Surgical ablation in patients undergoing mitral valve surgery: impact of lesion set and surgical techniques on long-term success.

AIMS: To assess the results and impact of lesion set and surgical technique on long-term success of surgical ablation during mitral surgery. METHODS AND RESULTS: The patient population consisted of 685 subjects with persistent and long-standing persistent atrial fibrillation (AF) undergoing cardiac surgery for mitral valve disease as the primary indication and concomitant ablation between January 2003 and January 2012 at three institutions. One hundred and sixty-six underwent unipolar (24.2%), 371 (54.2%) bipolar, and 148 (21.6%) had combined ablation. Median follow-up was 58.4 months (interquartile range 43.3-67.9). To appropriately account for death, a competing risk model was employed to identify predictors of cumulative incidence of recurrent AF among lesion set and surgical techniques. Eight-year freedom from recurrent arrhythmia without antiarrhythmic drugs was 0.60 ± 0.02. Success rate was higher using bipolar radiofrequency (RF) (P < 0.001), after performing mitral isthmus line (P = 0.003) and following the biatrial technique (P < 0.001). Competing risk regression revealed that use of unipolar RF [sub-hazard ratio (SHR) 2.41 (1.52-3.43), P < 0.001], combined unipolar/bipolar ablation [SHR 1.93 (0.89-2.57), P = 0.003] and the absence of right atrial ablation [SHR 2.79 (1.27-3.48), P < 0.001] were predictors of cumulative incidence of long-term recurrence. CONCLUSIONS: Our experience suggests that the use of bipolar clamp improves long-term results in surgical treatment of AF and that right-sided ablation should be routinely added. Randomized studies are necessary to confirm our findings.

Effects of Surgical Techniques on Long-Term Results in Patients with Degenerative Mitral Valve Bileaflet Prolapse.

BACKGROUND AND AIM OF THE STUDY: The study aim was to evaluate the long-term results in patients with degenerative mitral valve bileaflet prolapse (DMVBLP) undergoing mitral valve repair (MVr) or mitral valve replacement (MVR), and to compare the consequences of survival related to each technique. METHODS: Between 2001 and 2012, a total of 421 patients underwent isolated primary surgery for DMVBLP. MVr was performed in 146 patients (34.7%), and MVR in 275 (65.3%). MVR patients were allocated to two subgroups. Subgroup A were operated on in routine fashion, preserving the posterior subvalvular apparatus, and in selected cases the anterior or both apparatus (n = 119; 43.3%). In subgroup B, surgery was performed without preservation of the subvalvular apparatus (n = 156; 56.7%). RESULTS: There were no intraoperative deaths in all patient groups. The median length of follow up was 5.96 ± 3.28 years. Five patients (3.4%) in the MVr group died, while 11 in MVR subgroup A (9.2%) died, and 29 in MVR subgroup B (18.6%). Patients in the MVr group demonstrated significant and persistent postoperative decreases in left ventricular end-diastolic diameter (LVEDD) and left ventricular end-systolic diameter (LVESD) during the follow up, while the left ventricular ejection fraction (LVEF) showed a trend to improve. In MVR subgroup A, preservation of the mitral subvalvular structures resulted in a decrease in LVEDD; this resulted in a lesser worsening of the LVEF, as occurs when subvalvular structures are resected. In MVR subgroup B, the LVEDD and LVESD were each increased constantly, which resulted in a statistically significant worsening of the LVEF. CONCLUSIONS: MVr in DMVBLP patients achieved a better preservation of left ventricular systolic indices than MVR, and guaranteed better shortand long-term survivals. When MVr is not feasible, it is recommended that subvalvular preservation be performed during MVR, in order to reduce the risk of early and late mortality and to improve left ventricular function.

Pulsatile cardiopulmonary bypass with intra-aortic balloon pump improves organ function and reduces endothelial activation.

BACKGROUND: We aimed to evaluate if the use of an intra-aortic balloon pump (IABP) during cardioplegic arrest improves organ function and reduces endothelial activation in patients undergoing coronary artery bypass graft (CABG). METHODS AND RESULTS: Five-hundred and one CABG patients were randomized into 2 groups: (Group A n=270) linear cardiopulmonary bypass (CPB); and (Group B n=231) automatic 80 beats/min IABP-induced pulsatile CPB. We evaluated hemodynamic response, coagulation and fibrinolysis, transaminase, bilirubin, amylase, lactate, renal function (estimated glomerular filtration rate [eGFR], creatinine and any possibility of renal insufficiency or failure), respiratory function and endothelial markers (vascular endothelial growth factor [VEGF] and monocyte chemotactic protein-1 [MCP-1]). IABP, which induced surplus hemodynamic energy, was 21,387 ± 4,262 ergs/cm(3). Group B showed lower chest drainage, transfusions, international normalized ratio, and antithrombin III, together with higher platelets, activated partial thromboplastin time, fibrinogen and D-dimer. Transaminases, bilirubin, amylase, lactate were lower in Group B; there were better results for eGFR in Group B from ICU-arrival to 48 h, resulting in lower creatinine from ICU-arrival to 48 h. The necessity for renal replacement therapy was lower in Group B Stage-3. Group B P(a)O(2)/F(i)O(2) and lung compliance improved with aortic de-clamping on the first day with shorter intubation time. Group B showed lower VEGF and MCP-1. CONCLUSIONS: Pulsatile flow by IABP improves whole-body perfusion and reduces endothelial activation during CPB.

Stem cell therapy for arterial restenosis: potential parameters contributing to the success of bone marrow-derived mesenchymal stromal cells.

PURPOSE: Restenosis is a complex and heterogeneous pathophysiological phenomenon occurring in patients submitted to revascularization procedures. Previous studies proved the antirestenotic properties of injected allogenic mesenchymal stromal cells (MSCs) in an experimental model of rat carotid (re)stenosis induced through arteriotomy. In this study we describe some of the effects subsequent to MSC treatment of rats submitted to carotid arteriotomy and possibly responsible for their antirestenotic effect. METHODS: Rat MSCs were isolated from bone marrow, expanded in vitro and characterized. Subsequently, we evaluated the effects of MSC administration via tail vein at 3 and 7 days after carotid arteriotomy both in rat serum and in injured carotids, focusing on DNA oxidative damage (8-oxo-dG detection), cell proliferation index (BrdU incorporation assay), apoptotic index (TUNEL assay), the expression of inflammation- and proliferation-related genes (RT-PCR), the release of growth factors and of inflammation-related cytokines (antibody arrays and ELISA). RESULTS: MSC administration induced a greater cell proliferation in carotids after arteriotomy, together with an increased level of VEGF in the serum and with the higher expression of VEGF mRNA in injured carotids. Serum analysis also revealed a decreased level of the pro-inflammatory cytokines CXCL1, CXCL5, L-Selectin, ICAM-1 and LIX, and of TIMP1 and SDF-1alpha in MSC-treated rats. The MSC immunomodulatory activity was confirmed by the decreased expression of TLR2 and TLR4 in injured carotids. CONCLUSIONS: MSCs play an immunomodulatory paracrine role when injected in rats submitted to carotid arteriotomy, accompanied by the release of VEGF, possibly contributing to the accelerated repair of the injured vascular wall.

DNA damage and repair in a model of rat vascular injury.

Restenosis rate following vascular interventions still limits their long-term success. Oxidative stress plays a relevant role in this pathophysiological phenomenon, but less attention has been devoted to its effects on DNA damage and to the subsequent mechanisms of repair. We analysed in a model of arteriotomy-induced stenosis in rat carotids the time-dependent expression of DNA damage markers and of DNA repair genes, together with the assessment of proliferation and apoptosis indexes. The expression of the oxidative DNA damage marker 7,8-dihydro-8-oxo-2'-deoxyguanosine was increased at 3 and 7 days after arteriotomy, with immunostaining distributed in the injured vascular wall and in perivascular tissue. The expression of the DNA damage marker phospho-H2A.X was less relevant but increasing from 4 hrs to 7 days after arteriotomy, with immunostaining prevalently present in the adventitia and, to a lesser extent, in medial smooth muscle cells at the injury site. RT-PCR indicated a decrease of 8 out of 12 genes of the DNA repair machinery we selected from 4 hrs to 7 days after arteriotomy with the exception of increased Muyth and Slk genes (p<0.05). Western Blot revealed a decrease of p53 and catalase at 3 days after arteriotomy (p<0.05). A maximal 7% of BrdU-positive cells in endothelium and media occurred at 7 days after arteriotomy, while the apoptotic index peaked at 3 days after injury (p<0.05). Our results highlight a persistent DNA damage presumably related to a temporary decreased expression of the DNA repair machinery and of the antioxidant enzyme catalase, playing a role in stenosis progression.

A Starr-Edwards mitral prosthesis after 44 years of good performance.

The Starr-Edwards caged-ball prosthesis has been widely used to replace cardiac valves. The Model 6120 mitral prosthesis was introduced on the market in 1965 to reduce the high incidence of ball variance and thromboembolism of the previous model. We report the case of a Starr-Edwards Model 6120 which had been in place for 44 years and was still well functioning with no apparent structural damage.

Injury to rat carotid arteries causes time-dependent changes in gene expression in contralateral uninjured arteries.

Vascular surgery aimed at stenosis removal induces local reactions often leading to restenosis. Although extensive analysis has been focused on pathways activated in injured arteries, little attention has been devoted to associated systemic vascular reactions. The aim of the present study was to analyse changes occurring in contralateral uninjured rat carotid arteries in the acute phase following unilateral injury. WKY (Wistar-Kyoto) rats were subjected to unilateral carotid arteriotomy. Contralateral uninjured carotid arteries were harvested from 4 h to 7 days after injury. Carotid arteries were also harvested from sham-operated rats and uninjured rats. Carotid morphology and morphometry were examined. Affymetrix microarrays were used for differential analysis of gene expression. A subset of data was validated by real-time RT-PCR (reverse transcription-PCR) and verified at the protein level by Western blotting. A total of 1011 genes were differentially regulated in contralateral uninjured carotid arteries from 4 h to 7 days after arteriotomy (P<0.0001; fold change, >or=2) and were classified into 19 gene ontology functional categories. To a lesser extent, mRNA variations also occurred in carotid arteries of sham-operated rats. Among the changes, up-regulation of members of the RAS (renin-angiotensin system) was detected, with possible implications for vasocompensative mechanisms induced by arteriotomy. In particular, a selective increase in the 69 kDa isoform of the N-domain of ACE (angiotensin-converting enzyme), and not the classical somatic 195 kDa isoform, was observed in contralateral uninjured carotid arteries, suggesting that this 69 kDa isoenzyme could influence local AngII (angiotensin II) production. In conclusion, systemic reactions to injury occur in the vasculature, with potential clinical relevance, and suggest that caution is needed in the choice of controls during experimental design in vivo.

Surgery for prosthetic valve endocarditis: a retrospective study of a national registry.

OBJECTIVES: We described clinical-epidemiological features of prosthetic valve endocarditis (PVE) and assessed the determinants of early surgical outcomes in multicentre design. METHODS: Data regarding 2823 patients undergoing surgery for endocarditis at 19 Italian Centers between 1979 and 2015 were collected in a database. Of them, 582 had PVE: in this group, the determinants of early mortality and complications were assessed, also taking into account the different chronological eras encompassed by the study. RESULTS: Overall hospital (30-day) mortality was 19.2% (112 patients). Postoperative complications of any type occurred in 256 patients (44%). Across 3 eras (1980-2000, 2001-08 and 2009-14), early mortality did not significantly change (20.4%, 17.1%, 20.5%, respectively, P = 0.60), whereas complication rate increased (18.5%, 38.2%, 52.8%, P < 0.001), consistent with increasing mean patient age (56 ± 14, 64 ± 15, 65 ± 14 years, respectively, P < 0.001) and median logistic EuroSCORE (14%, 21%, 23%, P = 0.025). Older age, female sex, preoperative serum creatinine >-2 mg/dl, chronic pulmonary disease, low ejection fraction, non-streptococcal aetiology, active endocarditis, preoperative intubation, preoperative shock and triple valve surgery were significantly associated with mortality. In multivariable analysis, age (OR = 1.02; P = 0.03), renal insufficiency (OR = 2.1; P = 0.05), triple valve surgery (OR = 6.9; P = 0.004) and shock (OR = 4.5; P < 0.001) were independently associated with mortality, while streptococcal aetiology, healed endocarditis and ejection fraction with survival. Adjusting for study era, preoperative shock (OR = 3; P < 0.001), Enterococcus (OR = 2.3; P = 0.01) and female sex (OR = 1.5; P = 0.03) independently predicted complications, whereas ejection fraction was protective. CONCLUSIONS: PVE surgery remains a high-risk one. The strongest predictors of early outcome of PVE surgery are related to patient's haemodynamic status and microbiological factors.

A predictive model for early mortality after surgical treatment of heart valve or prosthesis infective endocarditis. The EndoSCORE.

BACKGROUND: The aim of this large retrospective study was to provide a logistic risk model along an additive score to predict early mortality after surgical treatment of patients with heart valve or prosthesis infective endocarditis (IE). METHODS: From 2000 to 2015, 2715 patients with native valve endocarditis (NVE) or prosthesis valve endocarditis (PVE) were operated on in 26 Italian Cardiac Surgery Centers. The relationship between early mortality and covariates was evaluated with logistic mixed effect models. Fixed effects are parameters associated with the entire population or with certain repeatable levels of experimental factors, while random effects are associated with individual experimental units (centers). RESULTS: Early mortality was 11.0% (298/2715); At mixed effect logistic regression the following variables were found associated with early mortality: age class, female gender, LVEF, preoperative shock, COPD, creatinine value above 2mg/dl, presence of abscess, number of treated valve/prosthesis (with respect to one treated valve/prosthesis) and the isolation of Staphylococcus aureus, Fungus spp., Pseudomonas Aeruginosa and other micro-organisms, while Streptococcus spp., Enterococcus spp. and other Staphylococci did not affect early mortality, as well as no micro-organisms isolation. LVEF was found linearly associated with outcomes while non-linear association between mortality and age was tested and the best model was found with a categorization into four classes (AUC=0.851). CONCLUSIONS: The following study provides a logistic risk model to predict early mortality in patients with heart valve or prosthesis infective endocarditis undergoing surgical treatment, called "The EndoSCORE".

[Acute aortic dissection type A: from the past to the present]. / Dissezione acuta dell'aorta di tipo A: uno sguardo al presente, imparando dal passato.

Acute aortic dissection type A (AADA) is a disease that has a catastrophic impact on a patient's life. Although refinements in perioperative and surgical care have translated into improved outcomes for patients affected by AADA, hospital mortality after surgery still remains very high, ranging from 15% to 30%. The management of AADA is complex and dictated by the modality of presentation, extent and location of the disease. Attempts to formulate consensus statements and relevant guidelines have identified significant gaps in the AADA knowledge with reference to pathogenesis, appropriate management and configuration for clinical services. Several international registries have been created to generate an evidence base that can address current and future management. In this context, the extensive use of surgical/hybrid approaches in treating AADA should be encouraged as well as more extensive interventions to replace the entire dissected aortic root and aortic arch tissues. In addition, the excellent outcome results recently achieved by high-volume surgical centers with focused expertise in AADA pointed out the need for regionalized super-centers offering specific multidisciplinary aortic surgery programs with dedicated high-specialized surgeons.

Cerebral perfusion issues in acute type A aortic dissection without preoperative malperfusion: how do surgical factors affect outcomes?

OBJECTIVES: Both preoperative (disease-related) and operative (management-related) variables make the assessment of the outcomes of acute type A aortic dissection (ATAAD) surgery a difficult task. Our aim was to evaluate the impact of operative factors, including arterial cannulation site, route of cerebral perfusion and surgeon's specific experience with ATAAD ('aortic surgeon'), on the early results of surgical management, with particular attention to neurological injury. METHODS: Penn classification was used to identify clinically homogeneous risk groups of ATAAD patients undergoing surgery. Between January 2007 and June 2014, 111 of 183 ATAAD patients treated with open surgery in a single centre were in Penn Class Aa (no ischaemic complications at presentation). They were divided in two groups depending on the arterial cannulation site: femoral artery (FemA; 56 patients) or right axillary artery (RAxA; 55 patients). Study outcomes included: 30-day mortality, major adverse cardiac and cerebrovascular events at 30 days, neurological complications and in particular, patterns of stroke as defined by Bamford classification. RESULTS: No significant differences in preoperative variables were observed between cannulation-site groups, except for myocardial ischaemic time (60.9 ± 30.4 min in the RAxA group vs 81.7 ± 52.3 in the FemA group, P = 0.014) and cerebral perfusion time (42.1 ± 25.5 min in the RAxA group vs 52.9 ± 32.6 in the FemA group, P = 0.048). Outcomes in terms of mortality and neurological injury did not differ except for a higher incidence of lacunar cerebral infarction (LACI) in the RAxA group (14.5 vs 3.6%, P = 0.043), mainly but not exclusively explained by a higher incidence of LACI in unilateral (17.2%) than in bilateral cerebral perfusion (6.9%) within the RAxA group. The 'non-aortic surgeon' was associated instead with 30-day mortality and composite outcome in multivariable analysis (respectively, OR 6.40, P = 0.002 and OR 4.68, P = 0.001). CONCLUSIONS: The RAxA cannulation and FemA cannulation are associated with comparable 30-day mortality following surgery for aortic dissection. However, the possible higher risk of LACI-type strokes in the RAxA group, especially when associated with unilateral brain perfusion, should be considered when RAxA cannulation is performed in ATAAD. The hypothesis that more experienced surgeons may produce better earlier outcomes warrants further investigation.

Italian multicentre study on type A acute aortic dissection: a 33-year follow-up†.

OBJECTIVES: Despite substantial progress in surgical techniques and perioperative management, the treatment and long-term follow-up of type A acute aortic dissection (AAD) still remain a major challenge. The objective of this retrospective, multicentre study was to assess in a large series of patients the early and long-term results after surgery for type A AAD. METHODS: We analysed the preoperative, intraoperative and postoperative conditions of 1.148 consecutive patients surgically treated in seven large referral centres from 1981 to 2013. We applied to each patient three different multi-parameter risk profiles (preadmission risk, admission risk and post-surgery risk) in order to compare risk factors and outcome. Long-term Kaplan-Meier survival was evaluated. RESULTS: The median age was 64 years and the male population was predominant (66%). Identified diagnosis of collagen disease was present in 9%, and Marfan syndrome in 5%. Bicuspid aortic valve was present in 69 patients (6%). Previous cardiac surgery was identified in 10% of the patients. During surgery, the native aortic valve was preserved in 72% of the cases, including leaflet resuspension in 23% and David operation in 1.2%. Considering aortic valve replacement (AVR: 28%), bioprosthesis implantation was performed in 14.7% of the subjects. Neurological impairment at discharge was shown in 23% of the cases among which 21% of patients had new neurological impairment versus preoperative conditions. The overall 30-day mortality rate was 25.7%. All risk profiles remained independently associated with in-hospital mortality. During the available follow-up of hospital survivors (median: 70 months, interquartile range: 34-113, maximum: 396), cardiac-related death occurred in 7.9% of the subjects. The cumulative survival rate for cardiac death was 95.3% at 5 years, 92.8% at 10 years and 52.8% at 20 years. Severe aortic regurgitation (AR) (grade 3-4) at the time of surgery showed to be a significant risk factor for reintervention during the follow-up (P < 0.001). Among risk profiles, only the preadmission risk was independently associated with late mortality after multivariate analysis. Unexpectedly, there was no difference in freedom from cardiac death between patients with and without AVR. CONCLUSIONS: Although surgery for type A has remained challenging over more than three decades, there is a positive trend in terms of hospital mortality and long-term follow-up. About 90% of patients were free from reoperation in the long term, although late AR remains a critical issue, suggesting that a thorough debate on surgical options, assessment and results of a conservative approach should be considered.

Age- and sex-related utilisation of cardiac procedures and interventions: a multicentric study in Italy.

BACKGROUND: Cardiovascular diseases represent the leading cause of death in Italy and one of the most frequent cause of disability in the elderly. The aim of the study was to investigate the influence of age and sex of patient on the utilisation of cardiac procedure and interventions in Italy. METHODS: Retrospective analysis of 2805 patients' medical case notes in cardiology, internal medicine and elderly clinics in six Italian Regions during the period 1996-1997, considering coronary catheterisation (CC), percutaneous transluminal coronary angioplasty (PCTA), coronary artery bypass grafting (CABG), thrombolysis (THR) and permanent pacemaker (PPM) implantation. RESULTS: Older patients (more than 75 years old) were less likely to undergo CC (OR=0.062). Trends for age and sex did not achieve significance for CAGB (OR=0.815 for older patient). Age is a strong predictor of receiving PTCA, with the oldest group of patients being discriminated (OR=0.093 for people older than 75 years), and the same trend was observed for THR (OR=0.264 for patients older than 75 years). For PPM, older patient has a higher likelihood of receiving this type of intervention (OR=3.45 for 65-74 years, and OR=7.77 for patients older than 75 years). As far as gender of patients is concerned, statistically significant differences for all cardiac procedures or interventions considered were not found. CONCLUSIONS: Clinical management of older patients with cardiac disease in Italy may be different from that of younger patients. One possible explanation would be that these patients are being discriminated against mainly because of their age.

Anatomic reconstruction in degenerative mitral valve bileaflet prolapse: long-term results.

BACKGROUND: Degenerative mitral valve (MV) bileaflet prolapse (DMVBP) is recognized as one of the most complex lesions to be treated by reconstructive surgery. In the present study, we report our long-term results with reconstructive surgery for DMVBP. METHODS: From 2000 to 2011, 140 patients with MV regurgitation due to DMVBP were treated at our institution. Mean age was 56.4±14.5 years (range 16 to 84). Of the 140 study patients, 24 (17%) were in functional class I, 48 (34%) in class II, 60 (43%) in III, and 8 (6%) in class IV of the New York Heart Association. The MV leaflets were reconstructed without using prosthetic material, maintaining the normal shape and dimension of the valve ring and inter-papillary distance. The standard surgical procedure included the excision of the most elongated or ruptured chordae area of the posterior leaflet, with subsequent transposition of second-order chordae from the posterior leaflet to the most elongated or ruptured chordae area of the anterior leaflet. This procedure was performed in 123 patients. A para-commissural edge-to-edge was performed in 16 patients and a triangular resection of the anterior MV leaflet in 1 patient. The posterior leaflet was reconstructed with different techniques: a longitudinal suture of the annulus and residual scallops in 86 patients, a Z-plasty suture in 51 and a sliding suture of the residual posterior scallops in 3 patients. A posterior trygon-to-trygon annuloplasty was performed with an autologous pericardium strip in all patients. During follow-up, serial echocardiograms were obtained once a year. RESULTS: There were no hospital deaths. Mean follow-up was 6.42±3.1 years. Of the 140 study patients, 7 developed severe (3+), 10 moderate (2+) and 18 mild (1+) MV regurgitation. Two patients were reoperated within 6 months; 1 after 8 years and 1 after 10 years for recurrence of severe MV regurgitation. At 12 years after the initial surgical procedure, overall survival was 95.8%, freedom from MV re-intervention was 91.8% and freedom from late recurrence of 2+ or greater MV regurgitation was 78.7%. All patients had a satisfactory residual MV area, leaflets motion, and inter-papillary muscle distance. No patient developed left ventricular outflow tract obstruction. CONCLUSIONS: Our results confirm the effectiveness of anatomic reconstruction in the DMVBP. Survival rate after mitral valve repair is identical to that of the general population when surgery is performed in asymptomatic or pauci-symptomatic patients; the identification of this kind of patient is required followed by a therapeutic strategy for early surgery. This management approach in patients with DMVBP leads to optimal long-term results of MV repair.

Primary cardiac angiosarcoma in a 25-year-old man: excision, adjuvant chemotherapy, and multikinase inhibitor therapy.

Primary cardiac tumors do not occur frequently, and only one quarter of them, chiefly sarcomas, are malignant. Patients with angiosarcoma typically have a shorter survival time than do patients with other sarcomas, and the prognosis for survival depends strictly on the stage of the disease at the time of diagnosis and the possibility of complete surgical excision. Chemotherapy and radiotherapy have well-established postoperative roles because of the high probability of metastasis. We report the case of a 25-year-old man who presented with pericardial effusion and echocardiographic evidence of an intracavitary right atrial mass but without the bulky, infiltrative growth typical of this location of the disease. Malignancy was suggested by the clinical presentation, the location of the mass in the right side of the heart, and the absence of conditions favoring thrombus formation. After complete surgical excision, the mass was confirmed to be an angiosarcoma. Conventional adjuvant chemotherapy and maintenance therapy with inhibitors of CD117 (c-kit) and vascular endothelial growth factor relieved the patient's clinical symptoms and enabled his long-term, disease-free survival. In addition to reporting this case, we discuss aspects of the diagnosis and treatment of angiosarcoma.

Apico-aortic conduit for severe hypertrophic cardiomyopathy: sudden death despite conduit patency 31 years postoperatively.

Although small experiences have been described with the use of apico-aortic valved conduit in the treatment of hypertrophic cardiomyopathy (HCM), the long-term follow-up has never been previously reported. In a young female patient with symptomatic HCM and a prognostically unfavorable phenotype, apico-aortic conduit was chosen instead of conventional myectomy because severe ventricular hypertrophy involved the whole ventricle, making outflow tract cavity virtually absent in systole. Close clinical and imaging follow-up was postoperatively performed. The patient remained asymptomatic, without cardioactive drug therapy for 30 years, also experiencing 2 successful pregnancies. A striking finding was the perfect patency of the conduit at the last follow-up control (31 years), with computed tomography and echocardiography showing no calcification of the porcine Hancock bioprosthesis inside the graft. Nevertheless, the disease slowly evolved towards the dilative phase and the patient experienced sudden death while scheduled for implantation of defibrillator in waiting list for heart transplant.The present case could suggest that, in selected cases of HCM not treatable by myectomy, apico-aortic conduit may be an option. The relief of the obstruction can provide even long-term freedom from symptoms, however, late evolution to end-stage cannot be prevented.

Local inhibition of ornithine decarboxylase reduces vascular stenosis in a murine model of carotid injury.

OBJECTIVES: Polyamines are organic polycations playing an essential role in cell proliferation and differentiation, as well as in cell contractility, migration and apoptosis. These processes are known to contribute to restenosis, a pathophysiological process often occurring in patients submitted to revascularization procedures. We aimed to test the effect of α-difluoromethylornithine (DFMO), an inhibitor of ornithine decarboxylase, on vascular cell pathophysiology in vitro and in a rat model of carotid arteriotomy-induced (re)stenosis. METHODS: The effect of DFMO on primary rat smooth muscle cells (SMCs) and mouse microvascular bEnd.3 endothelial cells (ECs) was evaluated through the analysis of DNA synthesis, polyamine concentration, cell viability, cell cycle phase distribution and by RT-PCR targeting cyclins and genes belonging to the polyamine pathway. The effect of DFMO was then evaluated in arteriotomy-injured rat carotids through the analysis of cell proliferation and apoptosis, RT-PCR and immunohistochemical analysis of differential gene expression. RESULTS: DFMO showed a differential effect on SMCs and on ECs, with a marked, sustained anti-proliferative effect of DFMO at 3 and 8 days of treatment on SMCs and a less pronounced, late effect on bEnd.3 ECs at 8 days of DFMO treatment. DFMO applied perivascularly in pluronic gel at arteriotomy site reduced subsequent cell proliferation and preserved smooth muscle differentiation without affecting the endothelial coverage. Lumen area in DFMO-treated carotids was 49% greater than in control arteries 4 weeks after injury. CONCLUSIONS: Our data support the key role of polyamines in restenosis and suggest a novel therapeutic approach for this pathophysiological process.

Evolution in the treatment of mediastinitis: single-center experience.

This study aimed to evaluate our 30-year experience in the treatment of deep sternal wound infection after cardiac surgery. Between 1979 and 2009, deep sternal wound infections occurred in 200 of 22,366 (0.89%) patients who underwent sternotomy. The study population was divided into 3 groups. In group A (62 patients; 1979-1994), an initial attempt at conservative antibiotic therapy was the rule, followed by surgery in case of failure. In group B (83 patients; 1995-2002), the treatment was in 3 steps: wound debridement and closed irrigation for 10 days; in case of failure, open dressing with sugar and hyperbaric treatment; delayed healing and negative wound cultures mandated plastic reconstruction. In group C (2002-2009), the treatment was based on early surgical debridement, vacuum application, and reconstruction using pectoralis muscle flap. Hospital mortality in group A was significantly higher than that in groups B and C. Hospital stay, time for normalization of white blood cell count and C reactive protein, and time for defervescence were significantly shorter in group C. In our experience, early surgical debridement and vacuum application followed by plastic reconstruction provided a satisfactory rate of healing and a good survival rate.

"Z-plasty suture": a new procedure for complex reconstructions of posterior mitral leaflet.

In recent years the conservative techniques to treat degenerative mitral valve insufficiency have developed to such an extent mainly due to a better understanding of the physiology and pathology of the mitral valve and to the possibility to get predictable and satisfactory results. Still a challenge persists for the cardiac surgeon when he has to deal with complex reconstructions. The technique described seems to offer an even better surgical option for patients with complex lesions involving the posterior mitral leaflet, especially as far as the hemodynamic performance is concerned.