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Background: R1 vascular resection for liver tumors was introduced in the early twenty-first century. However, its oncologic adequacy remains controversial. The aim of this study was to determine the oncologic adequacy of R1 vascular hepatectomy in hepatocellular carcinoma patients., Methods: A prospective cohort of patients with hepatocellular carcinoma resected between the years 2005 and 2015 was reviewed. R0 was any resection with a minimum 1 mm of negative margin. R1 vascular was any resection with tumor exposure attributable to the detachment from major intrahepatic vessel. R1 parenchymal was any resection with tumor exposure at parenchymal margin. The end points were the calculation of the local recurrence of R0, R1 parenchymal, and R1 vascular hepatectomy and their prognostic significances., Results: We analyzed 327 consecutive patients with 532 hepatocellular carcinoma and 448 resection areas. We found that 205 (63%) resulted R0, 56 (17%) resulted R1 parenchymal, 50 (15%) resulted R1 vascular, and 16 (5%) resulted both R1 parenchymal and R1 vascular. After a median follow-up of 33.5 months (range 6.1-107.6), the 5-year overall survival rates were 54%, 30%, 65%, and 36%, respectively for R0, R1 parenchymal, R1 vascular, and R1 parenchymal + R1 vascular (P = .031). Local recurrence rates were 3%, 14%, 4%, and 19%, respectively for R0, R1 parenchymal, R1 vascular, and R1 parenchymal + R1 vascular (P = .001) per patient, and 4%, 4%, 12%, and 18%, respectively for R0, R1 vascular, R1 parenchymal, and R1 parenchymal + R1 vascular (P = .001) per resection area. At multivariate analysis R1 parenchymal and R1 vascular + R1 parenchymal were independent detrimental factors., Conclusion: R1 vascular hepatectomy for hepatocellular carcinoma is not associated with increased local recurrence or decreased survival. Thus, detachment of hepatocellular carcinoma from intrahepatic vessels should be considered oncologically adequate., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Objectives: A history of percutaneous coronary intervention increases the risk of death and complications of coronary artery bypass grafting. This retrospective multicenter study evaluated the impact of continuative use of statin on postoperative outcomes when subsequent elective coronary artery bypass grafting is required after percutaneous coronary intervention., Methods: Among 14,575 patients who underwent isolated first-time coronary artery bypass grafting between January 2000 and December 2010, 2501 who had previous percutaneous coronary intervention with stenting and fulfilled inclusion criteria were enrolled. Continuative statin therapy was used in 1528 patients and not used in 973 patients. Logistic multiple regression and propensity score analyses were used to assess the risk-adjusted impact of statin therapy on in-hospital mortality and major adverse cardiac events. The Cox proportional hazards model was constructed to assess the effect of continuative statin therapy on 24-month outcome., Results: At multivariate analysis, age more than 70 years, 3-vessel or 2-vessel plus left main coronary disease, multivessel percutaneous coronary intervention, ejection fraction 0.40 or less, diabetes mellitus, and logistic European System for Cardiac Operative Risk Evaluation 5 or greater were independent predictors of hospital mortality and major adverse cardiac events. After propensity score matching, conditional logistic regression analysis demonstrated that continuative statin therapy before coronary artery bypass grafting reduced the risk for hospital and 2-year mortality (odds ratio [OR], 0.27; 95% confidence interval [CI], 0.12-0. 57; P=.004 and OR, 0.6; 95% CI, 0.36-0.96; P=.04, respectively) and major adverse cardiac events (OR, 0.31; 95% CI, 0.18-0.78; P=.003 and OR, 0.5; 95% CI, 0.34-0.76; P=.006, respectively)., Conclusions: Long-term statin treatment after percutaneous coronary intervention improves early and midterm outcome when surgical revascularization will be required., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: An increasing number of patients presenting for urgent coronary surgery have been exposed to clopidogrel, which constitutes a risk of bleeding and related events. Based on the wide variability in clopidogrel response and platelet function recovery after cessation, we evaluated the role of point-of-care platelet function testing to define the optimal time for off-pump coronary artery bypass graft (CABG) surgery in a case-control study., Methods: Three equally matched groups (300 patients in total) undergoing isolated off-pump CABG for acute coronary syndrome were compared. Group A were treated with clopidogrel and prospectively underwent a strategy guided by platelet function testing. Outcomes were compared with 2 propensity score matched groups: group B underwent CABG after the currently recommended 5 days without clopidogrel; group C were never exposed to clopidogrel., Results: Patients in group A had reduced postoperative bleeding compared with those in group B (523±202 mL vs 851±605 mL; P<.001) and a lower number of units packed red blood cells (PRBCs) transfused during the postoperative hospital stay (1.2±1.6 units vs 1.9±1.8 units; P=.004). Postoperative bleeding and the number of units of PRBCs transfused were similar in group A and group C. There was no difference in blood-derived products and platelet consumption, mortality, or the need for reoperation among the groups. Patients in group A waited 3.6±1.7 days for surgery. The strategy used for group A saved 280 days of hospital stay in total., Conclusions: The strategy guided by platelet function testing for off-pump CABG offers improved guidance for optimal timing of CABG in patients treated with clopidogrel. This strategy significantly reduces postoperative bleeding and blood consumption, and has a shorter waiting time for surgery than current clinical practice., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Asymmetric septal hypertrophy frequently coexists with severe aortic stenosis and can be unmasked after successful aortic valve replacement (AVR), jeopardizing the clinical and echocardiographic results. The aim of our study was to investigate, at 5 years postoperatively, the effectiveness of myectomy associated with AVR on left ventricular (LV) mass regression and LV diastolic function., Methods: From 1997 and 2004, 86 patients with a diagnosis of severe aortic stenosis and asymmetric septal hypertrophy consecutively underwent AVR (group A) or AVR and concomitant myectomy (group B). To assess the improvement in LV mass and LV diastolic function, we studied the 52 survivors (23 in group A and 29 in group B) who had the same prosthesis type (beleaflet mechanical), the same size (21 mm), and the same follow-up length., Results: In group A, the LV mass index regressed from 119.2 ± 22.0 to 113.8 ± 21.8, and in group B, it regressed from 121.6 ± 20.8 to 112.7 ± 20.0 (P < .0005). In group A, the E/E' ratio improved from 15.3 ± 3.0 to 11.8 ± 3.0, and in group B, it improved from 16.2 ± 3.2 to 12.1 ± 3.3 (P = .02)., Conclusions: Surgeons should inspect the LV outflow tract at AVR. Concomitant myectomy at AVR is a safe and effective procedure that improves LV mass regression and LV diastolic function., (Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Aortic valve replacement leads to improvement of coronary flow but not to complete normalization. Coronary hypoperfusion contributes to higher left ventricular mass persistence, arrhythmias, congestive heart failure and sudden death. This prospective study compares 2 similarly sized aortic prostheses (mechanical and porcine) regarding coronary flow and hemodynamic performances in patients who underwent surgery for pure aortic stenosis., Methods: Sixty patients having undergone aortic valve replacement for pure aortic stenosis with Medtronic Mosaic Ultra bioprosthesis 21 mm (n = 30) or St Jude Regent mechanical valve 19 mm (n = 30) were evaluated preoperatively and 12 months postoperatively comparing the coronary flow and the hemodynamic behavior. Echocardiography and cardiac positron emission tomography were performed at rest and during exercise or adenosine maximal stimulation, respectively., Results: The St Jude Regent mechanical valve, compared with the Medtronic Mosaic Ultra bioprosthesis, had reduced coronary flow reserve (2.1 ± 0.3 vs 2.3 ± 0.2; P = .003), less favorable systolic/diastolic time ratio (0.87 ± 0.02 vs 0.78 ± 0.03; P < .001), and higher mean transprosthetic gradient (46 ± 11 vs 38 ± 9; P = .003) during exercise. Multivariate analysis of impaired coronary reserve related indexed effective orifice area less than 0.65 cm/m(2) (risk ratio [RR], 1.9; 95% confidence intervals [CI], 1.5-2.8; P < .001), mechanical valve (RR, 2.5; 95% CI, 1.7-3.3; P < .001), and systolic/diastolic time ratio greater than 0.75 (RR, 2.6; 95% CI, 1.8-3.8; P < .001), as well as high transprosthetic gradient (RR, 1.7; 95% CI, 1.3-2.4; P < .001) ) during exercise with coronary reserve less than 2.2., Conclusions: Improvement of coronary flow and reserve was more evident for bioprostheses than for mechanical valves. The bioprostheses demonstrated superior hemodynamics during exercise, which may have some impact on exercise capability during normal daily life., (Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Previous studies reported an association between chronic Helicobacter pylori infection and cardiovascular disease; however, controversy still exists regarding the presence of bacterial genomic material in atherosclerotic plaques. Currently, the genetic polymorphisms of H. pylori have been investigated and many virulence factors have been identified. No one has tried to associate these polymorphisms with aortic dissections. This study evaluated whether more virulent strains of H. pylori represent a risk factor for acute ascending aorta dissections., Methods: The serologic status for H. pylori and type I strains were determined in 100 patients who underwent operative repair of acute, ascending aorta dissection and in 100 population-based control subjects matched fully for clinical, demographic, and socioeconomic characteristics. The specimens from dissected aorta were evaluated to identify the presence of bacterial genomic material in surgical patients., Results: No evidence of genomic material from H. pylori was found in the specimens. The prevalence of positive H. pylori serology was greater in patients than in controls (72 vs 50) with an adjusted odds ratio 2.8 (95% confidence interval, 1.8-4.1; P = .006). Patients with aortic dissection also had a greater prevalence of vacuolating cytotoxin gene subtypes s1m1 (73% vs 31%) with an odds ratio of 6.0 (95% confidence interval, 3.1-11; P < .001). Patients who were positive for vacuolating cytotoxin gene subtypes s1m1 were similar in demographic and clinical features compared with other patients., Conclusion: The findings provide support for the hypothesis that an association exists between the more virulent type I strains of H. pylori (vacuolating cytotoxin gene subtypes s1m1) infection and acute aortic dissection. The mechanism(s) underlying the association remain to be elucidated., (Copyright © 2011 Mosby, Inc. All rights reserved.)

Background: We investigated whether the use of left ventricular-assisted (LVA) technique in beating heart myocardial revascularization would exert less impact on patients adhesion molecules and oxygenation index as compared with conventional cardiopulmonary bypass (CPB)., Methods: Sixty-six consecutive patients undergoing myocardial revascularization were randomly assigned either to LVA (group A, 34 patients) or CPB (group B, 32 patients). Adhesion molecules and oxygenation indexes were measured at baseline and at various time points postoperatively., Results: Pre-operative clinical and demographic data did not differ between the 2 groups. The 2 groups were also similar with respect to mortality, number of grafts performed, duration of extracorporeal circulation, and need for inotropes. However, postoperatively patients treated with LVA had a reduced levels of adhesion molecules compared with patients treated with CPB, as indicated by a significant difference in endothelial leukocyte adhesion molecule-1 (P = .002), intercellullar adhesion molecule-1 (P = .0001), and vascular cell adhesion molecule-1 (P = .004). The oxygenation index at 1 (P = .04) and 3 hours (P = .03) postoperatively was better in the LVA group than in the CPB group., Conclusion: Patients undergoing beating heart myocardial revascularization with LVA show reduced levels of adhesion molecules and better oxygenation index than patients treated with CPB., (Copyright 2010 Mosby, Inc. All rights reserved.)

Objectives: The influence of prosthesis-patient mismatch on outcome after aortic valve replacement is controversial. This study analyzed the impact of prosthesis-patient mismatch on survival, the extent of left ventricular mass, and physical capacity after replacement with a small-size prosthesis., Patients and Methods: A total of 157 patients who underwent valve replacement for pure aortic stenosis were reviewed. Late mortality, morbidity, left ventricular mass regression, transprosthetic gradient at rest and after exercise, exercise capacity, and occurrence of arrhythmias were evaluated., Results: Prosthesis-patient mismatch, defined as an indexed effective orifice area of 0.75 cm(2)/m(2) or more, occurred in 96 (61.1%) patients and had no significant impact on early and late mortality. The only independent predictor of mortality was age greater than 65 years. At follow-up, multivariate analysis of prosthetic gradient at rest of 35 mm Hg end exercise capacity or more revealed that both these evidences were associated with high left ventricular mass (P < .001), female gender (P < .001), and follow-up time (P < .001). Arrhythmias occurred during exercise in 34.1% of patients (40/117). Multivariate analysis of occurrence of arrhythmias revealed that they were associated with high mean transprosthetic gradients: values of 50 mm Hg or more during exercise had 95% sensitivity and 72% specificity for predicting arrhythmias., Conclusion: Prosthesis-patient mismatch failed to demonstrate any significant impact on early and late mortality and morbidity and in left ventricular mass regression. High transprosthetic gradients influence exercise capacity and occurrence of arrhythmias.

Objective: The role of matrix metalloproteinases and their tissue endogenous inhibitors has been documented in abdominal aortic aneurysms, but few articles have investigated their role after thoracic aortic aneurysm treatment. Our report investigates matrix metalloproteinases and tissue endogenous inhibitor-1 plasmatic changes in patients who have undergone endovascular aneurysm repair for descending thoracic aortic aneurysms and assesses their clinical significance., Methods: Thirty-two patients with thoracic aortic aneurysms who underwent endovascular aneurysm repair were compared with 25 healthy volunteers. Plasma matrix metalloproteinase-3/matrix metalloproteinase-9 and tissue endogenous inhibitor-1 values were determined by an enzyme-linked immunosorbent assay method at a predetermined time interval., Results: The preoperative levels of matrix metalloproteinases in the endovascular aneurysm repair group were 3-fold and 2-fold higher than those in the control group (P < .001 and .02, respectively). Matrix metalloproteinase values normalized after endovascular aneurysm repair, whereas patients experiencing endoleaks had higher matrix metalloproteinase values and matrix metalloproteinase-9/tissue endogenous inhibitor-1 ratio compared with the control group (P = .003, < .001, and = .02, respectively, at 1-month follow-up). These values normalized with the resolution of the endoleak., Conclusions: Plasma matrix metalloproteinase values are increased in patients with thoracic aortic aneurysms, along with reduced tissue endogenous inhibitor-1 expression. Successful endovascular aneurysm repair results in values normalization, whereas high levels persist in patients with endoleaks. The enzyme-linked immunosorbent assay test is a simple and reliable technique that is useful to assess the efficacy of endovascular aneurysm repair and to detect endoleaks.