Early Postoperative Complications of Robotic-assisted Versus Minimally Invasive Mitral Valve Surgery: A Propensity Score-matched Analysis.

OBJECTIVE: The current work was designed to evaluate whether robotic-assisted mitral valve surgery is associated with a different incidence of early postoperative complications compared with the traditional minimally invasive approach. DESIGN: A retrospective monocentric cohort study was conducted. SETTING: The study was performed in an academic hospital. PARTICIPANTS: A total of 375 patients who underwent standard thoracoscopic minimally invasive mitral valve surgery and robotic-assisted mitral valve surgery between April 2014 and November 2022 were enrolled. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: After adjustment using propensity score analysis, 98 patients from each group were identified. Patients who underwent robotic surgery presented a similar rate of early complications to patients undergoing minimally invasive surgery. Nevertheless, they showed shorter intensive care unit and postoperative hospital stays. Finally, patients undergoing robotic-assisted surgery were more frequently discharged home. CONCLUSIONS: This study identified a similar incidence of early complications in robotic-assisted mitral valve surgery compared with minimally invasive mitral valve surgery; conversely, patients receiving robotic-assisted surgery were discharged earlier, and more frequently discharged home.

Robotic-Assisted Epicardial Hybrid Ablation and Left Appendage Closure in Persistent Atrial Fibrillation: First European Experience.

Background: Pulmonary vein isolation is currently considered to be the gold standard for ablating paroxysmal atrial fibrillation. However, its efficacy is limited in patients with persistent atrial fibrillation. The convergent procedure has emerged as a hybrid ablation. This study aims, for the first time in the literature, to introduce a hybrid approach that includes epicardial ablation with cutting-edge robotic technology and subsequent electrophysiological study to verify and an endocardial ablation to complete the ablation lines. Methods: We present 18 cases of robotic-assisted epicardial hybrid ablation performed between April and December 2023 on patients with long-standing persistent atrial fibrillation (mean age: 64 ± 5 years; mean duration: 4 ± 2 years). All of the procedures were performed at "Humanitas Gavazzeni Hospital", Bergamo, Italy. Robot-assisted epicardial ablation performed using the "Epi-Sense AtriCure" device was guided by monitoring electrogram morphology and point-by-point impedance drop. This approach also included left atrial appendage occlusion and the disconnection of the ligament of Marshall. An electrophysiological study and endocardial ablation were planned three months after the procedure. Results: The procedure was successfully executed in all patients with no major complications and a mean operative time of 142 ± 22 min. None of the cases required conversion to full sternotomy or minithoracotomy. The procedure was performed in all cases without extracorporeal circulation and on a beating heart. Fifteen patients (83%) were extubated in the operating room. The length of stay in the intensive care unit was less than 24 h. Acute restoration of sinus rhythm was achieved in 12 out of the 18 patients (67%); the median duration of their hospital stay was two days. In the electrophysiological study, seven pts had sinus rhythm, two had atrial fibrillation, and one patient developed atrial flutter at 3-month follow-up. Patients underwent transcatheter ablation to complete the lesion set and, at the time of discharge, were all in sinus rhythm. Conclusions: In our initial experience, surgical atrial fibrillation ablation consisting of a unilateral thoracoscopic technique facilitated by a robotic platform and continuous EGM monitoring has proven to be safe and feasible. For the electrophysiological study at 3 months, completing the gaps in the surgical ablation lines could improve the clinical results of the technique in terms of sinus rhythm stability. However, mid- and long-term follow-up is required to demonstrate this.

Risk Factors for Higher Postoperative Myocardial Injury in Minimally Invasive Mitral Valve Surgery Patients: A Cohort Study.

Background: Postoperative myocardial injury, as detected by an elevated concentration of high-sensitivity cardiac troponin I (hs-cTnI), is a common complication in cardiac surgery that may be linked to mortality. The primary aim of this study was to assess the risk factors associated with increased myocardial injury in patients undergoing minimally invasive mitral valve surgery. Methods: In this retrospective monocentric cohort study, we analyzed all patients who underwent elective minimally invasive mitral valve surgery between January 2019 and December 2022 and were subsequently admitted to our intensive care unit. The study population was divided into two groups based on the peak hs-cTnI level: the "lower myocardial injury" group comprised patients whose peak serum hs-cTnI level was less than 499 times the 99th percentile, while the "higher myocardial injury" group included those patients who exhibited hs-cTnI levels equal to or greater than 500 times the 99th percentile. A multivariable logistic regression analysis was performed to identify independent risk factors associated with higher myocardial injury. Results: In our final analysis, we enrolled 316 patients. Patients with higher myocardial injury (48; 15%) more frequently had a preoperative New York Heart Association (NYHA) class ≥3 compared to those with lower myocardial injury [33 (69%) vs. 128 (48%); p < 0.01-OR 2.41 (95% CI 1.24-4.64); p < 0.01]. Furthermore, cardiopulmonary bypass and aortic cross-clamp time were significantly longer in the higher myocardial injury group compared to the lower myocardial injury group [117 (91-145) vs. 86 (74-100) min; p < 0.01-OR 1.05 (95% CI 1.03-1.06); p < 0.01]. Moreover, patients who underwent robotic-assisted mitral valve surgery experienced lower myocardial injury rates [9 (19%) vs. 102 (38%); p = 0.01-OR 0.38 (95% CI 0.18-0.81); p = 0.01] than others. These findings remained consistent after adjustment in multivariate logistic regression. In terms of postoperative outcomes, patients with higher myocardial injury exhibited the highest lactate peak in the first 24 h, a higher incidence of postoperative acute kidney injury and a longer duration of mechanical ventilation. Although no patients died in either group, those with higher myocardial injury experienced a longer hospital length of stay. Conclusions: Higher myocardial injury is relatively common after minimally invasive mitral valve surgery. Prolonged aortic cross-clamp duration and higher NYHA class were independently associated with myocardial injury, while robotic-assisted mitral valve surgery was independently associated with lower postoperative myocardial injury.

Learning Curve Analysis of Robotic-Assisted Mitral Valve Repair with COVID-19 Exogenous Factor: A Single Center Experience.

Background and objective Renewed interest in robot-assisted cardiac procedures has been demonstrated by several studies. However, concerns have been raised about the need for a long and complex learning curve. In addition, the COVID-19 pandemic in 2020 might have affected the learning curve of these procedures. In this study, we investigated the impact of COVID-19 on the learning curve of robotic-assisted mitral valve surgery (RAMVS). The aim was to understand whether or not the benefits of RAMVS are compromised by its learning curve. Materials and Methods Between May 2019 and March 2023, 149 patients underwent RAMVS using the Da Vinci® X Surgical System at the Humanitas Gavazzeni Hospital, Bergamo, Italy. The selection of patients enrolled in the study was not influenced by case complexity. Regression models were used to formalize the learning curves, where preoperative data along with date of surgery and presence of COVID-19 were treated as the input covariates, while intraoperative and postoperative data were analyzed as output variables. Results The age of patients was 59.1 ± 13.3 years, and 70.5% were male. In total, 38.2% of the patients were operated on during the COVID-19 pandemic. The statistical analysis showed the positive impact of the learning curve on the trend of postoperative parameters, progressively reducing times and other key indicators. Focusing on the COVID-19 pandemic, statistical analysis did not recognize an impact on postoperative outcomes, although it became clear that variables not directly related to the intervention, especially ICU hours, were strongly influenced by hospital logistics during COVID-19. Conclusions Understanding the learning curve of robotic surgical procedures is essential to ensure their effectiveness and benefits. The learning curve involves not only surgeons but also other health care providers, and establishing a stable team in the early stage, as in our case, is important to shorten the duration. In fact, an exogenous factor such as the COVID-19 pandemic did not affect the robotic program despite the fact that the pandemic occurred early in the program.

Pharmacological prevention of postoperative delirium in patients undergoing cardiac surgery: a bayesian network meta-analysis.

The incidence of postoperative delirium in patients undergoing cardiac surgery is very high and increases morbidity and mortality. The possibility of pharmacological means to reduce its incidence is very attractive. At present, there is still no clear demonstration that any drug can prevent postoperative delirium in these patients. The aim of this Bayesian network meta-analysis (NMA) was to evaluate whether there is evidence that a drug is effective in reducing the incidence of POD in cardiac surgical patients. Our NMA showed that preoperative ketamine at subanesthetic doses can significantly reduce the incidence of POD. Risperidone also decreases the incidence of POD, but not significantly.

Comparative myocardial protection of endoaortic balloon versus external clamp in minimally invasive mitral valve surgery.

AIMS: Minimally invasive mitral valve surgery leads to shorter postoperative recovery time, cosmetic advantages and significant pain reduction compared with the standard sternotomy approach. Both an external aortic clamp and an endoaortic balloon occlusion can be used to manage the ascending aorta and the myocardial protection. In this study, we aimed to compare these two strategies in terms of effectiveness of myocardial protection and associated early postoperative outcomes. METHODS: We investigated the retrospective records of prospectively collected data of patients treated by minimally invasive mitral valve surgery from March 2014 to June 2019. A total of 180 cases (78 in the external aortic clamp group and 102 in the endoaortic balloon clamp group) were collected. A propensity weighting analysis was adopted to adjust for baseline variables. RESULTS: The endoaortic balloon clamp presented higher EuroSCORE II (higher reoperative surgery rate). The intra- and postoperative data were similar between the two groups: the postoperative troponin-I levels, peak of serum lactates and rate of myocardial infarction were also comparable. The endoaortic clamp group recorded longer operative, cardiopulmonary bypass and cross-clamp times. The external clamp group showed a higher rate of postoperative atrial fibrillation and conduction block. CONCLUSIONS: In experienced centers, the use of the endoaortic balloon clamp is safe, reproducible and comparable to the external aortic clamp regarding the effectiveness of myocardial protection: its employment might facilitate minimally invasive mitral valve surgery.

Evaluation of robotic-assisted mitral surgery in a contemporary experience.

AIMS: To evaluate the safety/effectiveness of a recently established robotic-assisted mitral surgery program. METHODS: Cohort study with prospective collection of clinical data of 59 consecutive recipients (May 2019-August 2021) of robotic-assisted (fourth-generation platform, DaVinci X) mitral valve repair for degenerative disease, using a totally endoscopic technique. Patients' selection was based on defined anatomical and clinical criteria. We established a dedicated multidisciplinary protocol to facilitate postoperative fast-tracking, and a systematic in-house clinical and echocardiographic follow-up at 3, 6, and 12 postoperative months. RESULTS: All patients (89.8% men, average age 58 ±â€Š12 years) received mitral valve repair; there was no operative mortality, one conversion to sternotomy (1.7%) and one stroke (1.7%). Extubation within the operative theater occurred in 28.8%; average mechanical ventilation time and ICU stay was 2.8 ±â€Š4.1 and 32.5 ±â€Š15.8 h (after exclusion of one outlier, learning-curve period, suffering from perioperative stroke); average postoperative hospital stay was 6.8 ±â€Š3.4 days and 96.6% of patients were discharged home. One patient was transfused (1.7%); there were no other complications. Follow-up revealed stability of the results of mitral repair, with one (1.7%) persistent (>2+/4+) mitral regurgitation, and stability of coaptation height over time. We observed optimal functional results (class I was 98% at 3 months and 96% at 12 months). Quarterly case load consistently increased during the experience. CONCLUSION: This initial experience suggests the reliability and clinical safety of a recently established local robotic-assisted mitral surgery. This strategy can facilitate faster postoperative recovery, and its positioning in the therapeutic armamentarium needs to be defined.

Less invasive aortic valve replacement using the trifecta bioprosthesis.

Objectives. The safety and effectiveness of the Trifecta GT bioprosthesis (introduced in 2016) in less invasive aortic valve replacement are scarcely investigated. Our aim was to evaluate the immediate and initial follow-up results of this device in the context of less invasive surgery. We discuss patient-specific strategies for the selection of the surgical approach. Methods. A retrospective review of 133 patients undergoing AVR with the Trifecta GT through three less invasive accesses (UMS, Upper ministernotomy; RMS, Reversed ministernotomy; RAMT, Right anterior minithoracotomy) was performed. In-hospital, follow-up and hemodynamic performance (PPM, Patient-prosthesis mismatch) data were collected. Results. Among patients, 79% received UMS, 11% RMS and 10% RAMT. Selection of approach was based on preoperative anatomical analysis (CT-scan) and planned concomitant procedures. There was no operative mortality, no valve-related adverse events. There were 36 concomitant procedures. No significant intergroup differences occurred in cardiopulmonary bypass, aortic clamp, mechanical ventilation time, ICU stay and average bleeding. There were two cases of moderate PPM (1.5%) and no instances of severe PPM; there were no significant (≥2/4) perivalvular leaks. Average mean gradient at discharge was 8 ± 3 mmHg. At follow-up (average: 2.5 ± 0.9 years, 100% complete, 315 patient years) there was no mortality and no valve-related adverse event. Hemodynamic performance was maintained at follow-up. Conclusions. The optimal device for less invasive AVR needs to be individualized, as well as the selection of the surgical approach. The use of the Trifecta GT bioprosthesis appears to be reproductible whatever less invasive approach is employed, with confirmed excellent hemodynamic performance.

Non-conventional and Investigational PET Radiotracers for Breast Cancer: A Systematic Review.

Breast cancer is one of the most common malignancies in women, with high morbidity and mortality rates. In breast cancer, the use of novel radiopharmaceuticals in nuclear medicine can improve the accuracy of diagnosis and staging, refine surveillance strategies and accuracy in choosing personalized treatment approaches, including radioligand therapy. Nuclear medicine thus shows great promise for improving the quality of life of breast cancer patients by allowing non-invasive assessment of the diverse and complex biological processes underlying the development of breast cancer and its evolution under therapy. This review aims to describe molecular probes currently in clinical use as well as those under investigation holding great promise for personalized medicine and precision oncology in breast cancer.

[Towards the age of computer-assisted surgery: how to establish a robotic-assisted mitral surgery program with a last-generation platform]. / Verso l'era della chirurgia computer-assistita: come iniziare un programma di chirurgia robotica della valvola mitrale.

Mitral valve therapy is rapidly evolving. In this context, there is a clear evolution towards the diffusion of minimally invasive techniques for surgical mitral valve replacement or repair, namely in the context of primary mitral regurgitation. The robotic-assisted mitral surgery strategy allows the greatest reduction in surgical trauma to the patients, as well as improved ergonomics and video-assistance for performance of the mitral procedure. We currently observe a rapid diffusion of robotic-assisted mitral valve surgery across Europe, which rightfully forms part of the treatment modalities available to multidisciplinary Mitral Teams. However, the development of a robotic cardiac surgery program should be established maintaining reproducibility and patient safety. Adequate training and preparation are essential to initiate and sustain a robotic-assisted mitral valve surgery program. Herein, we address its main steps: fundamentals, multidisciplinary approach, risk management, team management, development and consolidation. We also present the initial clinical results in our Center, and analyze some learning-curve aspects.

Transesophageal echocardiography (TEE) in cardiac arrest: results of a hands-on training for a simplified TEE protocol.

BACKGROUND: Integration of transesophageal echocardiography (TEE) with Focused Cardiac Ultrasound (FoCUS) can impact decision-making, assist in the diagnosis of reversible etiologies and help guiding resuscitation of patients with cardiac arrest. OBJECTIVE: To evaluate the ability of emergency physicians (EPs) to obtain and maintain skills in performing resusTEE after a course with clinical training in the cardiac surgery theatre. METHODS: Ten EPs without previous TEE experience underwent a resusTEE course, based on a 2-h workshop and an 8-h hands-on training. The training was performed in a cardiac surgery theatre tutored by cardiovascular anesthesiologists. The six taught views were mid-esophageal four-chamber (ME4CH), mid-esophageal long axis (MELAX), mid-esophageal two-chamber (ME2CH), mid-esophageal bicaval view (MEbicaval), transgastric short axis (TGSAX) and aorta view (AOview). The EPs were evaluated by a cardiovascular anesthesiologist at the end of the course as well as after 12 weeks according to a standardized evaluation method. Once the course was completed, resusTEE exams, performed by EPs in Emergency Department (ED), were monitored for a 12-week period. RESULTS: The average assessment of the ten EPs by the tutors was higher than 4 points out of 5, both at the end of the course and after 12 weeks. Probe insertion, acquisition and interpretation of the different views scored on average more than 4 points out of 5 except for TGSAX that showed worsening after 12 weeks. Trainees performed twelve resusTEE exams in ED in patients with out-of-hospital cardiac arrest (OHCA) over 12 weeks after the course. EPs used only four out of six taught views in clinical practice, in the following order of frequency: ME4CH, AOview, MEbicaval and MELAX. CONCLUSIONS: EPs, after a course with clinical training in the cardiac surgery theatre, can successfully acquire and maintain the skills needed to perform resusTEE. However, among the six views learned in the course, EPs used only four of them (ME4CH, MEbicaval, MELAX and AOview).

Interleukin-6 receptor blocking with intravenous tocilizumab in COVID-19 severe acute respiratory distress syndrome: A retrospective case-control survival analysis of 128 patients.

In cases of COVID-19 acute respiratory distress syndrome, an excessive host inflammatory response has been reported, with elevated serum interleukin-6 levels. In this multicenter retrospective cohort study we included adult patients with COVID-19, need of respiratory support, and elevated C-reactive protein who received intravenous tocilizumab in addition to standard of care. Control patients not receiving tocilizumab were matched for sex, age and respiratory support. We selected survival as the primary endpoint, along with need for invasive ventilation, thrombosis, hemorrhage, and infections as secondary endpoints at 30 days. We included 64 patients with COVID-19 in the tocilizumab group and 64 matched controls. At baseline the tocilizumab group had longer symptom duration (13 ± 5 vs. 9 ± 5 days) and received hydroxychloroquine more often than controls (100% vs. 81%). The mortality rate was similar between groups (27% with tocilizumab vs. 38%) and at multivariable analysis risk of death was not significantly influenced by tocilizumab (hazard ratio 0.61, 95% confidence interval 0.33-1.15), while being associated with the use at baseline of non invasive mechanical or invasive ventilation, and the presence of comorbidities. Among secondary outcomes, tocilizumab was associated with a lower probability of requiring invasive ventilation (hazard ratio 0.36, 95% confidence interval 0.16-0.83; P = 0.017) but not with the risk of thrombosis, bleeding, or infections. The use of intravenous tocilizumab was not associated with changes in 30-day mortality in patients with COVID-19 severe respiratory impairment. Among the secondary outcomes there was less use of invasive ventilation in the tocilizumab group.

Viscoelastic Blood Tests Use in Adult Cardiac Surgery: Meta-Analysis, Meta-Regression, and Trial Sequential Analysis.

OBJECTIVES: Postoperative hemorrhage in cardiac surgery is a significant cause of morbidity and mortality. Standard laboratory tests fail as predictors for bleeding in the surgical setting. The use of viscoelastic (VE) hemostatic assays thromboelastography (TEG) and rotational thromboelastometry (ROTEM) could be an advantage in patients undergoing cardiac surgery. The objective of this meta-analysis was to analyze the effects (benefits and harms) of VE-guided transfusion practice in cardiac surgery patients. DESIGN: A meta-analysis of randomized trials. SETTING: For this study, PubMed, EMBASE, Scopus, and the Cochrane Collaboration database were searched, and only randomized controlled trials were included. A systematic review and meta-analysis were performed in accordance with the standards set forth by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, using a random-effects model. PARTICIPANTS: The study comprised adult cardiac surgery patients. INTERVENTIONS: VE-hemostatic assays transfusion algorithm compared with transfusion algorithms based on clinicians' discretion. MEASUREMENTS AND MAIN RESULTS: Seven comparative randomized controlled trials were considered, including a total of 1,035 patients (522 patients in whom a TEG- or ROTEM-based transfusion algorithm was used). In patients treated according to VE-guided algorithms, red blood cell (odds ratio 0.61; 95% confidence interval [CI]: 0.37-0.99; p: 0.04; I2: 66%) and fresh frozen plasma transfusions (risk difference 0.22; 95% CI: 0.11-0.33; p < 0.0001; I2: 79%) use was reduced; platelets transfusion was not reduced (odds ratio 0.61; 95% CI: 0.32-1.15; p: 0.12; I2 74%). CONCLUSIONS: This study demonstrated that the use of VE assays in cardiac surgical patients is effective in reducing allogenic blood products exposure, postoperative bleeding at 12 and 24 hours after surgery, and the need for redo surgery unrelated to surgical bleeding.

Achievement of target SBP without attention to decrease in DBP can increase cardiovascular morbidity in treated arterial hypertension: the Campania Salute Network.

OBJECTIVES: Results of the SPRINT study have influenced recent guidelines on arterial hypertension, in the identification of target SBP, but scarce attention has been paid to the consequences on DBP. However, there is evidence that reducing DBP too much can be harmful. METHODS: We analyzed outcome in 4005 treated hypertensive patients (22% obesity, 8% diabetes and 21% current smoking habit) with target attended office SBP less than 140 mmHg, in relation to quintiles of DBP, cardiovascular risk profile and target organ damage (LV hypertrophy, carotid plaque and left atrial dilatation). Composite fatal and nonfatal cardiovascular event was the outcome variable in this analysis (stroke and myocardial infarction, sudden cardiac death, heart failure requiring hospitalization, transient ischemic attack, myocardial revascularization, de novo angina, carotid stenting and atrial fibrillation). RESULTS: Lower DBP was associated with greater proportion of women and diabetes, older age, decline in kidney function and greater values of LV mass index and left atrial volume and greater prevalence of carotid plaque (all 0.04 < P < 0.0001). The lowest quintile of DBP (74.1 ±â€Š3.7 mmHg) was associated with 1.49 higher hazard of composite cardiovascular events, independently of significant effect of older age, female sex, LV hypertrophy and borderline effect of left atrial dilatation (0.04 < P < 0.001). CONCLUSION: Increased risk associated with aggressive reduction of DBP should be balanced with the advantage of reducing aggressively SBP to predict the net benefit of antihypertensive treatment, especially in the oldest old individuals.

Versatility of endoaortic balloon occlusion device for less invasive management of complex and reoperative cardiac cases.

Heart Teams are increasingly confronted with decision-making in anatomically and clinically complex surgical candidates. Herein, we discuss the versatility of the endoaortic occlusion device (Intraclude; Edwards Lifesciences Inc) for the management of a various array of complex primary and reoperative cardiac cases. Three clinical scenarios are illustrated (ascending aortic pseudoaneurysm, mitral valve surgery after previous CABG, extensive thoracic aortic surgery with continuous visceral perfusion), suggesting the effectiveness of the patient-specific strategy to minimize operative morbidity. Evolution of surgical techniques needs to be considered in decision-making among alternative treatment strategies.

Strategy-specific durability of mitral valve repair through the video-assisted right minithoracotomy approach.

AIMS: We sought to analyze the early and follow-up results of minimally invasive video-assisted mitral valve repair. With particular focus on degenerative disease, results were stratified according to type of lesion, strategy of repair and surgical technique. METHODS: We retrospectively built a database over 241 patients who received mitral repair for severe regurgitation through right minithoracotomy in the 2009-17 period. Cause was degenerative in 92.1%, restrictive in 5.8% and mixed in the remainders. Clinical and echocardiographic follow-up (98.7% complete, average duration 2.9 years ±â€Š1.4) was obtained through contact of in-house and territorial cardiologists. Recurrent mitral regurgitation at follow-up was defined as being at least mild-to-moderate (2+). RESULTS: Operative mortality was 1.7%, and related to the technique in one case. Five-year actuarial survival was 95% ±â€Š2; there was no valve-related death and one reoperation. At follow-up, we observed eight cases of 2+ regurgitation and one instance of 4+ regurgitation (4-year actuarial freedom: 92% ±â€Š4). Freedom from recurrent regurgitation was significantly lower in the 'restrictive' subgroup vs. the 'degenerative' subgroup (P = 0.02); no statistically significant difference in freedom from recurrence was observed among patients who received mitral repair using a 'resect' vs. 'nonresection' strategy (P = 0.46), and in those who received the Totally Endoscopic technique (endoaortic balloon occlusion, no costal spreading) vs. controls (external aortic clamp, costal spreading) (P = 0.98). CONCLUSION: Durability of minimally invasive mitral repair is optimal. Nonresection repair techniques are at least noninferior to previous approaches based on leaflet resection.

A challenging diagnosis of dyspnea: A case report of contralateral reexpansion pulmonary edema.

Reexpansion pulmonary edema (RPE) is an uncommon complication of thoracentesis or chest drainage. It occurs in the ipsilateral or contralateral lung. Causes, pathogenesis and therapy are not well understood especially for contralateral RPE. We describe a case of fatal contralateral RPE in a 59-years-old woman with right lung cancer underwent ultrasound-guided thoracentesis for massive pleural effusion and severe dyspnea. Pathogenesis of contralateral RPE is probably multifactorial and in this case is mostly due to the overperfusion of the healthy lung and consequent capillary damage. The right therapy for this condition is not known.

Hybrid repair of type A acute aortic dissections with the Lupiae technique: ten-year results.

OBJECTIVES: Replacing the ascending aorta and the arch in patients with type A acute aortic dissection achieves good short-term results, but several patients are left with distal intimal tears or a patent false lumen in the descending aorta. In this series, we report the 10-year experience with the Lupiae technique, a hybrid aortic repair technique for patients with type A acute aortic dissection. METHODS: From 2003 to 2013, 89 patients with type A acute aortic dissections underwent replacement of the ascending aorta, the arch, and the rerouting of the neck vessels on the ascending aorta, creating a proximal Dacron landing zone for a completion with thoracic endovascular aortic repair if necessary. RESULTS: In-hospital mortality was 8.9%. In 16 patients, the false lumen healed spontaneously, whereas the remaining 65 patients underwent thoracic endovascular aortic repair. One patient died after thoracic endovascular aortic repair. Eighty patients were followed up. Complete thrombosis of the false lumen was obtained in 93.8% of patients. The median follow-up was 46 ± 35 months. Overall 8-year survival was 93.7% ± 5%, 100% for patients with spontaneously healed residual false lumen after just type A acute aortic dissection repair and 92.3% ± 7.7% for patients who underwent thoracic endovascular aortic repair after type A acute aortic dissection repair. In 10 years, 1 patient underwent a reoperation on the distal aorta (1.25%). CONCLUSIONS: The availability of a Dacron landing zone on the distal ascending aorta after type A acute aortic dissection repair allows the exclusion, with a thoracic endovascular aortic repair, of any residual intimal tear refilling a patent false lumen. This approach seems to be associated with a high probability of false lumen thrombosis and low rates of reoperations on the distal aorta.

A predictive model to reduce allogenic transfusions in primary total hip arthroplasty.

An efficient Blood Conservation Program (BCP) should be considered in preparation of the surgical patient transfusion requirement. BCP should account for the association between bleeding reduction and anemia during or post surgery. In this paper, our aim was to develop a predictive model of bleeding that could help direct decision making about the strategy to reduce unnecessary transfusions. Such a strategy could guarantee an adequate peri-operative hemoglobin value, to reduce the patients' risk and rehabilitation time. Moreover, an accurate prediction of bleeding and anemia helps to plan preventive autologous transfusion or erythropoietic stimulus, to enhance a conservative transfusion approach, reducing both costs and risks.

Perioperative management and monitoring of a super-obese patient.

Anesthetic management of super-obese patients is inferred from evidence which has been based on obese or morbidly obese patients. We present the perioperative management and monitoring of a 44-year-old 232-kg patient (BMI 70) admitted for laparoscopic gastric bypass surgery. Awake fiberoptic endotracheal intubation preceded induction with propofol and rocuronium. Anesthesia was maintained with desflurane and remifentanil. Desflurane was titrated on BIS values, whereas remifentanil was based on hemodynamic monitoring (invasive arterial pressure and HemoSonic). Rocuronium was administered based on ideal body weight and recovery of twitch tension. Safe and rapid extubation in the operating theatre was made possible by the use of short-acting agents coupled with continuous intraoperative monitoring. Recovery in the post-anesthesia care unit was uneventful, pain was managed with meperidine, and after 5 hours the patient was discharged to the surgical ward. Oxygen therapy and SpO2 monitoring were continued overnight. No desaturation episodes were recorded. Pain was managed with I.V. drip of ketorolac and tramadole.