Heart rate variability （HRV） refers to the variations between consecutive heartbeats, which depend on the continuous modulation of the sympathetic and parasympathetic branches of the autonomic nervous system. HRV ha...Heart rate variability （HRV） refers to the variations between consecutive heartbeats, which depend on the continuous modulation of the sympathetic and parasympathetic branches of the autonomic nervous system. HRV has been shown to be effective as a predictor of risk after myocardial infarction and an early warning sign of diabetic neuropathy, and in the cardiology setting is now recognized to be a useful tool for risk-stratification after hospital admission and after discharge. Recent evidences suggest that HRV analysis might predict complications even in patients undergoing cardiac surgery, and the present review summarizes the importance of HRV analysis in adult cardiac surgery and the perspectives for HRV use in current clinical practice. Although future larger studies are warranted before HRV can be included into daily clinical practice in adult cardiac surgery, HRV is a novel tool which might detect autonomic instability in the early postoperative phase and during hospital stay, thus predicting or prompt-diagnosing many of the post-operative complications.展开更多
BackgroundGeriatric patients with multivessel coronary artery disease （CAD） are a challenging group to treat; these cases elicit dis-cussion within heart teams regarding the actual benefit of undertaking major surge...BackgroundGeriatric patients with multivessel coronary artery disease （CAD） are a challenging group to treat; these cases elicit dis-cussion within heart teams regarding the actual benefit of undertaking major surgery on these patients and often lead to abandon the surgical option. Percutaneous procedures represent an important option, but coronary anatomy may be unfavorable. Off-pump coronary artery bypass （OPCAB） provides good quality graft on left anterior descending （LAD） without exposing the patient to cardiopulmonary bypass, and might be the ideal choice in patients with multiple comorbidities, not eligible to percutaneous or on-pump procedures. The objective of this study was to compare survival during a mid-term follow-up in high-risk patients with no percutaneous alternative, either treated with OPCAB or discharged in medical therapy.MethodsWe retrospectively evaluated from June 2008 to June 2013, 83 high-risk patients with multivessel CAD were included： 42 were treated with incomplete off-pump revascularization using left internal mammary artery （LIMA） on LAD; 41 were discharged in optimal medical therapy （OMT）, having refused surgery. Follow-up ended in March 2015, with a telephonic interview. Primary endpoint was survival from all-cause mortality; secondary endpoints were survival from cardiac-related mortality and freedom from non-fatal major adverse cardiac events （MACEs）.ResultsDuring follow up, 11 deaths in OPCAB group and 27 deaths in OMT group occurred. Death was due to cardiac factors in 6 and 15 patients, respectively. MACEs were observed in 6 patients in OPCAB group and in 4 patients in OMT group. With regards to survival from all-cause mortality, patients who underwent OPCAB survived more than those dis-charged in OMT （Log Rank ＆lt; 0.001）, and OMT group carries a propensity score-adjusted hazard ratio of 3.862 （P ＆lt; 0.001）. With regards to survival from cardiac-related events, patients who underwent OPCAB survived more than those discharged in OMT （Log Rank = 0.002）, and OMT group carries a propensity score-adjusted hazard ratio of 3.663 （P = 0.010）. There is no statistically significant difference concerning freedom from MACEs （Log Rank = 0.273）.ConclusionsFor high-risk patients with multivessel CAD, not eligible to on-pump complete revascularization surgery or percutaneous procedures, incomplete revascularization with OPCAB LIMA-on-LAD offers benefits in survival when compared to OMT alone.展开更多
Neurological complications after cardiac surgery, rang- ing from permanent stroke to transient dysfunction, repre- sent a key issue in the management of geriatric patients. Many patients aged 70 or more have history o...Neurological complications after cardiac surgery, rang- ing from permanent stroke to transient dysfunction, repre- sent a key issue in the management of geriatric patients. Many patients aged 70 or more have history of neurological dysfunctions, which increases the risk of complications and sequelae, Severe neurologic diseases, such as strokes, occur in up to 6% of patients undergoing cardiac surgery. Therefore, in the setting of fragile patients, prevention is more important than treatment. There are several intraop- erative mechanisms of neurological injury, such as embo- lism, inflammation, intraoperative anemia,展开更多
Cardiovascular aging is a physiological process gradually leading to structural degeneration and functional loss of all the cardiac and vascular components. Conduction system is also deeply influenced by the aging pro...Cardiovascular aging is a physiological process gradually leading to structural degeneration and functional loss of all the cardiac and vascular components. Conduction system is also deeply influenced by the aging process with relevant reflexes in the clinical side. Age-related arrhythmias carry significant morbidity and mortality and represent a clinical and economical burden. An important and unjustly unrecognized actor in the pathophysiology of aging is represented by the extracellular matrix （ECM） that not only structurally supports the heart determining its mechanical and functional properties, but also sends a biological signaling regulating cellular function and maintaining tissue homeostasis. At the biophysical level, cardiac ECM exhibits a peculiar degree of anisotropy, which is among the main determinants of the conductive properties of the specialized electrical conduction system. Age-associated alterations of cardiac ECM are therefore able to profoundly affect the function of the conduction system with striking impact on the patient clinical conditions. This review will focus on the ECM changes that occur during aging in the heart conduction system and on their translation to the clinical scenario. Potential diagnostic and therapeutical perspectives arising from the knowledge on ECM age-associated alterations are further discussed.展开更多
Geriatric patients affected by stable multi-vessel coronary artery disease （CAD） are at the crossroad： they can live with the risks of acute coronary syndrome, malignant arrhythmias or heart failure, or they can un...Geriatric patients affected by stable multi-vessel coronary artery disease （CAD） are at the crossroad： they can live with the risks of acute coronary syndrome, malignant arrhythmias or heart failure, or they can undergo a rapid evaluation for myocardial revascularization.展开更多
Objective Basic science studies demonstrated a general intramyocardial angiogenetic response potentially responsible for the creation of a microvascular neocapillaries network assisting myocardial function. We hypothe...Objective Basic science studies demonstrated a general intramyocardial angiogenetic response potentially responsible for the creation of a microvascular neocapillaries network assisting myocardial function. We hypothesized that the benefit provided by the reperfusion of left anterior descending （LAD） territories and the biological angiogenetic drive triggered by the revascularization could translate in a global improvement in ventricular contractility, not restricted to the grafted area. Methods High-risk patients with multivessel coronary artery disease and preoperative wall motion abnormalities were retrospectively analyzed to compare outcomes and regional ventricular function of those who received optimal medical therapy （OMT） versus those who underwent off-pump coronary artery bypass grafting （OPCABG） and received an incomplete myocardial revascularization using left internal mammary artery （LIMA） on LAD （OPCABG group）. From January 2007 to December 2014, 206 patients （OMT, n = 136, OPCABG, n = 70） were propensity-score matched to have 70 matched pairs. Variables included in propensity score analyses were ejection fraction （EF）, left ventricular end diastolic volume （LVEDVi）, EuroSCORE II. Primary endpoint was the variation in the global wall motion score index （AWMSI） as evaluated by transthoracic echocardiography. Follow up was completed at 3 years from surgery or hospital discharge. Results Regional analysis of ventricular function revealed a regional WMSI improvement in the OPCABG group not only for LAD territories but also for non-LAD regions, associated with a reduction in the negative left ventricular ischemic remodeling, compared to patients discharged in optimal medical therapy. Global AWMSI was negative in OPCABG group （-3.4 ± 2.8%） and positive in the OMT group （5.9 ± 3.1%）, indicating a better wall motion score for OPCAB patients. Surprisingly, regional WMSI improved also in non-grafted territories in the off-pump CABG group with a delta value of -3.7 ± 5.3% for left circumflex artery （LCX） area and -3.5 ± 5.4% for right coronary artery （RCA） area. Conclusions In patients with multivessel coronary artery disease, LIMA-to-LAD grafting is associated with an improvement in the WMSI involving also the surrounding non-LAD ungrafted segments and with the attenuation of negative global and regional ischemic ventricular remodeling.展开更多
文摘Heart rate variability （HRV） refers to the variations between consecutive heartbeats, which depend on the continuous modulation of the sympathetic and parasympathetic branches of the autonomic nervous system. HRV has been shown to be effective as a predictor of risk after myocardial infarction and an early warning sign of diabetic neuropathy, and in the cardiology setting is now recognized to be a useful tool for risk-stratification after hospital admission and after discharge. Recent evidences suggest that HRV analysis might predict complications even in patients undergoing cardiac surgery, and the present review summarizes the importance of HRV analysis in adult cardiac surgery and the perspectives for HRV use in current clinical practice. Although future larger studies are warranted before HRV can be included into daily clinical practice in adult cardiac surgery, HRV is a novel tool which might detect autonomic instability in the early postoperative phase and during hospital stay, thus predicting or prompt-diagnosing many of the post-operative complications.
文摘BackgroundGeriatric patients with multivessel coronary artery disease （CAD） are a challenging group to treat; these cases elicit dis-cussion within heart teams regarding the actual benefit of undertaking major surgery on these patients and often lead to abandon the surgical option. Percutaneous procedures represent an important option, but coronary anatomy may be unfavorable. Off-pump coronary artery bypass （OPCAB） provides good quality graft on left anterior descending （LAD） without exposing the patient to cardiopulmonary bypass, and might be the ideal choice in patients with multiple comorbidities, not eligible to percutaneous or on-pump procedures. The objective of this study was to compare survival during a mid-term follow-up in high-risk patients with no percutaneous alternative, either treated with OPCAB or discharged in medical therapy.MethodsWe retrospectively evaluated from June 2008 to June 2013, 83 high-risk patients with multivessel CAD were included： 42 were treated with incomplete off-pump revascularization using left internal mammary artery （LIMA） on LAD; 41 were discharged in optimal medical therapy （OMT）, having refused surgery. Follow-up ended in March 2015, with a telephonic interview. Primary endpoint was survival from all-cause mortality; secondary endpoints were survival from cardiac-related mortality and freedom from non-fatal major adverse cardiac events （MACEs）.ResultsDuring follow up, 11 deaths in OPCAB group and 27 deaths in OMT group occurred. Death was due to cardiac factors in 6 and 15 patients, respectively. MACEs were observed in 6 patients in OPCAB group and in 4 patients in OMT group. With regards to survival from all-cause mortality, patients who underwent OPCAB survived more than those dis-charged in OMT （Log Rank ＆lt; 0.001）, and OMT group carries a propensity score-adjusted hazard ratio of 3.862 （P ＆lt; 0.001）. With regards to survival from cardiac-related events, patients who underwent OPCAB survived more than those discharged in OMT （Log Rank = 0.002）, and OMT group carries a propensity score-adjusted hazard ratio of 3.663 （P = 0.010）. There is no statistically significant difference concerning freedom from MACEs （Log Rank = 0.273）.ConclusionsFor high-risk patients with multivessel CAD, not eligible to on-pump complete revascularization surgery or percutaneous procedures, incomplete revascularization with OPCAB LIMA-on-LAD offers benefits in survival when compared to OMT alone.
文摘Neurological complications after cardiac surgery, rang- ing from permanent stroke to transient dysfunction, repre- sent a key issue in the management of geriatric patients. Many patients aged 70 or more have history of neurological dysfunctions, which increases the risk of complications and sequelae, Severe neurologic diseases, such as strokes, occur in up to 6% of patients undergoing cardiac surgery. Therefore, in the setting of fragile patients, prevention is more important than treatment. There are several intraop- erative mechanisms of neurological injury, such as embo- lism, inflammation, intraoperative anemia,
文摘Cardiovascular aging is a physiological process gradually leading to structural degeneration and functional loss of all the cardiac and vascular components. Conduction system is also deeply influenced by the aging process with relevant reflexes in the clinical side. Age-related arrhythmias carry significant morbidity and mortality and represent a clinical and economical burden. An important and unjustly unrecognized actor in the pathophysiology of aging is represented by the extracellular matrix （ECM） that not only structurally supports the heart determining its mechanical and functional properties, but also sends a biological signaling regulating cellular function and maintaining tissue homeostasis. At the biophysical level, cardiac ECM exhibits a peculiar degree of anisotropy, which is among the main determinants of the conductive properties of the specialized electrical conduction system. Age-associated alterations of cardiac ECM are therefore able to profoundly affect the function of the conduction system with striking impact on the patient clinical conditions. This review will focus on the ECM changes that occur during aging in the heart conduction system and on their translation to the clinical scenario. Potential diagnostic and therapeutical perspectives arising from the knowledge on ECM age-associated alterations are further discussed.
文摘Geriatric patients affected by stable multi-vessel coronary artery disease （CAD） are at the crossroad： they can live with the risks of acute coronary syndrome, malignant arrhythmias or heart failure, or they can undergo a rapid evaluation for myocardial revascularization.
文摘Objective Basic science studies demonstrated a general intramyocardial angiogenetic response potentially responsible for the creation of a microvascular neocapillaries network assisting myocardial function. We hypothesized that the benefit provided by the reperfusion of left anterior descending （LAD） territories and the biological angiogenetic drive triggered by the revascularization could translate in a global improvement in ventricular contractility, not restricted to the grafted area. Methods High-risk patients with multivessel coronary artery disease and preoperative wall motion abnormalities were retrospectively analyzed to compare outcomes and regional ventricular function of those who received optimal medical therapy （OMT） versus those who underwent off-pump coronary artery bypass grafting （OPCABG） and received an incomplete myocardial revascularization using left internal mammary artery （LIMA） on LAD （OPCABG group）. From January 2007 to December 2014, 206 patients （OMT, n = 136, OPCABG, n = 70） were propensity-score matched to have 70 matched pairs. Variables included in propensity score analyses were ejection fraction （EF）, left ventricular end diastolic volume （LVEDVi）, EuroSCORE II. Primary endpoint was the variation in the global wall motion score index （AWMSI） as evaluated by transthoracic echocardiography. Follow up was completed at 3 years from surgery or hospital discharge. Results Regional analysis of ventricular function revealed a regional WMSI improvement in the OPCABG group not only for LAD territories but also for non-LAD regions, associated with a reduction in the negative left ventricular ischemic remodeling, compared to patients discharged in optimal medical therapy. Global AWMSI was negative in OPCABG group （-3.4 ± 2.8%） and positive in the OMT group （5.9 ± 3.1%）, indicating a better wall motion score for OPCAB patients. Surprisingly, regional WMSI improved also in non-grafted territories in the off-pump CABG group with a delta value of -3.7 ± 5.3% for left circumflex artery （LCX） area and -3.5 ± 5.4% for right coronary artery （RCA） area. Conclusions In patients with multivessel coronary artery disease, LIMA-to-LAD grafting is associated with an improvement in the WMSI involving also the surrounding non-LAD ungrafted segments and with the attenuation of negative global and regional ischemic ventricular remodeling.
