The frozen elephant trunk technique in acute aortic dissection: the ultimate solution? An institutional experience.

Objective: Acute aortic dissection remains a serious emergency in the field of cardiovascular medicine and a challenge for cardiothoracic surgeons. In the present study, we seek to compare the outcomes of different surgical techniques in the repair of type A acute aortic dissection. Methods: Between April 2015 and May 2023, 213 patients (82 women, aged: 63.9 ± 13.3 years) with acute aortic dissection (205 type A and 8 non-A-non-B dissections) underwent surgical treatment in our department. A total of 45 patients were treated with the frozen elephant trunk (FET) technique supported by the Thoraflex™ Hybrid prosthesis, 33 received total aortic arch replacement (TAR)-standard or conventional elephant trunk-treatment, and 135 were treated with hemiarch replacement (HR). Aortic arch surgery was performed in most patients under moderate hypothermic (28°C on average) circulatory arrest, with selective antegrade cerebral perfusion through the right axillary artery. Results: The rates of early mortality were 17.8% (38 perioperative deaths) in the whole population, 8.9% in the FET group of patients, and 33% and 17% in the TAR and HR group of patients, respectively (P-value 0.025). The rate of spinal cord injury was 2.3% (five patients), and a paresis of recurrent laryngeal occurred in 3.7% of patients (seven patients, four were treated with FET). Permanent neurological dysfunction occurred in 27 patients (12.7%). After a mean follow-up of 3 years, the rate of mid-term mortality of discharged patients was 19.4% (34 deaths: 7 FET, 4 TAR, and 23 HR) and the overall mortality rate was 33.8% [72 deaths: 11 FET (24.4%); 15 TAR (45.4%); 46 HR (34.1%)]. A total of 8 patients (17.8%) in whom FET was applied received additional endovascular treatment in the descending aorta. Conclusions: In our institutional experience, we found that the frozen elephant trunk technique with a high-end Thoraflex Hybrid prosthesis proved its surgical suitability in the treatment of acute aortic dissection with favorable outcomes. The FET technique and our perioperative management led to comparable neurological outcomes and reduced mortality rates in these emergency cases.

[Present-day policy of surgical treatment for type A acute aortic dissection]. / Sovremennaia taktika khirurgicheskogo lecheniia ostrogo rassloeniia aorty tipa A.

A surgical intervention for type A acute aortic dissection is the only effective method of treatment making it possible to prevent the development of life-threatening complications and to attain clinical recovery of the patient. Supracoronary replacement of the ascending aorta and the proximal portion of the aortic arch is considered to be the classical and most commonly used method of an open operative intervention. On the one hand, it is technically the simplest and shortest operation, and on the other, this surgical technique is often accompanied by long-term proximal and distal complications, and first of all those caused by a persistent false lumen. The accumulated surgical experience and contemporary operative techniques, as well as advances of intensive therapy in treatment of type A acute aortic dissection make it possible to currently perform more extensive primary resections in order to improve the remote results. Total aortic arch replacement, including the use of the 'frozen elephant trunk' technique leads to fast thrombosis of the false lumen, preventing progression of the disease of the thoracic aorta and promoting its positive remodelling. The article describes the perioperative therapeutic policy accepted and pursued in our medical facility, also presenting the authors' opinion on the role and place of the 'frozen elephant trunk' technique in rendering medical care for patients with type A acute aortic dissection.

A MSFD complementary approach for the assessment of pressures, knowledge and data gaps in Southern European Seas: The PERSEUS experience.

PERSEUS project aims to identify the most relevant pressures exerted on the ecosystems of the Southern European Seas (SES), highlighting knowledge and data gaps that endanger the achievement of SES Good Environmental Status (GES) as mandated by the Marine Strategy Framework Directive (MSFD). A complementary approach has been adopted, by a meta-analysis of existing literature on pressure/impact/knowledge gaps summarized in tables related to the MSFD descriptors, discriminating open waters from coastal areas. A comparative assessment of the Initial Assessments (IAs) for five SES countries has been also independently performed. The comparison between meta-analysis results and IAs shows similarities for coastal areas only. Major knowledge gaps have been detected for the biodiversity, marine food web, marine litter and underwater noise descriptors. The meta-analysis also allowed the identification of additional research themes targeting research topics that are requested to the achievement of GES.

Fatal Toxoplasma gondii Dissemination in a Heart Transplant Recipient: Description of a Case.

A 45-year-old heart transplant recipient presented with fever, anorexia, asthenia, and lethargy. She had received heart transplantation only 5 weeks earlier for primary systemic amyloidosis with severe cardiac involvement. Serum sodium was low, and tacrolimus through level was high. Blood cultures and serology tests for infection were negative, and atypical pneumonia was suspected. Despite broad antibiotic, antiviral, and antifungal treatment, the patient clinical condition rapidly deteriorated and she died within three days of admission. Postmortem examination revealed a disseminated Toxoplasma gondii infection as a result of donor (+)/recipient(-) mismatch for Toxoplasma serology. Although very rare, toxoplasmosis in heart transplant recipient should be suspect in case of neurological deficit and respiratory symptoms. Prophylaxis treatment is recommended in case of mismatch.

Long-term survival (>20 years) following heart transplantation.

AIM: Only a few papers with patients surviving more than 15 years after heart transplantation have been reported. Herein we report the characteristics of patients transplanted between 1984 and 1989 who are long-term survivors (>20 years). Survival after transplant, recipient and donor age and aetiology of heart failure were also compared with patients transplanted in the decades 1990-1999 and 2000-2009. METHODS: Our Heart Transplant Program Database and medical records of all cardiac transplants performed in our centre from July 1984 to 1989 were reviewed. Primary endpoint of the study was the long-term survival and secondary end points were the incidence of transplant-related complications over time. RESULTS: Forty-five transplants were performed in 1984-1989, 41 patients were male, median age was 46 years (IQR: 39-55), median donor age was 24 years (19-29) and mean graft ischemic time was 134±64 minutes. The actuarial survival of this cohort was 77.8%, 64.4%, 48.9%, 35.6% and 24.2% at 1, 5, 10, 15 and 20 years, respectively. Univariate Cox regression analysis revealed the female gender, the graft ischemic time, the recipient-donor gender mismatch, a diagnosis of diabetes and the number of acute rejection episodes during the first year post-transplant as significant risk factors adversely affecting long-term survival. Cardiac allograft vasculopathy is the main cause of death. The mean recipient and donor age and the graft ischemic time have progressively increased over time but survival has not changed. CONCLUSION: The long-term outcome of heart transplantation is noteworthy. The main limiting factor for survival is the allograft vasculopathy. Considering the tremendous advances in the immunosuppressive therapy and in the understanding of CAV pathophisyology, we can hope for even better results in the next years.

Should octogenarians be denied access to surgery for acute type A aortic dissection?

AIM: Outcomes after surgery for acute type A aortic dissection in the octogenarian are controversial. To analyze this issue further, the authors reviewed their experience in the hope of finding ways to improve results in these high-risk patients. METHODS: Between April 1990 and November 2006, 319 consecutive patients underwent emergency surgery for acute type A aortic dissection at the San Martino University Hospital of Genoa (Italy). Among them, 23 (7%) patients were aged 80 years or older (mean age 82 years, range 80 to 86 years) and represent the study population. On admission 7 patients (30%) had preoperative shock, 1 needed cardiopulmonary resuscitation, 7 (30%) had a neurological deficit, 2 (9%) had acute renal failure. Deep hypothermic circulatory arrest was performed in 19 patients (83%). Surgical procedures included isolated replacement of the ascending aorta in all patients associated with root replacement in 2 (9%) and total aortic arch replacement in 5 (22%). Median follow up was 4.1 years (range 3 to 83 months). RESULTS: Hospital mortality was 61% (14 of 23 patients). Late mortality was 11% (1 of 9 survivors). Stepwise logistic regression identified the extension of surgery to the arch as independent risk factors for hospital death. Fourteen patients (61%) had 1 or more postoperative complications. Overall survival was 39+/-10% and 33+/-10% after 1 and 5 years respectively. CONCLUSIONS: Surgery for acute type A aortic dissection in the octogenarian shows high hospital mortality but satisfactory long-term survival among discharged patients. A less aggressive approach should increase the outcomes of surgically managed patients.

[Extracorporeal circulation in no-cardiac surgery: experience at the Clinica Universidad de Navarra]. / La circolazione extracorporea in chirurgia non cardiaca. Esperienza della Clinica Universitaria di Navarra.

AIM: Analyse the use of the Extra-Corporeal Circulation (ECC) in no-cardiac operations at the Clinica Universidad de Navarra. MATERIAL OF STUDY: Between 1985 and 2009, the ECC has been involved in 28 operations for retroperitoneal tumour with inferior vena cava thrombus, in 43 isolated hyperthermic perfusion of a limb for locally advanced cancer and in 8 cases of chest mass with invasion of the pulmonary veins or bronchial carina. RESULTS: The intraoperative mortality for renal cancer has been of 7% while the 28% of patients showed a major complication. None patient died for the isolated hyperthermic perfusion and the 81% showed no toxicity. 1 patient out of 8 for chest mass died during the surgery for impossibility of weaning from the ECC. DISCUSSION: The ECC has been utilised in our experience mostly in cases of advanced cancer. It is an aggressive technique with a certain rate of complications. Nevertheless mid- and long-term results are encouraging. CONCLUSION: The ECC is the only technique in some advanced cancer in order to safely perform the mass removal. The precise co-ordination of the team is necessary to reduce the complication rate.

[Environmental quality of Volturno river with toxic and genotoxic findings]. / Stato di qualità ambientale del fiume Volturno integrato da indagini di tossicità e genotossicità.

In order to assess the environmental quality of Volturno river in Southern Italy, the Extended Biotic Index, chemical and microbiological parameters were determined in nine sampling points as provided for D. Lgs. 152/99. Furthermore, this study reported toxicity of surface waters and pore waters from sediments and genotoxicity of pore waters to improve the definition of the ecological condition of the investigated watercourse. Results showed that toxicity and genotoxicity testing contributed to assess environmental quality and pore waters are an useful tool to combine investigations.

Effects of ageing on peroxidase activity and localization in radish (Raphanus sativus L.) seeds.

Peroxidase activity was assayed in crude extracts of integument, cotyledons and embryo axis of radish seeds, deteriorated under accelerated ageing conditions. Over five days of ageing, in which germination decreased from 100 to 52%, the enzyme activity in integument was higher than that in other seed parts, increasing in the first days of ageing and then decreasing sharply in extremely aged seeds. Polyacrylamide gel electrophoresis analysis showed four peroxidase isoenzymes with MM of 98, 52.5, 32.8 and 29.5 kDa in the embryo axis of unaged seeds, and only the 32.8 and 29.5 kDa MM isoforms in the integument and cotyledons. In these parts of the seed, only the 29.5 kDa MM isoenzyme increased in activity in early days of ageing and decreased there-after. In the embryo axis, the 29.5 kDa MM isoenzyme activity increased slowly in the first day of ageing, while the 98 and 52.5 kDa MM isoenzyme activities disappeared. A cytochemical localization of peroxidase activity in the various tissues showed that main differences between unaged and extremely aged seeds occurred in the embryo axis.

Isolation in Brazil of nosocomial Staphylococcus aureus with reduced susceptibility to vancomycin.

OBJECTIVE: To evaluate the possible presence of vancomycin-resistant Staphylococcus aureus (VRSA) in a Brazilian hospital. DESIGN: Epidemiological and laboratory investigation of nosocomial VRSA. METHODS: 140 methicillin-resistant S aureus strains isolated between November 1998 and October 1999 were screened for susceptibility to vancomycin. The screening was carried out by using brain-heart infusion agar (BHIA) supplemented with 4, 6, and 8 microg/mL of vancomycin. The minimum inhibitory concentration (MIC) determination was carried out as standardized by the National Committee for Clinical Laboratory Standards using the broth macrodilution, agar-plate dilution, and E-test methods. PATIENTS: Hospitalized patients exposed to vancomycin. RESULTS: 5 of the 140 isolates had a vancomycin MIC of 8 microg/mL by broth macrodilution, agar plate dilution, and E-test methods. Four VRSA strains were isolated from patients in a burn unit who had been treated with vancomycin for more than 30 days, and one from an orthopedic unit patient who had received vancomycin treatment for 7 days. Pulsed-field gel electrophoresis characterized four of the VRSA strains as belonging to the Brazilian endemic clone. All five strains were negative for vanA, vanB, and vanC genes by polymerase chain reaction. Transmission electron microscopy of the five strains revealed significantly thickened cell walls. One patient died due to infection caused by the VRSA strain. CONCLUSIONS: This is the first report of isolation of VRSA in Brazil and the first report of isolation of multiple VRSA strains from one facility over a relatively short period of time. This alerts us to the possibility that VRSA may be capable of nosocomial transfer if adequate hospital infection control measures are not taken.

[Stomatologic approach in patients with congenital coagulation deficit]. / Approccio stomatologico in pazienti affetti da deficit coagulativi congeniti.

BACKGROUND: The purpose of the present paper was to resolve postoperative bleeding after oral surgery in patients with congenital coagulative defects, avoid transfusion of clotting factors and improve the patient's quality of life. METHODS: Since 1988, 1598 oral surgery procedures have been performed on patients with congenital coagulative defects treated with a protocol including pre- and postoperative tranexamic acid rinses. RESULTS: The use of tranexamic acid mouth washing has obtained effective hemostasis in 86% of cases and only 4% of surgical procedures required clotting factor transfusions. CONCLUSIONS: The results suggest that mouth washing with tranexamic acid prevents excessive oral bleeding in patients with congenital deficit of the coagulation system. Furthermore, a total elimination of the granulation tissue, that reduces the possibility of activation of the fibrinolytic mechanism, is also important.

[Necrotizing sialometaplasia of the submandibular gland. Report of a case]. / Scialometaplasia necrotizzante della ghiandola sottomandibolare. Descrizione di un caso.

A case report of swelling of the right submandibular gland, with spontaneous remission, is described. Clinical, ultrasonographical and cytological features suggest that the swelling could be ascribed to a necrotizing sialometaplasia. The etiopathological hypothesis and pathology of the lesion are presented, and the differential diagnosis with other spreading lesions of the submandibular gland is discussed.

[Odontogenic fibroma of the jaws. Report of a clinical case and etiopathogenic considerations]. / Il fibroma odontogenico dei mascellari. Presentazione di un caso clinico e considerazioni etiopatogenetiche.

A case of peripheral odontogenic fibroma is reported and its epidemiology, clinical aspects and etiopathogenesis are discussed. It is supposed that the epithelial component may be related to odontogenic embrionary tissue inclusions: These inclusions may stimulate a local mesenchymal reaction giving place to a proliferative lesion, as observed.

[A statistical contribution to fractures of the maxillofacial area]. / Contributo statistico alle fratture del distretto maxillo-facciale.

Twenty years experience (from 1975 to 1994), on 483 patients with injury of the maxillo-facial area observed at the Department of Maxillo-Facial Surgery of the University of Naples "Federico II" is reported. The analysis of the data, according to the literature, shows that the sex most involved is male (76%) with a prevalence of the second decade of life (38%); street injury is the most frequent cause of maxillo-facial fracture (48.5%), while in 1.6% the cause is not reported. Mandibular fractures (57%), particularly those of the left condyle, are more frequent. The type of treatment is discussed in relation to the site of fracture, in particular the therapy of the condylar ones. In fact, in the treatment of those fractures the authors use sequential functional plates, the first of whose presents a monolateral byte, homolateral to the injury, while the second a contralateral guide in closure. The use of such plates, even if it doesn't often obtain a perfect anatomical realignment of the fracture, allows an optimal functional rehabilitation due to the potential of remodelling of the condyle, avoiding complications related to surgical intervention.

[Etio-pathogenic considerations on the development of multiple bone cysts in the mandible. Report of a clinical case]. / Considerazioni etiopatogenetiche sullo sviluppo delle cisti ossee essenziali della mandibola. Presentazione di un caso clinico.

A case of a mandibular cyst, missing of wall lining and containing some solid material is described. The histologic examination showed that this material consisted of osteofibrous tissue with regressive phenomena, inflammatory cells and hyperplastic nervous tissue. On the basis of clinical and histologic findings it is suggested to be a solitary cyst and the solid material due to a local response to an injury suffered by the patient who is a sport practitioner.

[Paget disease of the jaws. Review of the subject. Clinical-therapeutic considerations]. / La malattia di Paget dei mascellari. Rassegna dell'argomento. Considerazioni clinico-terapeutiche.

Clinical and diagnostic findings of Paget's disease of the jaws are reported; up to date etiological and pathogenical hypotheses are presented. Laboratory data of increased P.A. as a marker of disease evolution is pointed out, particularly the relationship increasing hydroxyprolinuria, because the increase of a malignant transformation. Surgery, always modeling, is limited to cases of severe facial dysmorphosis associated or not with the local disturbance due to compression; in any case it is suggested to perform the surgery in the phases of inactivity of disease, to avoid local complications, such as hemorrhage a infection.

[Injuries of the nasal bone in boxing]. / I traumi dello scheletro nasale nella pratica pugilistica.

Nose fractures in boxers ar clamfied and their pathogenesis described. Therapy is related to boxer's activity; in fact in boxers in activity the respiratory tract was reinstated; in that one retired over respiratory tract, nose aesthetics was treated too.

[Granular-cell tumor of the oral cavity (a case report and statistical notes)]. / Tumore a cellule granulari della cavità orale (presentazione di un caso e contributo statistico).

The granular cell tumor is an uncommon benign lesion that may occur anywhere in the body presenting as a single nodular lesion. A case is reported with bilateral palatal lesions. This case, in authors' opinion, is exceptional both for its localization, near palatine foramina, suggesting a neural crest tissue origin, and bilaterality and symmetry pointing out its plurifocal potentiality.