Root-commando operation with a modified self-assembled aortic root conduit for endocarditis after sutureless aortic valve replacement.

We present a case of a Staphylococcus epidermidis early prosthetic valve endocarditis after minimally invasive sutureless aortic valve replacement. The patient developed a root abscess with a fistula, severe mitral and periprosthetic regurgitations, with a large mitral vegetation and a residual patent foramen ovale. The surgical approach consisted of a redo median sternotomy, explantation of a sutureless aortic prosthesis, resection of an intervalvular fibrosa and anterior mitral leaflet and debridement of an aortic root-left ventricle outflow tract abscess. These procedures were followed by a root-commando procedure with mitral and aortic root placement using a self-assembled mechanical aortic root conduit. The technique used is an alternative to a root-commando procedure performed with an allograft or a Medtronic Freestyle bioprosthesis. The same technique can be utilized with a commercially available stented bioprosthesis.

Non-Pharmacological Stroke Prevention in Atrial Fibrillation.

Atrial fibrillation (AF) is the most common arrhythmia worldwide. It is associated with increased mortality and morbidity, especially due to the increased risk of ischemic stroke and systemic embolism in these patients. For this reason, thromboembolism prevention is the cornerstone of managing AF, and oral anticoagulation is nowadays the first-line treatment. However, since most thrombi form in the left atrial appendage and anticoagulant therapy may have side effects and be contraindicated in some patients, surgical and percutaneous left atrial appendage occlusion (LAAO) have emerged as a non-pharmacological alternative. This review summarizes all existing evidence on surgical and percutaneous LAAO.

Age matters: variations in parasitoid diversity along a successional gradient in a dry semi-deciduous tropical forest.

Parasitoids are an important group of insects because their species number is among the highest. Multiple studies have addressed the relationships between forest successional age and insect diversity by focusing on herbivorous organisms, but changes in diversity of parasitoids are still poorly known. This work analyses the diversity of parasitoids in tropical forests representing three successional stages. A total of 30 traps were placed, ten in each forest successional stages. We estimated true diversity of Ichneumonidae species and guilds and explored the relationship between their diversity and the abundance of plant species using an Indicator Species Analysis; the relationship between parasitoid species and plant richness and abundance was tested using a Redundancy Analysis. A total of 1522 individuals and 168 morpho-species were captured in four months. Species richness showed no differences; however, parasitoid abundance was higher in young forest, while intermediate forest had the highest true diversity values (1D) with 71.6 effective species. According to insect guilds, richness, abundance, and diversity were similar in the three vegetation successional stages. This finding may be explained based on the intermediate disturbance hypothesis, which postulates that moderate disturbance levels favor the highest diversity. In conclusion, successional age matters, i.e., diversity is the highest in intermediate stages, while the old forests harbors guilds unique to that successional stage, such as parasitoids of melitophagous larvae of bees. Other successional stages were characterized by a single species of parasitoid, belonging to the genera Eiphosoma and Anomalon, which may indicate altered and preserved forests, respectively.

Cardiac retransplantation.

An orthotopic heart transplant remains the gold standard treatment for patients with end-stage heart failure. Despite significant developments and the widespread use of durable mechanical circulation support, a small number of patients will be considered for a heart retransplant. In this video tutorial, we describe the strategy and technique for patients who have already received an orthotopic heart transplant and who undergo a cardiac retransplant with a modified bicaval anastomosis technique.

Repair of mitral prolapse: comparison of thoracoscopic minimally invasive and conventional approaches.

OBJECTIVES: Surgical repair remains the best treatment for severe primary mitral regurgitation (MR). Minimally invasive mitral valve surgery is being increasingly performed, but there is a lack of solid evidence comparing thoracoscopic with conventional surgery. Our objective was to compare outcomes of both approaches for repair of leaflet prolapse. METHODS: All consecutive patients undergoing surgery for severe MR due to mitral prolapse from 2012 to 2020 were evaluated according to the approach used. Freedom from mortality, reoperation and recurrent severe MR were evaluated by Kaplan-Meier method. Differences in baseline characteristics were adjusted with propensity score-matched analysis (1:1, nearest neighbour). RESULTS: Three hundred patients met inclusion criteria and were divided into thoracoscopic (N = 188) and conventional (sternotomy; N = 112) groups. Unmatched patients in the thoracoscopic group were younger and had lower body mass index, New York Heart Association class and EuroSCORE II preoperatively. After matching, thoracoscopic group presented significantly shorter mechanical ventilation (9 vs 15 h), shorter intensive care unit stay (41 vs 65 h) and higher postoperative haemoglobin levels (11 vs 10.2 mg/dl) despite longer bypass and cross-clamp times (+30 and +17 min). There were no differences in mortality or MR grade at discharge between groups nor differences in survival, repair failures and reinterventions during follow-up. CONCLUSIONS: Minimally invasive mitral repair can be performed in the majority of patients with mitral prolapse, without compromising outcomes, repair rate or durability, while providing shorter mechanical ventilation and intensive care unit stay and less blood loss.

Does Quality of Life in Survivors of Surgery for Acute Left-Sided Infective Endocarditis Differ from Non-Endocarditis Patients?

Surgery for left-sided infective endocarditis (IE) has been demonstrated to improve patients' survival rates but information about quality of life (QoL) after surgery is scarce. The aim of this study was to assess the postoperative outcomes and QoL after surgery for IE patients compared to patients undergoing cardiac surgery for non-IE indications. Adult patients with definite acute left-sided IE were matched 1:1 to patients who underwent cardiac surgery for non-endocarditic purposes from 2014 to 2019. QoL was assessed using the SF-36 survey at the last follow-up. A total of 105 patients were matched. The IE group had higher rates of preoperative stroke (21% vs. 7.6%, p = 0.005) and higher stages of NYHA class (p < 0.001), EuroSCORE II (12.3 vs. 3.0, p < 0.001) and blood cell count abnormalities (p < 0.001). The IE group had higher incidence of low cardiac output syndrome (13.3% vs. 4.8%, p = 0.029), dialysis (10.5% vs 1.0%, p = 0.007) and prolonged mechanical ventilation (16.2% vs. 2.9%, p = 0.002) after surgery. At the last follow-up, subcomponents of the SF-36 QoL survey were not different between the groups. Patients who underwent cardiac surgery for IE demonstrated a higher risk profile with a higher rate of postoperative complications. Once recovered from the acute phase of the disease, the reported QoL at follow-up was comparable to that of matched cardiac patients operated for non-IE purposes.

A heart transplant under temporary paracorporeal biventricular circulatory support.

Mechanical circulatory support as a strategy for a bridge to a heart transplant for patients with end-stage heart failure is increasing. A heart transplant following short-term support is a challenging procedure with many particularities. In this video tutorial, we present a 44-year-old patient who was bridged to a heart transplant with biventricular short-term paracorporeal support. The patient, who had dilated non-ischaemic cardiomyopathy, suffered an arrhythmic storm and was refractory to medical treatment and multiple ablation attempts. At the time the support was initiated, he was sarcopenic due to cardiac cachexia. He received a heart from a suitable donor after 10 days on mechanical circulatory support.

Impact of Bedside Re-Explorations in a Cardiovascular Surgery Intensive Care Unit Led by Surgeons.

Surgical re-explorations represent 3-5% of all cardiac surgery. Concerns regarding mortality and major morbidity of re-explorations in the intensive care unit (ICU) setting exist. We sought to investigate whether they may have different outcomes compared with those performed in the operating room (OR). Single center retrospective review of patients who underwent mediastinal re-exploration in the ICU or in the OR after cardiac surgery. Mediastinal re-explorations were also classified as: "planned" and "unplanned". Primary outcome was 30-day mortality, secondary outcomes include deep sternal wound infection (DSWI), sepsis, ICU and hospital length of stay, prolonged intubation (>72 h), tracheostomy, pneumonia, acute kidney injury requiring dialysis and stroke. Between 2010 and 2019, 195 of 7263 patients (2.7%) underwent mediastinal re-exploration after cardiac surgery. More patients in the ICU group experienced two or more re-explorations (30.3% vs. 2.3%, p < 0.001), a higher incidence of postoperative pneumonia (22% vs. 7%, p = 0.004), prolonged intubation (46.8% vs. 19.8%, p < 0.001) and longer hospital stay (30.3 ± 34.2 vs. 20.8 ± 18.3 days, p = 0.014). There were no differences in mortality between ICU and OR (16.5% vs. 13.9%, p = 0.24) nor in sepsis (14.7% vs. 7%, p = 0.91) and DSWI rates (1.8% vs. 1.2%, p = 0.14). Re-explorations in the ICU were not associated with increased mortality, sepsis and mediastinitis rate.

Surgery for Hypertrophic Obstructive Cardiomyopathy: Comprehensive LVOT Management beyond Septal Myectomy.

Hypertrophic cardiomyopathy (HCM) is a complex, underestimated, multifaceted disease frequently associated with left ventricular outflow tract (LVOT) obstruction. It is clearly demonstrated that this is due not only to septal hypertrophy but also to systolic anterior motion (SAM) of mitral valve leaflets secondary to mitral valve/subvalvular apparatus abnormalities. Surgical treatment involves performing an extended septal myectomy, eventually followed by ancillary procedures to those structures responsible for maintaining LVOT obstruction, if necessary. In this review, we describe the spectrum of possible surgical techniques beyond septal myectomy and their pathophysiologic rationale.

Outcomes of Septal Myectomy beyond 65 Years, with and without Concomitant Procedures.

INTRODUCTION AND OBJECTIVES: Septal myectomy remains the first septal reduction therapy for hypertrophic obstructive cardiomyopathy in young patients and those requiring concomitant procedures. Its role in advanced ages is questioned due to perceived increased risk. We assess the outcomes of surgical relief of obstruction in patients beyond 65 years old. METHODS: A single-center retrospective review of patients ≥ 65 years old undergoing septal myectomy through median sternotomy between April 2015 and February 2020. RESULTS: We identified 52 patients. Mean age was 71.8 ± 4.9 years; 36 (69.2%) were females. All were symptomatic. Mean highest LVOT gradient was 90 ± 39 mmHg. All patients had systolic anterior motion (SAM) of the mitral valve and 36 (69.2%) ≥ moderate mitral regurgitation. Additional LVOT interventions beyond myectomy were performed in 34 (65.4%). At least one other cardiac concomitant procedure was performed 44 (84.6%). No perioperative mortality in elective surgery occurred. One patient (1.9%) developed atrio-ventricular block. Postoperative mean gradient was 4.3 ± 1.9 mmHg, with 46 (88.4%) achieving complete resolution of obstruction. Mitral regurgitation was reduced to grade ≤ I in 46 (88.5%). Mean follow-up time was 2.3 ± 1.2 years and 82% of patients were in NYHA I. Survival at 2 years was 98%. CONCLUSION: Septal myectomy in the elderly is a safe and effective operation despite the need for concomitant procedures. LVOT interventions beyond septal myectomy to relieve obstruction are common in this advanced cohort of hypertrophic cardiomyopathy patients. This operation carried at experienced centers seems an unmatched therapeutic option.

Abundance and Seasonality of Aedes aegypti (Diptera: Culicidae) in Two Suburban Localities of South Mexico, With Implications for Wolbachia (Rickettsiales: Rickettsiaceae)-Carrying Male Releases for Population Suppression.

We conducted a baseline characterization of the abundance and seasonality of Aedes aegypti (Linnaeus, 1762)-a vector of dengue, chikungunya, and Zika-in two suburban localities of Yucatan, Mexico, as the first step in the implementation of an integrated vector management (IVM) plan combining 'traditional Aedes control' (source reduction/truck-mounted ultra-low volume [ULV] spraying) and incompatible insect technique/sterile insect technique for population suppression in Yucatan, Mexico. Weekly entomological collections with ovitraps and BG-sentinel traps were performed in 1-ha quadrants of both localities for 1 yr. Three distinct periods/phases were identified, closely associated with precipitation: 1) a phase of low population abundance during the dry season (weekly average of Aedes eggs per ovitrap and adults per BG trap = 15.51 ± 0.71 and 10.07 ± 0.88, respectively); 2) a phase of population growth and greatest abundance of Aedes (49.03 ± 1.48 eggs and 25.69 ± 1.31 adults) during the rainy season; and finally 3) a phase of decline among populations (20.91 ± 0.97 eggs and 3.24 ± 0.21 adults) after the peak of the rainy season. Seasonal abundance and dynamics of Ae. aegypti populations suggest that it is feasible to develop and implement time-specific actions as part of an IVM approach incorporating integrating novel technologies (such as rear-and-release of Wolbachia-infected males) with classic (insecticide-based) approaches implemented routinely for vector control. In agreement with the local vector control program, we propose a pilot IVM strategy structured in a preparation phase, an attack phase with traditional vector control, and a suppression phase with inundative releases, which are described in this paper.

Presence of Adenovirus-36 DNA in Adipose Tissue of Women: Relationship with Adipocyte Morphology and the Expression of C/EBPß and HIF-1α.

BACKGROUND: Human adenovirus 36 (HAd36) infection has been associated with obesity. Experiments using 3T3-L1 adipocyte cultured cells and human adipose stem cells (hASCc) have shown that HAd36 stimulates the expression of genes implicated in cell differentiation and increased lipid accumulation. The presence of HAd36 in adipose tissue of overweight and obese women has also been confirmed. This study aims to analyze the presence of HAd36 DNA in the adipose tissue of women undergoing surgery for weight reduction and its relationship with obesity through changes in adipocyte morphology as well as the expression of C/EBPß and HIF-1α. METHODS: Fifty-two subcutaneous adipose tissue biopsies were collected. The anthropometric parameters measured were weight, height, skin folds, body circumferences, and body fat percentage. Biochemical measures were performed for glucose, cholesterol, triglycerides, cholesterol HDL-c, and LDL-c. The presence of HAd36 DNA was performed by conventional PCR. Adipocyte morphology was analyzed in H&E-stained sections using ImageJ/Fiji software. The expression of genes C/EBPß, HIF-1α and ß-actin was determined using TaqMan probes. RESULTS: HAd36 DNA was detected in 31% of adipose tissue samples. The presence of viral DNA was not significantly associated with anthropometric, clinical, or metabolic measurements, or with changes in adipose tissue morphology. The levels of mRNA expression for C/EBPß and HIF-1α did not show significant differences between positive and negative samples for HAd36 (p>0.05). CONCLUSION: The presence of HAd36 DNA in adipose tissue was identified, but it was not related to morphological changes of adipocytes, or the expression of C/EBPß and HIF-1α. Further studies are needed to confirm these findings.

Operative management of ascending aorta thrombus and bilateral pulmonary embolism in the setting of breast cancer.

Pulmonary embolism (PE) and concomitant floating aortic thrombus are a rare and potentially life-threatening association. Several therapeutic options are available and best management can be controversial when these conditions coexist. We describe a case of a 79-year-old woman presented with massive PE and simultaneous floating thrombus in the ascending aorta. She underwent concomitant ascending aortic replacement and surgical pulmonary embolectomy with an uneventful postoperative recovery. Open surgical repair is a one stage approach that may offer the most efficient treatment to allow survival.

Early degeneration of two different tricuspid bioprostheses in restrictive cardiomyopathy.

Early degeneration of tricuspid bioprostheses is a rare, but extremely serious, complication. Several mechanisms have been described, both for surgically implanted and transcatheter bioprosthesis. We report a case of early degeneration of tricuspid porcine bioprosthesis and a subsequent transcatheter valve-in-valve bovine prosthesis due to severe fibrosis with leaflet retraction in a patient with restrictive cardiomyopathy who finally underwent orthotopic heart transplantation.

Double aortic central cannulation for open thoracoabdominal aorta repair.

Establishment of extracorporeal circulation during open descending and thoracoabdominal aorta repair is necessary in almost all patients. Full cardiopulmonary bypass (CPB) with peripheral cannulation and left heart bypass are the most commonly used circulatory support strategies and they effectively minimize the risk of visceral and central nervous system ischemia. However, both strategies are associated with significant drawbacks. In this video tutorial we present 2 cases demonstrating an alternative strategy for CPB establishment during descending or thoracoabdominal aortic repair. This technique uses two simultaneous (proximal and distal) aortic perfusion cannulas and a single-stage right atrial cannula, both inserted through the main incision. This technique offers all the advantages of full CPB while lowering the risk of proximal hypoperfusion syndrome, and the use of central cannulas virtually eliminates the risk of retrograde perfusion. Complications associated with femoral incision/cannulation are avoided and excellent venous drainage is achieved. This alternative CPB strategy increases the surgical options for extensive thoracoabdominal aortic repair and allows bespoke management for this complex disease.

RAP2.4a Is Transported through the Phloem to Regulate Cold and Heat Tolerance in Papaya Tree (Carica papaya cv. Maradol): Implications for Protection Against Abiotic Stress.

Plants respond to stress through metabolic and morphological changes that increase their ability to survive and grow. To this end, several transcription factor families are responsible for transmitting the signals that are required for these changes. Here, we studied the transcription factor superfamily AP2/ERF, particularly, RAP2.4 from Carica papaya cv. Maradol. We isolated four genes (CpRap2.4a, CpRAap2.4b, CpRap2.1 and CpRap2.10), and an in silico analysis showed that the four genes encode proteins that contain a conserved APETALA2 (AP2) domain located within group I and II transcription factors of the AP2/ERF superfamily. Semiquantitative PCR experiments indicated that each CpRap2 gene is differentially expressed under stress conditions, such as extreme temperatures. Moreover, genetic transformants of tobacco plants overexpressing CpRap2.4a and CpRap2.4b genes show a high level of tolerance to cold and heat stress compared to non-transformed plants. Confocal microscopy analysis of tobacco transgenic plants showed that CpRAP2.4a and CpRAP2.4b proteins were mainly localized to the nuclei of cells from the leaves and roots and also in the sieve elements. Moreover, the movement of CpRap2.4a RNA in tobacco grafting was analyzed. Our results indicate that CpRap2.4a and CpRap2.4b RNA in the papaya tree have a functional role in the response to stress conditions such as exposure to extreme temperatures via direct translation outside the parental RNA cell.

Endovascular stent grafting for acute thoracic aortic pathology.

BACKGROUND: Endovascular repair of the thoracic aorta has shown reduced morbidity and mortality compared with open surgery. We describe our experience with endovascular stent grafting in the treatment of acute thoracic aortic pathology. METHODS: From October 2003 to January 2008, 25 patients underwent endovascular stent graft repair of the thoracic aorta. The underlying pathology was a complicated Stanford type B dissection (n = 13), a symptomatic or ruptured thoracic aorta aneurysm (n = 6), a symptomatic penetrating atherosclerotic ulcer (n = 5), or a traumatic aortic injury (n = 1). There were 21 males and four female patients with a mean age of 61.3 years (30-91 years). Routine surveillance included clinical evaluation and contrast-enhanced spiral computed tomography scans before discharge and at 3, 6, and 12 months after the procedure and yearly thereafter. RESULTS: Stent graft placement was technically successful in all patients. There was no intraoperative mortality. Hospital mortality was of two patients (8%). Paraparesis occurred in one patient (4%). Average intensive care unit and hospital stay was 1 and 10 days, respectively. The mean follow-up was 30 months (range, 7-53). Late mortality was in one patient (4%), due to a type A dissection. During the follow-up, four patients (16%) required a second procedure for type I endoleak. CONCLUSIONS: Mortality and morbidity in our small series were low. Close follow-up is mandatory and long-term results have to be awaited.

Gemelo acardiaco-acefálico, manifestación extrema del síndrome de transfusión feto-feto. Presentación de un caso / Acardiac-acephalic twin, an extreme manifestation fetus-fetus transfusion syndrome. A case presentation

Se presenta el caso clínico de un gemelo acardico-acefálico, la forma circunstancial en que se diagnóstico y se revisan los diferentes aspectos del diagnóstico temprano y modalidades terapéuticas