Publications by authors named "Francesco Santini"

238 Publications

Endovascular Versus Open Surgical Repair for Ruptured Descending Aortic Pathologies: A Systematic Review and Meta-Analysis of Observational Studies.

Cardiovasc Intervent Radiol 2021 Jun 25. Epub 2021 Jun 25.

Division of Cardiac Surgery, Ospedale Policlinico San Martino, Genoa, Italy.

Purpose: Ruptured descending thoracic aorta (rDTA) is an harmful condition requiring emergent treatment. Thoracic endovascular aortic repair (TEVAR) is replacing the traditional open repair in the majority of descending thoracic aortic disease. An unanimous agreement regarding the optimal approach to treat rDTA has not been reached yet due to the lack of evidences supporting the improvement of long-term survival. The present meta-analysis of observational cohort studies aims to estimate the outcome of endovascular (TEVAR) versus surgical (OR) approach in the treatment of rDTA.

Methods: Prisma Statement for performing and reporting meta-analysis has been used. MEDLINE, Scopus and the Cochrane Library databases were searched. A meta-analysis of observational cohort studies that examined the outcomes after OR and TEVAR for the management of rDTA was performed.

Results: A total of 10,466 patients with rDTA were screened. Endovascular therapy was associated with a lower risk of in-hospital mortality compared with open repair (Risk Ratio[RR] 0.63; 95% CI0.57-0.70). The risk of stroke rate was not statistically different between endovascular versus open approach (RR0.86; 95% CI0.62-1.19). Endovascular treatment had benefits on paraplegia (RR0.70; 95% CI0.55-0.91) and other neurological complications (RR0.24; 95% CI0.10-0.56). TEVAR was associated with lower renal failure, cardiac complications and vascular injuries. Late mortality (Hazard Ratio[HR] 0.84; 95% CI0.63-1.13) and re-intervention rate (RR1.48; 95% CI0.80-2.74) were not significantly different between TEVAR and OR.

Conclusions: TEVAR seems to offer advantages in terms of early mortality and complications rate. Moreover, data on late mortality and re-intervention are encouraging to consider endovascular treatment comparable to open repair for acute thoracic aorta emergency on long-term follow-up.
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http://dx.doi.org/10.1007/s00270-021-02893-3DOI Listing
June 2021

Neurological complications in high-risk patients undergoing coronary artery bypass surgery.

Ann Thorac Surg 2021 Jun 1. Epub 2021 Jun 1.

Research Unit of Surgery, Anesthesiology and Critical Care, University of Oulu, Oulu, Finland;; Heart and Lung Centre, Helsinki University Hospital, Helsinki, Finland.

Background: Coronary artery bypass grafting (CABG) without cardiopulmonary bypass and minimal or no aortic manipulation may be associated with a lower risk of neurological complications. We investigated this issue in patients with a high risk of perioperative stroke.

Methods: Data on 7352 patients who underwent isolated CABG from January 2015 to May 2017 were included in the multicenter study European Coronary Artery Bypass Grafting (E-CABG) registry. Of these, 684 patients had an increased risk of neurological complications, i.e. previous stroke or transient ischemic attack (TIA), severe carotid artery stenosis or occlusion, or previous carotid artery intervention. In this subgroup, we analyzed the rates of the combined primary endpoint comprising any postoperative stroke or TIA. A comparative analysis between CABG with and without aortic cross-clamping was performed.

Results: The primary endpoint was more often reached when aortic cross-clamping was used (propensity score matching, without vs. with aortic cross-clamp: 0.9% vs 7.2%, p=0.016). In comparison to all other revascularization techniques, off-pump CABG with avoidance of aortic manipulation was associated with the lowest rate of neurological complications (0.7%).

Conclusions: In patients with increased risk of perioperative stroke, aortic manipulation including the use of cardiopulmonary bypass or partial clamping for central anastomoses is associated with higher rates of postoperative neurological complications. These patients may benefit from off-pump surgery without aortic manipulation if complete revascularization can be ensured.
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http://dx.doi.org/10.1016/j.athoracsur.2021.05.018DOI Listing
June 2021

[Bileaflet mechanical valve dysfunction related to fibrous pannus: the role of cine-fluoroscopy].

G Ital Cardiol (Rome) 2021 Jun;22(6):490-493

Divisione di Cardiologia, DICATOV-Dipartimento Cardio-Toraco-Vascolare, Ospedale Policlinico San Martino IRCCS per l'Oncologia, Genova - Scuola di Scienze Mediche e Farmaceutiche, Università degli Studi, Policlinico San Martino IRCCS, Genova.

We report the case of a 72-year-old female patient admitted for worsening heart failure. The patient had undergone aortic valve replacement with a mechanical prosthesis 28 years before and since then she had several acute heart failure episodes, with a progressive increase in transprosthetic gradients, without identifying a specific cause.We describe the diagnostic tools used to reach a diagnosis, with particular emphasis on the use of cine-fluoroscopy that allowed to make the decisively diagnosis of prosthetic valve dysfunction, subsequently confirmed by cardiac computed tomography (CT). By cine-fluoroscopy, a widespread, easy, low-cost, and safe tool (no need for medium contrast and low radiation dose), it is possible to precisely define the function of the valve leaflets and measure their opening and closing angles, comparing them to the specific reference angles. To make the correct diagnosis we also performed a cardiac CT demonstrating a sub-aortic fibrous pannus. However, although cardiac CT is highly accurate for the identification of valve leaflet neoformations and abnormalities and for the discrimination between thrombotic formations and fibrous pannus, it is burdened by high costs, use of contrast medium, and limited available dedicated devices.
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http://dx.doi.org/10.1714/3612.35933DOI Listing
June 2021

Quantification and Monitoring of the Effect of Botulinum Toxin A on Paretic Calf Muscles of Children With Cerebral Palsy With MRI: A Preliminary Study.

Front Neurol 2021 16;12:630435. Epub 2021 Apr 16.

Department of Radiology, Division of Neuroradiology, University Hospital of Basel, Basel, Switzerland.

Muscles from patients with cerebral palsy (CP) are often spastic and form contractures that limit the range of motion. Injections of botulinum toxin A (BTX) into the calf muscles are an important treatment for functional equinus; however, improvement in gait function is not always achieved. BTX is also used to test muscle weakening for risk evaluation of muscle lengthening surgery. Our aim was to assess the effect of BTX over time on calf muscle properties in pediatric CP patients with MRI. Six toe-walking CP patients (mean age 11.6 years) with indication for lengthening surgery were prospectively enrolled and received BTX injections into the gastrocnemius and soleus muscles. MRI scans at 3T of the lower legs and clinical examinations were performed pre-BTX, 6 weeks (6w), and 12 weeks (12w) post-BTX. A fat-suppressed 2D multi-spin-echo sequence was used to acquire T maps and for segmentation. Fat fraction maps were calculated from 3D multi-echo Dixon images. Diffusion tensor imaging (DTI) with a 2D echo-planar imaging (EPI) sequence yielded maps of the mean apparent diffusion coefficient (ADC) and of the fractional anisotropy (FA). Hyperintense regions of interest (ROIs) on the T-weighted (Tw) images at 6w were segmented in treated muscles. Mean values of T, fat fraction, ADC, and FA were calculated in hyperintense ROIs and in reference ROIs in non-treated muscles. Hyperintensity on Tw scans and increased T (group mean ± standard deviation: 35 ± 1 ms pre-BTX, 45 ± 2 ms at 6w, and 44 ± 2 ms at 12w) were observed in all patients at the injection sites. The T increase was spatially limited to parts of the injected muscles. FA increased (0.30 ± 0.03 pre-BTX, 0.34 ± 0.02 at 6w, and 0.36 ± 0.03 at 12w) while ADC did not change in hyperintense ROIs, indicating a BTX-induced increase in extracellular space and a simultaneous decrease of muscle fiber diameter. Fat fraction showed a trend for increase at 12w. Mean values in reference ROIs remained unchanged. MRI showed limited spatial distribution of the BTX-induced effects in pediatric CP patients. It could be a promising non-invasive tool for future studies to test BTX treatment protocols.
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http://dx.doi.org/10.3389/fneur.2021.630435DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8085320PMC
April 2021

Pilot Study on Quantitative Cervical Cord and Muscular MRI in Spinal Muscular Atrophy: Promising Biomarkers of Disease Evolution and Treatment?

Front Neurol 2021 29;12:613834. Epub 2021 Mar 29.

Advanced Imaging and Radiomics Center, Neuroradiology Department, IRCCS Mondino Foundation, Pavia, Italy.

Nusinersen is a recent promising therapy approved for the treatment of spinal muscular atrophy (SMA), a rare disease characterized by the degeneration of alpha motor neurons (αMN) in the spinal cord (SC) leading to progressive muscle atrophy and dysfunction. Muscle and cervical SC quantitative magnetic resonance imaging (qMRI) has never been used to monitor drug treatment in SMA. The aim of this pilot study is to investigate whether qMRI can provide useful biomarkers for monitoring treatment efficacy in SMA. Three adult SMA 3a patients under treatment with nusinersen underwent longitudinal clinical and qMRI examinations every 4 months from baseline to 21-month follow-up. The qMRI protocol aimed to quantify thigh muscle fat fraction (FF) and water-T2 (w-T2) and to characterize SC volumes and microstructure. Eleven healthy controls underwent the same SC protocol (single time point). We evaluated clinical and imaging outcomes of SMA patients longitudinally and compared SC data between groups transversally. Patient motor function was stable, with only Patient 2 showing moderate improvements. Average muscle FF was already high at baseline (50%) and progressed over time (57%). w-T2 was also slightly higher than previously published data at baseline and slightly decreased over time. Cross-sectional area of the whole SC, gray matter (GM), and ventral horns (VHs) of Patients 1 and 3 were reduced compared to controls and remained stable over time, while GM and VHs areas of Patient 2 slightly increased. We found altered diffusion and magnetization transfer parameters in SC structures of SMA patients compared to controls, thus suggesting changes in tissue microstructure and myelin content. In this pilot study, we found a progression of FF in thigh muscles of SMA 3a patients during nusinersen therapy and a concurrent slight reduction of w-T2 over time. The SC qMRI analysis confirmed previous imaging and histopathological studies suggesting degeneration of αMN of the VHs, resulting in GM atrophy and demyelination. Our longitudinal data suggest that qMRI could represent a feasible technique for capturing microstructural changes induced by SMA and a candidate methodology for monitoring the effects of treatment, once replicated on a larger cohort.
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http://dx.doi.org/10.3389/fneur.2021.613834DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8039452PMC
March 2021

Combination of Quantitative MRI Fat Fraction and Texture Analysis to Evaluate Spastic Muscles of Children With Cerebral Palsy.

Front Neurol 2021 22;12:633808. Epub 2021 Mar 22.

Division of Radiological Physics, Department of Radiology, University Hospital of Basel, Basel, Switzerland.

Cerebral palsy (CP) is the most common cause of physical disability in childhood. Muscle pathologies occur due to spasticity and contractures; therefore, diagnostic imaging to detect pathologies is often required. Imaging has been used to assess torsion or estimate muscle volume, but additional methods for characterizing muscle composition have not thoroughly been investigated. MRI fat fraction (FF) measurement can quantify muscle fat and is often a part of standard imaging in neuromuscular dystrophies. To date, FF has been used to quantify muscle fat and assess function in CP. In this study, we aimed to utilize a radiomics and FF analysis along with the combination of both methods to differentiate affected muscles from healthy ones. A total of 9 patients (age range 8-15 years) with CP and 12 healthy controls (age range 9-16 years) were prospectively enrolled (2018-2020) after ethics committee approval. Multi-echo Dixon acquisition of the calf muscles was used for FF calculation. The images of the second echo (TE = 2.87 ms) were used for feature extraction from the soleus, gastrocnemius medialis, and gastrocnemius lateralis muscles. The least absolute shrinkage and selection operator (LASSO) regression was employed for feature selection. RM, FF model (FFM), and combined model (CM) were built for each calf muscle. The receiver operating characteristic (ROC) curve and their respective area under the curve (AUC) values were used to evaluate model performance. In total, the affected legs of 9 CP patients and the dominant legs of 12 healthy controls were analyzed. The performance of RM for soleus, gastrocnemius medialis, and gastrocnemius lateralis (AUC 0.92, 0.92, 0.82, respectively) was better than the FFM (AUC 0.88, 0.85, 0.69, respectively). The combination of both models always had a better performance than RM or FFM (AUC 0.95, 0.93, 0.83). FF was higher in the patient group (FF 9.1%, FF 8.5%, and FF 10.2%) than control group (FF 3.3%, FF 4.1%, FF 6.6%). The combination of MRI quantitative fat fraction analysis and texture analysis of muscles is a promising tool to evaluate muscle pathologies due to CP in a non-invasive manner.
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http://dx.doi.org/10.3389/fneur.2021.633808DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8019698PMC
March 2021

Variability of MRI Aortic Stiffness Measurements in a Multicenter Clinical Trial Setting: Intraobserver, Interobserver, and Intracenter Variability of Pulse Wave Velocity and Aortic Strain Measurement.

Radiol Cardiothorac Imaging 2020 Apr 30;2(2):e190090. Epub 2020 Apr 30.

Clinic of Radiology and Nuclear Medicine, University of Basel Hospital, Basel, Switzerland (M.H.P., S.K., F.S., J.B., T.H.); Department of Diagnostic and Interventional Radiology, University Hospital Center Zagreb, University of Zagreb School of Medicine, Kispaticeva 12, HR-10000 Zagreb, Croatia (M.H.P.); Radiologie-Team Ortenau, Lahr, Germany (A.K.); Shaikh Khalifa Medical City, Abu Dhabi, United Arab Emirates (S.A.S.); Department of Biomedical Engineering, University of Basel, Switzerland (F.S.); Department of Nephrology and Hypertension, University Hospital Erlangen, Germany (R.E.S.); Cardiovascular Imaging Department, European Hospital Georges Pompidou, University of Paris, France (N.K.); and Novartis Institutes for Biomedical Research, Cambridge, Mass (D.Y., T.L.).

Purpose: To assess intraobserver, interobserver, and scan-rescan variability of MRI aortic stiffness measurements in a multicenter trial setting.

Materials And Methods: This study was a retrospective analysis of prospectively collected data in a multicenter prospective clinical trial (clinicaltrials.gov ID NCT01870739). Forty-five adult patients (31 men; mean age, 58 years ± 12 [standard deviation]; 15 patients per center; three centers) with arterial hypertension underwent standardized 3-T baseline MRI assessments between June and September 2014. Aortic strain was calculated from maximum and minimum aortic area measurements repeated three times by three readers at three aortic levels on three retrospectively gated axial gradient-echo (GRE) data sets. Pulse wave velocity (PWV) was assessed three times by five readers as Δx/Δt: Δx was measured on a parasagittal GRE image of the aortic arch, and Δt was extracted from ascending and descending aortic velocity curves created on three axial phase-contrast acquisitions. Intraobserver, interobserver, and scan-rescan variability was calculated using percentage coefficient of variation (COV).

Results: Aortic strain variability was lowest at the level of the distal descending aorta (DDA) with median COVs of 1.6% for intraobserver variability, 4.0% for interobserver variability, and 10.3% for scan-rescan variability. It was highest at the ascending aorta (AA) with COVs of 3.6% for intraobserver variability, 10.7% for interobserver variability, and 19.8% for scan-rescan variability. Variability of PWV was low: 0.7% for intraobserver variability, 1.5% for interobserver variability, and 8.1% for scan-rescan variability.

Conclusion: Low variability can be achieved for aortic strain and PWV measurements in a multicenter trial setting using standardized MRI protocols. Although COV was lower when measuring aortic strain at DDA compared with AA, variability was acceptable at both anatomic locations.© RSNA, 2020.
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http://dx.doi.org/10.1148/ryct.2020190090DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7978027PMC
April 2020

Surgical myocardial revascularization outcomes in Kawasaki disease: systematic review and meta-analysis.

Open Med (Wars) 2021 9;16(1):375-386. Epub 2021 Mar 9.

Houston Children Heart Institute, Hermann Children's Hospital, Houston, Texas, United States of America.

Background: Kawasaki disease (KD) is a systemic inflammatory condition occurring predominantly in children. Coronary artery bypass grafting (CABG) is performed in the presence of inflammation and aneurysms of the coronary arteries. The objectives of our study were to assess which CABG strategy provides better graft patency and early and long-term outcomes.

Methods: A systematic review using Medline, Cochrane, and Scopus databases was performed in February 2020, incorporating a network meta-analysis, performed by random-effect model within a Bayesian framework, and pooled prevalence of adverse outcomes. Hazard ratios (HR) and corresponding 95% credible intervals (CI) were calculated by Markov chain Monte Carlo methods.

Results: Among 581 published reports, 32 studies were selected, including 1,191 patients undergoing CABG for KD. Graft patency of internal thoracic arteries (ITAs), saphenous veins (SV), and other arteries (gastroepiploic artery and radial artery) was compared. ITAs demonstrated the best patency rates at long-term follow-up (HR 0.33, 95% CI: 0.17-0.66). Pooled prevalence of early mortality after CABG was 0.28% (95% CI: 0.00-0.73%, = 0%, tau = 0), with 63/1,108 and 56/1,108 patients, undergoing interventional procedures and surgical re-interventions during follow-up, respectively. Pooled prevalence was 3.97% (95% CI: 1.91-6.02%, = 60%, tau = 0.0008) for interventional procedures and 3.47% (95% CI: 2.26-4.68%, = 5%, tau <0.0001) for surgical re-interventions. Patients treated with arterial, venous, and mixed (arterial plus second venous graft) CABG were compared to assess long-term mortality. Mixed CABG (HR 0.03, 95% CI: 0.00-0.30) and arterial CABG (HR 0.13, 95% CI: 0.00-1.78) showed reduced long-term mortality compared with venous CABG.

Conclusions: CABG in KD is a safe procedure. The use of arterial conduits provides better patency rates and lower mortality at long-term follow-up.
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http://dx.doi.org/10.1515/med-2021-0242DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7957190PMC
March 2021

In vitro evaluation of cerebrospinal fluid velocity measurement in type I Chiari malformation: repeatability, reproducibility, and agreement using 2D phase contrast and 4D flow MRI.

Fluids Barriers CNS 2021 Mar 18;18(1):12. Epub 2021 Mar 18.

Department of Chemical and Biological Engineering, University of Idaho, 875 Perimeter Dr. MC1122, Moscow, ID, 83844, USA.

Background: Phase contrast magnetic resonance imaging, PC MRI, is a valuable tool allowing for non-invasive quantification of CSF dynamics, but has lacked adoption in clinical practice for Chiari malformation diagnostics. To improve these diagnostic practices, a better understanding of PC MRI based measurement agreement, repeatability, and reproducibility of CSF dynamics is needed.

Methods: An anatomically realistic in vitro subject specific model of a Chiari malformation patient was scanned three times at five different scanning centers using 2D PC MRI and 4D Flow techniques to quantify intra-scanner repeatability, inter-scanner reproducibility, and agreement between imaging modalities. Peak systolic CSF velocities were measured at nine axial planes using 2D PC MRI, which were then compared to 4D Flow peak systolic velocity measurements extracted at those exact axial positions along the model.

Results: Comparison of measurement results showed good overall agreement of CSF velocity detection between 2D PC MRI and 4D Flow (p = 0.86), fair intra-scanner repeatability (confidence intervals ± 1.5 cm/s), and poor inter-scanner reproducibility. On average, 4D Flow measurements had a larger variability than 2D PC MRI measurements (standard deviations 1.83 and 1.04 cm/s, respectively).

Conclusion: Agreement, repeatability, and reproducibility of 2D PC MRI and 4D Flow detection of peak CSF velocities was quantified using a patient-specific in vitro model of Chiari malformation. In combination, the greatest factor leading to measurement inconsistency was determined to be a lack of reproducibility between different MRI centers. Overall, these findings may help lead to better understanding for application of 2D PC MRI and 4D Flow techniques as diagnostic tools for CSF dynamics quantification in Chiari malformation and related diseases.
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http://dx.doi.org/10.1186/s12987-021-00246-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7977612PMC
March 2021

Cancer Patient With Unusual Dyspnea in the COVID-19 Era: Challenging Management of a Rare Cardiac Tumor.

JACC Case Rep 2021 May 10;3(5):823-828. Epub 2021 Mar 10.

Division of Cardiac Surgery, IRCCS Ospedale Policlinico San Martino, University of Genova, Genova, Italy.

Heart failure symptoms, in particular dyspnea, may be difficult to frame in a patient with cancer. We report the case of an oncological patient whose dyspnea could have been attributable to various causes and whose management was challenging in the context of the coronavirus disease-2019 pandemic. ().
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http://dx.doi.org/10.1016/j.jaccas.2021.01.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7946348PMC
May 2021

Fast Open-Source Toolkit for Water T2 Mapping in the Presence of Fat From Multi-Echo Spin-Echo Acquisitions for Muscle MRI.

Front Neurol 2021 26;12:630387. Epub 2021 Feb 26.

Department of Neurology, Buffalo Neuroimaging Analysis Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, United States.

Imaging has become a valuable tool in the assessment of neuromuscular diseases, and, specifically, quantitative MR imaging provides robust biomarkers for the monitoring of disease progression. Quantitative evaluation of fat infiltration and quantification of the T2 values of the muscular tissue's water component (wT2) are two of the most essential indicators currently used. As each voxel of the image can contain both water and fat, a two-component model for the estimation of wT2 must be used. In this work, we present a fast method for reconstructing wT2 maps obtained from conventional multi-echo spin-echo (MESE) acquisitions and released as Free Open Source Software. The proposed software is capable of fast reconstruction thanks to extended phase graphs (EPG) simulations and dictionary matching implemented on a general-purpose graphic processing unit. The program can also perform more conventional biexponential least-squares fitting of the data and incorporate information from an external water-fat acquisition to increase the accuracy of the results. The method was applied to the scans of four healthy volunteers and five subjects suffering from facioscapulohumeral muscular dystrophy (FSHD). Conventional multi-slice MESE acquisitions were performed with 17 echoes, and additionally, a 6-echo multi-echo gradient-echo (MEGE) sequence was used for an independent fat fraction calculation. The proposed reconstruction software was applied on the full datasets, and additionally to reduced number of echoes, respectively, to 8, 5, and 3, using EPG and biexponential least-squares fitting, with and without incorporating information from the MEGE acquisition. The incorporation of external fat fraction maps increased the robustness of the fitting with a reduced number of echoes per datasets, whereas with unconstrained fitting, the total of 17 echoes was necessary to retain an independence of wT2 from the level of fat infiltration. In conclusion, the proposed software can successfully be used to calculate wT2 maps from conventional MESE acquisition, allowing the usage of an optimized protocol with similar precision and accuracy as a 17-echo acquisition. As it is freely released to the community, it can be used as a reference for more extensive cohort studies.
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http://dx.doi.org/10.3389/fneur.2021.630387DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7952742PMC
February 2021

Mechanical circulatory support in patients with cardiogenic shock not secondary to cardiotomy: a network meta-analysis.

Heart Fail Rev 2021 Mar 6. Epub 2021 Mar 6.

Cardiovascular Disease Unit, IRCCS Policlinic Hospital San Martino, Genova, Italy.

To compare the efficacy and safety of different mechanical circulatory support (MCS) devices in CS. A total of 24 studies (7 randomized controlled trials-RCTs-and 17 non-RCTs) involving 11,117 patients were entered in a Bayesian network meta-analysis. The primary endpoint was 30-day mortality. Secondary endpoints were stroke and bleeding (requiring transfusion and/or intracranial and/or fatal). Compared with no MCS, extra-corporeal membrane oxygenation (ECMO) reduced 30-day mortality when used both alone (OR 0.37, 95% CrI 0.15-0.90) and together with the micro-axial pump Impella (OR 0.13, 95% CrI 0.02-0.80) or intra-aortic balloon pump (IABP) (OR 0.19, 95% CrI 0.05-0.63), although the relevant articles were affected by significant publication bias. Consistent results were obtained in a sensitivity analysis including only studies of CS due to myocardial infarction. After halving the weight of studies with a non-RCT design, only the benefit of ECMO + IABP on 30-day mortality was maintained (OR 0.22, 95% CI 0.057-0.76). The risk of bleeding was increased by TandemHeart (OR 13, 95% CrI 3.50-59), Impella (OR 5, 95% CrI 1.60-18), and IABP (OR 2.2, 95% CrI 1.10-4.4). No significant differences were found across MCS strategies regarding stroke. Although limited by important quality issues, the studies performed so far indicate that ECMO, especially if combined with Impella or IABP, reduces short-term mortality in CS. MCS increases the hazard of bleeding.
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http://dx.doi.org/10.1007/s10741-021-10092-yDOI Listing
March 2021

Daily Caffeine Intake Induces Concentration-Dependent Medial Temporal Plasticity in Humans: A Multimodal Double-Blind Randomized Controlled Trial.

Cereb Cortex 2021 May;31(6):3096-3106

Centre for Chronobiology, University Psychiatric Clinics, University of Basel, 4002 Basel, Switzerland.

Caffeine is commonly used to combat high sleep pressure on a daily basis. However, interference with sleep-wake regulation could disturb neural homeostasis and insufficient sleep could lead to alterations in human gray matter. Hence, in this double-blind, randomized, cross-over study, we examined the impact of 10-day caffeine (3 × 150 mg/day) on human gray matter volumes (GMVs) and cerebral blood flow (CBF) by fMRI MP-RAGE and arterial spin-labeling sequences in 20 habitual caffeine consumers, compared with 10-day placebo (3 × 150 mg/day). Sleep pressure was quantified by electroencephalographic slow-wave activity (SWA) in the previous nighttime sleep. Nonparametric voxel-based analyses revealed a significant reduction in GMV in the medial temporal lobe (mTL) after 10 days of caffeine intake compared with 10 days of placebo, voxel-wisely adjusted for CBF considering the decreased perfusion after caffeine intake compared with placebo. Larger GMV reductions were associated with higher individual concentrations of caffeine and paraxanthine. Sleep SWA was, however, neither different between conditions nor associated with caffeine-induced GMV reductions. Therefore, the data do not suggest a link between sleep depth during daily caffeine intake and changes in brain morphology. In conclusion, daily caffeine intake might induce neural plasticity in the mTL depending on individual metabolic processes.
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http://dx.doi.org/10.1093/cercor/bhab005DOI Listing
May 2021

Extracorporeal Membrane Oxygenation for COVID-19 Respiratory Distress Syndrome: An Italian Society for Cardiac Surgery Report.

ASAIO J 2021 04;67(4):385-391

Cardiac Surgery Department, San Bortolo Hospital, Vicenza, Italy.

An increased need of extracorporeal membrane oxygenation (ECMO) support is going to become evident as treatment of SARS-CoV-2 respiratory distress syndrome. This is the first report of the Italian Society for Cardiac Surgery (SICCH) on preliminary experience with COVID-19 patients receiving ECMO support. Data from 12 Italian hospitals participating in SICCH were retrospectively analyzed. Between March 1 and September 15, 2020, a veno-venous (VV) ECMO system was installed in 67 patients (94%) and a veno-arterio-venous ECMO in four (6%). Five patients required VA ECMO after initial weaning from VV ECMO. Thirty (42.2%) patients were weaned from ECMO, while 39 (54.9%) died on ECMO, and six (8.5%) died after ECMO removal. Overall hospital survival was 36.6% (n = 26). Main causes of death were multiple organ failure (n = 14, 31.1%) and sepsis (n = 11, 24.4%). On multivariable analysis, predictors of death while on ECMO support were older age (p = 0.048), elevated pre-ECMO C-reactive protein level (p = 0.048), higher positive end-expiratory pressure on ventilator (p = 0.036) and lower lung compliance (p = 0.032). If the conservative treatment is not effective, ECMO support might be considered as life-saving rescue therapy for COVID-19 refractory respiratory failure. However warm caution and thoughtful approaches for timely detection and treatment should be taken for such a delicate patients population.
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http://dx.doi.org/10.1097/MAT.0000000000001399DOI Listing
April 2021

One-minute whole-brain magnetization transfer ratio imaging with intrinsic B -correction.

Magn Reson Med 2021 05 8;85(5):2686-2695. Epub 2020 Dec 8.

Division of Radiological Physics, Department of Radiology, University Hospital Basel, Basel, Switzerland.

Purpose: Magnetization transfer ratio (MTR) histograms are used widely for the assessment of diffuse pathological changes in the brain. For broad clinical application, MTR scans should not only be fast, but confounding factors should also be minimized for high reproducibility. To this end, a 1-minute whole-brain spiral MTR method with intrinsic B -field correction is introduced.

Methods: A spiral multislice spoiled gradient-echo sequence with adaptable magnetization-transfer saturation pulses (angle β) is proposed. After a low-resolution single-shot spiral readout and a dummy preparation period, high-resolution images are acquired using an interleaved spiral readout. For whole-brain MTR imaging, 50 interleaved slices with three different magnetization-transfer contrasts (β = 0°, 350°, and 550°) together with an intrinsic B -field map are recorded in 58.5 seconds on a clinical 3T system. From the three contrasts, two sets of MTR images are derived and used for subsequent B correction, assuming a linear dependency on β. For validation, a binary spin bath model is used.

Results: For the proposed B -correction scheme, numerical simulations indicate for brain tissue a decrease of about a factor of 10 for the B -related bias on MTR. As a result, following B correction, MTR differences in gray and white matter become markedly accentuated, and the reproducibility of MTR histograms from scan-rescan experiments is improved. Furthermore, B -corrected MTR histograms show a lower variability for age-matched normal-appearing brain tissue.

Conclusion: From its speed and offering intrinsic B correction, the proposed method shows excellent prospects for clinical studies that explore magnetization-transfer effects based on MTR histogram analysis.
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http://dx.doi.org/10.1002/mrm.28618DOI Listing
May 2021

Culture-negative infective endocarditis (CNIE): impact on postoperative mortality.

Open Med (Wars) 2020 20;15(1):571-579. Epub 2020 Jun 20.

Division of Cardiac Surgery, Ospedale Policlinico San Martino, University of Genoa, Genova, Italy.

Introduction: Poor postoperative outcomes have been reported after surgery for infective endocarditis (IE). Whether the absence of positive cultures impacts the prognosis remains a matter of discussion. The aim of this study was to evaluate the impact of negative cultures on the prognosis of surgically treated IE.

Methods: This was a single-center, retrospective study. From January 2000 to June 2019, all patients who underwent valvular surgery for IE were included in the study. The primary endpoint was early postoperative mortality. A covariate balancing propensity score was developed to minimize the differences between the culture-positive IE (CPIE) and culture-negative IE (CNIE) cohorts. Using the estimated propensity scores as weights, an inverse probability treatment weighting (IPTW) model was built to generate a weighted cohort. Then, to adjust for confounding related to CPIE and CNIE, a doubly robust method that combines regression model with IPTW by propensity score was adopted to estimate the causal effect of the exposure on the outcome.

Results: During the study period, 327 consecutive patients underwent valvular repair/replacement with the use of cardiopulmonary bypass and cardioplegic cardiac arrest for IE. Their mean age was 61.4 ± 15.4 years, and 246 were males (75.2%). Native valve IE and prosthetic valve IE accounted for 87.5% and 12.5% of cases, respectively. Aortic (182/327, 55.7%) and mitral valves (166/327, 50.8%) were mostly involved; 20.5% of isolated mitral valve diseases were repaired (22/107 patients). The tricuspid valve was involved in 10 patients (3.3%), and the pulmonary valve in 1 patient (<1%). Fifty-nine patients had multiple-valve disease (18.0%). Blood cultures were negative in 136/327 (41.6 %). A higher postoperative mortality was registered in CNIE than in CPIE patients (19% vs 9%, respectively, = 0.01). The doubly robust analysis after IPTW by propensity score showed CNIE to be associated with early postoperative mortality (odds ratio 2.10; 95% CI, 1.04-4.26, = 0.04).

Conclusions: In our cohort, CNIE was associated with a higher early postoperative mortality in surgically treated IE patients after dedicated adjustment for confounding. In this perspective, any effort to improve preoperative microbiological diagnosis, thus allowing targeted therapeutic initiatives, might lead to overall better postoperative outcomes in surgically treated IE.
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http://dx.doi.org/10.1515/med-2020-0193DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7712125PMC
June 2020

Texture analysis and machine learning to predict water T2 and fat fraction from non-quantitative MRI of thigh muscles in Facioscapulohumeral muscular dystrophy.

Eur J Radiol 2021 Jan 2;134:109460. Epub 2020 Dec 2.

Department of Neuroradiology, IRCCS Mondino Foundation, Pavia, Italy; Department of Brain and Behavioral Sciences, University of Pavia, Pavia, PV, Italy.

Purpose: Quantitative MRI (qMRI) plays a crucial role for assessing disease progression and treatment response in neuromuscular disorders, but the required MRI sequences are not routinely available in every center. The aim of this study was to predict qMRI values of water T2 (wT2) and fat fraction (FF) from conventional MRI, using texture analysis and machine learning.

Method: Fourteen patients affected by Facioscapulohumeral muscular dystrophy were imaged at both thighs using conventional and quantitative MR sequences. Muscle FF and wT2 were calculated for each muscle of the thighs. Forty-seven texture features were extracted for each muscle on the images obtained with conventional MRI. Multiple machine learning regressors were trained to predict qMRI values from the texture analysis dataset.

Results: Eight machine learning methods (linear, ridge and lasso regression, tree, random forest (RF), generalized additive model (GAM), k-nearest-neighbor (kNN) and support vector machine (SVM) provided mean absolute errors ranging from 0.110 to 0.133 for FF and 0.068 to 0.115 for wT2. The most accurate methods were RF, SVM and kNN to predict FF, and tree, RF and kNN to predict wT2.

Conclusion: This study demonstrates that it is possible to estimate with good accuracy qMRI parameters starting from texture analysis of conventional MRI.
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http://dx.doi.org/10.1016/j.ejrad.2020.109460DOI Listing
January 2021

Dynamic MRI of plantar flexion: A comprehensive repeatability study of electrical stimulation-gated muscle contraction standardized on evoked force.

PLoS One 2020 5;15(11):e0241832. Epub 2020 Nov 5.

Division of Radiological Physics, Department of Radiology, University Hospital Basel, Basel, Switzerland.

Quantification of skeletal muscle contraction in Magnetic Resonance Imaging (MRI) is a non-invasive method for studying muscle motion and deformation. The aim of this study was to evaluate the repeatability of quantitative measures such as strain, based on single slice dynamic MRI synchronized with neuromuscular electrical stimulation (NMES) and standardized to a similar relative force level across various individuals. Unilateral electrical stimulation of the triceps surae muscles was applied in eight volunteers during single-slice, three-directional phase contrast MRI acquisition at a 3T MRI scanner. To assess repeatability, the same process was executed on two different days by standardizing the stimulation aiming at evoking a fixed percentage of their maximal voluntary force in the same position. Except from the force, the effect of using the current as reference was evaluated on day two as a secondary acquisition. Finally, the presence of fatigue induced by NMES was assessed (on day one) by examining the difference between consecutive measurements. Strain maps were derived from the acquired slice at every time point; distribution of strain in the muscle and peak strain over the muscle of interest were evaluated for repeatability. It was found that fatigue did not have an appreciable effect on the results. The stimulation settings based on evoked force produced more repeatable results with respect to using the current as the only reference, with an intraclass correlation coefficient between different days of 0.95 for the former versus 0.88 for the latter. In conclusion, for repeatable strain imaging it is advisable to record the force output of the evoked contraction and use that for the standardization of the NMES setup rather than the current.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0241832PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7644050PMC
January 2021

On the optimal temporal resolution for phase contrast cardiovascular magnetic resonance imaging: establishment of baseline values.

J Cardiovasc Magn Reson 2020 10 5;22(1):72. Epub 2020 Oct 5.

Department of Neuroradiology, Zurich University Hospital, Zurich, Switzerland.

Background: The aim of this study is to quantify the frequency content of the blood velocity waveform in different body regions by means of phase contrast (PC) cardiovascular magnetic resonance (CMR) and Doppler ultrasound. The highest frequency component of the spectrum is inversely proportional to the ideal temporal resolution to be used for the acquisition of flow-sensitive imaging (Shannon-Nyquist theorem).

Methods: Ten healthy subjects (median age 33y, range 24-40) were scanned with a high-temporal-resolution PC-CMR and with Doppler ultrasound on three body regions (carotid arteries, aorta and femoral arteries). Furthermore, 111 patients (median age 61y) with mild to moderate arterial hypertension and 58 patients with aortic aregurgitation, atrial septal defect, or repaired tetralogy of Fallot underwent aortic CMR scanning. The frequency power distribution was calculated for each location and the maximum frequency component, f, was extracted and expected limits for the general population were inferred.

Results: In the healthy subject cohort, significantly different f values were found across the different body locations, but they were nonsignificant across modalities. No significant correlation was found with heart rate. The measured f ranged from 7.7 ± 1.1 Hz in the ascending aorta, up to 12.3 ± 5.1 Hz in the femoral artery (considering PC-CMR data). The calculated upper boundary for the general population ranged from 11.0 Hz to 27.5 Hz, corresponding to optimal temporal resolutions of 45 ms and 18 ms, respectively. The patient cohort exhibited similar values for the frequencies in the aorta, with no correlation between blood pressure and frequency content.

Conclusions: The temporal resolution of PC-CMR acquisitions can be adapted based on the scanned body region and in the adult population, should approach approximately 20 ms in the peripheral arteries and 40 ms in the aorta.

Trial Registration: This study presents results from a restrospective analysis of the clinical study NCT01870739 (ClinicalTrials.gov).
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http://dx.doi.org/10.1186/s12968-020-00669-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7534161PMC
October 2020

Variable echo time imaging for detecting the short T2* components of the sciatic nerve: a validation study.

MAGMA 2021 Jun 22;34(3):411-419. Epub 2020 Sep 22.

Department of Neuroradiology, IRCCS Mondino Foundation, Pavia, Italy.

Objective: The aim of this study was to develop and validate an MRI protocol based on a variable echo time (vTE) sensitive to the short T2* components of the sciatic nerve.

Materials And Methods: 15 healthy subjects (M/F: 9/6; age: 21-62) were scanned at 3T targeting the sciatic nerve at the thigh bilaterally, using a dual echo variable echo time (vTE) sequence (based on a spoiled gradient echo acquisition) with echo times of 0.98/5.37 ms. Apparent T2* (aT2*) values of the sciatic nerves were calculated with a mono-exponential fit and used for data comparison.

Results: There were no significant differences in aT2* related to side, sex, age, and BMI, even though small differences for side were reported. Good-to-excellent repeatability and reproducibility were found for geometry of ROIs (Dice indices: intra-rater 0.68-0.7; inter-rater 0.70-0.72) and the related aT2* measures (intra-inter reader ICC 0.95-0.97; 0.66-0.85) from two different operators. Side-related signal-to-noise-ratio non-significant differences were reported, while contrast-to-noise-ratio measures were excellent both for side and echo.

Discussion: Our study introduces a novel MR sequence sensitive to the short T2* components of the sciatic nerve and may be used for the study of peripheral nerve disorders.
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http://dx.doi.org/10.1007/s10334-020-00886-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8154754PMC
June 2021

Cardiac Surgery in Patients With Liver Cirrhosis (CASTER) Study: Early and Long-Term Outcomes.

Ann Thorac Surg 2021 04 11;111(4):1242-1251. Epub 2020 Sep 11.

Cardiac Surgery Division, IRCCS Policlinico San Donato, San Donato Milanese, Italy.

Background: Patients with liver cirrhosis (LC) undergoing cardiac surgery (CS) face perioperative high mortality and morbidity, but extensive studies on this topic are lacking.

Methods: All adult patients with LC undergoing a CS procedure between 2000 and 2017 at 10 Italian Institutions were included in this retrospective cohort study. LC was classified according to preoperative Child-Turcotte-Pugh (CTP) score and Model for End-Stage Liver Disease (MELD) score. Early-term and medium-term outcomes analysis was performed in the overall population and according to CTP classes.

Results: The study population included 144 patients (mean age 66 ± 9 years, 69% male). Ninety-eight, 20, and 26 patients were in CTP class A, in early CTP class B (MELD score <12), or advanced CTP class B (MELD score >12), respectively. The main LC etiologies were viral (43%) and alcoholic (36%). Liver-related clinical presentation (ascites, esophageal varices, and encephalopathy) and laboratory values (estimated glomerular filtration rate, serum albumin, and bilirubin, platelet count) significantly worsened across the CTP classes (P = .001). Coronary artery bypass grafting or valve surgery (87% bioprosthesis) were performed in 36% and 50%, respectively. Postoperative complications (especially acute kidney injury, liver complication, and length of stay) significantly worsened in advanced CTP class B (P = .001). Notably, observed mortality was 3-fold or 4-fold higher than the EuroSCORE (European System for Cardiac Operative Risk Evaluation) II-predicted mortality, in the overall population, and in the subgroups. At Kaplan-Meier analysis, 1-year and 5-year cumulative survival in the overall population was 82% ± 3% and 77% ± 4%, respectively. The 5-year survival in CTP class A, early CTP class B, and advanced CTP class B was 72% ± 5%, 68% ± 11%, and 61% ± 10%, respectively (P = .238).

Conclusions: CS outcomes in patients with LC are significantly affected in relation to the extent of preoperative liver dysfunction, but in early CTP classes, medium-term survival is acceptable. Further analysis are needed to better estimate the preoperative risk stratification of these patients.
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http://dx.doi.org/10.1016/j.athoracsur.2020.06.110DOI Listing
April 2021

The impact of segmentation on whole-lung functional MRI quantification: Repeatability and reproducibility from multiple human observers and an artificial neural network.

Magn Reson Med 2021 02 6;85(2):1079-1092. Epub 2020 Sep 6.

Division of Pediatric Respiratory Medicine, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.

Purpose: To investigate the repeatability and reproducibility of lung segmentation and their impact on the quantitative outcomes from functional pulmonary MRI. Additionally, to validate an artificial neural network (ANN) to accelerate whole-lung quantification.

Method: Ten healthy children and 25 children with cystic fibrosis underwent matrix pencil decomposition MRI (MP-MRI). Impaired relative fractional ventilation (R ) and relative perfusion (R ) from MP-MRI were compared using whole-lung segmentation performed by a physician at two time-points (A and A ), by an MRI technician (B), and by an ANN (C). Repeatability and reproducibility were assess with Dice similarity coefficient (DSC), paired t-test and Intraclass-correlation coefficient (ICC).

Results: The repeatability within an observer (A vs A ) resulted in a DSC of 0.94 ± 0.01 (mean ± SD) and an unsystematic difference of -0.01% for R (P = .92) and +0.1% for R (P = .21). The reproducibility between human observers (A vs B) resulted in a DSC of 0.88 ± 0.02, and a systematic absolute difference of -0.81% (P < .001) for R and -0.38% (P = .037) for R . The reproducibility between human and the ANN (A vs C) resulted in a DSC of 0.89 ± 0.03 and a systematic absolute difference of -0.36% for R (P = .017) and -0.35% for R (P = .002). The ICC was >0.98 for all variables and comparisons.

Conclusions: Despite high overall agreement, there were systematic differences in lung segmentation between observers. This needs to be considered for longitudinal studies and could be overcome by using an ANN, which performs as good as human observers and fully automatizes MP-MRI post-processing.
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http://dx.doi.org/10.1002/mrm.28476DOI Listing
February 2021

Risk Factors for Candidemia After Open Heart Surgery: Results From a Multicenter Case-Control Study.

Open Forum Infect Dis 2020 Aug 19;7(8):ofaa233. Epub 2020 Jun 19.

Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.

Background: species are among the most frequent causative agents of health care-associated bloodstream infections, with mortality >40% in critically ill patients. Specific populations of critically ill patients may present peculiar risk factors related to their reason for intensive care unit admission. The primary objective of the present study was to assess the predictors of candidemia after open heart surgery.

Methods: This retrospective, matched case-control study was conducted in 8 Italian hospitals from 2009 to 2016. The primary study objective was to assess factors associated with the development of candidemia after open heart surgery.

Results: Overall, 222 patients (74 cases and 148 controls) were included in the study. Candidemia developed at a median time (interquartile range) of 23 (14-36) days after surgery. In multivariable analysis, independent predictors of candidemia were New York Heart Association class III or IV (odds ratio [OR], 23.81; 95% CI, 5.73-98.95;  < .001), previous therapy with carbapenems (OR, 8.87; 95% CI, 2.57-30.67;  = .001), and previous therapy with fluoroquinolones (OR, 5.73; 95% CI, 1.61-20.41;  = .007). Crude 30-day mortality of candidemia was 53% (39/74). Septic shock was independently associated with mortality in the multivariable model (OR, 5.64; 95% CI, 1.91-16.63;  = .002). No association between prolonged cardiopulmonary bypass time and candidemia was observed in this study.

Conclusions: Previous broad-spectrum antibiotic therapy and high NYHA class were independent predictors of candidemia in cardiac surgery patients with prolonged postoperative intensive care unit stay.
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http://dx.doi.org/10.1093/ofid/ofaa233DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7397829PMC
August 2020

Isolated Congenital Coronary Ostial Stenosis in a Young Infant: A Case Report.

World J Pediatr Congenit Heart Surg 2020 09 14;11(5):649-651. Epub 2020 Jul 14.

Unit of Cardiac Surgery, 18572IRCCS Policlinico San Martino, University of Genoa, Genoa, Italy.

Coronary ostial stenosis is a rare congenital cardiac anomaly, frequently associated with hypoplasia of the proximal coronary artery. This condition is potentially life-threatening, as it may present with myocardial ischemia and sudden death. We present a case of left coronary ostial stenosis in a 48-day-old infant symptomatic for sudden cardiac arrest, who successfully underwent surgical angioplasty. Any cardiac arrest in a neonate or young infant should raise suspicion of coronary ostial stenosis/atresia, considering the difficulty in diagnosing this congenital heart defect.
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http://dx.doi.org/10.1177/2150135120928994DOI Listing
September 2020

On-pump beating-heart coronary artery bypass grafting in high-risk patients: A systematic review and meta-analysis.

J Card Surg 2020 Aug 9;35(8):1958-1978. Epub 2020 Jul 9.

Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy.

Background: Operative technique for surgical myocardial revascularization in high-risk patients remains an argument of debate. On-pump coronary artery bypass graft (CABG) with cardioplegic arrest and off-pump CABG have intrinsic limitations. The hybrid approach of on-pump beating-heart CABG (OPBHC) has been proposed over the years with conflicting results. This systematic review and meta-analysis intends to summarize the contemporary literature.

Methods: A literature search was conducted through major electronic databases. The systematic review provided a total of 279 articles, of those 17 studies were included in the present study.

Results: Compared with on-pump CABG, OPBHC patients showed a preoperative higher risk profile but had reduced early mortality (risk ratio [RR], 0.59, 95% CI, 0.36-0.97) and reduced postoperative stroke (RR, 0.60, 95% CI, 0.39-0.91). Also, interesting trends towards reduced postoperative intra-aortic balloon pump use (RR, 0.56, 95% CI, 0.31-1.01) and myocardial infarction (RR, 0.48, 95% CI, 0.22-1.07) were observed. Baseline characteristics and postoperative complications were similar between OPBHC and off-pump CABG, but limited data are available. The risk of incomplete revascularization in OPBHC is lower than off-pump CABG (RR, 0.53, 95% CI, 0.33-0.87) but higher than conventional on-pump CABG (RR, 1.71, 95% CI, 1.23-2.39).

Conclusion: OPBHC is an effective technique to perform surgical revascularization in high-risk patients as preventing haemodynamic deterioration and guaranteeing adequate end-organ perfusion. OPBHC represents an alternative technique to on-pump and off-pump CABG, in those cases in which complications deriving from cardioplegic arrest or manipulation of the heart are more likely. For these reasons, OPBHC might be useful in patients with recent myocardial infarction or with left ventricular dysfunction.
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http://dx.doi.org/10.1111/jocs.14780DOI Listing
August 2020

A Nomogram for Predicting Long Length of Stay in The Intensive Care Unit in Patients Undergoing CABG: Results From the Multicenter E-CABG Registry.

J Cardiothorac Vasc Anesth 2020 Nov 12;34(11):2951-2961. Epub 2020 Jun 12.

Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy.

Objective: Many papers evaluated predictive factors for prolonged intensive care unit (ICU) stay after cardiac surgery, but efforts in translating those models in practical clinical tools is lacking. The aim of this study was to build a new nomogram score and test its calibration and discrimination power for predicting a long length of stay in the ICU among patients undergoing coronary artery bypass graft surgery (CABG).

Design: Retrospective analysis of an international registry.

Setting: Multicentric.

Participants: Based on the european multicenter study on coronary artery bypass grafting (E-CABG) registry (NCT02319083), a total of 7,352 consecutive patients who underwent isolated CABG were analyzed.

Interventions: A "long length of stay" in the ICU was considered when equal to or more than 3 days. Predictive factors were analyzed through a multivariate logistic regression model that was used for the nomogram.

Results: Long length of ICU stay was observed in 2,665 patients (36.2%). Ten independent variables were included in the final regression model: the SYNTAX score class critical preoperative state, left ventricular ejection fraction class, angina at rest, poor mobility, recent potent antiplatelet use, estimated glomerular filtration rate class, body mass index, sex, and age. Based on this 10-risk factors logistic regression model, a nomogram has been designed.

Conclusion: The authors defined a nomogram model that can provide an individual prediction of long length of ICU stay in cardiovascular surgical patients undergoing CABG. This type of model would allow an early recognition of high-risk patients who might receive different preoperative and postoperative treatments to improve outcomes.
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http://dx.doi.org/10.1053/j.jvca.2020.06.015DOI Listing
November 2020

Correlated Evolution of Sex Allocation and Mating System in Wrasses and Parrotfishes.

Am Nat 2020 07 22;196(1):57-73. Epub 2020 May 22.

In accordance with predictions of the size-advantage model, comparative evidence confirms that protogynous sex change is lost when mating behavior is characterized by weak size advantage. However, we lack comparative evidence supporting the adaptive significance of sex change. Specifically, it remains unclear whether increasing male size advantage induces transitions to protogynous sex change across species, as it can within species. We show that in wrasses and parrotfishes (Labridae) the evolution of protogynous sex change is correlated with polygynous mating and that the degree of male size advantage expressed by polygynous species influences transitions between different types of protogynous sex change. Phylogenetic reconstructions reveal strikingly similar patterns of sex allocation and mating system evolution with comparable lability. Despite the plasticity of sex-determination mechanisms in labrids, transitions trend toward monandry (all males derived from sex-changed females), with all observed losses of protogyny accounted for by shifts in the timing of sex change to prematuration. Likewise, transitions in mating system trend from the ancestral condition of lek-like polygyny toward greater male size advantage, characteristic of haremic polygyny. The results of our comparative analyses are among the first to confirm the adaptive significance of sex change as described by the size-advantage model.
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http://dx.doi.org/10.1086/708764DOI Listing
July 2020

Right ventricular assessment can improve prognostic value of Euroscore II.

J Card Surg 2020 Jul 3;35(7):1548-1555. Epub 2020 Jun 3.

Dipartimento dell'Emergenza e Trapianti d'Organo, Sezione di Cardiochirurgia, Università di Bari Aldo Moro. Ospedale Santa Maria, GVM Care & Research, Bari, Italy.

Background: The aim of this multicenter prospective study was to evaluate the prognostic weight of preoperative right ventricular assessment on early mortality in cardiac surgery.

Methods: This is a multicenter prospective observational study performed by the Italian Group of Research for Outcome in Cardiac Surgery (GIROC) including 11 centers. From October 2017 to March 2019, out of 923 patients undergoing cardiac surgery, 28 patients with some missing data were excluded and 895 patients were enrolled in the study right ventricular dilatation was defined as a basal end-diastolic diameter >42 mm. The right ventricle (RV) function was assessed using the combination of three parameters: fractional area changing (FAC), tricuspid annular plane systolic excursion (TAPSE), and S'-wave using tissue Doppler imaging (TDI-S'); RV dysfunction was defined as the presence of at least two of the following cutoffs: FAC <35%, TAPSE <17 mm, and TDI S' <9.5 mm RESULTS: Among the entire cohort, 624 (70%) showed normal RV, 92 (10%) isolated RV dilatation, 154 (17%) isolated RV dysfunction, and 25 (3%) both RV dilatation and dysfunction. Non-surviving patients showed a significantly higher rate of RV alteration at multivariable analysis, RV status was found to be an independent predictor for higher in-hospital mortality beside Euroscore II.

Conclusions: This prospective multicenter observation study shows the importance to assess RV preoperatively and to include both RV function and dimension in a risk score model such as Euroscore II to implement its predictivity, since PH cannot always mirror the status of the right ventricle.
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http://dx.doi.org/10.1111/jocs.14672DOI Listing
July 2020

Failure to achieve a satisfactory cardiac outcome after isolated coronary surgery in low-risk patients.

Interact Cardiovasc Thorac Surg 2020 07;31(1):9-15

Department of Surgery, Oulu University Hospital and Research Unit of Surgery, Anesthesiology and Critical Care, University of Oulu, Oulu, Finland.

Objectives: This study aims to investigate the incidence and determinants of major early adverse events in low-risk patients undergoing isolated coronary artery bypass grafting (CABG).

Methods: The multicentre E-CABG registry included 7352 consecutive patients who underwent isolated CABG from January 2015 to December 2016. Patients with an European System for Cardiac Operative Risk Evaluation (EuroSCORE) II of <2% and without any major comorbidity were the subjects of the present analysis.

Results: Out of 2397 low-risk patients, 11 (0.46%) died during the index hospitalization or within 30 days from surgery. Five deaths were cardiac related, 4 of which were secondary to technical failures. We estimated that 8 out of 11 deaths were potentially preventable. Logistic regression model identified porcelain aorta [odds ratio (OR) 34.3, 95% confidence interval (CI) 1.3-346.3] and E-CABG bleeding grades 2-3 (OR 30.2, 95% CI 8.3-112.9) as independent predictors of hospital death.

Conclusions: Mortality and major complications, although infrequently, do occur even in low-risk patients undergoing CABG. Identification of modifiable causes of postoperative adverse events may be useful to develop preventative strategies to improve the quality of care of patients undergoing cardiac surgery.

Clinical Trial Registration: NCT02319083 (https://clinicaltrials.gov/ct2/show/NCT02319083).
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http://dx.doi.org/10.1093/icvts/ivaa062DOI Listing
July 2020

Aorto-Right Ventricular Tunnel: A Case Series and Literature Review.

Semin Thorac Cardiovasc Surg 2020 Winter;32(4):876-880. Epub 2020 May 17.

Unit of Cardiac Surgery, IRCCS Policlinico San Martino - University of Genoa, Genoa, GE, Italy.

Aorto-right ventricular tunnel (ARVT) is a rare cardiac congenital anomaly where an extracardiac channel connects the ascending aorta above the sinutubular junction to the right ventricle. This defect is caused by an abnormal development of the cushions of the aorto-pulmonary outflow tract. A case series and literature review are described. Two cases of ARVT are described. A literature review was conducted, in which 31 cases were reported. In our 2 cases, both ARVTs connected the ascending aorta above the left aortic sinus to the right ventricle (one to the right ventricular outflow tract and one to the right ventricular apex). Both patients underwent successful surgical correction by patch closure of both tunnel orifices, with uneventful postoperative course. Of the 31 ARVT cases described in our review, only 10 patients (32.3%) had an anatomy similar to the 2 cases described. Coronary artery anomalies can be associated, as reported in our 2 patients and in 16 cases (51.6%) in the review. Surgical correction can be achieved by direct closure or, more often, by patch closure of one or both tunnel orifices, depending mostly on coronary anatomy. Two cases of transcatheter device closure were described in literature, in favorable anatomy cases. Careful attention is required during repair to avoid coronary lesions, due to the high incidence of comorbid coronary anomalies.
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http://dx.doi.org/10.1053/j.semtcvs.2020.05.004DOI Listing
April 2021
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