heart failure. Improved understanding of the metabolic alterations of the heart may provide new biomarkers or therapeutic targets.

Purpose

It has been speculated that aerobic glycolysis, known as the Warburg effect, may be advantageous for cell survival whereby there is the opportunity for simultaneous energy production and production of intermediary metabolites crucial for anabolic pathways that sustain cell division and maintenance, and protein synthesis (1,2). In this study, we studied a preclinical model of ischaemic cardiomyopathy to investigate transcriptional patterns in two defined areas; peri-infarct and remote locations. Specifically, we investigated if aerobic glycolysis may be present in this setting.

Methods

18 female Yorkshire pigs were studied. 10 animals underwent balloon catheter myocardial infarction followed by termination at 4 weeks. A group of 8 healthy animals served as controls. All animals underwent cardiac MRI prior to termination confirming ventricular impairment and remodelling in the chronic animals (see Table 1). Gene expression profiles of glucose mobilisation and glucose metabolic markers (GLUT1, GLUT4, ANK2, GAPDH and LDHA), oxidative phosphorylation and mitochondrial function (ND1, TFAM, and PGC1-alpha), key markers of insulin resistance (AKT1, AS160) and a hypoxia marker (HIF1-alpha) were measured.

Results

Our results indicate the presence of two distinct metabolic profiles at the gene expression level, differing from control tissue but more interestingly with striking differences regionally. In the remote region compared to controls, we demonstrate a picture suggestive of increased glycolysis with significant transcriptional upregulation of GLUT1 and GLUT4 glucose transporters (p=0.01 and p=0.02 respectively), alongside a significant reduction in PGC1-alpha (p=0.04) with maintained transcriptional levels of LDHA and HIF1-alpha. Combined, these results are suggestive of reduced oxidative phosphorylation alongside compensated, or early stage, aerobic glycolytic metabolism in this region. In contrast, in peri-infarct tissue versus controls, we demonstrate a reduction in glycolysis (GLUT1 p=0.09, GLUT4 p=0.01 with a dramatic increase in GLUT1/GLUT4 ratio of 6.7 times) and reduced markers of mitochondrial function indicative of insulin-resistance with evidence of a fetal-pattern metabolic profile (see Table 2 for detailed results).

Conclusions

This study demonstrates distinct transcriptional profiles within hearts with ischaemic cardiomyopathy and for the first time suggests that the Warburg effect may be present in remote myocardium in this setting supporting the need for further work in this area.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): This research work was supported by grants awarded to Professor Ascione: the British Heart Foundation (BHF) (BHF IG/14/2/30991, BHF RM/13/2/30158), and the Medical Research Council (MRC) (MRC MR/L012723/1). Table 1. CMR parameters for animals studiedTable 2. Transcriptional signals

624 Twenty Years' Experience of Coronary Artery Bypass Grafting in Patients with Reduced Left Ventricular Ejection Fraction

Aim

Reduced Left Ventricular Ejection Fraction (LVEF) is a risk factor for patients undergoing Coronary Artery Bypass Grafting (CABG). The aim of our study was to compare short term outcomes and long-term (20 years) survival rates of patients with reduced LVEF undergoing CABG.

Method

Between 1996 and 2015, 5016 patients with reduced LVEF underwent CABG: 1024 (20.4%) had poor LVEF (&lt; 30%) and 3992 (79.6%) had moderate LVEF dysfunction (30-49%). After excluding reoperations and combined procedures, the final sample consisted of 3867 patients. Our primary outcomes were early in-hospital mortality and complications and long-term survivals.

Results

In-hospital mortality rate was 4.4%, stroke rate 1.4% and renal failure 2.9%. Survival rates at 1, 5, 10 and 20 years were 91.1%, 76.7%, 55.1% and 22.1% respectively. Additive Euroscore and Logistic Euroscore (AUC 0.78) is less reliable compared to normal LV patients. Complete revascularization was an independent factor affecting long term survival (HR: 0.85). No difference between OPCABG and ONCABG were found.

Conclusions

CABG is still safe and most likely the best treatment option for patients with reduced LVEF. Completeness of revascularization plays an important role in long term outcomes while OPCABG has no significant advantages. Euroscore has a reduced predicting ability in this group of patients.

Acute regional changes in myocardial strain may predict ventricular remodelling after myocardial infarction in a large animal model

To identify predictors of left ventricular remodelling (LVR) post-myocardial infarction (MI) and related molecular signatures, a porcine model of closed-chest balloon MI was used along with serial cardiac magnetic resonance imaging (CMRI) up to 5-6 weeks post-MI. Changes in myocardial strain and strain rates were derived from CMRI data. Tissue proteomics was compared between infarcted and non-infarcted territories. Peak values of left ventricular (LV) apical circumferential strain (ACS) changed over time together with peak global circumferential strain (GCS) while peak GLS epicardial strains or strain rates did not change over time. Early LVR post-MI enhanced abundance of 39 proteins in infarcted LV territories, 21 of which correlated with LV equatorial circumferential strain rate. The strongest associations were observed for D-3-phosphoglycerate dehydrogenase (D-3PGDH), cysteine and glycine-rich protein-2, and secreted frizzled-related protein 1 (sFRP1). This study shows that early changes in regional peak ACS persist at 5-6 weeks post-MI, when early LVR is observed along with increased tissue levels of D-3PGDH and sFRP1. More studies are needed to ascertain if the observed increase in tissue levels of D-3PGDH and sFRP1 might be casually involved in the pathogenesis of adverse LV remodelling.

A Rare Case of Solitary Fibrous Tumour of the Pelvis in an 18-Year-Old Young Man: CT and MRI Features with Pathologic Correlations

Solitary fibrous tumors (SFTs) are mesenchymal neoplasms of fibroblastic origin, even if commonly seen in the pleura, they can occur anywhere in the body. SFT presents as a slow growing, often asymptomatic mass, generally affecting middle-aged adults regardless of the sex. We report a rare case of an 18-year-old man referred to our institution to perform computed tomography (CT) and magnetic resonance imaging (MRI), to investigate a pelvic mass incidentally discovered at abdominal ultrasound examination. A well circumscribed, heterogenous and hypervascular lesion was described at imaging, with absence of calcifications, hemorrhage, necrosis nor cystic degeneration. The mass removal was performed via the Da Vinci-assisted robotic surgery. Histopathological evaluation confirmed the diagnosis of SFT. CT and MRI can aid the identification of SFT, providing useful information which needs to be supported by histopathological analysis.

Cardiac magnetic resonance imaging during the COVID-19 pandemic: A southern Italian single-center experience

Purpose

We aimed to assess the impact of COVID-19 pandemic on cardiac magnetic resonance (CMR) imaging studies performed during the lockdown imposed by the Italian Government from March 2020 to May 2020.

Materials and method

We reviewed the number and the findings of CMR scans performed during the COVID-19 pandemic between March and May 2020 at University of Naples Federico II. The number and the findings of CMR studies acquired in the corresponding months of 2017, 2018 and 2019 were also assessed for direct comparison.

Results

A total of 117 CMR studies was considered, including the procedures performed during the pandemic (n = 18) and those performed in the corresponding months of the prior 3 years (n = 99). The number of CMR studies performed during the COVID-19 pandemic was significantly (P < .01) lower compared to the mean number (n = 33) of the procedures performed in the corresponding months of 2017-2019. The percentage of abnormal CMR studies was similar (P = 0.73) during the pandemic (67 %) compared to that found in the corresponding months of 2017-2019 (70 %) suggesting that many abnormal tests were missed due to the lockdown.

Conclusion

The number of CMR studies was significantly reduced during the COVID-19 pandemic compared to the corresponding period of the previous three years. The lack of difference in the prevalence of abnormal CMR studies between the two study time intervals strongly suggests that many patients with potentially abnormal imaging test have been missed during the pandemic.

Significant functional mitral regurgitation affects left atrial function in heart failure patients: haemodynamic correlations and prognostic implications

AIMS

Functional mitral regurgitation (FMR) is a well-known pathophysiological factor in heart failure (HF) patients, and left atrial function (LAF) is a novel determinant of clinical status and outcome in this setting. However, little is known about the pathophysiological role of FMR on LAF in HFrEF patients. Aim of this study is to explore the possible interplay between the severity of FMR and LAF in heart failure with reduce ejection fraction (HFrEF) patients and their possible consequences.

METHODS AND RESULTS

We studied 97 consecutive patients with FMR classified in two groups: mild-to-moderate MR ore less (FMR group, n = 38) and moderate-to-severe or more (SFMR group, n = 59). Using the phasic method, left atrial contractile, conduit, reservoir, and total emptying function (TLAEF) were calculated to assess LAF. SFMR group showed significantly lower values of LAF compared to FMR group. LA dysfunction (LA-dys) was defined for TLAEF values below the median and groups divided in four subgroups based on its presence. Patient with LA-Dys in SFMR group showed a worse clinical status, higher incidence of right ventricular dysfunction (RV-Dys), and pulmonary hypertension (PH), and a significant worse clinical survival compared to all other groups.

CONCLUSION

In our study, the survival was significantly lower in SFMR/LA-Dys+ group. Furthermore, LA-Dys was strongly related with worse clinical status and higher incidence of PH and RV-Dys. These results suggest that in patients with SFMR and HFrEF, LA-Dys may represent both a marker of more advanced disease and a novel prognostic factor.

P664 Relationship of left atrial function assessed by 2D speckle tracking echocardiography with left ventricular systolic function in patients with degenerative mitral regurgitation

Funding Acknowledgements

none

Background

In degenerative mitral regurgitation (DMR), left ventricle (LV) and left atrium (LA) undergo progressive volume overload leading to chamber remodelling and dysfunction in advanced stages. Speckle tracking echocardiography (STE) is an estabilished technique able in detecting subclinical LA and LV dysfunction in this setting. However data are lacking on the relationship of LA and LV function in DMR patients.

Purpose

Our aim was to assess LA function in patients with DMR and to explore its possible correlations with LV dimensions and systolic function.

Methods

We enrolled 95 patients with mild to severe DMR, dichotomizing them on the basis of mitral regurgitation severity (DMR 1-2: mild and mild-to-moderate MR; DMR 3-4: at least moderate to severe MR). LA function was assesed with 2D speckle tracking echocardiography.

Results

The two groups were well matched. DMR 3-4 group (n= 48) showed higher LA and LV volumes, lower right ventricle longitudinal systolic function and higher values of systolic pulmonary pressure. There was not significant difference in LV ejection fraction (LVEF) and global longitudinal strain (GLS). Among LA function indexes, only peak systolic reservoir strain was significantly reduced in DMR 3-4 group (21,9± 6,2% vs 24,7± 7,2% ; p= 0,04). Then population study was further divided in two groups according to the presence (LA dys+) or absence (LA dys-) of LA dysfunction, defined as reservoir strain values below the median [median 23.7%; LAdys- group (n. 49), LAdys+ group (n.46) ]. At the comparison of continuous variables (Tab.1), LAdys+ group showed larger LV end systolic diameter and more impaired LVEF (60,9± 9,8% vs 65,4± 4,8%; p: 0,004) and GLS (20,04 ± 3,7% vs 23,53 ± 2,7%; p &lt;0,001).

Conclusions

Our data showed that LA reservoir strain was impaired in patients with moderate to severe DMR. Furthermore, patients with LA dysfunction showed reduced LVEF and GLS values. Consequently, LA dysfunction assessed with STE may be a novel marker of early LV systolic dysfunction in patients with degenerative mitral regurgitation.

Tab.1 LAdysf- (n = 49) LAdysf+ (n = 46) P value LVESD (mm) 31.78 ± 4.1 34.74 ± 7.6 0.020 LAVI (mL/mq) 44.5 ± 15.1 55.6 ± 25.6 0.015 TAPSE (mm) 26.30 ± 3.96 24.02 ± 3.31 0.004 sPAP (mmHg) 31.4 ± 7.0 36.4 ± 10.9 0.009 LVEF (%) 65.4 ± 4.8 60.9 ± 9.8 0.004 GLS (%) 23.5 ± 2.7 20.0 ± 3.7 &lt;0.001 Comparison of continuous variables between patients with and without LA dysfunction.

The mitral-to-aortic flow-velocity integral ratio in the real world echocardiographic evaluation of functional mitral regurgitation before and after percutaneous repair

INTRODUCTION

Percutaneous mitral valve repair (PMVR) using MitraClip system has emerged as a therapeutic option for patients with functional severe mitral regurgitation (FMR) at prohibitive risk for surgery. In this setting, the echocardiographic assessment of FMR severity is challenging because the traditional echocardiographic methods have important limitations. The aim of this study was to assess the accuracy and reliability of a simple Doppler index, the mitral/aortic flow velocity integral ratio (MAVIR), to evaluate residual FMR severity after PMVR.

METHODS

Eighty-five heart failure patients with functional MR and LV dysfunction (LVEF ≤ 40%) were included. FMR was quantified on the basis of traditional quantitative parameters of MR severity. MAVIR was expressed as the ratio of mitral and aortic time velocity integral (TVI) values. According to MR severity, 25 patients underwent MC implantation and at 6 months a complete echocardiographic follow-up was performed.

RESULTS

A significant linear relationship was found between MAVIR and both VC and EROA. A MAVIR ≥1.02 identified pts with severe MR with a sensitivity of 86.7% and a specificity of 90.9%. At the 6 months echocardiographic follow-up after the MitraClip implantation, we observed a significant reduction of LAVI, LVED and LVES volume, while LVEF improved. Furthermore, MAVIR significantly decreased its decrease showed a significant linear relationship with LAVI reduction.

CONCLUSION

Our data show a close relationship between MAVIR and traditional indexes of MR severity in patients with FMR. This Doppler-derived index seems applicable after PMVR where traditional echocardiographic index of MR severity shows significant limitations.

Inflammation, oxidative stress and postoperative atrial fibrillation in cardiac surgery

Postoperative atrial fibrillation (POAF) is a common complication of cardiac surgery that occurs in up to 60% of patients. POAF is associated with increased risk of cardiovascular mortality, stroke and other arrhythmias that can impact on early and long term clinical outcomes and health economics. Many factors such as disease-induced cardiac remodelling, operative trauma, changes in atrial pressure and chemical stimulation and reflex sympathetic/parasympathetic activation have been implicated in the development of POAF. There is mounting evidence to support a major role for inflammation and oxidative stress in the pathogenesis of POAF. Both are consequences of using cardiopulmonary bypass and reperfusion following ischaemic cardioplegic arrest. Subsequently, several anti-inflammatory and antioxidant drugs have been tested in an attempt to reduce the incidence of POAF. However, prevention remains suboptimal and thus far none of the tested drugs has provided sufficient efficacy to be widely introduced in clinical practice. A better understanding of the cellular and molecular mechanisms responsible for the onset and persistence of POAF is needed to develop more effective prediction and interventions.

Recoordination of opposing walls drives the response to cardiac resynchronization therapy: a longitudinal study using a strain discoordination index

BACKGROUND AND AIMS

Intraventricular dyssynchrony has traditionally been studied by means of contraction delays between different myocardial segments. Recently, the discoordination of opposing wall contraction throughout the cardiac cycle has been proposed as a more faithful predictor of response. Aim of the current study was to evaluate which parameters - mechanical dyssynchrony or discoordination - normalize with left ventricular response to cardiac resynchronization therapy (CRT).

METHODS

Cardiac mechanics were analysed before and after 6 months of CRT in 53 patients with left bundle branch block and advanced heart failure. Discoordination was quantified by means of the transverse strain discoordination index (TSDI) at basal and mid-ventricular segments; this index takes into account the percentage of time in the cardiac cycle in which cardiac deformation (transverse strain) of the two opposing walls occurs in noncoordinated directions. Dyssynchrony indices included septal to lateral peak-to-peak transverse strain delay and the standard deviation of time to peak tissue velocity in 12 mid-basal segments (Yu index).

RESULTS

Around 63% of patients met the response criteria. Several baseline indices were predictive of reverse remodelling; TSDI at the mid-ventricular level demonstrated the best accuracy. Time from Q to peak velocity and strain tended to increase in all explored myocardial segments; despite a trend towards a decrease in septal-to-lateral strain delay, the latter decreased equally in responders and in nonresponding patients. Yu index decreased in responders more than in nonresponders, with borderline significance. Basal and medium TSDI remained unchanged in nonresponders and consistently normalized in patients who responded to CRT. The changes in TSDI were significantly correlated with improvements in left ventricular end-systolic volume and ejection fraction; the strongest correlation was observed for changes in TSDI measured at the mid-ventricular level.

CONCLUSION

Left ventricular reverse remodelling after CRT is accompanied by the recoordination of opposite-wall contraction, as testified by changes in mid-ventricular TSDI, which also reveals as a very good predictor of response. On the contrary, changes of segmental peak-to-peak delays (dyssynchrony indices) fail to capture the complex nature of left ventricular response to CRT.

Expression of ets family genes in hematopoietic-cells

We have examined the expression of the ets family of transcription factors in different types of hematopoietic cells. Our results demonstrate that several members of the ets gene family are expressed differentially in hematopoietic cells. During phorbol ester induced differentiation of HL60 cells, ETS2, PEA3, as well as GABPalpha and GABPbeta mRNAs are coordinately induced. During the activation of T-cells, ETS2 proteins are induced; however, the expression of the ETS1 and ERGB gene products are reduced. These results demonstrate that the regulation of ets family of genes is complex and depends on cell type. This observation leads to the conclusion that the regulation of ets target genes, will be dependent, in part, upon the type of ets genes expressed in each particular cell type.

Influence of nucleotides flanking the ggaa core sequence on ets1 and ets2 DNA-binding activity and the mechanism of ets1 autoregulation

The Ets family of genes encode nuclear proteins that activate transcription by binding to a specific purine-rich (GGAA) ets binding sequence (EBS) present in promoters/enhancers of various genes. We have previously shown that over-expression of ets1 via transfection of ets1 expression vectors into NIH3T3 cells induced the expression of the endogenous Ets1 gene. Here we report that the autoregulation occurs as a result of the ets1 protein binding to the EBS-core located in its own promoter. In the present study, we have also identified Ets binding sites in the IL-4, G-CSF (granulocyte colony stimulating factor), and the 2'5' OAS (oligoadenylate synthetase) promoters by binding with Ets1 and Ets2 proteins using electrophoretic mobility shift assays. Interestingly, we have found that the EBS containing T nucleotides on either side of the GGAA core sequence, does not bind Ets1 or Ets2 proteins. Our findings demonstrate that the sequences surrounding the purine core - GGAA- have a profound influence on the binding of Ets proteins.

The competent isolated double orifice mitral valve: an incidental finding during excision of a papillary fibroelastoma

The double orifice mitral valve is associated with a number of congenital abnormalities and comprises two mitral orifices separated by an accessory bridge of fibrous tissue and surrounded by a single fibrous annulus. We present our management of a case of a double orifice mitral valve associated with a papillary fibroelastoma.

Body dissatisfaction, abnormal eating behaviours and eating disorder attitude in homo- and heterosexuals

OBJECTIVE

The primary aim of this study was to investigate the relationship between sexual orientation and disordered eating attitudes and behaviours in a sample of homosexuals and heterosexuals subject.

METHODS

We screened 110 homosexuals (85 males and 25 females) and 121 heterosexuals (85 males and 36 females) by means of: a) an ad hoc socio-demographic schedule; b) the Eating Disorders Inventory 2 (EDI 2); the Eating Disorders Inventory 2 - Symptom Checklist (EDI-SC); the Body Uneasiness Test (BUT).

RESULTS

Male homosexuals obtained much higher scores than male heterosexuals on the EDI 2 Drive for thinness, Bulimia, Ineffectiveness, Interoceptive awareness, Impulse regulation scales and on all the BUT subscales. Similarly, with regard to eating behaviours, a significantly higher frequency in the use of strategies to compensate weight increase was observed. On all these scales the sample of homosexual males did not show any significant differences from the group of hetero- and homosexual women. The male homosexuals who claimed they were not in a stable relationship scored higher in all the variables considered.

DISCUSSION

Our findings seem to suggest that homosexual orientation is associated with greater body dissatisfaction and abnormal eating behaviours in males, in particular among those who claimed they were not in a sentimental relationship.

Laboratory culturing of a thermophilic alga at high temperature

Conditions for laboratory growth of the thermophilic alga Cyanidium caldarium at elevated temperatures have been developed. Growth characteristics of the organisms are described.

The importance of myocardial amino acids during ischemia and reperfusion in dilated left ventricle of patients with degenerative mitral valve disease

Taurine, glutamine, glutamate, aspartate, and alanine are the most abundant intracellular free amino acids in human heart. The myocardial concentration of these amino acids changes during ischemia and reperfusion due to alterations in metabolic and ionic homeostasis. We hypothesized that dilated left ventricle secondary to mitral valve disease has different levels of amino acids compared to the right ventricle and that such differences determine the extent of amino acids' changes during ischemia and reperfusion. Myocardial concentration of amino acids was measured in biopsies collected from left and right ventricles before cardioplegic arrest (Custodiol HTK) and 10 min after reperfusion in patients undergoing mitral valve surgery. The dilated left ventricle had markedly higher (P < 0.05) concentrations (nmol/mg wet weight) of taurine (17.0 +/- 1.5 vs. 10.9 +/- 1.5), glutamine (20.5 +/- 2.4 vs. 12.1 +/- 1.2), and glutamate (18.3 +/- 2.2 vs. 11.4 +/- 1.5) when compared to right ventricle. There were no differences in the basal levels of alanine or aspartate. Upon reperfusion, a significant (P < 0.05) fall in taurine and glutamine was seen only in the left ventricle. These changes are likely to be due to transport (taurine) and/or metabolism (glutamine). There was a marked increase in the alanine to glutamate ratio in both ventricles indicative of ischemic stress which was confirmed by global release of lactate during reperfusion. This study shows that in contrast to the right ventricle, the dilated left ventricle had remodeled to accumulate amino acids which are used during ischemia and reperfusion. Whether these changes reflect differences in degree of cardioplegic protection between the two ventricles remain to be investigated.

Inadequate blood glucose control is associated with in-hospital mortality and morbidity in diabetic and nondiabetic patients undergoing cardiac surgery

BACKGROUND

Derangement of glucose metabolism after surgery is not specific to patients with diabetes mellitus. We investigated the effect of different degrees of blood glucose control (BGC) on clinical outcomes after cardiac surgery.

METHODS AND RESULTS

We analyzed 8727 adults operated on between April 1996 and March 2004. The highest blood glucose level recorded over the first 60 hours postoperatively was used to classify patients as having good (<200 mg/dL), moderate (200 to 250 mg/dL), or poor (>250 mg/dL) BGC; 7547 patients (85%) had good, 905 (10%) had moderate, and 365 (4%) had poor BGC. Patients with inadequate BGC were more likely to present with advanced New York Heart Association class, congestive heart failure, hypertension, renal dysfunction, and ejection fraction <50% (P0<or=.001). We found that 52% of patients with poor, 31% with moderate, and 8% with good BGC had diabetes mellitus. Inadequate BGC, but not diabetes mellitus (P=0.79), was associated with in-hospital mortality (good, 1.8%; moderate, 4.2%; poor, 9.6%; adjusted odds ratio: poor versus good BGC, 3.90 [95% confidence interval, 2.47 to 6.15]; moderate versus good BGC, 1.68 [95% confidence interval, 1.25 to 2.25]). Inadequate BGC also was associated with postoperative myocardial infarction (eg, odds ratio, poor versus good BGC: 2.73 [95% confidence interval, 1.74 to 4.26]) and with pulmonary and renal complications in patients without known diabetes mellitus (eg, odds ratio, poor versus good BGC: 2.27 [95% confidence interval, 1.65 to 3.12] and 2.82 [95% confidence interval, 1.54 to 5.14] respectively).

CONCLUSIONS

More than 50% of patients with moderate to poor BGC after cardiac surgery were not previously identified as diabetic. Inadequate postoperative BGC is a predictor of in-hospital mortality and morbidity.

Risk factors for and economic implications of prolonged ventilation after cardiac surgery

OBJECTIVE

The study's objective was to identify predictors of prolonged ventilation and assess clinical and cost implications in patients undergoing cardiac surgery.

METHODS

Patients undergoing cardiac surgery were classified as (1) ventilated less than 96 hours or (2) ventilated 96 hours or more. Multivariate modeling was used to identify predictors of prolonged ventilation and to ascertain the impact of prolonged ventilation on in-hospital mortality and bed occupancy costs and 5-year survival.

RESULTS

A total of 7553 patients were studied; 197 (2.6%) had prolonged ventilation. Median ventilation times were 8 and 192 hours, and in-hospital mortality was 1.0% and 22.2% in the control and prolonged ventilation groups, respectively (P < .001). In-hospital mortality remained higher in the prolonged ventilation group after adjustment and when comparing propensity-matched patients (odds ratio 8.06; 95% confidence interval [CI] 4.27-15.2; P < .001 for propensity-matched groups). Independent predictors of prolonged ventilation were as follows: older age, New York Heart Association class, ejection fraction less than 50%, creatinine greater than 200 micromol/L, multiple valve replacements, aortic procedures, operative priority, reoperation for bleeding, inotropes, and preoperative intra-aortic balloon pump. Five-year survival was lower in the prolonged ventilation group (56.1% [95% CI 46.6%-64.6%] vs 88.8% [95% CI 87.9%-89.6%]) also after adjustment for imbalances and when comparing propensity-matched patients (hazard ratio 2.39; 95% CI 1.75-3.27; P < .001 for propensity-matched groups). Mean bed occupancy costs were 14,286 dollars (95% CI 12,731 dollars-15,690 dollars) and 2761 dollars (95% CI 2705 dollars-2814 dollars) in the prolonged ventilation and control groups, respectively (P < .001).

CONCLUSION

Prolonged ventilation is associated with high in-hospital mortality and costs, and poor 5-year survival. Identified predictors of prolonged ventilation might help to optimize the clinical management of these patients.

ETS transcription factors and targets in tumour invasion, angiogenesis and bone metastasis

The ETS gene family encodes unique transcription regulators that have a common ETS DNA binding domain. At least 25 distinct ETS related genes have been isolated from various species. The ETS family transcription factors are known to regulate genetic programs essential for differentiation and development processes and play diverse roles in a number of biological processes such as organogenesis and tissue remodelling during murine development, hematopoiesis, B-cell development, activation of T-cells and signal transduction, as well as osteogenesis, osteoblast differentiation and extracellular matrix mineralization. Based on the observation of overexpression of ETS related genes in various primary and metastatic tumors, their utility as potential therapeutic targets has been suggested. Antisense oligonucleotides, transdominant, and dominant-negative mutants have been exploited to target and inhibit ETS gene expression selectively. These ETS-targeted studies are being pursued to assess their antitumour effect, and hold the potential that such specific ETS-targeted inhibitors may become a viable option for cancer therapy. Collectively, these studies also demonstrate that Ets factors can regulate multiple aspects of the malignant phenotype of many tumor cells in particular neoangiogenesis and extracellular matrix-regulated (ECM-regulated) cell proliferation, motility and invasiveness.

Operative factors that contribute to post-operative atrial fibrillation: insights from a prospective randomized trial

Atrial fibrillation (AF) is the most common complication following cardiac surgery and is associated with significant increases in postoperative morbidity, length of stay and cost of care. In a randomized study we assessed the impact of coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB) (off-pump, n = 100), compared to conventional (on-pump, n = 100) CABG, on the frequency of postoperative AF. Arrhythmias were detected using an automated arrhythmia detector for the first 72 hours following surgery and by four hourly clinical observations thereafter. AF was defined as an irregular narrow complex rhythm (in the absence of bundle branch block) with absence of discrete P waves lasting greater then 10 minutes. There was a significant reduction in the incidence of postoperative AF in the off-pump group (11% versus 45%, P < 0.001) in addition to significant reductions in blood usage, postoperative pneumonia, inotrope requirements, and hospital and intensive care unit stay. Univariate analysis identified all these variables as risk factors for AF, however multivariate regression analysis identified CPB and cardioplegic arrest as the only independent predictor of postoperative AF (OR 7.4; 95% CI 3.4 to 17.9). This study therefore suggests that the inflammatory response to bypass, myocardial ischaemia and atrial cannulation are significant contributory factors to the development of AF following cardiac surgery. In the light of more recent trials it is apparent that this benefit may be most marked in patients with multiple perioperative risk factors for postoperative AF.

Socioeconomic deprivation is a predictor of poor postoperative cardiovascular outcomes in patients undergoing coronary artery bypass grafting

OBJECTIVE

To investigate the effects of socioeconomic deprivation on cardiovascular risk factors and postoperative clinical outcomes of patients undergoing coronary artery bypass grafting (CABG).

DESIGN

Retrospective analysis of prospectively collected data.

SETTING

Surgical population of the southwest of England, April 1996 and August 2000.

STUDY GROUP

Data on 3578 consecutive patients undergoing CABG at the Bristol Royal Infirmary NHS Trust were abstracted. Data were retrieved from the Patient Analysis & Tracking System. Carstairs index was used to measure socioeconomic deprivation of area of residence and was divided into five quintiles, where quintile 1 denotes least deprived and 5 most deprived.

OUTCOME MEASURES

End points were postoperative complications and 30 day mortality.

RESULTS

Higher deprivation scores were associated with younger age (p < 0.004), greater body mass index, diabetes, smoking at time of surgery, and higher EuroSCOREs (all p < or = 0.001). After adjustment for EuroSCORE, socioeconomic deprivation was independently associated with postoperative myocardial infarction (p = 0.05) and combined postoperative myocardial infarction, stroke, and death (p = 0.016). Hospital length of stay for the patients in the highest quintiles was also significantly longer than for those in the lower quintiles (p = 0.04).

CONCLUSION

Patients undergoing CABG living in areas with high deprivation scores are younger, have more clinical risk factors, and experience more postoperative cardiovascular complications than patients living in low deprivation score areas.