Morphological and molecular characterization of healthy human ascending aorta.

Knowledge of the characteristics of the normal human aorta has been constrained by lack of data on fresh aortic tissue, especially from healthy individuals. In this study, the gene expression and morphological characteristics of the thoracic ascending aorta (AA) of healthy organ donors have been evaluated, with the aim of providing reference data for the analysis of pathological AAs. We analysed by RT-PCR the differential expression of mRNAs coding for myocardin, smoothelin, alpha-smooth muscle actin (alpha-SMA) and the ED-A isoform of fibronectin (ED-A FN) in AA specimens from donors, integrating the results with immunohistochemical analysis of the same targets. Morphological and morphometric characteristics of the AAs were also evaluated. In order to account for possible regional variations in wall structure, the convexity of the aortic profile was compared to the concavity. No differences in gene expression occurred for any of the target genes between the concavity and the convexity of AAs. Immunohistochemistry revealed a different distribution of total FN and of its ED-A isoform in the media and in the intima. Smoothelin is expressed by the majority of cells in the media, with some positive cells also in the intima. Alpha-SMA is expressed in all the tunicae. Immunohistochemistry also revealed in the convexity of 50% of AAs the presence of discrete areas in the subadventital media with altered structure and cell morphology and with altered gene expression, resulting positive for ED-A FN and alpha-SMA, but not for smoothelin, indicating the occurrence of early lesions also in macroscopically healthy AAs.

Pilot study on prevention of lung injury during surgery for type A acute aortic dissection: no evident improvements with celsior flushing through the pulmonary artery.

OBJECTIVE: Postoperative respiratory failure is a frequent and serious complication in patients with type A acute aortic dissection. Experimental evidence suggests that pulmonary artery perfusion using hypothermic protective solutions helps prevent lung injury. The aim of this pilot prospective study was to evaluate the effect of pulmonary artery flushing during selective cerebral perfusion (SCP) on lung function. METHODS: Twenty patients referred for acute type A aortic dissection, who were free from preoperative respiratory dysfunction, were assigned prospectively and alternately to two treatment groups. Pulmonary flushing was performed during SCP in group P (10 patients), while conventional Kazui technique was applied in group N (10 patients). Lung perfusion consisted of single-shot hypothermic pulmonary artery flush with Celsior. Lung function was evaluated by intubation time, scoring of chest radiograms at 12 hours after CPB, and PaO2/FiO2 assessed from immediately before surgery to 72 hours after termination of cardiopulmonary bypass. RESULTS: Incidence of pre, intra and post operative determinants of lung dysfunction proved homogeneous in both groups. Lung oxygenation function showed a marked post operative decline followed by a slow improvement in both groups. Analysis of respiratory ratios did not disclose significant differences even though the flushed group had a better performance in all study patients. The incidence of prolonged ventilator support (longer than 72 hours) (30% vs 20%, p = NS) and severity of x-ray pulmonary infiltrate score were comparable (mean score 1.7 +/- 0.71 vs 1.6 +/- 0.68, p = NS). CONCLUSIONS: Pulmonary artery flushing with Celsior solution does not seem to provide an effective preservation of lung function.

Long-term results of heart valve replacement with bileaflet prostheses.

Bileaflet cardiac prostheses (St. Jude, CarboMedics, Duromedics, Bicarbon, Jyros) have shown a low incidence of complications and good haemodynamic performance. In the last twelve years, 783 bileaflet prostheses were implanted in 690 patients at our Institution. The population of our study comprises 591 bileaflet prostheses (418 CarboMedics, 124 St. Jude, 49 Bicarbon) implanted in the mitral (MVR) (n = 305) or aortic (AVR), (n = 286) position. The follow-up study evaluated 292 male and 295 female patients with age ranging from 13 and 79 years (mean 50.4 +/- 14.7 years). Hospital mortality was 6.6%. Follow-up was 97% complete, with 1822 +/- 33 patient/years and a mean follow-up of 37 months (range 1 to 144 months). Twelve years actuarial freedom from complication according to prosthetic site were calculated as follows (linearized rates in parentheses): late mortality AVR 97.6% +/- 0.6% (2.3%), MVR 96% +/- 0.5% (2.1%); thrombosis AVR 100%, MVR 96% +/- 0.9% (0.8%); embolism AVR 97% +/- 0.5% (1.5%), MVR 96.6% +/- 0.7% (1.8%). Global freedom from anticoagulant-related haemorrhage was 95% +/- 1.2% (2.3%) and 94.5% +/- 0.7% (2.2%) following AVR, 94 +/- 0.6% (2.1%) following MVR. The difference of the haemorrhagic risk for prosthetic site was not significant (p > 0.05). Functional improvement was confirmed by the low postoperative NYHA functional class. According to our results, cumulative experience with bileaflet valves has shown very good long-term results in term of low rate of complication, long-term survival and quality of life.

Long-term follow-up of different models of mechanical and biological mitral prostheses.

Three hundred eighty-five valve prostheses were implanted between 1974 and 1981 in patients with isolated mitral disease: 157 caged-ball valves (156 Starr-Edwards; 1 Smeloff-Cutter) (group A), 107 tilting-disc valves (44 Bjork-Shiley, 49 Sorin, 14 Lillehei-Kaster) (group B), 121 porcine bioprostheses (45 Carpentier-Edwards, 66 Liotta, 10 Hancock) (group C). Perioperative mortality was 9.5% in group A, 11.2% in group B and 6.6% in group C. The follow-up was 86% complete. Actuarial freedom from complications was calculated as follows (linearised rates in brackets) in groups A, B and C, respectively: survival: 47.01% +/- 0.11 (3% patient/yr), 53.37% +/- 0.08 (1.8% patient/yr), 61.24% +/- 0.05 (2.2% patient/yr); thromboembolism: 67.94% +/- 0.09 (1.18% patient/yr); 73.07% +/- 0.06 (1% patient/yr); 97.43% +/- 0.02 (0.02% patient/yr); anticoagulation-related hemorrhage: 84.10% +/- 0.13 (0.18% patient/yr), 97.21% +/- 0.01 (0.12% patient/yr), 100%; prosthetic valve endocarditis: 100% in groups A and B, 95.76% +/- 0.02 (0.18% patient/yr) in group C; valve-related mortality: 87.52% +/- 0.03 (0.75% patient/yr), 87.96% +/- 0.03 (0.56% patient/yr), 82.53% +/- 0.04 (0.93% patient/yr); valve failure: 81.22% +/- 0.07 (0.56% patient/yr), 63.36% +/- 0.1 (1.06% patient/yr), 14.31% +/- 0.05 (4% patient/yr); treatment failure: 78.81% +/- 0.05 (1.12% patient/yr), 76.44% +/- 0.09 (0.62% patient/yr), 80.97% +/- 0.04 (1% patient/yr); all valve-related morbidity and mortality: 40.43% +/- 0.13 (1.93% patient/yr), 57.76% +/- 0.08 (1.43% patient/yr), 14.96% +/- 0.05 (4.18% patient/yr); all valve-related morbidity and mortality at 5 years: 91.97% +/- 0.02 (7.8% patient/yr), 87.06% +/- 0.03 (3.6% patient/yr), 90.27% +/- 0.03 (2.6% patient/yr); at 10 years: 80.4% +/- 0.03 (4.6% patient/yr), 75.91% +/- 0.03 (2.6% patient/yr), 37.44% +/- 0.05 (4.18% patient/yr).(ABSTRACT TRUNCATED AT 250 WORDS)

Ascending aorta to femoral arteries by-pass: a safe surgical technique of lower limb revascularization in high risk patients undergoing coronary artery by-pass.

The coexistence of a coronary artery obstructive disease (CAOD) with aorto-iliac obstructive disease (AIOD) often represents a surgical problem. Because of left main coronary disease (LMCOD) the contemporary correction of AIOD should be performed with a simple non traumatic procedure. The case of a high risk patient in whom aortoiliac obstructive disease has been corrected with the implantation of a bifurcated vascular prosthesis from the ascending aorta to the bilateral common femoral arteries, and with a double aorto-coronary by-pass, is reported.

Prosthetic creation of a double outlet left ventricle: clinical experience of five cases.

Five clinical cases were treated with the implantation of an apical-aortic conduit. Two adult patients were affected by obstructive myocardiopathy associated to subaortic membrane in one case, and three children by different forms of aortic stenosis (subaortic tunnel in one case; subaortic tunnel associated to severe coartation of the thoracic aorta in one case; aortic annulus hypoplasia in one case). A double outlet left ventricle has been created in all cases by implanting a composite prosthesis between the apex by implanting a composite prosthesis between the apex of the left ventricle and the aorta. The extracardiac conduit consisted of an apical curved connector and a valved dacron tubular prosthesis. The site of implantation was the supraceliac abdominal aorta in three cases and the ascending aorta in two cases. All patients survived the operation and one late mortality was observed for cerebral bleeding. The surviving patients have been restudied with satisfactory data.

[The surgical treatment of Klippel-Trenaunay syndrome (author's transl)]. / Trattamento chirurgico della sindrome di Klippel-Trenaunay.

Three cases of congenital angiodysplasies of the extremities, classified as Klippel-Trenaunay syndrome, underwent to surgical treatment. These cases, clinically similar, have shown a quite different pathogenesis, according to which the surgical treatment has been modified. Once again we recommend a complete diagnostic study every time one find varicosities of the extremities which are atipical for time of appearance, territories involved or for aspect and thus be congenital varicosities with complex pathogenesis.