Reduction of blood coagulation and monocyte-platelet interaction following the use of a minimal extracorporeal circulation system (Synergy) in coronary artery bypass grafting (CABG).

Cardiovascular surgery with cardiopulmonary bypass (CPB) induces activation of blood coagulation and systemic inflammation involved in post-operative complications. Our study evaluated the impact of the minimal extracorporeal circulation (mini-CPB) system (Synergy, Sorin Group) on these functional aspects. Twenty patients were randomly assigned to standard CPB (n = 10) or to Synergy (n = 10). Platelet expression of PAC-1, and monocyte/granulocyte-platelet conjugates were evaluated by flow cytometry. A leukocyte-platelet adhesion index was calculated after cell number normalization. ELISAs were performed to measure IL-6 and TNF-alpha, thrombin-antithrombin III complexes (TAT), prothrombin fragments (F1+2), beta-thromboglobulin (beta-TG) and sP-selectin (sCD62P). Blood samples were drawn at the time of anesthesia (T1), at the end of CPB (T2), and at 4 (T3) and 24 hours (T4) after weaning from CPB. All patients were similar for clinical characteristics. When compared to standard CPB, the Synergy showed lower levels of the monocyte-platelet adhesion index at T2 (0.023 +/- 0.005 vs 0.063 +/- 0.013, P = 0.0092) and T4 (0.031 +/- 0.003 vs 0.055 +/- 0.005, P = 0.0017), TAT complexes at T2 (27.175 +/- 5.967 vs 86.592 +/- 5.415, P = 0.0005) and T3 (26.977 +/- 2.468 vs 45.146 +/- 4.365, P = 0.0041), F1+2 fragments at T2 (2.222 +/- 0.226 vs 4.249 +/- 0.292, P = 0.0009), and sP-selectin at T3 (115.17 +/- 19.623 vs 169.554 +/- 19.709, P = 0.0703) and T4 (108.542 +/- 6.429 vs 140.799 +/- 14.771, P = 0.0833). In summary, the Synergy exhibited a lower post-operative activation of blood coagulation, together with a reduced interaction between circulating monocytes and platelets.

Reproducibility of thoracic aortic diameter measurement using computed tomographic scans.

OBJECTIVES: Decisions to recommend elective surgical repair of thoracic aortic aneurysms (TAA) may be based on size or expansion rate, which are used as indices of the risk of rupture. Measurement error may thus affect clinical decision-making. In order to evaluate the reproducibility of aortic diameter measurements of TAA, we assessed departmental inter- and intra-observer variability of measurement of pre-selected computed tomographic scan images of aneurysmal segments of the thoracic aorta. METHODS: We compared measurements of minimum aortic diameter made by four observers in 50 pre-selected scans and at different times by two observers using a calliper method and a measurement tool within the scan. Differences in measured dimension were analysed using Wilcoxon's signed ranks test and the repeatability assessed using the method of Bland and Altman. RESULTS: There were no significant inter-observer differences among three observers but there were significant differences between another observer and two other observers (P < 0.05). No significant intra-observer differences existed. The best intra-observer repeatability was 2.25 while the worst inter-observer repeatability was 4.37. The mean and maximum difference in measurement were +/-0.88 mm and +/-8.0 mm, respectively. Variability of measurement increased with aortic diameter. CONCLUSIONS: Calliper measurement of TAA is an acceptable measurement method for surveillance of TAA but appears most accurate with a single observer. Increasing error is seen with increasing diameter which may compound error in estimation of expansion rate. Standardisation of technique is advisable for multiple observers and aortic units should adopt quality assurance protocols to minimise error.

Prediction of thoracic aortic aneurysm expansion: validation of formulae describing growth.

BACKGROUND: The expansion rate of thoracic aortic aneurysms may be an important and clinically relevant index of the risk of rupture. The aims of this study were to assess the validity of three published exponential equations that predict expansion rate in a separate sample population, and to calculate an expansion rate formula for this cohort of patients. METHODS: We studied 88 consecutive patients undergoing serial computed tomographic or magnetic resonance imaging scanning to monitor thoracic aortic aneurysm progression. In interval scans of at least 6 months, we measured minimum coronal aortic diameter at seven set levels and maximal diameter, yielding 780 segment-intervals. RESULTS: The linear expansion rate (mean 2.6 mm/year) increased with incremental aortic diameter (aortic diameter < 40 mm: 2.0; 40-49 mm: 2.3; 50-59 mm: 3.6; > or = 60 mm: 5.6 mm/year; p < 0.01). Regression analysis showed close correlation between predicted and sample data, but there were significant differences between observed and expected measurements. The Yale formula underestimated growth by 0.8 mm, while Mt. Sinai and Osaka formulae overestimated actual change by 1.5 and 0.2 mm, respectively. The expansion rate derived from our population was: last diameter = initial diameter x e(0.00367 x time) (r = 0.617). CONCLUSIONS: Although formulae derived from one thoracic aortic aneurysm sample population may not extrapolate exactly to others, there is close concordance of results for patient populations in three different continents.

Cardiac papillary fibroelastoma of the mitral valve chordae.

Papillary fibroelastomas are rare, benign, primary cardiac tumors, usually single and small. The neoplasm consists of a leafy, soft excrescence typically located on the cardiac valves. Although papillary fibroelastomas are usually an asymptomatic incidental finding at autopsy, or during cardiac operation, they are occasionally associated with embolic coronary or cerebral symptoms. A case of a patient is reported with papillary fibroelastoma of the mitral valve chordae, who presented several transitory ischemic attacks characterized by loss of conscience, visual bilateral deficit and right emiparesis. Because of their potential systemic embolization, we believe that these lesions should be always excised.

Leiomyosarcoma of the pulmonary vein: case report with immunohistochemical and ultrastructural findings.

We report a case of neoplasia of pulmonary vein in a 45-year-old woman who presented with increasing dyspnea. As a consequence, the neoplasia filled the entire left atrium and appeared to be attached to the left superior pulmonary vein on surgical excision. Histologically, it was composed of a proliferation of sarcomatous cells, with a high mitotic rate and diffuse immunohistochemical positivity for smooth muscle actin, consistent with a leiomyosarcoma. The microscopic, immunohistochemical, and ultrastructural findings are discussed.

[Intima flap of the external carotid and postoperative stroke in a patient surgically treated with thromboendarterectomy of the internal carotid]. / Flap intimale della carotide esterna e stroke postoperatorio in paziente operato di tromboendoarteriectomia della carotide interna.

Retrograde thrombosis of the carotid bifurcation rising from an intimal flap of the external carotid artery represent a rare complication of carotid surgery. We present the case of a patient who had undergone carotid thromboendarterectomy (TEA) whose postoperative course was complicated by the appearance of left hemiplegia and coscience disorders. The timely diagnosis of acute carotid thrombosis and the immediate reoperation prevented neurological deficits becoming settled. An attentive intraoperative evaluation of carotid bifurcation showed only the presence of an intimal flap of the external carotid artery from which a big occluding thrombus, involving the bifurcation, rose. The internal and common carotid arteries showed a successful result of the TEA and a good retrograde flow through the internal carotid artery. The authors underline the existence of this perioperative complication and the need for a timely recognition and treatment to avoid serious neurologic consequences.

Correlation between plasma or blood transfusion and survival after curative surgery for colorectal cancer.

Out of 473 patients operated radically for colon or rectal cancer different survival curves have been calculated according to whether they had received or not blood or plasma transfusions during their hospital stay. The non-transfused patients have a better 5-year survival rate and the difference is statistically significant both including and not including Duke's C stage cases. Anemia on hospital admission, on the contrary, does not seem to influence patients survival. Immune depression after blood or plasma transfusion is a very well known phenomenon in transplant surgery and actually depends on the infusion of leucocytes. Is not yet clearly demonstrated that in cancer surgery immune depression may lead to a poorer survival of transfused patients but several papers, including ours, suggest that this effect is very likely. At present in cancer patients it is preferable to limit transfusions to the minimum. If they are absolutely necessary leucocyte poor or, better still, leucocyte free preparations should be administered.