Engineering human stellate cells for beta cell replacement therapy promotes in vivo recruitment of regulatory T cells.

Type 1 diabetes (T1D) is an autoimmune disease characterized by destruction of pancreatic ß cells. One of the promising therapeutic approaches in T1D is the transplantation of islets; however, it has serious limitations. To address these limitations, immunotherapeutic strategies have focused on restoring immunologic tolerance, preventing transplanted cell destruction by patients' own immune system. Macrophage-derived chemokines such as chemokine-ligand-22 (CCL22) can be utilized for regulatory T cell (Treg) recruitment and graft tolerance. Stellate cells (SCs) have various immunomodulatory functions: recruitment of Tregs and induction of T-cell apoptosis. Here, we designed a unique immune-privileged microenvironment around implantable islets through overexpression of CCL22 proteins by SCs. We prepared pseudoislets with insulin-secreting mouse insulinoma-6 (MIN6) cells and human SCs as a model to mimic naive islet morphology. Our results demonstrated that transduced SCs can secrete CCL22 and recruit Tregs toward â€‹the implantation site in vivo. This study is promising to provide a fundamental understanding of SC-islet interaction and ligand synthesis and transport from SCs at the graft site for ensuring local immune tolerance. Our results also establish a new paradigm for creating tolerable grafts for other chronic diseases such as diabetes, anemia, and central nervous system (CNS) diseases, and advance the science of graft tolerance.

Effects of taurine on contractions of human internal mammary artery: a potassium channel opening action.

OBJECTIVE: Taurine is an abundant amino acid that is widely distributed in human and animal tissues. Pharmacodynamic studies show that taurine has hypotensive and myocardial protective effects. Studies in isolated tissue baths show that taurine relaxes precontracted arteries. This study aimed to show the effects of taurine on human internal mammary artery (IMA) in vitro and to explain the mechanisms of its effects. METHODS: The response in the IMA was recorded isometrically by a force displacement transducer in isolated organ baths. Taurine (20, 40, 80 mM) was added to organ baths after precontraction with KCl (45 mM) or serotonin (5-HT, 30 µM). Taurine-induced relaxations were also tested in the presence of the cyclooxygenase inhibitor indomethacin (10 µM), the nitric oxide synthase inhibitor L-NAME (100 µM), the large conductance Ca2+-activated K+ channel inhibitor tetraethylammonium (TEA, 1 mM), the ATP-sensitive K+ channel inhibitor glibenclamide (GLI, 10 µM), the voltage-sensitive K+ channel inhibitor 4-aminopyridine (4-AP, 1 mM) and the inward rectifier K+ channel inhibitor barium chloride (BaCl2, 30 µM). RESULTS: Taurine did not affect the resting tone of IMA. However, it produced relaxation in the 5-HT and KCl -precontracted preparations. The relaxation to IMA was not affected by GLI, 4-AP, BaCl2, indomethacin and L-NAME. But, TEA inhibited taurine -induced relaxations significantly (p < 0.05). CONCLUSIONS: The preincubation of IMA with taurine antagonized KCl and 5-HT induced contractions in a concentration dependent manner, while it did not affect the resting tone. The relaxations to taurine were significantly antagonized by pretreatment with TEA. These results suggest that mechanism of vasodilator effect of taurine in IMA may be the activation of large conductance Ca2+-activated K+ channels.

Redo off-pump coronary artery bypass grafting via a left thoracotomy.

BACKGROUND: In this study, we retrospectively reviewed our experience in a meticulously selected group of patients undergoing redo off-pump coronary artery bypass graft (CABG) surgery from the descending aorta to the circumflex artery (Cx) and its branches. METHODS: Between January 2001 and October 2013, 32 patients at our hospital underwent redo off-pump CABG from the descending aorta to the Cx and its branches via a left posterolateral thoracotomy. Of these patients, 27 were male (84.3%) and five were female (15.7%), with a mean age of 61.66 ± 8.63 years. All patients had a patent left internal thoracic artery-to-left anterior descending coronary artery (LITA-LAD) anastomosis. Thoracotomy was performed through the fifth intercostal space. The saphenous vein or radial artery was prepared as a graft at the same time as the left posterolateral thoracotomy from the contralateral extremity, without any positional problem. RESULTS: The main reasons for surgery in this group of patients were new lesion formation in 19, graft occlusion in six, and both in seven patients. The average operating time was 143.90 ± 36.93 minutes, respiratory assist time was 5.08 ± 1.88 hours, intensive care unit (ICU) stay was 21.3 ± 4.41 hours and hospital stay was 5.06 ± 2.74 days. Thirty-eight bypasses were performed. The follow-up period was 56.17 ± 39.2 months. Six patients were lost in the follow-up period and four patients died. Twenty-two were alive and free of cardiac problems. CONCLUSION: Redo off-pump CABG via a left posterolateral thoracotomy provided a safe and effective surgical approach with lower rates of postoperative morbidity and mortality in patients who required revascularisation of the Cx and its branches.

Our early experience with iliofemoral vein stenting in patients with post-thrombotic syndrome.

INTRODUCTION: Venous balloon dilation and stent therapy have been proposed as effective treatments for chronic iliofemoral thrombosis. In this study, we report our experience and describe the one-year outcome and efficacy of balloon angioplasty and stenting for the treatment of post-thrombotic syndrome (PTS) in iliofemoral vein segments. METHODS: From June 2011 to June 2012, 52 consecutive patients with chronic PTS (59 limbs; 75% women; median age 58 years; range: 23-76 years) referred to our unit for interventional assessment were included in the study. Treatment effects were assessed using Villalta scale, Venous Clinical Severity Score (VCSS) and Chronic Venous Insufficiency Questionnaire (CIVIQ)-20 for PTS, CEAP (clinical, aetiological, anatomical and pathological elements) grading and measurement of leg circumference, before and after intervention. RESULTS: Stenting was successfully accomplished in all patients. Coagulation abnormality was identified in 21 subjects (40.3%). CEAP grades were as follows: C3 in 19 patients, C4 in 24 patients, C5 in one patient and C6 in eight patients. According to Villalta scores, three patients were mild, seven patients were moderate and 42 patients were severe PTS. VCSS, Villalta scale and CIVIQ-20 showed a significant decrease in the severity of PTS signs and symptoms (P < 0.001). The calf and middle thigh circumferences decreased significantly on both sides (P < 0.001). CONCLUSION: Treatment of iliac venous obstruction with balloon angioplasty and stenting appears to be a minimally invasive and safe therapeutic approach in patients with PTS offering quick symptomatic relief, good patency and minimal morbidity.

Serosurveillance study on transmission of H5N1 virus during a 2006 avian influenza epidemic.

In 2006 an outbreak of avian influenza A(H5N1) in Turkey caused 12 human infections, including four deaths. We conducted a serological survey to determine the extent of subclinical infection caused by the outbreak. Single serum samples were collected from five individuals with avian influenza whose nasopharyngeal swabs tested positive for H5 RNA by polymerase chain reaction, 28 family contacts of the cases, 95 poultry cullers, 75 individuals known to have had contact with diseased chickens and 81 individuals living in the region with no known contact with infected chickens and/or patients. Paired serum samples were collected from 97 healthcare workers. All sera were tested for the presence of neutralizing antibodies by enzyme-linked immunoassay, haemagglutination inhibition and microneutralization assays. Only one serum sample, from a parent of an avian influenza patient, tested positive for H5N1 by microneutralization assay. This survey shows that there was minimal subclinical H5N1 infection among contacts of human cases and infected poultry in Turkey in 2006. Further, the low rate of subclinical infection following contact with diseased poultry gave further support to the reported low infectivity of the virus.

Evaluation and comparison of three different anti-hepatitis C virus antibody tests based on chemiluminescence and enzyme-linked immunosorbent assay methods used in the diagnosis of hepatitis C infections in Turkey.

The routine diagnosis of hepatitis C virus (HCV) infection is based on the detection of anti-HCV antibodies by two main methods (enzyme immunoassay [EIA] and chemiluminescence immunoassay [CIA]) but false-positives are a problem. We investigated three anti-HCV tests: two CIAs (Cobas e 601 and Architect i2000SR); and one EIA (Ortho HCV 3.0). Two other anti-HCV tests were also performed as supplementary and confirmatory tests, respectively: a recombinant strip immunoblot assay (RIBA HCV 3.0 SIA) and a reverse transcriptase polymerase chain reaction-based assay for HCV-RNA. After discriminating the false-positive results, the true anti-HCV seropositivity rate in 7156 serum samples was 0.91%. The seropositivity and false-positive rates for the Cobas e 601, Architect i2000SR and Ortho HCV 3.0 anti-HCV tests were 1.9% and 0.99%, 1.2% and 0.29%, and 0.87% and 0.01%, respectively. The mean level of HCV-RNA was 3399 x 10(3) IU/ml. Critical levels for false-positivity for HCV-RNA were a cut-off index of 200 for Cobas e 601, a signal/cut-off (S/CO) of 5 for Architect i2000SR and an S/CO of 1.2 for Ortho HCV 3.0. Positive and negative results for the RIBA HCV 3.0 SIA assay all accorded with the HCV-RNA assay, except for 23 (17%) 'indeterminate' results, all of which were negative with the HCV-RNA assay. In conclusion, to eliminate doubts related to false-positive findings in the initial HCV screening tests, additional confirmatory HCV-RNA assay should be performed.

Correlation of slime production investigated via three different methods in coagulase-negative staphylococci with crystal violet reaction and antimicrobial resistance.

This study investigated slime production by coagulase-negative staphylococci (CNS) using the standard tube (ST), Congo red agar (CRA) plate and Christensen's tube (CT) methods, and compared the results with those of the crystal violet reaction (CVR) test. The potential correlation between slime production and antimicrobial resistance was also evaluated. In total, 205 CNS strains were isolated from biological samples: 92 (44.9%) were shown to produce slime by the ST method; 96 (46.8%) by the CRA plate method; 90 (43.9%) by the CT method; and 89 (43.4%) strains were CVR positive. Eighty-three (40.5%) CNS strains were positive for slime production by the ST, CRA and CT methods. The findings of the ST, CRA and CT test methods were consistent with each other but were not related to CVR positivity. Based on the ST method, rates of antibiotic resistance to several antimicrobial agents were higher in slime-positive strains than in slime-negative strains and, in some cases, this was statistically significant.

Distribution, optimum detection time and antimicrobial susceptibility rates of the microorganisms isolated from blood cultures over a 4-year time period in a Turkish university hospital and a review of the international literature.

This study retrospectively examined 8986 blood cultures from patients over a 4-year time period in an eastern Turkish university hospital to determine the detection times and distribution of isolated microorganisms using the automated BACTEC 9050 and BACTEC 9120 systems. A total of 1914 (21.3%) blood cultures contained pathogenic microorganisms and 252 (2.8%) positive cultures were considered contaminated. Of all the cultures, 18 (0.2%) were false positives and 224 (2.5%) were false negatives. In cultures containing pathogenic microorganisms, Gram-positive and Gram-negative bacterial isolation rates were 436 (22.8%) and 1440 (75.2%), respectively, and yeasts (all Candida sp.) were found in 38 (2.0%) cultures. Coagulase-negative staphylococci occurred in 936 (48.9%) cultures and Staphylococcus aureus occurred in 302 (15.8%) cultures. The mean detection time for all of the pathogens was 21 h and Brucella spp were isolated within 10 days. This study helps in understanding the epidemiology of the region and in providing positive therapeutic approaches. A review of the international literature helps to place this understanding into a global context.

Percutaneous transcatheter embolization in arterial injuries of the lower limbs.

PURPOSE: To evaluate the efficacy and safety of percutaneous transcatheter arterial embolization (PTE) in lower extremity arterial injuries. MATERIAL AND METHODS: From January 2000 to June 2004, patients who presented with a penetrating trauma of the lower limbs, along with bleeding and with no sign of ischemia or hemodynamic instability, were included in the study. The injuries were embolized by coils and Gelfoam. The efficacy of PTE was defined as its ability to stop bleeding both radiographically and clinically, and its safety was determined by the complication rate. RESULTS: There were 10 embolizations, which consisted of 5 profundal femoral, 3 superior gluteal, and 2 inferior gluteal artery embolizations. PTE was effective in all patients. There were two inguinal hematomas, which did not require any intervention, and there was a temporary renal function alteration. The mean hospital stay of these patients was 2.67 +/- 0.91 days. CONCLUSION: PTE may be an effective and safe method of treatment in certain cases with lower limb arterial injuries. However, patients should be selected meticulously by both the vascular surgeon and the interventional radiologist, and PTE should be undertaken only in experienced hands.

Trans-sternal cardiac injury caused by a hooked needle.

Cardiac injuries remain the most challenging of all injuries seen in the field of trauma surgery. Penetrating injury to the heart generally occurs less frequently than blunt injury and most commonly injures the large anterior right ventricle. We present an unusual, and to our knowledge a previously unreported, cause of cardiac penetrating trauma in a child, involving a hooked needle (a 15 cm long, metallic device usually used for crocheting or lacemaking). A ventricular septal defect was managed conservatively shortly after the primary cardiorrhaphy. Evaluation methods for this rare presentation and its possible surgical treatments are discussed.

Change in serum concentrations of interleukin-2 and interferon-gamma during treatment of tuberculosis.

We aimed to investigate changes in serum concentrations of the cytokines interleukin (IL)-2 and interferon (IFN)-gamma during the clinical course of active tuberculosis, to establish the presence of cellular immunity before and after treatment. Blood samples were taken from 18 patients with active tuberculosis before and 2 months after therapy; IL-2 and IFN-gamma concentrations were evaluated. The mean serum IL-2 concentration before therapy was 164.5 pg/ml (range 12-980 pg/ml) and the concentration 2 months after therapy was 92.11 pg/ml (range 1-490 pg/ml). The mean serum IFN-gamma concentrations were 10.83 pg/ml (range 1-22.2 pg/ml) and 4.64 pg/ml (range 1-28.5 pg/ml), respectively. The decrease in concentrations of both cytokines after therapy was statistically significant. Further studies investigating the benefits of adding cytokines to drug treatment for tuberculosis are needed.

[Results of conservative treatment for solid abdominal organ trauma]. / Solid organ yaralanmalarinda konservatif tedavi sonuçlarimiz.

We analyzed 59 cases of intraabdominal solid organ injury treated at the Surgical Emergency Service of Istanbul Medical School between January 1996 and January 2001. Fifty-six of these cases suffered blunt and 3 penetrating trauma. Twenty-three cases had injuries involving the liver, 14 spleen, 5 kidney, 6 liver and spleen, 6 liver and kidney, 6 spleen and kidney and four liver and kidney. In 4 of splenic and 5 of hepatic injuries Grade IV injuries were detected. Among the cases, 21% were Grade I, 45% were Grade II, 19% were Grade III, and 15% were Grade IV. Associated injuries were: head trauma in 34 cases (57.6%--Glasgow Coma Score under 7 in 6 cases), thoracic trauma in 19 cases (32%), pelvic fracture in 6 cases (10%), vertebral compression fracture in 3 cases (5%). One patient with splenic (Grade III) and hepatic (Grade II) injury, and one patient with Grade IV splenic injury required surgery during close follow-up due to hemodynamic instability. Our failure rate for conservative treatment of solid organ injuries is 3.3%. Three patients with polytrauma in the ICU died (5% mortality rate). Conservative management in solid organ injuries is gaining more popularity every day. Our work, and current studies accept physiologic parameters in the follow-up of solid organ injuries. Conservative treatment guided with hemodynamic stability, accounts almost a 98% success rate.

[Applications of the inferior vena cava filter for the prevention of the risk for pulmonary emboli]. / Pulmoner emboli riskini önlemede inferior vena kava filtresi uygulamalarimiz.

The most serious and fatal complication of deep venous thrombosis (DVT) is still accepted as pulmonary embolism (PE). One of the methods used for PE prophylaxis is inferior vena cava filter(VCF). Between 1999 and 2000, VCF is used in 12 patients (8 male, 4 female) who were hospitalized in Trauma and Surgical Emergency Service of Istanbul Medical Faculty. 10 of the VCF used were permanent and 2 of them were temporary filters. 8 permanent filter were applied to patients with life-long paraplegia or quadriplegia due to spinal cord injury. Two patients to whom permanent filters were applied had malignancy. Patient who had the diagnosis of late stage cervical carcinoma, had DVT. In this patient, because of the high bleeding risk, we applied permanent filter. In the other patient, who had the diagnosis bladder carcinoma, had DVT despite the usage of low molecular weight heparin. In two patients who needed short term PE prophylaxis, had temporary VCF. In one of these patients, primary diagnosis was subarachnoidal hemorrhage due to head trauma. In the 8th day of hospitalization, DVT occurred. Because of high risk of intracranial bleeding, VCF was performed. The second patient had the diagnosis of subdural hematoma and subarachnoidal hemorrhage due to head trauma and multiple lower extremity fractures. VCF were applied in Istanbul Medical Faculty, Department of Radiology. For cannulation line of permanent VCF (LGM Venatech-B. Braun) right femoral vein was used. For temporary filters (Proliser Cordis-Johnson and Johnson Company), right internal jugular vein was the preferred way. Two multitrauma patients who had permanent filters died due to sepsis and multiorgan failure. In the follow up of other patients during the average period of 7.6 months, any problem due VCF application or by related complication and PE did not occur. Although larger patient groups with follow up period are necessary to evaluate better, we think that in PE prophylaxis, VCF is safe and effective modality.

[Thrombolysis of acute arterial occlusion with rt PA]. / Akut arter tikanmalarinin rt PA ile trombolitik tedavisi.

The use of thrombolytic agents to treat peripheral arterial occlusions is a new method. There have been clinical trials with Streptokinase, Urokinase and rt-PA (recombinant tissue plasminogen activator). Despite its advantages, information about complications caused by the use of rt-PA and about its place in treatment is still not complete. And there are not enough studies that are made to form a safe protocol for the use of rt-PA in the treatment of acute peripheral arterial occlusions. The aim of this study was to establish a dose range for rt-PA and to follow the patients with a protocol during and after thrombolysis. Between May 1999 to January 2000, 14 patients with symptoms of pain, poikilothermia, cyanosis and loss of function came to Istanbul Medical Faculty Emergency Surgery Unit. Bolus injection of 5 mgr of rt-PA was followed by 15 minutes of interval. The extent of thrombolysis was checked by angiography and then bolus injection of 5 mgr of rt-PA was repeated. After angiographic control, patients having insufficient thrombolysis, received 0.05 mgr/kg/hour of infusion for 12 hours. At the end of 12 hours, thrombolytic treatment ended with a control angiography. A thromboembolectomy operation was made to patients still having an occlusion after thrombolysis. On the other hand, to avoid re-occlusions, all of the patients received 1.5 mgr/kg/day low molecular weight heparin (enoxyparine).

Thrombolysis of Acute Arterial Occlusion with rt-PA.

The use of thrombolytic agents to treat peripheral arterial occlusions is a new method. Despite its advantages, information about complications caused by the use of rt-PA and about its place in treatment is still incomplete. The aim of this study was to establish a dose range for rt-PA and to follow the patients with a protocol during and after thrombolysis. Between May 1999 to January 2000, 14 patients with symptoms of peripheral arterial occlusion came to Istanbul Medical Faculty Emergency Surgery Unit. The duration of ischaemia before their hospitalization took an average of 44 hours. (Range 3 hours-7 days). A pulse-spray catheter was directed to the thrombus under angiographic control. Bolus injection of 5 mg of rt-PA was followed by 15 minutes of interval. The extent of thrombolysis was checked by angiography and then bolus injection of 5 mg of rt- PA was repeated. After angiographic control, patients having insufficient thrombolysis, received 0.05 mg/kg/hour of infusion for 12 hours. At the end of 12 hours, thrombolytic treatment ended with a control angiography. A thromboembolectomy operation was made to patients still having an occlusion after thrombolysis. To avoid re-occlusions, all of the patients received 1.5 mg/kg/day low molecular weight heparin (enoxaparin) for 1 week. At the end of thrombolysis, 9 patients had complete lysis. A patient, having an occlusion in superior mesenteric artery had 60% recanalisation. 2 patients (14%) having 90% stenosis, needed a balloon angioplasty besides thrombolysis, and both of them had complete reperfusion. 2 patients (14%) needed a thromboembolectomy operation due to insufficient thrombolysis. 2 patients (14%) had a minor bleeding after thrombolytic treatment. After thrombolysis, 2 patients (14%) had a stroke. There were no amputations. 1 of the patients having a stroke, died 2 days after thrombolytic treatment 1 patient died due to myocardial infarction during thrombolysis. 1 patient (7%) died due to diabetic coma on the 20th day. Acute myocardial infarction was the cause of death in 1 patient on the 25th day. In conclusion pulse spray thrombolysis with rt-PA is safe and efficient. Moreover there is a reduction in complications and need for surgical procedure. The recent problem is to find the optimum dosages for the best thrombolysis and for least complications.

Coronary artery bypass grafting in the conscious patient without endotracheal general anesthesia.

BACKGROUND: Over the past several years, considerable experience has accumulated in performing coronary anastomoses on the beating heart, and various aspects of minimally invasive approaches have been simplified. In an attempt to further simplify and decrease the "invasiveness" of this procedure, performing this operation without endotracheal general anesthesia was deemed feasible in certain subsets of patients. METHODS: Between October 1998 and June 1999, 5 patients underwent coronary artery bypass grafting without endotracheal general anesthesia, using high thoracic epidural block to construct extension grafts with a short segment of radial artery, between the in situ left or right internal thoracic arteries and the left anterior descending (n = 4) or right coronary arteries (n = 1). There were 2 female and 3 male patients, with a mean age of 67.4 +/- 8.3 years. RESULTS: The perioperative course of the patients was uneventful. There was no perioperative morbidity or mortality. No patient was converted to general anesthesia or to conventional operation. Control angiograms revealed patent anastomoses in all patients. In 1 patient, spasm of the radial artery graft was observed that was relieved 3 weeks later spontaneously. Mean length of hospital stay was 2.2 +/- 0.4 days. All patients were symptom free and returned to normal daily life at the first postoperative month. CONCLUSIONS: Our initial experience confirms the feasibility of performing coronary bypass grafting in the conscious patient without endotracheal general anesthesia.

Minimally invasive mitral valve surgery: the subxiphoid approach.

BACKGROUND: This report describes mitral valve replacement using a unique subxiphoid approach with a lower ministernotomy and a skin crease incision and compares the operative and echocardiographic results to patients undergoing mitral valve replacements using previously described strategies. METHODS: Fifty-four patients underwent mitral valve replacement using a subxiphoid approach (group 1); 32 patients underwent mitral valve replacement, 11 patients underwent mitral valve replacement + tricuspid reconstruction, 2 patients underwent mitral valve replacement + tricuspid valve replacement, and 9 patients underwent mitral reconstruction. This group of patients was compared to 11 patients who underwent mitral valve replacement through a superior ministernotomy (group 2) and 29 patients who underwent mitral valve replacement with full median sternotomy (group 3, 22 mitral valve replacements, 2 mitral valve replacements + tricuspid reconstruction, 2 mitral reconstructions, and 3 mitral reconstructions + tricuspid reconstruction). RESULTS: There was no operative mortality in all groups. The operation lasted significantly longer in group 2 patients compared to group 1 and 3 patients (p < 0.01). Postoperative mediastinal drainage was significantly lower in groups 1 and 2 (p < 0.001). Pain assessment revealed no difference between the groups. Three patients in group 1 presented with pericardial effusion. Except for this complication, early postoperative echocardiographic findings of the patients were similar in all three groups. All patients were in New York Heart Association functional class I or II at the second postoperative month, irrespective of the surgical technique used. CONCLUSIONS: There was no prominent superiority of the ministernotomy approaches over the standard median sternotomy approach. However, the reliability of the subxiphoid approach is documented echocardiographically and any type of mitral replacement can be performed with this approach.

Minimally invasive replacement of ascending aortic aneurysms: intermediate term results.

BACKGROUND: Minimally invasive techniques have gained recent interest in the realm of cardiac surgery. This report describes our initial experience with graft replacement of ascending aortic aneurysms using a superior mini-sternotomy approach. METHODS: Between March 1997 and October 1997, four patients underwent operation for ascending aortic aneurysm via superior mini-sternotomy approach. There were two female and two male patients, ranging in age from 52 to 62 years (mean 53.7 +/- 7.6). All patients had the stigmata of Marfan's syndrome. Mean diameter of the ascending aortas was 6.1 +/- 0.9 cm. Composite graft replacement with coronary reimplantation was performed in all cases. In one patient hemiarch replacement was performed under total circulatory arrest. There was no hospital (30-day) mortality. Mean aortic cross clamp and cardiopulmonary bypass times were 63 +/- 14.1 minutes (range 44 to 78) and 116.7 +/- 43.3 minutes (range 81 to 177), respectively. One patient was re-explored for bleeding. RESULTS: Lengths of hospital stay ranged from 5 to 7 days (mean 5.5 +/- 1). Patients were followed-up for at least 18 months. One patient suffered a fatal stroke in her third postoperative month. All surviving patients were in NYHA Class I at the sixth postoperative month and thereafter. CONCLUSIONS: Minimally invasive graft replacement of ascending aortic aneurysms can be performed safely and effectively. Long term results are likely to be similar to those of conventional cases performed through a full median sternotomy.