Search PubMed⌕ Search

Biomedical subjects

D Pagano

Publications and source records attributed to D Pagano.

At least 37 records · Page 2Linked to original sources
PubMed1999

Coronary revascularisation for postischaemic heart failure: how myocardial viability affects survival.

OBJECTIVE: To assess the impact of revascularisation of viable myocardium on survival in patients with postischaemic heart failure. METHODS: 35 patients (mean (SD) age 58 (7) years) with severe heart failure (New York Heart Association (NYHA) functional class > or = III), mean left ventricular ejection fraction (LVEF) 24 (7)% (range 10-35%), and limited exercise capacity (peak oxygen consumption (VO(2)) 15 (4) ml/kg/min) were studied. 21/35 patients had no angina. Myocardial viability was assessed with quantitative positron emission tomography and the glucose analogue (18)F-fluorodeoxyglucose (FDG) (viable segment = FDG uptake > or = 0.25 micromol/min/g) in all patients before coronary artery bypass grafting. Patients were divided into two groups: group 1, > or = 8 viable dysfunctional segments (mean 12 (2), range 8-15); and group 2, < 8 viable dysfunctional segments (mean 3.5 (3), range 0-7). The two groups were comparable for age, sex, NYHA class, LVEF, and peak VO(2). RESULTS: Two patients died perioperatively and seven patients died during follow up (mean 33 (14) months). All deaths were from cardiac causes. Kaplan-Meyer survival analysis showed 86% survival for group 1 patients versus 57% for group 2 (p = 0.03). Analysis by Cox proportional hazard model revealed three independent factors for cardiac event free survival: presence of > or = 8 viable segments (p = 0.006); preoperative LVEF (p = 0.002); and patient age (p = 0.01). CONCLUSION: Revascularisation for postischaemic heart failure can be associated with good survival, which is critically dependent upon the amount of viable myocardium.

Adult↗
PubMed1998

Coronary revascularization in the treatment of moderate and severe postischemic left ventricular dysfunction.

Chronic postischemic left ventricular (LV) dysfunction can improve following coronary revascularization (hibernating myocardium). However, it is not clear whether the severity of LV dysfunction determines functional outcome after revascularization and the accuracy of tests to predict myocardial viability. We studied 47 patients with coronary artery disease and chronic LV dysfunction. Before coronary bypass, patients underwent (18F)2-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) during euglycemic hyperinsulinemic clamp to assess viability. Global and regional LV function were assessed before and 4 to 6 months after surgery. Patients were arbitrarily divided into 2 groups with moderate and severe LV dysfunction. Group 1 (n = 26) had an ejection fraction (EF) of < or = 30% and group 2 (n = 21) > 30%. After bypass, the EF (22+/-6% vs 31+/-10%; p <0.0001) and global wall motion score (WMS) (2.05+/-0.39 vs 1.56+/-0.34; p <0.001) improved in group 1, whereas the EF (43+/-9% vs 43+/-12%; p = NS) was unchanged in group 2, although WMS tended to improve (1.42+/-0.38 vs 1.32+/-0.39; p = 0.09). The proportion of dysfunctional segments (72% vs 32%; p <0.0001) and FDG uptake in these segments (0.44+/-0.15 vs 0.34+/-0.15 micromol/g/min, p <0.0001) were greater in group 1 than in group 2. The baseline EF influenced the predictive accuracy of PET, with highest positive predictive accuracy in group 2 and highest negative predictive accuracy in group 1. Thus, coronary revascularization has the potential for greatest benefit in patients with the most severe dysfunction, but with evidence of viability, and the entity of LV dysfunction affects the predictive accuracy of viability studies.

Adult↗
PubMed1998

Multiplanar reformatting and three-dimensional reconstruction: for pre-operative assessment of the thoracic aorta by computed tomography.

INTRODUCTION: Conventional CT demonstrates pathology of the thoracic aorta. This study aimed to evaluate the additional contributions to surgical planning of multiplanar reformatting, maximum intensity projections and three-dimensional (3-D) reconstruction. DESIGN: Retrospective. SUBJECT AND METHODOLOGY: Fifty-three patients with newly diagnosed pathology of the thoracic aorta were scanned over a 15-month period; 25 scans were spiral acquisitions. Scans were acquired during and following rapid injection of 100 ml of intravenous iopromide. The reconstructed data was displayed as axial images, oblique or other multiplanar reformats and shaded surface display 3-D reconstructions. Two radiologists and two surgeons reviewed the images. The axial images were assessed initially, subsequently the reformats and 3-D reconstructed views were examined looking particularly for additional information that might add to the surgical management. RESULTS: Pathologies encountered were aortic dissection (21 patients, including two with Marfan's syndrome), saccular aneurysms (eight), fusiform aneurysms (16), aortic root and ascending aortic dilatation (seven) and coarctation (one). The relationship of aneurysms and dissections to major vessels are better shown with 3-D reconstruction or oblique reformats. Morphology of saccular aneurysms, particularly the neck, is well shown with 3-D reconstruction. Coarctation was best demonstrated by oblique reformats. There was little additional information from 3-D reconstruction or reformats in assessment of type A dissection. Improved spatial orientation by visualization in varying projections was helpful for surgical planning in certain cases of type B dissection, fusiform aneurysms and aortic root and ascending aortic root dilatation. Spiral acquisitions have the advantage of speed and hence a greater anatomical coverage for a single breath-hold. CONCLUSION: Oblique reformats and 3-D reconstruction, although using identical data as the axial images, in specific cases were felt to aid surgical assessment of aneurysms and dissections, thus assisting pre-operative planning.

Aortic Dissection↗
PubMed1998

Coronary artery bypass surgery as treatment for ischemic heart failure: the predictive value of viability assessment with quantitative positron emission tomography for symptomatic and functional outcome.

OBJECTIVES: To determine the predictive value of quantitative evaluation of myocardial viability on changes in left ventricular function, exercise capacity, and quality of life after coronary artery bypass grafting in patients with ischemic heart failure (congestive heart failure, New York Heart Association class > or = III) with and without angina. METHODS: Thirty-five patients, 14 with congestive heart failure and angina (CHF-angina) and 21 with congestive heart failure without angina (CHF-no angina) were studied at baseline and 6 months after coronary bypass grafting. Left ventricular function was evaluated with transthoracic echocardiography and radionuclide ventriculography. Myocardial viability was assessed with [18F]-2-fluoro-2-deoxy-D-glucose using positron emission tomography. Peak aerobic capacity (peak oxygen consumption) and anaerobic threshold were assessed with treadmill exercise test and quality of life with a questionnaire. RESULTS: A total of 286 of 336 dysfunctional left ventricular segments were viable. There were two perioperative deaths (5.7%) and three late deaths. Left ventricular ejection fraction increased from 23% +/- 7% to 32% +/- 9% (p < 0.0001), and a linear correlation was found between the number of viable segments and the changes in ejection fraction (r = 0.65; p = 0.0001). Receiver operating characteristics curve identified eight viable segments as the best predictor for increase of ejection fraction more than 5 percentage points. Peak oxygen consumption increased from 15 +/- 4 to 22 +/- 5 ml/kg per minute (p < 0.0001). Preoperatively, anaerobic threshold was identified in one patient from the CHF-angina group and in all from the CHF-no angina group and increased from 13 +/- 4 to 19 +/- 4 ml/kg per minute (p < 0.0001). Quality of life scores improved significantly in both groups. No correlation was found between the amount of viable dysfunctional myocardium and changes in exercise capacity or quality of life. CONCLUSIONS: In patients with postischemic congestive heart failure the amount of viable myocardium dictates the degree of improvement in left ventricular function after revascularization.

Angina Pectoris↗
PubMed1998

von Willebrand factor and urinary albumin excretion are possible indicators of endothelial dysfunction in cardiopulmonary bypass.

OBJECTIVE: Experimental evidence suggests that cardiopulmonary bypass (CPB) associated inflammatory response leads to endothelial injury and increased permeability, but this has been difficult to show clinically. We have investigated the use of von Willebrand factor (vWF), and urinary albumin excretion, as measured by the urinary albumin creatinine ratio (ACR), to demonstrate this. METHODS: A total of 23 patients undergoing elective coronary artery bypass grafting were studied. Complement fragment C3a, leukotrienne B4 (LTB4), interleukin 6 (IL6), neutrophil elastase, vWF and ACR were measured on anaesthetic induction (baseline), 20 min after starting CPB, 5 min after cross-clamp removal, 5 min, 2, 6 and 24 h after termination of CPB. Anaesthetic, CPB and myocardial protection techniques were standardised. ANOVA was performed by using the distribution free Friedman test for each measured parameter. When significance differences were found (P < 0.05), post hoc analysis with Wilcoxon signed rank test was used for comparison of each time point with the base line level and differences were only accepted as significant following the Bonferroni correction (P < 0.008). Summary measures of peak versus peak and area under the cure were also analysed for ACR with vWF. RESULTS: Peak vs. baseline levels for C3a were 4.9 vs. 2.1 microg/ml (P < 0.0001), LTB4 was 800 vs. 20 pg/ml (P < 0.0001), neutrophil elastase was 250 vs. 115 ng/ml (P < 0.001), IL6 was 620 vs. 1.4 pg/ml (P < 0.0001), vWF was 2.2 vs. 1.3 IU/ml (P < 0.0001) and ACR was 17.6 vs. 2.0 mg/mmol (P < 0.0001). C3a, LTB4 and ACR peaked during the operation. Neutrophil elastase peaked at 2 h following CPB. IL6 and vWF peaked at 6 h following CPB. The correlation coefficient between vWF and ACR following peak versus peak analysis was 0.48 (P = 0.035), and area under the curve analysis was 0.6 (P < 0.01). CONCLUSION: These results demonstrate that endothelial permeability and injury, as measured by urinary albumin excretion and vWF, respectively, are related and the use of these easily detectable and sensitive biochemical markers warrants further investigation.

Aged↗
PubMed1998

Pitfalls in the economic evaluation of thrombolysis in myocardial infarction. The impact of national differences in the cost of thrombolytics and of differences in the efficacy across patient subgroups.

BACKGROUND: The economic evaluation of the results of the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Artery (GUSTO) trial found that recombinant tissue plasminogen activator is more cost-effective than streptokinase for the treatment of acute myocardial infarction. AIM: We evaluated the impact on a cost effectiveness analysis, of the differences in the cost of thrombolytics among countries and of differences in efficacy across patient subgroups. METHODS: We considered the crude costs of streptokinase and recombinant tissue plasminogen activator in Germany, Italy, the United Kingdom, and the United States of America, and the 30-day mortality found in the GUSTO trial. We calculated the incremental costs for each life saved when streptokinase is substituted by recombinant tissue plasminogen activator. We also calculated the incremental costs for each life saved for two protocols implying a selective use of streptokinase and recombinant tissue plasminogen activator (age-selective protocol: recombinant tissue plasminogen activator in patients < or = 75 years, streptokinase in older patients; site-selective protocol: recombinant tissue plasminogen activator in anterior acute myocardial infarction, streptokinase in non-anterior acute myocardial infarction). RESULTS: The incremental costs for each life saved when streptokinase is substituted by recombinant tissue plasminogen activator in all GUSTO patients vary greatly among countries: the incremental costs for each life saved are 31%, 45%, and 97% higher in Germany, Italy, and the United States of America compared to the United Kingdom. The use of a site-selective protocol implies a halved cost-effectiveness ratio compared to the use of recombinant tissue plasminogen activator in all cases of acute myocardial infarction. CONCLUSIONS: (1) The cost-efficacy of recombinant tissue plasminogen activator vs streptokinase in acute myocardial infarction varies greatly among countries due to differences in the cost of drugs. (2) A selective use of thrombolytics for some sites of infarction is more cost-effective than the exclusive use of recombinant tissue plasminogen activator.

Aged↗
PubMed1998

Predictive value of dobutamine echocardiography and positron emission tomography in identifying hibernating myocardium in patients with postischaemic heart failure.

OBJECTIVE: To compare the predictive value of dobutamine echocardiography (DE) and positron emission tomography (PET) in identifying reversible chronic left ventricular (LV) dysfunction (hibernating myocardium) in patients with coronary artery disease (CAD) and overt heart failure. PATIENTS: 30 patients (four women) with CAD and heart failure undergoing coronary artery bypass grafting (CABG). METHODS: Myocardial viability was assessed with DE (5 and 10 micrograms/kg/min) and PET with [18F] 2-fluoro-2-deoxy-D-glucose (FDG) under hyperinsulinaemic euglycaemic clamp. Regional (echo) and global LV function (MUGA) were assessed at baseline and six months after CABG. RESULTS: 192 of the 336 (57%) dysfunctional LV segments improved function following CABG (hibernating) and the LV ejection fraction (EF) increased from 23(7) to 32(9)% (p < 0.0001) (in 17 patients > 5%). DE and PET had similar positive predictive values (68% and 66%) in the identification of hibernating myocardium, but DE had a significantly lower negative predictive value than PET (54% v 96%; p < 0.0001). A significant linear correlation was found between the number of PET viable segments and the changes in EF following CABG (r = 0.65; p = 0.0001). Stepwise logistic regression identified the number of PET viable segments as an independent predictor of improvement in EF > 5%, whereas the number of DE viable segments, the baseline LVEF, and wall motion were not. CONCLUSIONS: DE has a higher false negative rate than PET in identifying recoverable LV dysfunction in patients with severe postischaemic heart failure. The amount of PET viable myocardium correlates with the functional outcome following CABG.

Cardiotonic Agents↗
PubMed1998

[Comparative characterization of oxidative stress in some hereditary diseases differing in predisposition of neoplasms and early aging].

Two groups of hereditary diseases are considered. One group is characterized by chromosomal instability (Fanconi's anemia, ataxiatelenagioectasia, xeroderma pigmentosum). The other group includes diseases with marked genotypic changes (Down's disease, cystic fibrosis). All these diseases predispose to malignant neoplasms and premature ageing, which is due to different manifestations of oxidative stress. The paper gives in greatest detail the mechanism responsible for Fanconi's anemia which has been much studied by the authors. Chromosomal instability in this disease is associated with regeneration defect in DNA impaired by oxygen radicals.

Aging↗
PubMed1997

Aprotinin in aortic surgery requiring profound hypothermia and circulatory arrest.

OBJECTIVE: The use of aprotinin in cardiac surgery to improve haemostasis and reduce blood loss particularly in patient groups at increased risk of bleeding is well established. Previous retrospective studies in profound hypothermic surgery have highlighted concerns that in this circumstances aprotinin may paradoxically cause increased bleeding and intravascular thrombosis. We therefore adopted a modified protocol for administering aprotinin, which was not started until cardiopulmonary bypass had been reinstituted after circulatory arrest. METHODS: Between April 1993 and June 1995, 45 patients underwent 46 thoracic aortic procedures which required hypothermic circulatory arrest; 25 of these were emergencies. All of these patients received aprotinin. RESULTS: There were five deaths (10.8%) in hospital. Two patients with preoperative oliguric renal failure required postoperative dialysis, and a further six (13%) developed transient renal dysfunction with complete recovery. Two patients suffered postoperative stroke; one from embolisation of a severely diseased aorta, while the other had signs of an acute evolving stroke before surgery. None of the patients suffered acute Q-wave perioperative myocardial infarction. The mean blood loss was 575 ml in the first 12 h, with a mean postoperative transfusion requirement of 1 U blood. CONCLUSIONS: We cannot implicate aprotinin in increased postoperative blood loss, renal dysfunction or mortality when used with hypothermic circulatory arrest according to this protocol. Elucidating the role of aprotinin in hypothermic circulatory arrest requires a randomised prospective study.

Adult↗
PubMed1997

[Renal angiomyolipoma].

Renal angiomyolipoma is a benign tumor that can be observed in two distinct types: the solitary type and the tuberous sclerosis associated type. It is now diagnosed, even if asymptomatic, with increasing frequency by means of ultrasonography and computerized tomography owing to its particular features. The possibility of preoperative diagnosis and the biological characteristics of this benign lesion should induce a more conservative management.

Angiomyolipoma↗
PubMed1996

Homograft replacement of thoraco-abdominal aorta for a leaking mycotic aneurysm.

We report the case of a 67-year-old, diabetic patient who underwent antibiotic-preserved homograft replacement of a thoraco-abdominal segment of the aorta for leaking mycotic aneurysm. This was successful in eradicating the sepsis and no graft complication had occurred at (18 months). Follow-up with computed tomography (CT) scanning.

Aged↗
PubMed1996

Surgery of the thoracic aorta with hypothermic circulatory arrest: experience with retrograde perfusion via the superior vena cava and demonstration of cerebral perfusion.

OBJECTIVE: Retrograde cerebral perfusion (RCP) via the superior vena cava has been described as an adjunctive technique to enhance the safety of hypothermic circulatory arrest (HCA), but perfusion of cerebral tissue in humans during RCP has not been demonstrated to date. We report our clinical experience with RCP and our attempt to demonstrate "true" perfusion of the brain. METHODS: Between April 1993 and June 1995, 49 thoracic aortic procedures were performed in 48 patients (male:female = 26:22) (emergency: elective = 25:24). The indications for surgery were acute type "A" dissection (18) chronic aneurysm (28) and infected valved conduit (3). Hypothermic circulatory arrest (15 degrees C) and RCP were implemented in all cases (mean HCA time 29 min, range 11-69) (mean RCP time 26 min, range 10-65). The 99mTechnetium labelled brain perfusion agent d,l, hexamethyl propylene amine oxime (99mTc-HMPAO) was administered (100 MBq) into the cardiotomy reservoir following institution of HCA (15 degrees C) in three consecutive patients and planar dynamic brain imaging with a portable gamma camera was commenced at the start of RCP. RESULTS: Six hospital deaths (12.2%) occurred in the emergency group due to atheromatous embolic stroke in one patient, sepsis in one, ruptured infrarenal aortic aneurysm in one, myocardial failure in one, renal failure in one and multi-system organ failure in one patient. The remaining patients suffered no major neurological complications (median Intensive Care Unit stay 1 day, range 1-5). Inspection of the images acquired showed 99mTc-HMPAO activity spreading quickly from the jugular bulb and the superior sagittal sinus throughout the cerebral white and gray matter. Time-activity curves calculated for both cerebral hemispheres showed homogeneous regional cerebral perfusion. CONCLUSIONS: Retrograde cerebral perfusion is easy to establish, "safe" and provides blood flow to the brain during HCA. The flow quantification and metabolic contribution of RCP require further investigation.

Adult↗
PubMed1996

A comparison of inhaled nitric oxide with intravenous vasodilators in the assessment of pulmonary haemodynamics prior to cardiac transplantation.

OBJECTIVE: Elevated pulmonary vascular resistance and transpulmonary gradient are predictors of increased perioperative mortality in patients undergoing orthotopic heart transplantation. Sodium nitroprusside and prostacyclin PGI2 are routinely used to assess the reversibility of pulmonary vascular resistance and transpulmonary gradient in heart transplant candidates, but their use is limited by their systemic vasodilatory effect. The aim of this study was to evaluate the systemic and pulmonary haemodynamic effects of low concentration (10 and 20 parts per million) inhaled nitric oxide in patients with severe heart failure with elevated transpulmonary gradient and pulmonary vascular resistance undergoing assessment for cardiac transplantation, and to compare the haemodynamic effects of inhaled nitric oxide with those of sodium nitroprusside and prostacyclin PGI2. METHOD: In 10 consecutive patients with elevated transpulmonary gradient (16+/-2 mm Hg) and pulmonary vascular resistance (3.6 +/-0.3 Wood units (WU)) nitric oxide (10 and 20 parts per million in 23% inspired oxygen (O2) via a tight fitting facemask) and increasing doses of intravenous sodium nitroprusside and prostacyclin were administered in a random, single-blinded fashion. RESULTS: Inhalation of nitric oxide (10 ppm) reduced the transpulmonary gradient (-7+/-2 mm Hg; P<0.01) and pulmonary vascular resistance (-1.8+/-0.4 WU; P<0.001) but did not affect the systemic vascular resistance (-0.3+/-1 WU) or mean systemic arterial pressure (-1.3 5 mm Hg). Sodium nitroprusside and prostacyclin reduced the transpulmonary gradient (-4.5+/-2 mm Hg; P<0.01 and -3.6+/-2 mm Hg; P<0.05), pulmonary vascular resistance (-1.5+/-0.4 WU; P<0.001 and -1.3+/-0.4 WU; P<0.01), systemic vascular resistance (-7+/-2 WU; P<0.01 and -7.2+/-2 WU; P<0.01) and mean systemic arterial pressure (-15+/-5 mm Hg; P<0.01 and -18+/-4 mm Hg; P<0.01). CONCLUSION: Low-concentration inhaled nitric oxide is as effective as sodium nitroprusside and prostacyclin in reducing transpulmonary gradient and pulmonary vascular resistance, and is highly pulmonary vasoselective.

Administration, Inhalation↗
PubMed1995

Retrograde cerebral perfusion: clinical experience in emergency and elective aortic operations.

We recently have used retrograde cerebral perfusion via the superior vena cava in association with hypothermic circulatory arrest as an adjunct to cerebral protection during aortic arch operations. Between April 1993 and March 1994, 23 patients (14 male; 9 female; median age, 64 years; age range, 25 to 76 years; 14 emergency, 9 elective) underwent operation on the ascending aorta, aortic arch, or both for acute dissection (11) or aneurysm (12). Aortic root replacement was performed in 13 patients (7 with arch replacement), ascending aortic replacement in 7 (4 with arch replacement), isolated aortic arch replacement in 2, and repair of sinus of Valsalva aneurysm in 1. Coronary artery bypass grafting was performed in 4 patients. Hypothermic circulatory arrest (15 degrees C) and retrograde cerebral perfusion were implemented in all cases (median circulatory arrest time, 21 minutes; range, 13 to 51 minutes; median retrograde cerebral perfusion time, 20 minutes; range, 12 to 50 minutes). Three hospital deaths occurred (atheromatous embolic stroke, sepsis, rupture of infrarenal aortic aneurysm). The remaining patients had no neurologic damage (median intensive therapy unit stay, 1 day; range, 1 to 5 days). Retrograde cerebral perfusion is easy to establish and safe, and may improve brain protection during hypothermic circulatory arrest.

Adult↗
PubMed1995

Anomalous aortic origin of the right coronary artery. An unusual cause of angina pectoris and its surgical correction.

A 45-year-old female presented with typical recent-onset exertional angina pectoris. Subsequent investigation showed that the likely cause was an aberrant origin of the right coronary artery arising from the left coronary sinus. This anomaly is uncommon and is not usually associated with angina pectoris. Surgical rerouting of the origin of the right coronary artery produced complete resolution of ischaemia.

Angina Pectoris↗
PubMed1995

Results of surgical revascularization in ischaemic heart failure without angina.

Seventeen patients with severe ischaemic heart failure without angina were studied prospectively to determine the effects of surgical revascularization on exercise tolerance, peak oxygen consumption and left ventricular function at rest and during inotropic stimulation at 3 months after surgery. Suitability for surgery was assessed by the presence of ischaemia identified by thallium scintigraphy and stress electrocardiographic (ECG) testing and the left ventricular response to dobutamine measured by radionuclide ventriculography. One patient died awaiting surgery and one required cardiac transplantation. Fifteen patients underwent coronary artery surgery with two perioperative deaths. Thirteen patients were restudied 3 months after surgery. Mean treadmill exercise time (362 +/- 204 s to 562 +/- 303 s, P < 0.05) and peak oxygen consumption (14.9 +/- 3.5 ml/kg per min to 20.8 ml/kg per min, P < 0.01) increased significantly. Resting ejection fraction was not changed after surgery (20 +/- 5% to 21 +/- 6%) but ejection fraction during derived from thermodilution Swan-Ganz catheter data both at rest during dobutamine stimulation were unchanged after surgery. At 13 +/- 3 months after surgery there had been three sudden deaths and one patient had undergone successful cardiac transplantation. Of the remaining nine patients, three had improved to NYHA symptomatic class I, three were in NYHA class II and three in NYHA class III. Repeat treadmill exercise testing in seven patients showed that the improvement in exercise capacity evident in the first follow-up visit was maintained during long-term follow-up.

Adult↗