Huge ascending aorta and aortic arch aneurysm in ultra octogenarian.

Giant ascending aorta aneurysms (AAA), which are larger than 10 cm, are rarely been reported (1-7). We hereby present the case of a giant AAA of about 11 cm in a very old women who was successfully operated on for ascending aorta and aortic arch replacement under deep hypothermic circulatory arrest.

Two cases of right atrial myxoma in redo patients. A mere coincidence?

We describe two cases of right atrial myxoma in redo patients who had previously undergone to coronary artery by-pass grafting (CABGs) and mitral valve replacement respectively. Both of patients experienced effort dyspnea and were assessed by trans-thoracic echocardiography, revealing the right atrial masses. They were operated on for myxoma resection and postoperative course was uneventful. Our report deals with the interesting topic of the location of benign masses that are usually more common in the left atrium. Should we hypothesize that the right atrial manipulation during the previous surgery induces the onset of the right atrial mass? It is an interesting matter to debate.

Transcutaneous insertion of the Chitwood® clamp in case of minimally invasive cardiac surgery. Personal experience.

We describe a simple trick consisting of an insertion of a trans-thoracic Chitwood® clamp (Scanlan International, Inc, St Paul, MN, USA) through a small skin incision (<1cm), via the second intercostal space along the anterior axillary line, in case of minimally invasive mitral surgery, through right thoracotomy. This trick has been used in more than 100 patients and no complication or discomfort have been reported so far.

Additional applications of the Foley catheter in cardiac surgery.

We describe an additional use of the Foley catheter for preoperative and postoperative evaluation of the regurgitant mitral valve.

Aortic valve replacement through the upper ministernotomy: preliminary experience with modified technique.

Minimally invasive approach for aortic valve surgery has been developed since 1995, reducing the complications related to the full sternotomy. We have introduced a new method for central cannulation that reduces the length of surgical incision for the aortic valve replacement through upper mini-sternotomy. To improve the surgical view without enlargement of the incision, two small additional incisions are performed for both arterial and atrial cannulation. We have used the modified technique in 60 patients without sternal infection or other surgical complications and with good cosmetic results.

A prospective study of prevalence of 60-days postoperative wound infections after cardiac surgery. An updated risk factor analysis.

AIM: Postoperative wound infections generally cause considerable extra morbidity, mortality and costs. The prevalence of total wound infections after cardiac surgery, including both sternal wound and donor site infections, ranges from 1.3 to 12.8%. The present study was conducted to identify the incidence of wound infections following cardiac surgery, to identify the risk factors and evaluate the efficacy of present modes of management. METHODS: From September 2004 to May 2005, 493 consecutive patients undergoing cardiac surgery were included in the study and were followed for the prevalence of surgical site infection (SSI) up to 60 days postoperatively. The wound infections were defined according to the Centers for Disease Control and Prevention (CDC) and U.S. National Nosocomial Infections Surveillance (NNIS) system criteria. RESULTS: The total incidence of SSI was 3.9%. Sternal wound infection (SWI) occurred in 17 patients (3.4%). Superficial wound infection was diagnosed in 10 patients (2%) and deep wound infection in 7 patients (1.4%). Donor site infection (DSI) occurred in 2 patients (0.4%). Early reoperation for bleeding, postoperative dialysis and the use of one internal mammary artery were independently associated with an increased risk of SWI. CONCLUSION: Preventing SSI in the operating room is the primary goal of the surgical team. Attention should be paid to antibiotic prophylaxis and Methicillin-resistant Staphylococcus aureus (MRSA) nasal carriage treatment. The identification of risk factors will help to further reduce the incidence of wound infection.

Effect of synthetic luteinizing hormone releasing hormone (LH-RH) on the release of gonadotropins in Cushing's disease.

The effect of intravenous synthetic luteinizing hormone releasing hormone (LH-RH) on plasma radioimmunoassayable levels of gonadotropins was investigated in 6 women suffering from Cushing's disease with bilateral adrenal hyperplasia. In five of six cases no significant variation of plasma LH levels was found following stimulation; in one case the response to LH-RH was present although slightly reduced below the normal range. By contrast in all cases the plasma FSH response was similar to that recorded in normal subjects. The explanation of impaired LH response is not clear but the possibility that endogenous hypercortisolism affects the pituitary responsiveness to LH-RH has to be considered.

Hyperprolactinemia in girls with idiopathic precocious puberty under prolonged treatment with cyproterone acetate.

Pasma prolactin response to the acute injection of sulpiride (1.5 mg/k BW im) was measured at 0800-0900h in 4 girls with idiopathic precocious puberty before and after 6 to 11 months of continuous therapy with 50 mg daily of cyproterone acetate (CA) orally administered. Two additional girls were examined after 26 and 28 months of therapy, respectively. Mean baseline prolactin concentrations were significantly higher in untreated girls with precocious puberty as compared to that of normal controls of the same chronological age and of a comparable degree of sexual maturation (14.5 +/- 1.9 SE vs. 7.4 +/- 1.8 SE ng/ml and vs. 9.5 +/- 1.8 ng/ml, respectively; P less than .02). Treatment with CA caused a significant further increase of plasma prolactin concentration (P less than .02 as compared to pre-treatment values); no correlation was observed between prolactin concentration and duration of treatment. No significant change in the integrated areas of prlactin response to sulpiride occurred after prolonged CA therapy. The results suggest that in idiopathic precocious puberty the action of CA upon the hypothalamic-hypophyseal complex is not solely antigonadotropic and that prolactin secretion is enhanced in patients given this drug.

Effect of cyproterone acetate therapy on gonadotropin response to synthetic luteinizing hormone-releasing hormone (LRH) in girls with idiopathic precocious puberty.

50 mg daily of cyproterone acetate (CA) were orally administered for 8 to 35 months to 7 girls with idiopathic precocious puberty. Plasma levels of FSH and LH, cortisol, testosterone, estradiol, and progesterone were measured in 6 patients before treatment. Compared with control subjects of the same chronological age, significantly higher values were found for gonadotropins, testosterone, and estradiol. After treatment, no significant variation was observed in FSH and LH levels; testosterone was reduced in the majority of the cases without significant decline in mean values; estradiol fell significantly and returned in the prepubertal range. The plasma gonadotropin pattern following exogenously administered luteinizing hormone-releasing hormone (LRH, 100 mug iv) was characterized before treatment by an exaggerated LH response both in terms of maximum level (32.02 +/- 4.35 SE mIU/ml; prepubertal controls: 16.20 +/- 1.45 SE mIU/ml) and maximum increment above baseline values (25.36 +/- 2.84 SE mIU/ml; prepubertal controls: 13.78 +/- 1.71 mIU/ml); plasma FSH response was similar to prepubertal subjects. Treatment with CA caused a significant reduction of mean LH response (P less than .025 in comparison with pre-treatment values for maximum level and maximum increment), whereas effect on FSH response was minimal. In all patients examined, a gonadotropin release from the pituitary after the injection of synthetic LRH was evident also after several months of therapy.

Diurnal variation of prednisolone binding to serum corticosteroid-binding globulin in man.

Serum corticosteroid-binding globulin (CBG, transcortin) binding capacity for prednisolone and for cortisol, and levels of the circulating cortisol were evaluated in healthy adult subjects and in patients under long-term treatment with prednisone. Blood samples were drawn at 4-hr intervals throughout at least 24 hr; the prednisone administration was discontinued 24 hr before starting examination. Circadian fluctuations in the CBG-binding capacity for prednisolone occurred in healthy subjects: maximum binding was at 12 midnight and minimum binding at 8 a.m. The diurnal pattern of prednisolone-binding capacity was characterized by phase shifts of approximately 12 hr and 8 hr compared with those of serum cortisol and cortisol-binding capacity, respectively. There were no diurnal variations of prednisolone- and cortisol-binding capacity in the prednisone-treated patients. Moreover, the levels of both capacities, expressed as micrograms bound steroid/100 ml, were significantly reduced with respect to normal control subjects. Cyclic variations in serum CBG-binding capacity may represent an additional factor accounting for temporal differences in the action of synthetic corticoids which are bound by the transport protein. Synthetic derivatives when chronically administered may interfere not only with the adrenal secretion but also with the serum transport of glucocorticoids.

Role of oral sildenafil in the treatment of right ventricular dysfunction after heart transplantation.

OBJECTIVE: Right ventricular dysfunction (RVD) after heart transplantation is a major complication, especially in patients with pulmonary hypertension (PH). Herein we have presented our initial experience with oral sildenafil for RVD following heart transplantation. MATERIALS AND METHODS: From February 2006 to February 2008, 10 patients (7 males and 3 females) of overall mean age of 56.7 +/- 9.5 years suffered from acute RVD immediately after heart transplantation. Preoperative hemodynamic data before and after a vasodilatation test (sodium nitroprusside; NTP) showed: systolic pulmonary arterial pressure (SPAP) 59.5 +/- 12.9 and 44.2 +/- 12.4 mm Hg; cardiac output (CO) 3.3 +/- 0.9 and 3.7 +/- 0.8 L/min; transpulmonary gradient (TPG) 11.7 +/- 3.9 and 8.7 +/- 3.6 mm Hg; and pulmonary vascular resistance (PVR) 3.9 +/- 2.1 and 2.4 +/- 1.3 wood units (WU), respectively. All patients required inotropes and inhaled nitric oxide (iNO) to be weaned from cardiopulmonary bypass (CPB). RESULTS: Intravenous (IV) or inhaled vasodilators could be weaned using oral sildenafil in all patients. The hemodynamic data obtained during IV or inhaled drugs (between postoperative days 5 and 10) compared with those obtained on sildenafil therapy alone (about 1 month after transplantation) showed a significant decrease in SPAP (39.0 +/- 8.2 vs 32.0 +/- 6.5 mm Hg; P = .049). CONCLUSION: These data suggested that oral sildenafil may have a role in the treatment of RVD after heart transplantation.

Circannual rhythmicities of cortisol levels in the peripheral plasma of healthy subjects.

Seasonal variations of endocrine function have been extensively studied both in rodents and in man. However, only few studies have attempted to concomitantly evaluate and compare circadian and circannual components by inferential rhythmometric procedures. We have examined [9] circadian profiles (single cosinor: P less than 0.01) of plasma cortisol obtained from samples drawn at 4-h intervals in healthy adult subjects of both sexes (71 males, 120 females, aged 20-54 years) along a 7-year span, from 1974 to 1980. All subjects were routine synchronized. Circulating cortisol was measured by a competitive protein-binding technique and expressed as microgram/dl; intra-assay coefficient of variation was always less than 5%. Both conventional and rhythmometric analysis were used to evaluate seasonal differences of mesor, amplitude and acrophase. The population-mean cosinor analyses revealed statistically significant differences as a function of the time of the year in both the circadian amplitude and acrophase. Examining data year by year revealed in 5 out of 7 annual cycles an apparent tendency to a delayed acrophase and to a reduced amplitude with advancing months towards winter. No significant changes in mesor values were found. Further fitting to a 365.25-day cosine curve of circadian parameters available for different months of an 'average' year yielded significant circannual rhythmicity for acrophase and amplitude; crest-value resulted in spring and autumn, respectively. Our data extend previous observations and are consistent with the existence of circannual variations in plasma cortisol levels in the human. In Italian people, cortisol secretion is conceivably higher in cold months; seasonal changes, on the other hand, appear to be of minor entity of at least as inferred by transverse sampling on a relatively large population. Effects of lighting regimen and of other climatological variables upon the adrenal cycle have to be considered.