Pattern of resolution of pulmonary hypertension, long-term allograft right ventricular function, and exercise capacity in high-risk heart transplant recipients listed under oral sildenafil.

Unresponsive pulmonary hypertension (PH) implies poor posttransplant outcomes. Data on late adaptation of the right ventricle (RV) are still few. This study evaluated three-yr RV function and remodeling, exercise capacity, and hemodynamic data in a selected group of patients initially disqualified because of PH. Between May 2005 and December 2009, 31 consecutive patients were qualified for oral sildenafil because of unresponsive PH at baseline right heart catheterization (RHC). After a 12-wk trial, RHC disclosed PH reversibility (mean PVR: 5.41 ± 3 Wood units, mean TPG 14.5 ± 5.6 mmHg, and mean systolic PAP 68.9 ± 15.1 mmHg), allowing listing even though as high-risk procedures. All patients underwent heart transplantation. RV failure developed in three patients (9.6%), and hospital mortality was 3.2%. Protocol RHC disclosed pulmonary hemodynamic profile normalization within the third postoperative month, allowing weaning from sildenafil in the 30 hospital survivors. One- and three-yr RHCs confirmed stable PH reversal (n = 26, all three-yr survivors). Parameters of late RV function and remodeling proved satisfactory. Parameters of functional capacity (Vo2 peak 19.7 ± 3.6 mL/kg/min and slope VE/Vco2 34.8 ± 2.7) proved homogeneous to those measured in transplant recipients with normal preoperative pulmonary artery pressure. Oral sildenafil is effective in allowing candidacy, safe transplantation, and long-term survival in PH recipients initially disqualified.

Heart transplant with donor-specific antibody after immunoadsorption plus rituximab: a case report.

Different desensitization strategies are available for treating patients with preformed human leukocyte antigen (HLA) antibodies. A highly presensitized heart recipient received immunoadsorption and rituximab therapy. The patient, with end-stage heart failure, was positive only for antibodies of HLA class I (anti-A2, A10, B17), and Luminex platform (One Lambda kit) showed a panel-reactive antibody score of 64%. The patient's serum was tested repeatedly in both complement-dependent cytotoxicity and flow-cytometry crossmatches against cells from different potential organ donors. The results of these crossmatches were positive on flow cytometry when tested with HLA-A2, A10, and B17 but were still negative on cytotoxicity. The patient was treated with a desensitization regimen; this treatment immediately decreased antibody levels of 70% and the patient subsequently received a transplant with donor-specific HLA antibody (HLA-A2). After more than 2 years, graft function remains normal and the clinical status of the patient is stable.

A Deep Learning Ensemble Approach for Automated COVID-19 Detection from Chest CT Images.

BACKGROUND: The aim of this study was to evaluate the performance of an automated COVID-19 detection method based on a transfer learning technique that makes use of chest computed tomography (CT) images. METHOD: In this study, we used a publicly available multiclass CT scan dataset containing 4171 CT scans of 210 different patients. In particular, we extracted features from the CT images using a set of convolutional neural networks (CNNs) that had been pretrained on the ImageNet dataset as feature extractors, and we then selected a subset of these features using the Information Gain filter. The resulting feature vectors were then used to train a set of k Nearest Neighbors classifiers with 10-fold cross validation to assess the classification performance of the features that had been extracted by each CNN. Finally, a majority voting approach was used to classify each image into two different classes: COVID-19 and NO COVID-19. RESULTS: A total of 414 images of the test set (10% of the complete dataset) were correctly classified, and only 4 were misclassified, yielding a final classification accuracy of 99.04%. CONCLUSIONS: The high performance that was achieved by the method could make it feasible option that could be used to assist radiologists in COVID-19 diagnosis through the use of CT images.

RIFLE criteria for acute kidney injury in valvular surgery.

BACKGROUND AND AIM OF THE STUDY: The RIFLE classification, which defines three grades of increasing severity of acute kidney injury--risk (RIFLE R), injury (RIFLE I) and failure (RIFLE F), and two outcome classes (L, loss) and E (end-stage kidney disease)--represents a valuable method for evaluating acute renal failure. Risk factors for acute kidney injury (AKI) according to the RIFLE criteria and for operative mortality were identified in patients undergoing valvular procedures. METHODS: A single-center prospective cohort study of 1424 patients who were not receiving renal replacement therapy preoperatively was conducted between January 2004 and December 2007. A total of 100 variables was collected from each patient. RESULTS: The main features were: mean age 61.9 +/- 12.9 years (range: 15-88 years), 47% females, 6% endocarditis, 11% redo surgery, 8% urgent/emergent surgery, 30% combined procedures, 5% complex, and 16% associated coronary artery bypass grafting (CABG). The overall AKI prevalence was 10%, with RIFLE scores of I or F being detected in 8% and continuous veno-venous hemofiltration being required in 5%. Risk factors for AKI were age (OR 1.03; 95% CI 1.14-4.15), time of extracorporeal circulation (ECC) (OR 1.09; 95% CI 1.005-1.013), redo procedure (OR 2.35; 95% CI 1.42-3.8), chronic kidney disease (OR 3.2; 95% CI 1.6-6.1), and blood transfusion (OR 3.8; 95% CI 2.5-6.5). The transfusion of leukodepleted blood exerted a protective effect on AKI development (OR 0.6; 95% CI 0.4-0.9). The average overall hospital mortality was 4.8%. Risk factors for operative mortality included: ECC time (OR 1; 95% CI 1.002-1.014), age (OR 1.043; 95% CI 1.01-1.07), chronic kidney disease (OR 4.8; 95% CI 2.2-10.6), blood transfusion (OR 6.43; 95% CI 2.8-14.7), surgical priority (OR 6.5; 95% CI 2.8-14.7), RIFLE class I (OR 11.9; 95% CI 5.5-25.7), and RIFLE class F (OR 30; 95% CI 8.1-111.7). Mortality increased with each RIFLE stratification (Normal 1.7%, RIFLE R = 4.1%, RR = 2.5; RIFLE I = 27.6%, RR = 16.2; and RIFLE F = 43.8% RR = 25.8). CONCLUSION: AKI is a highly prevalent and prognostically important complication, for which the majority of risk factors that have been identified are not modifiable. The transfusion of leukodepleted blood products was seen to exert a preventive effect.

CD117-positive cells in adult human heart are localized in the subepicardium, and their activation is associated with laminin-1 and alpha6 integrin expression.

CD117-positive cells contributing to cardiac cell turnover in normal and pathological conditions have recently been described in adult human heart. Since the precise spatial and temporal expression of extracellular matrix proteins and their receptors is critical for organ formation, we compared the distribution of cardiac primitive CD117-positive cells in the human adult normal and pathological hearts with ischemic cardiomyopathy, with respect to localization and expression of laminin and integrin isoforms. In the pathological hearts, CD117-positive cells were significantly more numerous than in the normal hearts. They were localized mainly in the atria and were up to 38-fold more numerous in the subepicardium than in the myocardium. Compared with normal hearts, most CD117-positive cells in the subepicardium of pathological hearts were alpha(6) integrin-positive. Laminin-1, typical of developing heart, was found predominantly in the subepicardium of adult heart. Immunoblotting revealed its highest expression in the normal atrium and pathological left ventricle. Both laminin isoforms reduced apoptosis and increased proliferation and migration of CD117-positive cells in vitro with respect to control, but the effects of laminin-1 significantly outweighed those of laminin-2. Signaling mediated by alpha(6) integrin was implicated in the migration and protection from apoptosis, as documented by transfection with specific small interfering RNA. These data reveal that the increase in the number of cardiac CD117-positive cells and the expression of laminin-1 are observed in ischemic cardiomyopathy. Subepicardial localization of CD117-positive cells and expression of laminin-1 and alpha(6) integrin subunits may all correspond to the activation of regeneration involving an epithelial-mesenchymal transition recently described in adult heart.

Microbiologically documented nosocomial infections after cardiac surgery: an 18-month prospective tertiary care centre report.

OBJECTIVE: The aim of this study was to prospectively evaluate frequency, characteristics, and predictors of nosocomial infections (NI) in a tertiary care centre. METHODS: Study population included 925 patients (mean age 62.3+/-12.5, 32.3% females, 22.9% diabetics, 6.8% with previous cardiac procedures) operated on between June 2005 and December 2006 (CABG 48.72%, valvular procedures 30.05%, thoracic aortic 10.9%, heart transplantations 3.78% and miscellanea 6.55%, procedure status: elective 72.9%, urgent 15.9% and emergent 11.2%). The study population was divided in two groups according to development of NI. Primary endpoints were multiorgan failure (MOF) and hospital mortality in the two groups. Secondary endpoints were length of intubation, intensive care unit (ICU) stay and overall hospitalisation. Univariate and multivariate analysis of NI predictors was conducted between 115 perioperative variables. RESULTS: Eighty-three patients (9%) developed a NI. Infections affected respiratory tract in 51.8%, blood stream in 20.5 and wound infection in 27.7 (13.3% deep wound). Staphylococcal species (60.6%) predominated in blood stream and surgical wound infections while Gram-negative species predominated in respiratory infections. Patients affected by NI experienced significantly higher incidence of MOF (12% vs 0.8%) and hospital mortality (24.1 vs 6.9%). Development of NI significantly lengthened all the steps of postoperative process of care (length of intubation: 49.9+/-73 h vs 19.1+/-35.2; ICU stay: 10.4+/-12.8 days vs 3.4+/-4.6 and hospitalisation 20.7+/-15.3 vs 10.6+/-7). Independent predictors of NI were immunosuppressive therapy [OR 12.9 (CI 5.07-31.2)], reintubation [OR 10.3 (CI 4.6-2.3)], stroke [OR 9.5 (CI 1.8-49)], resternotomy for bleeding [OR 6.7 (CI 1.9-23.6)], emergent/urgent status [OR 3.6 (CI 1.5-8.4)], CVVH [OR 3.2 (CI 1.4-7.5)] and length of intubation [OR 1.03 (CI 1.01-1.1)]. CONCLUSIONS: NI still represents a serious complication. Presence of identified determinants of NI should prompt modification of management algorithms.

Low-dose anticoagulation after isolated mechanical aortic valve replacement with Liva Nova Bicarbon prosthesis: A post hoc analysis of LOWERING-IT Trial.

Thromboembolic complications after cardiac valve replacement are due to a complex interplay between patients' characteristics, device features and anticoagulation intensity. Subtle design and material differences in available prostheses may thrombosis. We conducted a post-hoc sub-analysis of the LOWERING-IT database to test the safety and feasibility of a low-level oral anticoagulant regime in low-risk patients with aortic LivaNova prosthetic valve replacement. The study population included 148 patients randomized to a low INR target (1.5-2.5; LOW-INR group), and 144 patients to the standard INR (2.0-3.0; CONVENTIONAL-INR group). The non-inferiority of thromboembolic events between LOW-INR and CONVENTIONAL-INR groups was tested. Cumulative follow-up reached 1,545 patient/years. The mean INR was 1.91 ± 0.23 in the LOW-INR group, and 2.59 ± 0.26 in the CONVENTIONAL-INR group (P < 0.001). There were 3 thromboembolic events, all in the CONVENTIONAL-INR group. Comparison of thromboembolic events was not significant. The 1-sided 97.5% exact CI for the difference in primary event proportion was 0.54%, satisfying criteria non-inferiority. Bleeding events were significantly different: 6.61 per 1,000 patient-year in LOW-INR group vs 18.65 per 1,000 patient-year in CONVENTIONAL-INR group (p < 0.045, RR 0.37). In conclusions these data suggest that low-dose anticoagulation is safe in selected patients after aortic LivaNova Bicarbon prosthesis implantation.

Age and blood transfusion: relationship and prognostic implications in cardiac surgery.

BACKGROUND: Red blood cell (RBC) transfusion is a well-known predictor of acute kidney injury (AKI) and death after cardiac surgery. This study aimed to define the relationship between age and the need for RBC. METHODS: Study population included 1,765 consecutive patients undergoing on-pump procedures from 2013 to 2015. The relationship between RBC transfusion and both survival and AKI, and any interaction with age was estimated. A propensity score for the likelihood to receive RBC transfusion was calculated using multivariate logistic regression analysis to adjust for the effect of confounding factors. A logistic estimation curve was developed to investigate the interaction between this score and age. RESULTS: Patients receiving RBC transfusions had more comorbidities irrespective of age. Elderly patients underwent transfusion more often than younger patients with a 1.3-fold increase in the relative risk for transfusion. Age did not independently predict the need for RBC. AKI and mortality rates were significantly higher in transfused subsets irrespective of age. CONCLUSIONS: Comorbidity profile and not age per se confers an increased risk of transfusion.

Spatial patterns of matrix protein expression in dilated ascending aorta with aortic regurgitation: congenital bicuspid valve versus Marfan's syndrome.

BACKGROUND AND AIM OF THE STUDY: Aortic wall stress has been shown to increase locally at the convex aspect of the ascending tract when axial root motion is increased, as occurs in aortic valve regurgitation. The study aim was to assess the expression of extracellular matrix (ECM) proteins involved in stress-induced vascular remodeling in the convexity and the concavity of dilated ascending aortas with aortic valve regurgitation. METHODS: Aortic wall specimens, harvested at the convexity and concavity of eight dilated ascending aortas with severe aortic valve regurgitation underwent morphometry, Western blot, RT-PCR and confocal immunohistochemistry. Five patients (group A) had congenital bicuspid aortic valve (BAV), and three (group B) had Marfan's syndrome. Specimens from the aorta of three multi-organ donors served as controls. RESULTS: At morphometry, medial degeneration was more severe in the convexity than in the concavity, especially in group A. Western blot, RT-PCR and immunohistochemistry disclosed an asymmetric pattern in the expression of some ECM proteins (laminin, tenascin, fibronectin). Fibronectin was increased in the convexity of both groups compared to controls at Western blot. Immunohistochemistry confirmed this pattern only in BAV. Higher levels of tenascin were found in the convexity in group A. The laminin content was greater in the concavity than in the convexity of both groups, but in group B the type of laminin was different, with the beta2 chain particularly expressed, and almost absent in non-Marfan patients. Type I and type III collagens were more markedly reduced in the convexity than in the concavity in BAV. In group B, type I collagen was decreased and type III increased, but without any significant difference between the two aspects of the aorta. CONCLUSION: A tissue remodeling response to valve disease-related wall stress may underlie aortic dilatation with BAV regurgitation. Although morphometry showed similar changes in Marfan aortas, molecular investigations differentiated this condition, qualitatively, from BAV.

Infective endocarditis in intravenous drug abusers: patterns of presentation and long-term outcomes of surgical treatment.

BACKGROUND AND AIM OF THE STUDY: Few data exist on infective endocarditis (IE) in intravenous drug abuse (IVDA) patients. In particular, clinical features, site of involvement and bacteriologic findings are controversial. Little is also known on the results of surgical treatment and on the long-term prognosis. METHODS: The clinical and microbiological characteristics of IE in a series of 39 IVDA patients were retrospectively assessed and compared to those in 85 non-IVDA patients with a likely similar life expectancy. The total follow up of patients was 717.6 patient-years (119.9 pt-yr for IVDA, 597.7 pt-yr for non-IVDA). RESULTS: Although tricuspid involvement was significantly more frequent in IVDA cases than in non-IVDA cases (p = 0.001), left-sided endocarditis prevailed in both groups. In addition to Staphylococcus aureus (51.3%), Staph. epidermidis (15.4%) and streptococcal spp. (23.1%) were emerging pathogens in IVDA cases. A worse cardiac function (p < 0.002) and a higher rate of embolism (p = 0.04) characterized the preoperative status of IVDA patients. No difference was observed as to indications, emergency procedures and pathologic findings. Hospital and long-term survival did not significantly differ between the two groups. The rate of recurrence was higher in IVDA cases; this difference was mostly accounted for by early postoperative events. CONCLUSION: A new pattern of IE in IVDA is emerging, characterized by more frequent left heart involvement (61.5%), a severe clinical course, and a need for surgery in the active phase. Staph. epidermidis and streptococci are emerging pathogens. Drug abuse does not affect postoperative prognosis when an aggressive surgical attitude is combined with prolonged medical therapy. Higher rates of early recurrence are expected during the follow up period.

Left ventricular mass regression after aortic valve replacement with 17-mm St Jude Medical mechanical prostheses in isolated aortic stenosis.

OBJECTIVE: The present study investigated the outcomes of aortic valve replacement with 17-mm mechanical prostheses in patients with isolated aortic stenosis. METHODS: Between January 1997 and January 2003, 35 patients (mean age, 63.4 +/- 17 years; median age, 70 years; age range, 16-84 years) underwent isolated aortic valve replacement with a 17-mm St Jude Medical Hemodynamic Plus (16 [45.7%] patients) or a St Jude Medical Regent prosthesis (19 [54.3%] patients). The paired Student t test or the paired Wilcoxon rank sum test were used to compare preoperative with follow-up echocardiographic measurements. RESULTS: Thirty-two (91.4%) patients were female, mean height was 154.4 +/- 8.3 cm, mean weight was 62.2 +/- 9.2 kg, and mean body surface area was 1.59 +/- 0.13 m 2 . The preoperative average New York Heart Association class was 2.8 +/- 0.8. The mean preoperative left ventricular mass index was 135.2 +/- 31 g/m 2 . Preoperative echocardiography showed an average gradient of 65.7 +/- 19.2 mm Hg (mean) and 103.6 +/- 30.7 mm Hg (peak) and a mean indexed effective orifice area of 0.40 +/- 0.1 cm 2 /m 2 . Echocardiographic follow-up time averaged 28.2 +/- 22.7 months (range, 13-72 months). Follow-up was 100% complete (1131.7 patient-months). Hospital mortality was 8.6% (3 patients). Actuarial 5-year survival was 94.7%. The mean postoperative New York Heart Association class was 1.13 +/- 0.34 ( P < .001), with 27 (87.1%) patients in class I and 4 patients in class II. A significant regression of the indexed left ventricular mass was found (postoperative mean value, 107.8 +/- 22.8 g/m 2 ; P < .0001), despite a mean indexed effective orifice area of 0.67 +/- 0.14 cm 2 /m 2 (median, 0.66 cm 2 /m 2 ). CONCLUSIONS: Selected patients with aortic stenosis can experience satisfactory clinical improvement and significant indexed left ventricular mass regression after aortic valve replacement with modern small-diameter bileaflet prostheses.

Mitral mechanical replacement in young rheumatic women: analysis of long-term survival, valve-related complications, and pregnancy outcomes over a 3707-patient-year follow-up.

OBJECTIVE: A follow-up study was performed to assess long-term survival, valve-related complications, and pregnancy outcomes in young rheumatic women undergoing isolated mitral mechanical replacement. The influence of prosthetic type on outcomes was also investigated. METHODS: Between 1975 and 2003, 267 isolated mitral mechanical prostheses were implanted. Follow-up reached 3707.8 patient-years. RESULTS: Actuarial survival at 1, 5, 10, 15, 20, and 25 years was 97% +/- 0.01%, 90.4% +/- 0.017%, 85.3% +/- 0.023%, 82.3% +/- 0.025%, 71.7% +/- 0.036%, and 70.2% +/- 0.038%, respectively. At multivariate analysis, atrial fibrillation at follow-up was identified as an independent risk factor for late mortality, whereas left ventricular ejection fraction at 12 postoperative months proved to be a protective factor. Freedom from thromboembolism at 1, 5, 10, 15, 20, and 25 years was 98.1% +/- 0.01%, 94.1% +/- 0.015%, 89.1% +/- 0.021%, 85.9% +/- 0.025%, 81.1% +/- 0.031%, and 75.3% +/- 0.063%, respectively. Atrial fibrillation and Carbomedics device were significantly associated with an increase in thromboembolic events. Freedom from reoperation at 1, 5, 10, 15, 20, and 25 years was 99.2% +/- 0.005%, 95% +/- 0.014%, 91.6% +/- 0.018%, 88.6% +/- 0.022%, and 85.7% +/- 0.041%. Type of prosthesis (tilting disc) was identified as a predictor of reoperation. At the end of the study, 208 patients were still alive: 94.7% were in New York Heart Association class I or II. When receiving warfarin therapy, no patient undertaking pregnancy (n = 35) experienced adverse cardiac or valve-related events. Fetal events were significantly less frequent with a daily warfarin dose less than 5 mg. CONCLUSIONS: Mechanical devices provided excellent performance, safety, and durability. The prognostic role of left ventricular function and atrial fibrillation overwhelmed any differences that might exist between different prosthetic designs. Pregnancies entail virtually no maternal risk and predictable fetal complications.

Different patterns of extracellular matrix protein expression in the convexity and the concavity of the dilated aorta with bicuspid aortic valve: preliminary results.

OBJECTIVE: This study aimed to assess extracellular matrix protein expression patterns at the convexity (right anterolateral wall) and the concavity of the dilated ascending aorta in patients with bicuspid aortic valve disease. METHODS: Aortic wall specimens were retrieved from the convexity and the concavity in 27 bicuspid aortic valve patients (12 with stenosis and 15 with regurgitation) and 6 heart donors (controls). Morphometry, immunohistochemistry, Western blot, and polymerase chain reaction were performed, focusing on matrix proteins involved in vascular remodeling. RESULTS: Type I and III collagens were significantly decreased in bicuspid-associated dilated aortas versus controls (P < .001), particularly at the convexity (P < .05 vs concavity). Expression of messenger RNA for collagens was lower than normal only in the regurgitant subgroup. At immunohistochemistry, proteins whose overproduction has been demonstrated in response to abnormal wall stress, such as tenascin and fibronectin, were more expressed in the convexity than in the concavity, especially in the stenosis subgroup. Tenascin, which is produced by smooth muscle cells in the synthetic phenotype, was nearly undetectable in controls. Fewer smooth muscle cells (stenosis, P = .017; regurgitation, P = .008) and more severe elastic fiber fragmentation (P = .029 and P < .001) were observed in the convexity versus the concavity. CONCLUSIONS: In bicuspid-associated aortic dilations, an asymmetric pattern of matrix protein expression was found that was consistent with the asymmetry in wall-stress distribution reported previously. Differences exist between patients with stenosis and those with regurgitation in terms of protein expression and content in the aortic wall. Further studies could clarify the relations between these findings and the pathogenesis of aortic dilatation in bicuspid aortic valve patients.

Treatment of extensive ischemic cardiomyopathy: quality of life following two different surgical strategies.

OBJECTIVE: To review outcomes and quality of life following two surgical strategies for severe left ventricular dysfunction due to ischemic dilated cardiomyopathy. METHODS: Hospital and follow-up records of 111 patients with extensive ischemic cardiomyopathy (mean age 57.3+/-8.4) referring to our institution between January 1996 and December 2003 were reviewed. Group A included 42 patients (mean age 62.4+/-7.9) with morphological and functional cardiac parameters allowing for ventricular restoration (including endoventricular circular patch plasty, coronary artery by-pass grafting, and, when needed, mitral surgery). Group B included 69 patients (mean age 54.3+/-7.2), undergoing cardiac transplantation. Hospital mortality, treatment-related late mortality, incidence of cardiac events, freedom from cardiac failure, freedom from hospital re-admission, functional recovery at follow-up (3075.2pts/months; 100% complete) and quality of life (WHOQOL test) were assessed. RESULTS: Hospital mortality was 19% in group A and 8.7% in group B (P=0.143). No treatment-related late deaths were observed in group A, while six deaths (9.5%) occurred in group B (P=0.063). Incidence of cardiac events was comparable. At 60 months, freedom from cardiac failure was 93.5+/-0.04 and 86.2+/-0.05%, respectively (P=0.23), freedom from hospital re-admission was 93.5+/-0.04 and 61.3+/-0.07% (P=0.002). Exertion dyspnea was present in 40% patients in group A versus 13% in group B (P=0.006). WHOQOL test showed a satisfying quality of life in both groups, although patients undergoing restoration reached higher scores in the psychological and social domains. CONCLUSIONS: Selected patients with ischemic cardiomyopathy, potentially eligible for transplantation, can be managed by ventricular restoration. In those patients post-operative quality of life is satisfactory, with comparable survival and low risk of re-hospitalization.

Perioperative myocardial injury after adult heart transplant: determinants and prognostic value.

BACKGROUND AND AIM OF THE STUDY: Implications of Cardiac troponin (cTnI) release after cardiac transplantation are still unclear. This study disclosed risk factors and prognostic implication of cTnI early levels in a single centre cohort operated on between January 1999 and December 2010. METHODS: Data on 362 consecutive recipients (mean age: 47.8±13.7, 20.2% female, 18.2% diabetics, 22.1% with previous cardiac operations, 27.6% hospitalized, 84.9±29.4 ml/min preoperative glomerular filtration rate) were analyzed using multivariable logistic regression modeling. Target outcomes were determinants of troponin release, early graft failure (EGF), acute kidney injury (AKI) and operative death. RESULTS: Mean cTnI release measured 24 hours after transplant was 10.9±11.6 µg/L. Overall hospital mortality was 10.8%, EGF 10.5%, and AKI was 12.2%. cTnI release>10 µg/L proved an independent predictor of EGF (OR 2.2; 95% CI, 1.06-4.6) and AKI (OR 1.031; 95% CI, 1.001-1.064). EGF, in turn, proved a determinant of hospital mortality. Risk factors for cTnI>10 µg/L release were: status 2B (OR 0.35; 95% CI, 0.18-0.69, protective), duration of the ischemic period (OR 1.006; 95% CI, 1.001-1.011), previous cardiac operation (OR 2.9; 95% CI, 1.67-5.0), and left ventricular hypertrophy (OR 3.3; 95% CI, 1.9-5.6). CONCLUSIONS: Myocardial enzyme leakage clearly emerged as an epiphenomenon of more complicated clinical course. The complex interplay between surgical procedure features, graft characteristics and recipient end-organ function highlights cTnI release as a risk marker of graft failure and acute kidney injury. The search for optimal myocardial preservation is still an issue.

Surgical repair of acute type A aortic dissection: continuous pulmonary perfusion during retrograde cerebral perfusion prevents lung injury in a pilot study.

OBJECTIVE: Postoperative respiratory failure is a frequent and serious complication in patients with type A acute aortic dissection operated on with deep systemic hypothermia. Interaction between neutrophils and pulmonary endothelium along with ischemic insult and reperfusion are the major determinants of lung injury. The aim of this prospective study was to evaluate the effect of continuous pulmonary perfusion during retrograde cerebral perfusion on lung function. METHODS: Twenty-two patients referred for acute type A aortic dissection, who were free from preoperative respiratory dysfunction, were assigned prospectively and alternately to one of 2 treatment groups. Pulmonary perfusion was performed during retrograde cerebral perfusion in group B (11 patients), whereas the conventional Ueda technique was applied in group A (11 patients). Lung function was evaluated on the basis of intubation time, scoring of chest radiographs at 12 hours after cardiopulmonary bypass, and Pao(2)/fraction of inspired oxygen ratio assessed from immediately before the operation to 72 hours after termination of cardiopulmonary bypass. RESULTS: Study groups were homogeneous for age, sex, interval between symptom onset and surgical operation, previous aortic surgery, preoperative ejection fraction and pulmonary gas exchange function, extent of aortic repair, and concomitant procedures. Cardiopulmonary bypass time, length of retrograde cerebral perfusion, operation time, need for blood substitutes, and surgical revision for bleeding did not differ between treatment groups. Postoperative Pao(2)/fraction of inspired oxygen ratios were higher in group B than in group A, and the difference remained statistically significant throughout the study period. The incidence of prolonged ventilator support (>72 hours) and the severity of the radiographic pulmonary infiltrate score were lower in the perfused group (18.2% vs 72.7% [P =.015] and 0.81 +/- 0.75 vs 1.8 +/- 0.78 [P =.028], respectively). CONCLUSIONS: Continuous pulmonary perfusion provided a better preservation of lung function in patients operated on with deep systemic hypothermia.

Risk of warfarin during pregnancy with mechanical valve prostheses.

OBJECTIVE: To assess the determinants of pregnancy outcome in patients with mechanical valve prostheses anticoagulated with warfarin. METHODS: Between January 1987 and January 2000, 52 patients with mechanical valve prostheses who had 71 pregnancies were anticoagulated with warfarin for the entire duration of pregnancy. Warfarin was withdrawn 48 hours before and 24 hours after a scheduled cesarean delivery carried out by the end of the 37th gestational week. The targeted international normalized ratio ranged between 2.25 and 4.0, depending on the prosthetic model. Exact univariate and multivariable analyses were performed to assess which among the following variables predicted poor pregnancy outcome: patient age, prosthetic model, site of implantation, average international normalized ratio, and average daily dose of warfarin. RESULTS: Pregnancy loss occurred in 23 of 71 of pregnancies, stillbirth in five of 71, embryopathy in four of 71 (two aborted fetuses and two full-term infants). There were no maternal deaths or thromboembolic or hemorrhagic complications. Warfarin daily dosage over 5 mg per day was a significant predictor of poor pregnancy outcome (P <.001). CONCLUSION: The risk for pregnancy complications in patients treated with sodium warfarin is higher when the mean daily dose exceeds 5 mg.

Treatment of recurrent staphylococcal mediastinitis: still a controversial issue.

BACKGROUND: Although surgical management with early debridement and closed mediastinal irrigation has proved successful in reducing early mortality following poststernotomy deep sternal wound infection, recurrence rates are still up to 20%. This study compared the effectiveness and safety of wound dressing with granulated sugar versus early muscle flap surgery in the management of recurrent postoperative Staphylococcal mediastinitis. METHODS: Between January 1995 and January 2002, 25 patients with severe recurrent staphylococcal mediastinitis were treated with granulated sugar wound dressing (group A) or with wound debridement, v-shape sternectomy and associated muscle flap surgery (group B). Clinical outcomes and perioperative data were analyzed. Outcomes were compared between the groups evaluating the length of time for normalization of white blood cell (WBC) count and of body temperature and length of hospital stay. Patient characteristics determining best treatment option were identified. Survival and incidence of recurrence at follow-up were also analyzed. RESULTS: Study groups proved homogenous as to preoperative characteristics. Complete cure was achieved earlier in group A than in group B (defervescence: p = 0.0005; WBC normalization: p = 0.0001, respectively). Hospital stay was shorter in group A. A statistically significant difference was found in hospital mortality (16% overall) between the two groups with better outcomes in group A (p = 0.039). In the patient subset with the most severe preoperative profile (hemodialysis, tracheostomy, inotropic support) surgical treatment produced worse results than the sugar dressing method (p 0.048). No case of recurrence was observed. CONCLUSIONS: Both treatments proved effective in recurrent type IV A Staphylococcal mediastinitis. Granulated sugar proved a safer option in severely compromised patients.

Native versus primary prosthetic valve endocarditis: comparison of clinical features and long-term outcome in 353 patients.

BACKGROUND AND AIM OF THE STUDY: The study aim was to compare preoperative and intraoperative features, and long-term outcome of patients operated on for native (NVE) and primary prosthetic valve endocarditis (PVE). METHODS: Between January 1978 and December 2002, 258 patients (mean age 47.5 +/- 16 years) were referred for NVE, and 95 for PVE. Demographics, clinical preoperative conditions, indications to surgery, microbiological data, surgical pathology, early postoperative course and long-term outcome were compared via hospital chart review and outpatient clinic follow up. RESULTS: Female sex prevailed in the PVE group (49.5%) versus NVE (27.1%; p < 0.0001). Mitral valve involvement was more common in PVE (46.3% versus 24.8%, p = 0.0001), and multivalvular in 16.3% of NVE patients versus 4.2% of PVE (p = 0.001). Active endocarditis (80.6% versus 58.9%, p = 0.00004) and preoperative embolism (29.5% versus 11.6%, p = 0.0002) were significantly prevalent in the NVE group. Emergency operation (21.1% versus 10.5%, p = 0.009) and preoperative NYHA class IV or V (40% versus 19.8%, p < 0.0001) were significantly more frequent in PVE. Overall hospital mortality was 11.3% (n = 40), with 6.6% among NVE patients and 24.2% among PVE (p < 0.0001). Mean follow up (94% complete) was 5.8 +/- 5.3 years (6.0 +/- 5.5 years for NVE versus 5.1 +/- 4.6 years for PVE, p = 0.191), and total follow up was 1,707.85 patient-years. Actuarial survival at 1, 5, 10 and 15 years was respectively 91, 82, 67.5 and 48.8% in NVE, and 79.7, 64.2, 33.5 and 33.5% in PVE (p = 0.0016). A significantly lower survival in PVE versus NVE was found for the mitral site subgroup (p = 0.018), but not for the aortic site (p = 0.14). Actuarial freedom from reoperation for recurrent endocarditis at 1, 5, 10 and 15 years was 97.5, 91.4, 80.5 and 49.4% in NVE versus 90.8, 84.9, 59.4 and 43.9% in PVE (p = 0.015). CONCLUSION: PVE patients were older, presented with more compromised clinical conditions, and had worse early and long-term outcomes than NVE patients. PVE had a higher incidence of recurrence and worse prognosis, especially if the mitral valve was involved.

The impact of gender on heart transplantation outcomes: a single center experience.

BACKGROUND: According to the data of the Registry of the International Society for Heart and Lung Transplantation, donor and recipient female gender is a significant risk factor for mortality after heart transplantation. It has also been reported that donor-recipient gender mismatch is a determinant of post-transplant morbidity and mortality. To examine the effect of gender on the early and mid-term outcomes, we retrospectively reviewed data of a consecutive group of heart transplant recipients at our Institution. METHODS: The study population comprised 99 patients undergoing heart transplantation between 1996 and 1998. This population was divided into four groups on the basis of donor and recipient matching. Group A consisted of 61 men who received male donor hearts, group B of 12 women who received female donor hearts, group C of 9 women who received male donor hearts, and group D of 17 men who received female donor hearts. Standard heart transplantation protocols were applied to all patient groups [graft preservation with Celsior solution, Shumway surgical technique, donor-recipient size matching > or = 1.0, induction therapy with polyclonal antithymocyte globulins, triple immunosuppressive therapy (neoral, azathioprine, steroids)]. RESULTS: The study groups were found to be homogeneous with regard to the major preoperative risk factors (etiology, status at transplantation, donor and recipient age, total ischemic time). Donor gender, recipient gender and donor-recipient gender mismatching did not significantly modify the short and mid-term survivals, functional recovery and freedom from rejection. CONCLUSIONS: Even though previous reports suggest that gender negatively affects survival, this factor proved to have no influence on the outcomes of the present series. These results can be explained by a correct donor-recipient size matching. The well-documented female recipients tendency to more frequent and fatal rejection was not confirmed in our experience. The patient's age at transplantation, the routine use of induction therapy and an aggressive immunosuppressive regimen may be the substrate of these findings.