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1.  The impact of drug eluting stents availability on the treatment choice among medical therapy, percutaneous or surgical revascularisation and on 4-year clinical outcome in patients with coronary artery disease: a cohort study 
BMJ Open  2012;2(5):e001926.
To investigate the influence of the availability of drug eluting stents (DES) on treatment choice (TC) among medical therapy (MT), coronary by-pass surgery (CABG) or percutaneous coronary interventions (PCI) and the consequent clinical outcomes in patients hospitalised because of coronary artery disease (CAD).
Observational study comparing two cohorts hospitalised immediately before, and 3 years after DES availability.
Thirteen hospitals with cardiology facilities.
2131 consecutive patients with at least one coronary stenosis >50% at coronary angiography (CA) after exclusion of those with acute myocardial infarction or previous CABG or associated relevant valvular disease.
Main outcome measures
Treatment choice after CA and 4-year clinical outcomes.
TC among MT (27% vs 29.2%), PCI (58.6% vs 55.5%) and CABG (14.5% vs 15.3%) was similar in the DES and bare metal stent (BMS) periods (p = 0.51). At least one DES was implanted in 57% of patients treated with PCI in 2005. After 4 years, no difference in mortality (13.8% vs 13.2%, p = 0.72), hospital admissions for myocardial infarction (6.6% vs 5.2%, p = 0.26), stroke (2.2% vs 1.7%, p = 0.49) and further revascularisations (22.3% vs 19.7%, p = 0.25) were observed in patients enrolled in the DES and BMS periods. Only in patients with Syntax score 23–32 a significant change of TC (p = 0.0002) occurred in the DES versus BMS period: MT in 17.4% vs 31%, PCI in 62.2% vs 35.8%, CABG in 20.3% vs 33.2%, with similar 4-year combined end-point of mortality, stroke, myocardial infarction and further revascularisations (45.3% vs 34.2%, p = 0.087).
Three years after DES availability, the TC in patients with CAD has not changed significantly as well as the 4-year incidence of death, myocardial infarction, stroke and further revascularisations. In subgroup with Syntax score 23–32, a significant increase of indications to PCI was observed in the DES period, without any improvement of the 4-year clinical outcome.
PMCID: PMC3488738  PMID: 23103608
2.  Microembolic signals and strategy to prevent gas embolism during extracorporeal membrane oxygenation 
Extracorporeal membrane oxygenation (ECMO) supplies systemic blood perfusion and gas exchange in patients with cardiopulmonary failure. The current literature lacks of papers reporting the possible risks of microembolism among the complications of this treatment.
In this study we present our preliminary experience on brain blood flow velocity and emboli detection through the transcranial Doppler monitoring during ECMO.
Six patients suffering of heart failure, four after cardiac surgery and two after cardiopulmonary resuscitation were treated with ECMO and submitted to transcranial doppler monitoring to accomplish the neurophysiological evaluation for coma.
Four patients had a full extracorporeal flow supply while in the remaining two patients the support was maintained 50% in respect to normal demand.
All patients had a bilateral transcranial brain blood flow monitoring for 15 minutes during the first clinical evaluation.
Microembolic signals were detected only in patients with the full extracorporeal blood flow supply due to air embolism.
We established that the microembolic load depends on gas embolism from the central venous lines and on the level of blood flow assistance.
The gas microemboli that enter in the blood circulation and in the extracorporeal circuits are not removed by the membrane oxygenator filter.
Maximum care is required in drugs and fluid infusion of this kind of patients as a possible source of microemboli. This harmful phenomenon may be overcome adding an air filter device to the intravenous catheters.
PMCID: PMC2825509  PMID: 20132556
3.  Microbubbles detection during cardiopulmonary bypass with transoesophageal echocardiography: a case report 
Cases Journal  2008;1:141.
Microembolic signals are usually detected with transcranial doppler during cardiac surgery.
This report focuses on suggesting the transesophageal echocardiography as a different diagnostic approach to detect microemboli during cardiopulmonary bypass.
Case presentation
A 58 year old male patient, caucasian race, was operated on video assisted minimally invasive mitral valve repair using right minithoracotomy approach. His past medical history included an uncontrolled hypertension, dyslipidemia, insulin dependent diabetes mellitus, carotid arteries stenosis. The extracorporeal circulation was performed with femoral-femoral artery and venous approach. Negative pressure for vacuum assist venous drainage was applied in order to facilitate venous blood return. The patient had a brain monitoring with bilateral transcranial doppler of middle cerebral arteries and a double channels electroencephalogram. A three dimensional transesophageal echocardiography to evaluate the mitral valve repair was performed.
During the cardiopulmonary bypass a significant microembolic activity was detected in the middle cerebral arteries spectrum velocities due to gas embolism from venous return. Simultaneous recording of microbubbles was also observed on the descending thoracic aorta transesophageal echo views.
During the aortic cross-clamping time the transesophageal echocardiography can be useful as an alternative method to assess the amount of gas embolism coming from cardiopulmonary bypass. These informations can promote immediate interaction between perfusionist, surgeon and anesthesiologist to perform adequate manoeuvres in order to reduce the microembolism during extracorporeal circulation.
PMCID: PMC2542348  PMID: 18775067
4.  Brain function monitoring during off-pump cardiac surgery: a case report 
Cases Journal  2008;1:94.
Early postoperative stroke is an adverse syndrome after coronary bypass surgery. This report focuses on overcoming of cerebral ischemia as a result of haemodynamic instability during heart enucleation in off-pump procedure.
Case presentation
A 67 year old male patient, Caucasian race, with a body mass index of 28, had a recent non-Q posterolateral myocardial infarction one month before and recurrent instable angina. His past history includes an uncontrolled hypertension, dyslipidemia, insulin dependent diabetes mellitus, epiaortic vessel stenosis. The patient was scheduled for an off-pump procedure and monitored with bilateral somatosensory evoked potentials, whose alteration signalled the decrement of the cardiac index during operation.
The somatosensory evoked potentials appeared when the blood pressure was increased with a pharmacological treatment.
During the off-pump coronary bypass surgery, a lower cardiac index, predisposes patients, with multiple stroke risk factors, to a reduction of the cerebral blood flow. Intraoperative somatosensory evoked potentials monitoring provides informations about the functional status of somatosensory cortex to reverse effects of brain ischemia.
PMCID: PMC2531095  PMID: 18706094

Results 1-4 (4)