Stentectomy for LAD "full metal jacket" with in-stent restenosis: How to do it.

We report our technique for the surgical revascularization of symptomatic severe in-stent restenosis of a "full metal jacket" (≥60 mm overlapping stents) of the left anterior descending coronary artery without suitable distal targets: on-pump cardioplegic-arrest stent removal (stentectomy) with endarterectomy and skeletonized left internal mammary artery onlay patch reconstruction. We also describe our follow-up protocol, including antiplatelet/anticoagulation and angiography. With proper patient selection, multidisciplinary collaboration, and surgical expertise, this advanced coronary procedure can be beneficial to a growing population of patients otherwise deemed to be untreatable.

Smart Node Networks Orchestration: A New E2E Approach for Analysis and Design for Agile 4.0 Implementation.

The field of cyber-physical systems is a growing IT research area that addresses the deep integration of computing, communication and process control, possibly with humans in the loop. The goal of such area is to define modelling, controlling and programming methodologies for designing and managing complex mechatronics systems, also called industrial agents. Our research topic mainly focuses on the area of data mining and analysis by means of multi-agent orchestration of intelligent sensor nodes using internet protocols, providing also web-based HMI visualizations for data interpretability and analysis. Thanks to the rapid spreading of IoT systems, supported by modern and efficient telecommunication infrastructures and new decentralized control paradigms, the field of service-oriented programming finds new application in wireless sensor networks and microservices paradigm: we adopted such paradigm in the implementation of two different industrial use cases. Indeed, we expect a concrete and deep use of such technologies with 5G spreading. In the article, we describe the common software architectural pattern in IoT applications we used for the distributed smart sensors, providing also design and implementation details. In the use case section, the prototypes developed as proof of concept and the KPIs used for the system validation are described to provide a concrete solution overview.

Endovascular Fenestration/Stenting First Followed by Delayed Open Aortic Repair for Acute Type A Aortic Dissection With Malperfusion Syndrome.

BACKGROUND: Immediate open repair of acute type A aortic dissection is traditionally recommended to prevent death from aortic rupture. However, organ failure because of malperfusion syndrome (MPS) might be the most imminent life-threatening problem for a subset of patients. METHODS: From 1996 to 2017, among 597 patients with acute type A aortic dissection, 135 patients with MPS were treated with upfront endovascular reperfusion (fenestration/stenting) followed by delayed open repair (OR). We compared outcomes between the first and second decades and observed mortalities with those expected with an "upfront OR for every patient" approach, determined using prognostic models from the literature (Verona, Leipzig-Halifax, Stockholm, Penn, and GERAADA [German Registry for Acute Aortic Dissection Type A] models). RESULTS: Overall, in-hospital mortality improved between the 2 decades (21.0% versus 10.7%, P<0.001). In the second decade, for patients with MPS initially treated with fenestration/stenting, mortality from aortic rupture decreased from 16% to 4% ( P=0.05), the risk of dying from organ failure was 6.6 times higher than dying from aortic rupture (hazard ratio=6.63; 95% CI, 1.5-29; P=0.01), and 30-day mortality after OR for MPS patients was 3.7%. Compared to the expected mortalities with the upfront OR for every patient models, our observed 30-day and in-hospital mortalities (9% and 11%, respectively) of all patients with acute type A aortic dissection were significantly lower ( P≤0.03). CONCLUSIONS: Immediate OR is the strategy to prevent death from aortic rupture for the majority of patients with acute type A aortic dissection. However, relatively stable (no rupture, no tamponade) patients with MPS benefit from a staged approach: upfront endovascular reperfusion followed by aortic OR at resolution of organ failure.

Severe re-expansion pulmonary edema after conventional cardiac surgery: Identification and management.

Re-expansion Pulmonary Edema (REPE) is a recognized but rare complication of lung re-inflation after pathologic collapse or intentional deflation. The presentation of REPE may be highly variable, ranging from a clinically asymptomatic, incidental radiologic finding to acute respiratory failure accompanied by severe, life-threatening hypoxemia. With the current report, we present a patient with severe aortic insufficiency, severe mitral regurgitation, coronary artery disease, pulmonary hypertension, who underwent aortic valve replacement, mitral valvuloplasty, coronary artery bypass grafting, and developed at the immediate post- operative period severe respiratory failure due to REPE, requiring venous-venous Extracorporeal Membrane Oxygenation (VV-ECMO).

Training Patterns and Lifetime Career Achievements of US Academic Cardiothoracic Surgeons.

BACKGROUND: We aimed to investigate the impact of taking dedicated time for research (DTR) during training and/or getting a PhD on subsequent career achievements of US academic cardiothoracic surgeons. METHODS: Online resources (institutional Web sites, CTSNet, Scopus, NIH RePORTER) were queried to collect training information (timing of medical school/residency/fellowship graduation, DTR, PhD) and academic metrics (publications, citations, research funding) for 694 academic cardiothoracic surgeons practicing at 56 premiere US institutions. RESULTS: Excluding missing data, 464 (75 %) surgeons took DTR and 156 (25 %) did not; 629 (91 %) were MD only and 65 (9 %) also had a PhD. DTR was associated with higher number of ongoing publications (~5.6/year vs. ~3.8/year), with no difference for accrued number of total citations. History of DTR was more prevalent among surgeons with versus without NIH funding (87 vs. 71 %; p < 0.001), but no difference was seen across academic ranks and among those who were division/department chiefs. No overall increase in publications/citations, academic rank advancement, NIH funding, or leadership roles was found for those with a PhD. CONCLUSIONS: Among cardiothoracic surgeons, devoting time during the training years exclusively to research might be associated with higher career-long academic productivity in terms of annual number new publications and ability to get NIH funding, but without significant impact in terms of academic rank or institutional role advancement. No significant difference was found between those with versus without a PhD in terms of career-long number of publications/citations, academic rank, NIH funding, or leadership role, even though sample size might have been insufficient to identify any such potential difference.

Academic Productivity of US Cardiothoracic Surgical Centers.

BACKGROUND AND AIM: We investigated which metrics represent valid correlates of the academic productivity of cardiothoracic (CT) surgical centers. METHODS: We collected data from 57 US academic CT surgical groups (663 surgeons), including H index and institutional role of each surgeon, ranking by US News & World Report (USNWR) and NIH funding, and designation as department versus division. RESULTS: Academic productivity (median H-index of each group) was significantly different across institutions (p < 0.001). Several USNWR hospital categories ("Honor Roll", "Adult Cardiology and Heart Surgery", "Adult Pulmonology", "Adult Cancer") and medical school ranking for research were associated with differences in academic productivity, while ranking by NIH funding or designation as department versus division was not. Groups with chairperson's individual H-index ≥50 were overall more productive than those with chairperson's H-index <50 (median H-index: 18 vs. 14; p = 0.005). CONCLUSIONS: USNWR rankings provide a good representation of academic productivity, while NIH funding ranking or designation as department versus division does not. The individual productivity of the chairperson is correlated with that of the whole group. doi: 10.1111/jocs.12773 (J Card Surg 2016;31:423-428).

Follow-up of secondary diabetic complications after pancreas transplantation.

PURPOSE OF REVIEW: Successful pancreas transplantation restores physiologic glycemic and metabolic control. Its effects on overall patient survival (especially for simultaneous pancreas-kidney transplantation) are clear-cut. We herein review the available literature to define the impact of pancreas transplantation on chronic complications of diabetes mellitus. RECENT FINDINGS: With longer-term follow-up, wider patient populations, and more accurate investigational tools (clinical and functional tests, noninvasive imaging, histology, and molecular biology), growing data show that successful pancreas transplantation may slow the progression, stabilize, and even favor the regression of secondary complications of diabetes, both microvascular and macrovascular, in a relevant proportion of recipients. SUMMARY: Patients who are referred for pancreas transplantation usually suffer from advanced chronic complications of diabetes, which have classically been deemed irreversible. A successful pancreas transplantation is often able to slow the progression, stabilize, and even reverse many microvascular and macrovascular complications of diabetes. Growing clinical evidence shows that the expected natural history of long-term diabetic complications can be significantly modified by successful pancreas transplantation.

Volatile emissions of scented Alstroemeria genotypes are dominated by terpenes, and a myrcene synthase gene is highly expressed in scented Alstroemeria flowers.

Native to South America, Alstroemeria flowers are known for their colourful tepals, and Alstroemeria hybrids are an important cut flower. However, in common with many commercial cut flowers, virtually all the commercial Alstroemeria hybrids are not scented. The cultivar 'Sweet Laura' is one of very few scented commercial Alstroemeria hybrids. Characterization of the volatile emission profile of these cut flowers revealed three major terpene compounds: (E)-caryophyllene, humulene (also known as α-caryophyllene), an ocimene-like compound, and several minor peaks, one of which was identified as myrcene. The profile is completely different from that of the parental scented species A. caryophyllaea. Volatile emission peaked at anthesis in both scented genotypes, coincident in cv. 'Sweet Laura' with the maximal expression of a putative terpene synthase gene AlstroTPS. This gene was preferentially expressed in floral tissues of both cv. 'Sweet Laura' and A. caryophyllaea. Characterization of the AlstroTPS gene structure from cv. 'Sweet Laura' placed it as a member of the class III terpene synthases, and the predicted 567 amino acid sequence placed it into the subfamily TPS-b. The conserved sequences R(28)(R)X(8)W and D(321)DXXD are the putative Mg(2+)-binding sites, and in vitro assay of AlstroTPS expressed in Escherichia coli revealed that the encoded enzyme possesses myrcene synthase activity, consistent with a role for AlstroTPS in scent production in Alstroemeria cv. 'Sweet Laura' flowers.

Robot-assisted excision of a huge pararectal dermoid cyst via a totally transabdominal route.

Herein is reported the case of a 17-year-old adolescent with a huge cystic mass located between the vagina and the rectum, with extension into the gluteal region. The lesion caused compression and dislocation of the bladder, uterus, adnexae, and rectum. The patient underwent robot-assisted surgical excision of the mass via a totally transabdominal route. Postoperative recovery was uneventful, with excellent functional and cosmetic results. To our knowledge, this is the first case of a huge pelvic pararectal cyst reaching up to the gluteus and excised via a totally transabdominal approach with the aid of robotic assistance. Robot-assisted surgery seems to be appropriate for therapeutic management of huge pararectal tumors, the major advantages being minimum damage to contiguous structures, rapid postoperative recovery, and excellent cosmetic results.

Pulmonary Endarterectomy for Chronic Thromboembolic Pulmonary Hypertension: An STS Database Analysis.

BACKGROUND: Chronic thromboembolic pulmonary hypertension is optimally treated by pulmonary thromboendarterectomy (PEA). Treatment effectiveness has been evaluated principally using single-center series. Data from The Society of Thoracic Surgeons Adult Cardiac Surgery Database were used to evaluate a volume-outcomes relationship for PEA. METHODS: Circulatory arrest procedures performed between 2012 and 2018 were identified through a Society of Thoracic Surgeons Adult Cardiac Surgery Database Participant User File. For descriptive purposes, total center procedural volume categories were computed: low (0-75th percentile, <16); medium (76-95th percentile, 16-100); high (>95th percentile, >100). Mixed effect modeling was used to evaluate the effect of center procedural volume (modeled continuously) on operative mortality, adjusting for preoperative risk factors, with centers as a random effect. RESULTS: There were 1358 cases performed across 64 centers (low volume: n = 49 of 172; medium volume: n = 12 of 527; high volume: n = 3 of 659), with 42 centers performing less than 10 operations during the period. Procedural volume increased 2.6-fold between 2012 and 2018 (94 vs 339), with 79% of the change in volume accounted for by 4 centers. The median preoperative pulmonary artery systolic value was 74 (interquartile range, 57-88) mm Hg, with no difference (P = .55) by center volume categories. In unadjusted analysis, patients at high-volume centers required fewer transfusions, had shorter ventilator and intensive care unit duration, had a lower frequency of postoperative extracorporeal membrane oxygenation, and trended toward lower mortality (2.1% vs 5.2%; P = .051). Operative mortality was lower at higher-volume centers (adjusted odds ratio [1-case increase], 0.997; 95% confidence interval, 0.994-1.0; P = .025). CONCLUSIONS: Most PEA procedures are performed among a small number of centers, with high-volume hospitals having favorable outcomes. These data suggest a potential role for PEA regionalization.

Graft flow evaluation with intraoperative transit-time flow measurement in off-pump versus on-pump coronary artery bypass grafting.

Objective: We aimed to compare transit-time flow measurement (TTFM) parameters for on-pump (ONCAB) and off-pump (OPCAB) coronary artery bypass procedures. Methods: The database of the Registry for Quality AssESsmenT with Ultrasound Imaging and TTFM in Cardiac Bypass Surgery (REQUEST) study was retrospectively reviewed. Only single grafts were included (ie, no sequential or Y/T grafts). Primary end points were mean graft flow (MGF), pulsatility index (PI), diastolic fraction (DF), and backflow (BF). Unadjusted and propensity score-matching comparisons were performed. Results: Of 1016 patients in the REQUEST registry, 846 had at least 1 graft for which TTFM was performed. Of these, 512 patients (60.6%) underwent ONCAB and 334 (39.4%) OPCAB procedures. Mean arterial pressure (MAP) during measurements was higher in the OPCAB group. After propensity score-matching, 312 well balanced pairs were left. In these matched patients, MGF was higher for the ONCAB versus the OPCAB group (32 vs 28 mL/min, respectively, for all grafts [P < .001]; 30 vs 27 mL/min for arterial grafts [P = .002]; and 35 vs 31 mL/min for venous grafts [P = .006], respectively). PI was lower in the ONCAB group (2.1 vs 2.3, for all grafts; P < .001). Diastolic fraction was slightly lower in the ONCAB group (65% vs 67.5%; P < .001). The backflow was also lower in the ONCAB group (0.6 vs 1.3; P < .001) with trends similar to MGF and PI for venous and arterial grafts. There were 21 (3.3%) revisions in the OPCAB group and 14 (2.1%) in the ONCAB group (P = .198). Conclusions: ONCAB surgery was associated with higher MGF and lower PI values, especially in venous grafts. Different TTFM cutoff values for ONCAB versus OPCAB surgery might be considered.

Study of 'Redhaven' peach and its white-fleshed mutant suggests a key role of CCD4 carotenoid dioxygenase in carotenoid and norisoprenoid volatile metabolism.

BACKGROUND: Carotenoids are plant metabolites which are not only essential in photosynthesis but also important quality factors in determining the pigmentation and aroma of flowers and fruits. To investigate the regulation of carotenoid metabolism, as related to norisoprenoids and other volatile compounds in peach (Prunus persica L. Batsch.), and the role of carotenoid dioxygenases in determining differences in flesh color phenotype and volatile composition, the expression patterns of relevant carotenoid genes and metabolites were studied during fruit development along with volatile compound content. Two contrasted cultivars, the yellow-fleshed 'Redhaven' (RH) and its white-fleshed mutant 'Redhaven Bianca' (RHB) were examined. RESULTS: The two genotypes displayed marked differences in the accumulation of carotenoid pigments in mesocarp tissues. Lower carotenoid levels and higher levels of norisoprenoid volatiles were observed in RHB, which might be explained by differential activity of carotenoid cleavage dioxygenase (CCD) enzymes. In fact, the ccd4 transcript levels were dramatically higher at late ripening stages in RHB with respect to RH. The two genotypes also showed differences in the expression patterns of several carotenoid and isoprenoid transcripts, compatible with a feed-back regulation of these transcripts. Abamine SG - an inhibitor of CCD enzymes - decreased the levels of both isoprenoid and non-isoprenoid volatiles in RHB fruits, indicating a complex regulation of volatile production. CONCLUSIONS: Differential expression of ccd4 is likely to be the major determinant in the accumulation of carotenoids and carotenoid-derived volatiles in peach fruit flesh. More in general, dioxygenases appear to be key factors controlling volatile composition in peach fruit, since abamine SG-treated 'Redhaven Bianca' fruits had strongly reduced levels of norisoprenoids and other volatile classes. Comparative functional studies of peach carotenoid cleavage enzymes are required to fully elucidate their role in peach fruit pigmentation and aroma.

Surgical explantation of transcatheter aortic bioprostheses: Results and clinical implications.

OBJECTIVE: Despite the rapid adoption of transcatheter aortic valve replacement (TAVR) and worldwide interest in its implantation, TAVR valve explantation has not been well described. METHODS: We retrospectively reviewed 1442 consecutive patients who underwent a TAVR procedure between 2011 and 2019, in which TAVR explantation was performed in 15 patients (1.0%). In addition, 2 patients from outside institutions also underwent TAVR explantation at our institution. We reviewed the clinical details of these 17 patients. RESULTS: The frequency of TAVR explant increased over time from 0 to 1 during the period from 2011 to 2015 to 6 in 2019. The mean age was 73.0 ± 9.3 years. The majority of patients (88.2%) were in New York Heart Association functional class IV heart failure. The Society of Thoracic Surgeons Predicted Risk of Mortality score was significantly higher at the time of explantation than at the time of the original TAVR (3.5% vs 9.9%; P < .001). The indication for explantation included structural valve degeneration (23.5%), severe paravalvular leak (41.2%), TAVR procedure-related complications (23.5%), endocarditis (5.9%), and bridge-to-definitive surgery (5.9%). Neoendothelialization of the TAVR valve into the aortic wall requiring intense aortic endarterectomy was noted in all 5 of the TAVR valves older than 1 year, in which 2 (40%) required unplanned aortic root repair. There were 2 (11.8%) in-hospital mortalities. CONCLUSIONS: Surgical TAVR valve explant is increasing and may become common in the near future. The clinical effects of explanting chronically implanted valves with the potential need for aortic repair is not negligible. These data should be used to more appropriately select TAVR candidates as TAVR practices expand into younger and lower risk patients.

Transit time flow measurement of coronary bypass grafts before and after protamine administration.

BACKGROUND: Intraoperative graft assessment with tools like Transit Time Flow Measurement (TTFM) is imperative for quality control in coronary surgery. We investigated the variation of TTFM parameters before and after protamine administration to identify new benchmark parameters for graft quality assessment. METHODS: The database of the REQUEST ("REgistry for QUality AssESsmenT with Ultrasound Imaging and TTFM in Cardiac Bypass Surgery") study was retrospectively reviewed. A per graft analysis was performed. Only single grafts (i.e., no sequential nor composite grafts) where both pre- and post-protamine TTFM values were recorded with an acoustical coupling index > 30% were included. Grafts with incomplete data and mixed grafts (arterio-venous) were excluded. A second analysis was performed including single grafts only in the same MAP range pre- and post- protamine administration. RESULTS: After adjusting for MAP, we found a small increase in MGF (29 mL/min to 30 mL/min, p = 0.009) and decrease in PI (2.3 to 2.2, p <  0.001) were observed after the administration of protamine. These changes were especially notable for venous conduits and for CABG procedures performed on-pump. CONCLUSION: The small changes in TTFM parameters observed before and after protamine administration seem to be clinically irrelevant, despite being statistically significant in aggregate. Our data do not support a need to perform TTFM measurements both before and after protamine administration. A single TTFM measurement taken either before or after protamine may suffice to achieve reliable data on each graft's performance. Depending on the specific clinical situation and intraoperative changes, more measurements may be informative. TRIAL REGISTRATION: Clinical Trials Number: NCT02385344 , registered February 17th, 2015.

Biosynthesis and engineering of carotenoids and apocarotenoids in plants: state of the art and future prospects.

Carotenoids and their apocarotenoid derivatives are isoprenoid molecules important for the primary and secondary metabolisms of plants and other living organisms, displaying also key health-related roles in humans and animals. Progress in the knowledge of the carotenoid pathway at the genetic, biochemical and molecular level, supported by successful genetic engineering examples for an increasing number of important plant crops have paved the way for precise molecular breeding of carotenoids. In this review, following a description of the general carotenoid pathway, select examples of plant species able to produce specialty carotenoids and apocarotenoids are illustrated. An update on plant carotenoid engineering is also provided for non-solanaceous crops and members of the Solanaceae family, by means of different strategies and making use of plant and bacterial genes.

Acute Type A Aortic Dissection During the COVID-19 Outbreak.

As of April 7, 2020, approximately 1,300,000 cases and 80,000 deaths related to coronavirus disease 2019 (COVID-19) have been reported in more than 180 countries/territories. Health care infrastructures and resources, particularly as it relates to the care of the most critically ill patients, are currently being strained globally. In this context, however, there has been little clinical guidance or information regarding life-threatening conditions requiring emergency operation that cannot be delayed. We present a case of acute type A aortic dissection in a patient with COVID-19 to highlight the clinical implications of a true emergent procedure during the COVID-19 outbreak.

Is previous cardiac surgery a risk factor for open repair of acute type A aortic dissection?

OBJECTIVE: The study objective was to determine the optimal treatment for patients with acute type A aortic dissection and previous cardiac surgery. METHODS: A total of 545 patients underwent open repair of an acute type A aortic dissection (July 1996 to January 2017), including patients with (n = 50) and without previous cardiac surgery (n = 495). Data were collected through the University of Michigan Cardiac Surgery Data Warehouse, medical record review, and the National Death Index database. RESULTS: Compared with patients without previous cardiac surgery, patients with previous cardiac surgery were older (62 vs 59 years, P = .24) and had significantly more coronary artery disease (48% vs 14%, P < .001), peripheral arterial disease (24% vs 11%, P = .01), connective tissue disorders (15% vs 4.5%, P = .004), and acute renal failure on presentation (28% vs 15%, P = .02); and significantly more concomitant mitral or tricuspid procedures, longer cardiopulmonary bypass time, and more intraoperative blood transfusions. There were no statistically significant differences in postoperative major complications between previous cardiac surgery and no previous cardiac surgery groups, including stroke, myocardial infarction, new-onset dialysis, and 30-day mortality (8.9% vs 6.3%, P = .55). Multivariable logistic model showed the significant risk factors for operative mortality were cardiogenic shock (odds ratio, 9.6; P < .0001) and male gender (odds ratio, 3.7; P = .006). The 5- and 10-year unadjusted survivals were significantly lower in the previous cardiac surgery group compared with the no previous cardiac surgery group (66% vs 80% and 42% vs 66%, respectively, P = .02). However, previous cardiac surgery itself was not a significant risk factor for operative mortality (odds ratio, 1.6; P = .36) or all-time mortality (hazard ratio, 1.3; P = .33). CONCLUSIONS: Acute type A aortic dissection in patients with previous cardiac surgery can be repaired with favorable operative mortality and long-term survival, and should be treated surgically.

Developmental, genetic and environmental factors affect the expression of flavonoid genes, enzymes and metabolites in strawberry fruits.

The influence of internal (genetic and developmental) and external (environmental) factors on levels of flavonoid gene transcripts, enzyme activity and metabolites was studied in fruit of six cultivated strawberry (Fragaria x ananassa Duch.) genotypes grown at two Italian locations. Gene expression and enzyme activity showed development- and genotype-associated patterns, revealing gene coordination. Analysis clarified the regulation mechanism of the hydroxylation status of the B-ring of the major flavonoid pools and pointed out examples of genotype-specific post-transcriptional regulation mechanisms and key steps of pathway regulation in strawberry fruits. Metabolite profiles were strongly affected by development and genotype. Flavan-3-ols, their proanthocyanidin (PA) derivatives and anthocyanins were the most abundant metabolites. Flavonol levels and PA-associated traits (epicatechin/catechin ratio and mean degree of polymerization) showed significant environmental effects. Multivariate and correlation analyses determined the relationships among genes, enzymes and metabolites. The combined molecular and biochemical information elucidated more in depth the role of genetic and environmental factors on flavonoid metabolism during strawberry fruit development, highlighting the major impact of developmental processes, and revealing genotype-dependent differences and environmental effects on PA-related traits.