Surgical Management of Type A Acute Aortic Dissection in Patients With Marfan Syndrome: A Single Center Experience.

Introduction: Acute aortic dissection is the most common cause of death in patients with Marfan syndrome and untreated aortic root enlargement. Emergency surgery for replacement of the ascending aorta has the potential of life saving procedure, but is associated with high morbidity and mortality. Long-term outcomes after surgical repair of acute aortic dissection type A in patients with Marfan syndrome are limited. Material and methods: We made a retrospective study concerning emergency surgical intervention for acute aortic dissection type A, by Bentall procedure, performed in Emergency Institute for Cardiovascular Diseases "Prof dr. C. C. Iliescu" Bucharest between January 2005 and July 2014. We included 332 patients with type a acute aortic dissection divided into two groups: group A - 16 patients with Marfan syndrome and group B - 316 patients with other etiologies. We analyzed differences between these two groups regarding perioperative characteristics, surgical technique and short and long-term morbidity and mortality. Results: The patients from group A were significantly younger than those in group B (35.1±12.7 years vs. 56.8±7.1 years; p<0.001). Arterial hypertension was three times more common in group B as compared to group A (p<0.001). The incidence of postoperative morbidity, and intraoperative and 30-days mortality death rates were similar between groups, but overall mortality at 10 years was lower in group A (31.3%) vs. group B (44.9 %). Conclusions: Emergency surgical in Marfan syndrome, by Bentall procedure could improve perioperative morbidity and mortality of patients with acute aortic dissection, but need an early diagnosis, proper medical therapy and imagistic surveillance.

Aortic regurgitation due to quadricuspid aortic valve--case report and literature review.

Quadricuspid aortic valve is a rare variant of aortic semilunar valve, often being an unexpected discovery during cardiac surgery. We present the case of a 59 years old patient, who was admitted for dyspnea on light exertion and palpitations. The transthoracic echocardiography revealed severe aortic valve regurgitation due to a quadricuspid aortic valve, the result being confirmed by the transesophageal echo examination. The patient had a first class indication for aortic valve replacement and the surgical intervention was uneventful. The operative technique and case particularities are discussed in view of the literature published so far regarding this uncommon condition.

Pyoderma gangrenosum--a postoperative "pseudo-infection".

Pyoderma gangrenosum is a skin ulcerative necrosis, due to dermal neutrophilic infiltration, through a non-infectious exacerbation of cell -mediated immunity. Being characterized by pathergy, the disease may be triggered by surgery; in this case, it is easily mistaken for a postoperative infection. We report a case of pyoderma gangrenosum after coronary artery bypass surgery. The patient developed, from the 7th postoperative day, around the incisions, dermo-epidermic lesions specific for the disease, high fever with chills and a severe biological inflammatory syndrome. Treatment for wound sepsis was ineffective. After pyoderma gangrenosum was recognized, corticosteroids (Prednisone 80 mg/d) led, in two days time, to a spectacular improvement, and in 7 weeks, to complete epithelization of the lesions. If after debridement of a supposedly infected wound (with pustules, bullae or ulcerations), there is no improvement, but a centrifugal extension of the lesions, with a "sepsis-like" syndrome and persistent negative cultures, one should think at pyoderma gangrenosum; in that case, not the antibiotics, but corticosteroids (or other immunosuppressants) are the treatment.

[Second recurrence of cardiac myxoma 7 years after the initial operation]. / A doua recidiva a unui mixom cardiac aparuta la 7 ani de la prima operatie.

We report a rare case of a 23-year-old woman in who recurrent multiple cardiac myxomas were resected first time 4 years after the initial operation and second time three years after the second operation. In February 2000, she was diagnosed with right ventricular myxoma. The initial cardiac tumor was successfully resected through a right atrium approach and the tricuspid valve was changed with a biological prosthesis; the patient has been followed-up by ultrasound echocardiography every 6-month after discharge. Four years after, the echocardiography revealed one masse in the left atrium, which was resected using a trans-septal approach. Due to malfunction of the tricuspid prosthesis, this was changed with a biological one. After another three years, the echocardiography revealed once again two masses, this time in the right atrium and left ventricle. The third surgery was performed and all 2 myxomas were successfully resected through a combined right atrial and left ventricle approach. One year after the third operation, she has been doing well without any sign of recurrence of myxoma. A long-term follow-up is mandatory in patients after the resection of a cardiac myxoma.

[The surgical angioplasty of the left main coronary ostial stenosis--a low risk operation]. / Plastia de largire a ostiului coronarian stâng--o interventie chirurgicala cu risc scazut.

To evaluate a different technique for the treatment of the left main coronary artery ostial stenosis, the coronary ostial surgical angioplasty. Three patients underwent this operation. After placing the patient on cardiopulmonary bypass and aortic cross clamping, the main pulmonary trunk was retracted laterally. The left main coronary artery was approached anteriorly through a curved aortotomy. Reconstruction was performed using fresh or treated with glutaraldehyde pericardial patch. There were no in-hospital deaths. In one case, the aortic suture had to be reconstructed with a GoreTex patch. We didn't note other complications. The patch plasty of the left main coronary trunk is a safe procedure, with no important complications, despite its technical difficulty.

[Fungal native aortic valve endocarditis. Combined medico-surgical treatment]. / Endocardita fungica de valva aortica nativa. Rezolvare medico-chirurgicala.

The fungal etiology of the native aortic endocarditis is a rare situation. Most often the etiologic factors are medical manoeuvres like cardiovascular surgery (cardiac prosthesis), cardiac defibrillators or stimulators, the prolonged use of the intravenous catheters, antibiotics, immunosuppressors, etc. We are presenting the case of a patient with cardiac stimulator, with rare fungal native aortic endocarditis, complicated with cerebral embolization, in which we have chosen a combined therapy: aortic replacement with biologic prosthesis and pre and post operative anti fungal therapy. We are considering that in this case the combined medico-surgical therapy was the right choice.

[A comparison between systolic pressure variations under mechanical ventilation and classic pressure parameters in predicting fluid responsiveness in patients after coronary surgery]. / Studiu comparativ intre variatiile presiunii arteriale sistolice si parametrii presionali clasici in predictia raspunsului hemodinamic la umplere la pacientii post by-pass aorto-coronarian.

Evaluation of the value of the systolic pressure variations (SPV) under mechanical ventilation and of its components (delta down and delta up) in predicting fluid responsiveness in patients after coronary surgery by comparison with classic parameters. A prospective,randomized study, on 50 patients who underwent CABG surgery, in the early postoperative period (the first two hours). We assessed the following parameters: CO, CI, CVP, PCWP, SAP, DAP, MAP, SVP, delta down and delta up. The including criteria were: sinus rhythm, CI < or = 2,5 l/min/m2, PCP < 18 mmHg. All the patients underwent a fluid challenge (500 ml of colloids in 10 min). Three patients were excluded: 3 for a PCWP > 18 mm Hg, 1 for loosing the sinus rhythm and 1 for an early return in the OR for bleeding. After a new assessment of the same parameters the patients were divided in two groups: group A (28 pts) with a raise of CI > 15%, and group B (22 pts) with a CI variation < 15%. In each group was statistically analyzed the variation of each parameter. Results Both parameters provided by SPV analysis are able to predict the fluid responsiveness with a great accuracy: the positive predictive value of a SPV > 12 mmHg is above 92,85% and of a delta down > 5 mm Hg is above 96,42%; the negative predictive value of a SPV < or = 12 mmHg is above 90,90% and of a delta down = 5 mm Hg is above 95,45%. None of the "classic" pressure parameters (MAP, CVP, PCWP) used in hemodynamic assessment have revealed a statistical significant variation. The SVP method's parameters are superior to classic pressure parameters (MAP, CVP, PCWP) in predicting fluid responsiveness in patients after coronary surgery.

The brachio-brachial arteriovenous fistula: a new method in patients without a superficial venous system in the upper limb.

PURPOSE: This study aimed to report our experience in the creation of brachio-brachial arteriovenous fistulas (AVFs) in patients without adequate superficial venous circulation at the upper limb. METHODS: A retrospective study of 33 patients, operated on between 2004-2005, in whom we created a brachio-brachial fistula between the brachial artery and the brachial vein. After dissection and adequate mobilization, the brachial vein was anastomized to the brachial artery in an end-to-side fashion. After the maturation period (1 month) the brachial vein was transposed into the subcutaneous tissue. RESULTS: Thirty-three patients underwent 33 brachio-brachial fistula constructions. Primary patency was achieved in all patients. After 1 month, 27 fistulas (81.8%) were functional. Six patients developed fistula occlusion. The 27 remaining patients had subsequently good fistulas for hemodialysis (HD) afterwards. Discrete edema of the forearm was noted in 12 patients (36%); in one of these patients the edema was extended to the entire arm. No other complications were noted. A follow-up study, extended from 3-26 months (mean 14 +/- 6.6 months), was performed. The overall patency rate of the brachio-brachial fistula at the end of the follow-up was 85.2%. CONCLUSIONS: The brachio-brachial fistula can represent a viable choice in patients with an inadequate superficial venous system in the upper limb.

[Pulmonary embolism--complication of proximal deep venous thrombosis in colorectal cancer. Diagnosis and management]. / Tromboembolismul pulmonar--complicatie a tromboflebitei proximale paraneoplazice în cadrul neoplasmului colo-rectal. abordare diagnostica si terapeutica.

We present the case of a 57 years old male, without cardiovascular history, with colorectal cancer and proximal deep venous thrombosis, who develops a massive pulmonary embolism. The surgical treatment consists in embolectomy of right ventricle, pulmonary trunk, left and right pulmonary artery. The specifics of the case is discussed: etiology and prevention of pulmonary embolism (caval filter) and treatment: the contraindications of thrombolytic therapy and the indications and perspectives of surgical treatment.

In vitro production of the general transformation antibody related to survival in human cancer patients: antimalignin antibody.

Human antimalignin antibody (AMA) appears to have clinical significance because in actuarial studies its concentration relates quantitatively to survival (Bogoch et al. Protides Biol Fluids 1984; 31:739-747). Therefore isolation, characterization, and production in vitro of AMA were undertaken. Serum AMA concentrations are elevated in cancer, regardless of cell type, as demonstrated by earlier blind studies of 1,026 (Bogoch et al. J. Med 1982; 13:49-69) and 501 (Bogoch and Bogoch. Protides Biol Fluids 1983; 30:337-352) and independently confirmed by others on 354 (Bogoch et al. Protides Biol Fluids 1984; 31: 739-747) cancer patients and controls. Mouse monoclonal AMA was produced earlier (Bogoch et al. Lancet 1981; 2:141-142). To validate the identity of the natural substrate AMA in the serum determination (AMAS test) and to prepare for human imaging and therapeutic trials, human AMA has now been produced in vitro from human lymphocytes and has been shown to be increased when primed with its specific 10,000-dalton peptide antigen malignin. This synthesized human AMA adsorbs specifically to its immobilized antigen in vitro and resembles in cancer cell staining and in other properties human AMA isolated from sera of cancer patients and mouse monoclonal AMA. All are predominantly IgM, as shown by reduction to heavy and light chains followed by sodium dodecyl sulfate-polyacrylamide gel electrophoresis.

B cell growth and differentiation induced by supernatants of transformed epithelial cell lines.

Growth and differentiation of B cells is thought to be regulated by soluble factors derived from T cells. However, human T cell lines and hybridomas have proved to be notoriously unreliable and unstable sources of such factors. We report here that three stable human bladder carcinoma cell lines T24, RT4 and 5637 produce, in a constitutive fashion, factors which promote growth and differentiation of human B cells.

Epstein-Barr virus infection and immunity in bone marrow transplant recipients.

Studies on patients for up to one year following allogeneic, HLA-matched bone marrow transplants have shown no increased incidence of salivary Epstein-Barr (EB) virus secretion and no significant rise in EB-virus-specific antibody titers. EB-virus-specific cytotoxic T cells could be detected in the peripheral blood of all patients by six months posttransplant. For up to one year posttransplantation in vitro EB virus infection of peripheral blood B lymphocytes from the majority of patients leads to an abortive infection followed by cell death, and without the establishment of continuously growing cell lines. This abnormality appeared to be due to patients' monocytes, which formed a defective feeder cell layer in culture, and it could be circumvented by culturing the EB-virus-infected B cells from patients on a feeder layer of x-irradiated adherent cells from normal peripheral blood. These findings may explain the relative lack of EB-virus-associated lymphoma seen in bone marrow transplant recipients when compared with other groups of transplant patients.

Epstein-Barr (EB) virus infection in homosexual men in London.

Twenty five homosexual men from London, 14 of whom had persistent lymphadenopathy and 11 of whom did not, were tested for immunity to Epstein-Barr (EB) virus. All yielded positive results to serological tests for the viral capsid antibody, and 11 had antibodies to the early antigen. Thirteen out of 17 were excreting virus into the saliva; culture of peripheral blood mononuclear cells from two of these patients showed no detectable regression induced by T cells that was specific to EB virus. No differences were found between the patients with and without lymphadenopathy. Peripheral blood B cells from six patients with hypergammaglobulinaemia were double stained for cytoplasmic immunoglobulin and EB viral nuclear antigen, and in all cases the activated B cells producing immunoglobulin did not contain EB nuclear antigen. Similarly, lymph node biopsy specimens from five patients showed no cells with EB nuclear antigen. These results indicate that although homosexual men have a high incidence of reactivated infection with EB virus, this viral infection is not the cause of the polyclonal activation of B cells seen in peripheral blood and is not implicated in the aetiology of the lymphadenopathy found in these men.

Expression of HLA-DR antigens in nasopharyngeal carcinoma: an immunohistological analysis of the tumour cells and infiltrating lymphocytes.

A panel of conventional and monoclonal antibodies was used to examine the immunohistological characteristics of malignant epithelial cells and infiltrating lymphocytes in frozen sections of nasopharyngeal carcinoma (NPC) biopsies from 10 Tunisian patients. Three main categories of cells were identified. (1) Tumour cells which were positive for Epstein-Barr nuclear antigen, HLA-ABC and keratin determinants. In most samples, the tumour cells also expressed variable amounts of HLA-DR antigens. The presence of HLA-DR antigens has not been previously reported in NPC and may be a contributory factor in effecting the transfer of Epstein-Barr virus to the epithelial cells. (2) Infiltrating lymphocytes which were mainly composed of T inducer (T4+) and T suppressor/cytotoxic (T8+) cells although one sample contained predominantly immature T cells expressing the HTA-I+ cortical thymocyte phenotype. Few B cells or natural killer cells were demonstrated. (3) Large HTA-I+ dendritic cells which were invariably present within the tumour masses. These were morphologically and phenotypically similar to antigen presenting Langerhans cells which are usually located in the skin but also found in other epithelial sites. These cells may be a residual population from the normal nasopharynx or represent part of a specific immunological response to the presence of Epstein-Barr virus in the epithelial cells.

Homosexual men in London: lymphadenopathy, immune status, and Epstein-Barr virus infection.

By November 7, 1983, 24 cases of AIDS in the United Kingdom had been reported to the Communicable Disease Surveillance Centre. At the same time an increasing number of homosexual men with unexplained lymphadenopathy syndrome (LAS) have been seen in our department. Between December 1982 and July 1983, 14 homosexual men with LAS and 11 healthy homosexual men were studied. Patients with LAS had a high number of lifetime episodes of sexually transmitted diseases, a history of recent sexual activity in the United States (9 of 14), sexual contact with British AIDS patients or other persons with LAS (7 of 14), and hypergammaglobulinemia. Low T-helper/T-suppressor ratios (less than 0.8), due mainly to a decrease in T-helper cells, were found in both groups. Lymph node biopsies showed follicular hyperplasia and hypocellular pattern. All 25 patients studied had antibodies to Epstein-Barr virus capsid antigen (anti-VCA) and 11 had antibodies to early antigen (anti-EA); 13 of 17 were excreting the virus; and two showed no Epstein-Barr-virus-specific regression. Peripheral blood immunoglobulin-producing B-cells from six patients with hypergammaglobulinemia were negative for the Epstein-Barr virus nuclear antigen (EBNA). Five lymph node biopsies showed no EBNA-positive cells. Epstein-Barr virus reactivation is common in the patients with LAS and healthy homosexual men in London, but would not seem to be the cause of the polyclonal B-cell activation or lymphadenopathy.

Characterisation of Epstein-Barr virus-specific memory T cells from the peripheral blood of seropositive individuals.

We have investigated the regression phenomenon which occurs when EBV-infected peripheral blood mononuclear cells from seropositive individuals are cultured for one month at high cell concentration and have confirmed that regression is mediated by E+ lymphocytes. When helper/inducer (Leu 3a+) and suppressor/cytotoxic (Leu 2a+) cells are separated by fluorescence-activated cell sorting from fresh peripheral blood and co-cultured with EBV-infected autologous E- mononuclear cells, regression only regularly occurs in cultures receiving suppressor/cytotoxic lymphocytes. Titration experiments show that suppressor/cytotoxic lymphocytes are more active in the regression assay that unfractionated E+ cells. When Ia+ E+ and Ia- E+ cells are separated one week after initiation of co-cultures of E+ cells and EBV-infected E- cells, both Ia+ E+ and Ia- E+ cells are active in the regression assay although regression occurs earlier in cultures receiving Ia+ E+ cells. Experiments in which NK cells are isolated using the monoclonal antibodies H25 and H366 show that NK cells do not influence the regression phenomenon in normal individuals.

Erythrodermia sézary with immunological deficiency and antibodies against human albumin.

A case of erythrodermia Sézary, in which lymphocyte stimulation tests and quantitation of T and B lymphocytes were performed, is reported. The patient developed during 10 years of evolution an immunological deficiency with low IgA, IgG and IgM values. Passive hemagglutination techniques showed an antibody titer of 1:8000 against human serum albumin.