Panoramic on Epigenetics in Coronary Artery Disease and the Approach of Personalized Medicine

Epigenetic modifications play a fundamental role in the progression of coronary artery disease (CAD). This panoramic review aims to provide an overview of the current understanding of the epigenetic mechanisms involved in CAD pathogenesis and highlights the potential implications for personalized medicine approaches. Epigenetics is the study of heritable changes that do not influence alterations in the DNA sequence of the genome. It has been shown that epigenetic processes, including DNA/histone methylation, acetylation, and phosphorylation, play an important role. Additionally, miRNAs, lncRNAs, and circRNAs are also involved in epigenetics, regulating gene expression patterns in response to various environmental factors and lifestyle choices. In the context of CAD, epigenetic alterations contribute to the dysregulation of genes involved in inflammation, oxidative stress, lipid metabolism, and vascular function. These epigenetic changes can occur during early developmental stages and persist throughout life, predisposing individuals to an increased risk of CAD. Furthermore, in recent years, the concept of personalized medicine has gained significant attention. Personalized medicine aims to tailor medical interventions based on an individual's unique genetic, epigenetic, environmental, and lifestyle factors. In the context of CAD, understanding the interplay between genetic variants and epigenetic modifications holds promise for the development of more precise diagnostic tools, risk stratification models, and targeted therapies. This review summarizes the current knowledge of epigenetic mechanisms in CAD and discusses the fundamental principles of personalized medicine.

Diagnostic and surgical management of HeartMate 3 outflow graft obstruction due to two different mechanisms

Outflow graft obstruction is a potentially catastrophic complication of left ventricular assist devices that may occur secondary to different mechanisms. Two cases of Heartmate 3 outflow graft obstruction associated with two different pathophysiological mechanisms are presented. The first one was a 70-year-old man who developed outflow graft obstruction secondary to kinking. The second case was a 72-year-old man who presented with signs and symptoms of heart failure due to outflow graft extrinsic obstruction. Both cases were diagnosed with 3D-CT scan and successfully surgically treated.

644 Clinical outcomes of patients with end-stage heart failure treated with left ventricular assist devices

Aims

During the last decades left ventricular assist devices (LVAD) have assumed a central role in the management of patients with symptomatic end-stage heart failure (HF). The mortality rate and prognosis of these patients is poor, but the substantial progress in LVAD technologies has led to significant improvements in clinical outcomes. The third generation LVADs are small, centrifugal flow pumps, contained within the pericardium and based on full magnetic levitation, which allow to reduce the risks of pump thrombosis. The aim of our study is to evaluate the clinical outcomes and functional capacity of patients with end-stage HF before and after the implantation of a third generation LVAD, the HeartMate 3™.

Methods and results

We evaluated eight patients with end-stage HF, followed to Cardiology Unit of Brotzu Hospital in Cagliari and consecutively implanted with the HeartMate 3™ LVAD in the Cardiac Surgery Unit from 12 May 2017 to 24 October 2019. For each patient we collected socio-demographic and clinical features, as well as laboratory tests, therapy, echocardiographic and haemodynamics parameters and any complication. Most of our patients were male (87.5%), with mean age 65.6 ± 5.7 years and higher prevalence of cardiovascular risk factors, like smoke (87.5%), hypertension (62.5%) and hypercholesterolaemia (62.5%). The etiology of HF was mainly due to idiopatic dilated cardiomyopathy (62.5%) and ischaemic heart disease (25%); the only female patient had a history of iatrogenic dilated cardiomyopathy, post-chemo and radiotherapy. Before the implantation most of our patients experienced severe symptoms, recurrent decompensations resulting in NYHA class IV (50%) and III (37.5%); the 100% was inotrope dependant and needed short-term support devices like IABP (75%) and ECMO (25%); the 62.5% underwent mechanical ventilation. The patients had severe left ventricular (LV) dysfunction, with low LV ejection fraction (18.6 ± 1.8%), cardiac output (3.08 ± 1.2 l/min) and cardiac index (1.81 ± 0.83 l/min/m2) and increasing filling pressure (26.5 ± 9.7 mmHg), central venous pression (12.7 ± 5 mmHg) and pulmonary arteries resistance (3.81 ± 1 μW). We also found important LV structural changes, with a severe dilatation and increased volumes (EDV 140.62 ± 67.1 ml/m2; ESV 113.7 ± 55.3 ml/m2). Mild right ventricle dysfunction was present only in 50% of patients with normal diameters. We observed few complications, mainly driveline infections (42.8%) and only one case of in-hospital mortality due to multiple organ failure. The seven patients presenting at FU shown a significant improvement in everyday symptoms and functional capacity compared to pre-operative features (P = 0.029). We also found a mild improvement of systolic LV function compared to pre-operatory values, with increase of CO (3.58 ± 0.65 l/min vs. 3.08 ± 1.2) and EF (21.2 ± 9.4% vs. 18.71 ± 97) even though not statistically significant.

Conclusions

Our study confirms that patients with end-stage HF are mostly male, older, experience severe symptoms and require frequent hospitalizations. The survival rate reached the 87.5% and remained stable even three years after implantation. On the whole our study showed that LVADs can significally improve clinical outcomes and survival rates, confirming the role as treatment of choice for many patients with end-stage HF who cannot undergo heart transplantation, which still remains the gold standard. The complications related to LVAD were few, thanks to careful patients selection, showing a favourable risk benefit ratio.

650 Quality of life of patients with end stage heart failure treated with left ventricular assist devices

Aims

Nowadays continuous flow left ventricular assist devices (LVAD) have become a reality for patients with end-stage heart failure (HF) who are failing maximal medical treatment, both eligible or not for heart transplantation. LVADs have demonstrated to improve functional capacity and clinical outcomes, including breathing and activity tolerance, but the impact on patients quality of life (QoL) is still a vexed and open question. Moreover, the device implantation actually requires significant life style changes, high motivation and adherence to treatment, both for patients and their caregivers. Patients must learn to live with the device and to interface with the controller and batteries system, adjusting everyday life’s activities to the device presence. The purpose of our study is to evaluate how the implantation of HeartMate 3™ impact on patients-related QoL and clinical outcomes, compared with general population and other chronic diseases.

Methods and results

Eight patients (pts) with a diagnosis of end-stage HF were implanted with the HeartMate 3™ LVAD from May 2017 to October 2019 in the Cardiac Surgery Unit of Brotzu Hospital. During a follow-up visit (28.7 ± 11.9 months after surgery), the 7 pts presenting were assessed with two questionnaires, the SF-12 and EuroQoL-5D, in order to evaluate improvement of quality of life compared with clinical presentation. Afterwards we compared the average SF-12 total result with 28 controls from general population and with other important chronic diseases. The analysis of SF-12 questionnaires showed an average of 28.00 ± 8.98 (VN: 12–47) as total score, 11.7 ± 3.4 (VN: 6–20) as physical health component score and 16.2 ± 6.5 (VN: 6–27) as mental health component score. These findings, though within the range of ‘normality’, are closer to the lower scores and show the negative impact of LVAD in everyday patients-related quality of life. Comparing the NYHA functional class with these results, we found a statistically significant negative linear correlation for both total (−0.80, P = 0.03) and mental health component scores (−0.75, P = 0.049). Average total score of our pts significatively differs compared with 28 controls of general population (28.00 ± 8.98 vs. 38.64 ± 6.80, P = 0.014), as well as compared with other chronic diseases like Wilson’s disease (P < 0.001), celiac disease (P < 0.001), obsessive-compulsive disorder (P < 0.001), panic disorder (P < 0.001), major depressive disorder (P = 0.009), multiple sclerosis (P < 0.011), food disorders (P = 0.023), and carotid atherosclerosis (P = 0.049). The EuroQoL-5D questionnaire investigates five particular ‘dimensions’ of the subjectively perceived health-related quality of life (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) and shows similar. We found a poor average score at Visual Analogue Scale (58.5 ± 18.86) and a statistically significant negative linear correlation with NYHA functional class (−0.76, P = 0.046). The 42.86% referred no pain or discomfort and in the other four dimensions most of them reported ‘moderate limitations’, both physical or mental, especially for self-care domain (85.71%), as inevitable result of the device’s size.

Conclusions

LVAD can improve clinical outcomes and functional capacity of carefully select pts with end-stage HF, but the complications encountered during mechanical support and the lifestyle changes required can affect negatively patients well-being. Many studies have shown that most patients experience significant improvement even in QoL’s perception but for others the device have a negative impact on many aspects of normal daily living as well as emotional, mental and social functioning. Our study confirms this conflicting results: physical related-quality of life improves after LVAD implantation but emotional and psychological distress may persist, especially during long-term support, as a result of complications, co-morbidities and personal’s attitudes, values and way of life.

Durability of the Liotta porcine bioprosthesis beyond two decades

Porcine valves are generally known to have a limited durability. The case is reported of a 35-year-old male patient who underwent mitral valve replacement with a 28 mm Liotta porcine bioprosthesis. At reoperation 21 years later, the bioprosthesis was replaced (uneventfully) with a second porcine bioprosthesis. Pathological and X-radiographic examinations of the excised valve demonstrated focal calcification of the leaflets, confirming the long-term durability of the Liotta porcine bioprosthesis.

[Omentopexy associated with the use of Redon catheters in post-cardiac surgery mediastinitis with vascular prosthesis infection: immediate results in five patients]

BACKGROUND

Post-cardiac surgery mediastinitis is a dangerous complication with an elevated mortality risk particularly when infection affects vascular prostheses. In this paper we report our experience with the use of extensive disinfection and washing of the mediastinum with iodopovidone, followed by omental transposition into the chest with the use of Redon catheters.

METHODS

Between September 2001 and March 2007, 5 patients were treated with this technique (submitted to Bentall intervention in 2 cases, substitution of the ascending aorta, Bentall intervention with substitution of the aortic arch and substitution of the aortic arch in 1 case, respectively), due to a sternomediastinitis and correlated infection of the vascular prosthesis. Among them, 3 consisted of a redo surgery.

RESULTS

One patient with unstable hemodynamic conditions died of multiorgan failure following a state of generalized sepsis; the remaining 4 patients had complete resolution of the clinical picture. None showed complications related to the procedure. The 4 survived patients were followed up at 1 month and underwent clinical and instrumental evaluation by chest computed tomography, which yielded negative results without signs of infection.

CONCLUSIONS

Our limited experience definitely encourages us to use these combined techniques in the treatment of post-cardiac surgery mediastinitis in patients with vascular prostheses.

Clinical outcomes of mitral valve repair with the Colvin-Galloway Future Band: a single-center experience

OBJECTIVES

In 2001, a semirigid band (Colvin-Galloway Future Band, Medtronic, Inc., Minneapolis, Minnesota, USA) for mitral valve repair came onto the market. We report our experience of the correction of all types of mitral regurgitation using this device.

METHODS

From August 2003 to December 2006, 140 patients (71% men, mean age 64 +/- 11 years) underwent valvuloplasty with this device for all types of mitral regurgitation: 94 (67%) degenerative, 34 (24%) postischemic, 11 (8%) dilative cardiomyopathy, and one (1%) postendocarditic. The patients underwent clinical and echocardiographic evaluation preoperatively, postoperatively before discharge, and after a median follow-up of 7 months (25th-75th percentile, 4-24 months).

RESULTS

Total mortality was 6.4% (nine out of 140 patients): four patients (2.8%) died within 30 days (early death) and five died subsequently (the cause was cardiac in one case). Predischarge echocardiographic examination revealed a reduction in mitral regurgitation of at least 2 degrees in 99.2% of patients and the absence of systolic anterior movement. At the last follow-up, we recorded an improvement in New York Heart Association functional class (2.4 +/- 0.9 vs. 1.1 +/- 0.4, P < 0.0001), a significant reduction in the degree of mitral regurgitation (3.5 +/- 0.9 vs. 0.9 +/- 0.5, P < 0.0001), an increase in ejection fraction (54 +/- 11 vs. 55 +/- 9, P = 0.09), and a significant reduction in end-diastolic diameter (59 +/- 6 vs. 55 +/- 6, P < 0.0001). Two patients were reoperated on for mitral valve replacement, and no postoperative thromboembolic events occurred.

CONCLUSION

Our experience shows that the Colvin-Galloway Future Band yields good results in mitral valvuloplasty for all types of mitral regurgitation. We are encouraged to continue using this device.

[Bentall operation after previous repair of tetralogy of Fallot]

Pathologies that involve the ascending aorta are described in case reports of patients after complete repair of tetralogy of Fallot. Here, we present a case report. Preoperative tests showed an aortic ratio of > 1.5. The patient was operated on replacement of the ascending aorta according to the Bentall technique. At present, the guidelines for replacement of the ascending aorta recommend an aortic ratio of > 1.5 and in case of Marfan syndrome of > 1.3. In these patient subsets, cystic medial necrosis and an increased risk of aortic dissection have been described. Therefore, as for Marfan syndrome, why an aortic ratio of >1.3 should not be considered a proper surgical indication also for these patients?

[Surgical treatment of chronic thromboembolic pulmonary hypertension with pulmonary endarterectomy]

Acute pulmonary embolism is the third most common cardiovascular disease in Italy with approximately 65 000 new cases a year. Appropriate medical therapy does not necessarily prevent evolution of acute pulmonary embolism into chronic thromboembolic pulmonary hypertension (CTEPH), which occurs in 0.1-4.0% of cases. In our country, there are approximately up to 2600 new CTEPH patients a year. CTEPH is a progressive and potentially lethal disease. Medical therapy is palliative and only surgery can modify its natural history. Pulmonary endarterectomy (PEA) is the treatment of choice and lung transplantation should be considered only when PEA is contraindicated. Currently, nearly 4000 PEAs have been performed worldwide. Approximately ten centers are able to carry out this intervention with excellent and permanent results. Solid experience and close multidisciplinary collaboration allow appropriate patient selection, rigorous surgical technique, and adequate postoperative management. All these aspects represent the key to the success in the treatment of CTEPH. After PEA, quality and expected length of life are similar to the age-matched general population and the only therapy required is oral anticoagulation.