Acute Aortic Syndromes from Diagnosis to Treatment-A Comprehensive Review.

This work aims to provide a comprehensive description of the characteristics of a group of acute aortic diseases that are all potentially life-threatening and are collectively referred to as acute aortic syndromes (AASs). There have been recent developments in the care and diagnostic plan for AAS. A substantial clinical index of suspicion is required to identify AASs before irreversible fatal consequences arise because of their indefinite symptoms and physical indicators. A methodical approach to the diagnosis of AAS is addressed. Timely and suitable therapy should be started immediately after diagnosis. Improving clinical outcomes requires centralising patients with AAS in high-volume centres with high-volume surgeons. Consequently, the management of these patients benefits from the increased use of aortic centres, multidisciplinary teams and an "aorta code". Each acute aortic entity requires a different patient treatment strategy; these are outlined below. Finally, numerous preventive strategies for AAS are discussed. The keys to good results are early diagnosis, understanding the natural history of these disorders and, where necessary, prompt surgical intervention. It is important to keep in mind that chest pain does not necessarily correspond with coronary heart disease and to be alert to the possible existence of aortic diseases because once antiplatelet drugs are administered, a blocked coagulation system can complicate aortic surgery and affect prognosis. The management of AAS in "aortic centres" improves long-term outcomes and decreases mortality rates.

Intraplaque Neovascularization, CD68+ and iNOS2+ Macrophage Infiltrate Intensity Are Associated with Atherothrombosis and Intraplaque Hemorrhage in Severe Carotid Atherosclerosis.

BACKGROUND: Atherosclerosis is a progressive disease that results from endothelial dysfunction, inflammatory arterial wall disorder and the formation of the atheromatous plaque. This results in carotid artery stenosis and is responsible for atherothrombotic stroke and ischemic injury. Low-grade plaque inflammation determines biological stability and lesion progression. METHODS: Sixty-seven cases with active perilesional inflammatory cell infiltrate were selected from a larger cohort of patients undergoing carotid endarterectomy. CD68+, iNOS2+ and Arg1+ macrophages and CD31+ endothelial cells were quantified around the atheroma lipid core using digital morphometry, and expression levels were correlated with determinants of instability: ulceration, thrombosis, plaque hemorrhage, calcification patterns and neovessel formation. RESULTS: Patients with intraplaque hemorrhage had greater CD68+ macrophage infiltration (p = 0.003). In 12 cases where iNOS2 predominated over Arg1 positivity, the occurrence of atherothrombotic events was significantly more frequent (p = 0.046). CD31 expression, representing neovessel formation, correlated positively with atherothrombosis (p = 0.020). CONCLUSIONS: Intraplaque hemorrhage is often described against the background of an intense inflammatory cell infiltrate. Atherothrombosis is associated with the presence of neovessels and pro-inflammatory macrophages expressing iNOS2. Modulating macrophage polarization may be a successful therapeutic approach to prevent plaque destabilization.

Histopathological Gap in Aortic Diseases: A Prospective Analysis.

Aortic dissection (AD) is a critical cardiovascular condition with the potential for devastating consequences. This study evaluated the histological changes in the aorta wall in patients with AD and aortic aneurysm (AA) who received surgical aortic replacement. Histopathological data showed that modifications of the media layer (p = 0.0197), myxomatous aspect (p = 0.0001), and subendothelial layer degeneration (p = 0.0107) were more frequently seen in AA versus AD samples. Patients with AA were approximately twice as likely to develop histological changes than those with AD (p = 0.0037). Patients with moderate or severe medial degeneration had a higher chance of developing AD (p = 0.0001). Because the histopathological score proved to be a predictor of both in-hospital and overall mortality, its evaluation should become the standard of care in any patients who undergo aortic replacement. Individualized postoperative management might be influenced by the histopathological aspect of the aortic layer.

A single-center prospective study on the efficiency of negative pressure wound therapy versus conventional wound therapy in the postoperative management of devitalized and infected wounds.

INTRODUCTION: In this study, we aim to present the benefits of using negative pressure wound therapy, particularly with respect to the speed up of recovery time of devitalized and infected post-operative wounds, cost-effectiveness of local healing, pain relief during treatment, and returning to work and resuming normal daily activities at an earlier time. MATERIALS AND METHODS: This was a prospective study performed in General Surgery Clinic, between 2016-2018. The study comprised 67 patients divided into two groups: A (29 patients who underwent negative pressure wound therapy) and B (38 patients who underwent conventional wound therapy). RESULTS: The average age of patients included in group A was 64.2 ± 12.3 years and in group B, 63.2 ± 9.7 years (p=0.440). The wounds were located on the foot, thigh, abdomen, and other areas, and the average length of stay in hospital was 33 ± 18 days for group A versus 17 ± 14 days for group B (p=0.042) but with an average local healing time of 12 ± 5 days in group A versus 44 ± 17 days in group B (p<0.001). The average cost of hospitalization was higher in group A: 17,868 ± 9,560 RON (3,834 ± 2,051 euros) compared to group B: 6,025 ± 4,137 RON (1,292 ± 887 euros) (p=0.443) but the average cost of local healing was lower in group A: 5,437 ± 2,238 RON (1,166 ± 480 euro) compared to group B: 6,840 ± 3,520 RON (1,467 ± 755 euro) (p=0.005). CONCLUSIONS: The treatment of devitalized and infected post-operative wounds by using negative pressure wound therapy reduces local and complete healing time by approximately 30%, local healing costs by 26%, and allows better pain management during treatment with minimal complications. KEY WORDS: Negative pressure wound Therapy, Conventional wound therapy, Local healing, average cost.

The Gender Gap in Aortic Dissection: A Prospective Analysis of Risk and Outcomes.

Aortic dissection (AD) is a severe cardiovascular condition that could have negative consequences. Our study employed a prospective design and examined preoperative, perioperative, and postoperative data to evaluate the effects of gender on various medical conditions. We looked at how gender affected the results of aortic dissection (AD). In contrast to female patients who had more systemic hypertension (p=0.031), male patients had higher rates of hemopericardium (p=0.003), pulmonary hypertension (p=0.039), and hemopericardium (p=0.003). Dobutamine administration during surgery significantly raised the mortality risk (p=0.015). There were noticeably more women patients (p=0.01) in the 71 to 80 age group. Significant differences in age (p=0.004), eGFR at admission (p=0.009), and eGFR at discharge (p=0.006) were seen, however, there was no association between gender and mortality. In conclusion, our findings highlight that gender may no longer be such an important aspect of aortic dissection disease as we previously thought, and this information could have an important contribution for surgeons as well as for anesthesiologists involved in the management of acute aortic dissection.

Platelet-to-Albumin Ratio: The Prognostic Utility in the Prediction of 2-Month Postoperative Heart Transplant Complications.

BACKGROUND: The platelet-to-albumin ratio (PAR), leucocyte-to-albumin ratio (LAR), neutrophil percentage-to-albumin ratio (NPAR), and monocyte-to-albumin ratio (MAR) represent easily reproducible markers, which may predict the outcomes in various diseases. Early postoperative complications might appear after heart transplantation, such as infections, diabetes mellitus type 2 (DM2), acute graft rejection, and atrial fibrillation (AFib). OBJECTIVE: The aim of our study was to investigate the PAR, LAR, NPAR, and MAR values before and after heart transplantation, and the associations of the preoperative levels of these markers with the presence of postoperative complications in first two months after surgery. METHODS: Our retrospective research was directed from May 2014 to January 2021, with a total number of 38 patients being included. We used cut-off values for the ratios from previously published studies, as well as our own determination of these levels by using a receiver operating characteristic (ROC) curve. RESULTS: By ROC analysis, the optimal preoperative PAR cut-off value was 38.84 (AUC: 0.771, p = 0.0039), with 83.3% sensitivity, and 75.0% specificity. Applying a Chi square (χ2) test, PAR > 38.84 represented an independent risk factor for complications, regardless of cause, and postoperative infections. CONCLUSIONS: Preoperative PAR > 38.84 was a risk factor of developing complications of any cause, and postoperative infections in the first two months after heart transplantation.

The Role of Preoperative Chronic Statin Therapy in Heart Transplant Receipts-A Retrospective Single-Center Cohort Study.

BACKGROUND: Statin therapy has been proven to reduce the risk of cardiovascular events. The objective of our retrospective study was to investigate the relationship between preoperative chronic administration of statins to postoperative 2-month heart transplantation complications. METHODS: A total number of 38 heart transplantation recipients from the Cardiovascular and Transplant Emergency Institute of Târgu Mureș between May 2014 and January 2021 were included in our study. RESULTS: In logistic regression, we found a statistical significance between statin treatment and the presence of postoperative complications of any cause (OR: 0.06, 95% CI: 0.008-0.56; p = 0.0128), simultaneously presenting an elevated risk for early-postoperative acute kidney injury (AKI). From the statin group, atorvastatin therapy had a higher risk of type 2 diabetes mellitus (T2DM) development (OR: 29.73, 95% CI: 1.19-741.76; p = 0.0387) and AKI (OR: 29.73, 95% CI: 1.19-741.76; p = 0.0387). C-reactive protein (CRP), total cholesterol (TC), and low-density lipoprotein cholesterol (LDL-c) represented risk factors, atorvastatin administration being independently associated with lower CRP values. CONCLUSIONS: Chronic previous administration of statins represented a protective factor to the development of 2-month postoperative complications of any cause in heart transplant receipts.

Elevated Levels of Neutrophil-to Monocyte Ratio Are Associated with the Initiation of Paroxysmal Documented Atrial Fibrillation in the First Two Months after Heart Transplantation: A Uni-Institutional Retrospective Study.

BACKGROUND: Heart transplantation represents the treatment for patients with end-stage heart failure (HF) being symptomatic despite optimal medical therapy. We investigated the role of NMR (neutrophil-to-monocyte ratio), NLR (neutrophil-to-lymphocyte ratio), NPR (neutrophil-to-platelet ratio), NWR (neutrophil-to-white cells ratio), MLR (monocyte-to-lymphocyte ratio), PLR (platelet-to-lymphocyte ratio), MWR (neutrophil-to-white cells ratio), and LWR (lymphocyte-to-white cells ratio) at the same cut-off values previously studied, to predict complications after heart transplant within 2 months after surgery. METHODS: From May 2014 to January 2021, was included 38 patients in our study from the Cardiovascular and Transplant Emergency Institute of Târgu Mureș. RESULTS: Preoperative NMR > 8.9 (OR: 70.71, 95% CI: 3.39-1473.64; p = 0.006) was a risk factor for the apparition of post-operative paroxysmal atrial fibrillation (Afib). In contrast, preoperative MWR > 0.09 (OR: 0.04, 95% CI: 0.003-0.58; p = 0.0182) represented a protective factor against AFib, but being the risk of complications of any cause (OR: 14.74, 95% CI: 1.05-206.59, p = 0.0458). CONCLUSION: Preoperative elevated levels of NMR were associated with the apparition of documented AFib, with high levels of MWR as a protective factor. High MWR was a risk factor in developing complications of any cause in the first 2 months after heart transplantation.

Right Heart Failure as an Atypical Presentation of Chronic Type a Aortic Dissection - Multimodality Imaging for Accurate Diagnosis and Treatment. A Case Report and Mini-review of Literature.

Background: An intrapericardial organized haematoma secondary to chronic type A aortic dissection is an extremely rare cause of right heart failure. Imaging studies are essential in recognising and diagnosis of this distinctive medical condition and guiding the anticipated treatment. Case presentation: A 70-year-old male patient was admitted for progressive symptoms of right heart failure. His cardiovascular history exposed an aortic valve replacement 22 years before with a Medtronic Hall 23 tilting valve with no regular follow-up. Classical signs of congestion were recognized at physical examination. Transthoracic two-dimensional echocardiography and thoraco-abdominal computed tomography angiography, as essential parts of multimodality imaging algorithm, established the underlying cause of right heart failure. Under total cardiopulmonary bypass and cardiac arrest, surgical removal of the haematoma and proximal repair of the ascending aorta with a patient-matched vascular graft were successfully performed. The patient was discharged in good condition with appropriate pharmacological treatment, guideline-directed; no imagistic signs of acute post-surgery complications were ascertained. Conclusion: This paper highlights the importance of recognizing and providing a timely clinical and imagistic diagnosis of this very rare, potentially avoidable cause of right heart failure in patients with previous cardiac surgery.

Severe Coronary Artery Vasospasm after Mitral Valve Replacement in a Diabetic Patient with Previous Stent Implantation: A Case Report.

Postoperative coronary vasospasm is a well-known cause of angina that may lead to myocardial infarction if not treated promptly. We report a case of a 70-year-old female with severe mitral regurgitation submitted to mitral valve replacement, and a history of diabetes mellitus type II, stroke, idiopathic thrombocytopenic purpura on steroid therapy, and previous percutaneous coronary intervention (PCI) for severe obstruction of the circumflex coronary artery, 4 months prior to surgery. Immediately after intensive care unit admission, the patient developed pulseless electrical activity which required extracorporeal membrane oxygenation for hemodynamic support. The coronary angiography showed diffuse occlusive coronary artery vasospasm, ameliorated after intra-coronary administration of nitroglycerin. The following postoperative evolution was marked by cardiogenic shock and multiple organ dysfunction syndrome. Subsequent echocardiographic findings showed an increase in left ventricular function with an EF of 40%, and extracorporeal membrane oxygenation (ECMO) support was weaned after seven days. However, after a few hours, the patient progressively deteriorated, with cardiac arrest and no response to resuscitation maneuvers. Hemodynamic instability following the surgical procedure in a patient with previous PCI associated with an autoimmune disease and diabetes mellitus should raise the suspicion of a coronary artery vasospasm.

A Rare Case of Undifferentiated Pleomorphic Cardiac Sarcoma with Inflammatory Pattern.

Cardiac undifferentiated pleomorphic sarcoma (UPS) associated with fever and inflammatory response is an extremely rare condition. Herein, we report a rare case of cardiac UPS with unusual clinical presentation and inflammatory response. A 67-year-old male complaining of progressive dyspnea and intermittent fever of unknown cause was referred to our hospital for surgical resection of a left atrial mass. Laboratory analysis showed leukocytosis (26 × 103/µL) and high C-reactive protein (CRP) levels (155.4 mg/L). Hemoculture tests and urine analysis were negative for infection. A contrast chest computed tomography revealed a mass measuring 5.5 × 4.5 cm, occupying the left atrium cavity. The patient underwent surgical excision of the mass, however, surgical margin of the resected tumor could not be evaluated, due to the multifragmented nature of the resection specimen. Postoperative CRP and leukocyte levels normalized, highlighting the relationship between the tumor and the inflammatory status. Early diagnosis is crucial for a proper management and favorable outcome, enabling patients to undergo chemotherapy and achieve complete surgical resection.

Staphylococcus-induced proliferative glomerulonephritis and cerebral hemorrhage - fatal complications in a young female with postpartum cardiomyopathy and an implanted left ventricular assist device: a case report and review of the literature.

Background: The continuous-flow left ventricular assist device (CF-LVAD) is used to save the lives of patients in the final stage of congestive heart failure, replacing the pump function of the left ventricle. Although quality of life increases significantly, CF-LVAD-related complications might prove fatal, as in the case presented in this paper.Methods: A 20-year-old female, during her second pregnancy, presented with signs of heart failure. Emergency caesarean section was necessary to save the baby, but peripartum cardiomyopathy developed in the mother. The use of an implantable cardioverter-defibrillator (ICD) was necessary 5 years later. As the clinical progression was unfavorable under medical treatment, with the patient reaching INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) Profile 1 (refractory cardiogenic shock), the treatment of choice was the implantation of a CF-LVAD.Results: After 3 years of follow-up (at the age of 28), the patient presented with a positive hemoculture for Staphylococcus aureus. Prolonged antibiotic therapy and attentive follow-up was prescribed. Although an effective antiplatelet and anticoagulant treatment was applied, and despite therapeutic values of prothrombin time and international normalized ratio (INR), the patient died as result of a fatal cerebral hemorrhage. The autopsy also revealed septic emboli, disseminated intravascular coagulation, and focal proliferative glomerulonephritis.Conclusions: Although the benefits of CF-LVAD are significant, bleeding episodes can be severe and LVAD-associated infection can trigger glomerular injury and increase mortality.

Surgical treatment for patent ductus arteriosus in adult patients: a single center experience.

In contemporary practice, percutaneous closure of the patent ductus arteriosus (PDA) has become the procedure of choice. While the surgical ligation of ductus arteriosus ensures an immediate and definitive obliteration of the ductus, this therapeutic option is rarely used and reserved for situations when percutaneous solution is unsuitable. In this manuscript, we summarize the clinical and intraoperative findings of consecutive adult patients referred to our Institution in an interval of 10 years for surgical treatment of PDA. A total of five cases of surgical closure for PDA were performed in our Center. Four subjects were not suitable for percutaneous closure, and one was discovered intraoperatively, during surgery for another cardiac condition. In all patients, the closure of the PDA was carried out by means of a suture with reinforced patch threads, in a double layer. The intervention was performed in total cardiopulmonary bypass and mild or moderate hypothermia, through a transpulmonary approach. Total circulatory arrest was not required, in any of the cases. The occlusive balloon technique was applied to all patients. All patients survived the intervention and did not suffer perioperative complications. Postoperative follow-up at 36 months did not show repermeabilization of the arterial duct or aneurysmal dilation of the adjacent aorta. Moreover, all patients showed postoperative improvement in the performance of the left ventricle. In adult patients with PDA and contraindication to percutaneous closure or in those who require surgical sanction for other cardiac diseases, surgical closure of the duct is safe and associated with favorable clinical evolution.

Preclinical Testing of Living Tissue-Engineered Heart Valves for Pediatric Patients, Challenges and Opportunities.

Introduction: Pediatric patients with cardiac congenital diseases require heart valve implants that can grow with their natural somatic increase in size. Current artificial valves perform poorly in children and cannot grow; thus, living-tissue-engineered valves capable of sustaining matrix homeostasis could overcome the current drawbacks of artificial prostheses and minimize the need for repeat surgeries. Materials and Methods: To prepare living-tissue-engineered valves, we produced completely acellular ovine pulmonary valves by perfusion. We then collected autologous adipose tissue, isolated stem cells, and differentiated them into fibroblasts and separately into endothelial cells. We seeded the fibroblasts in the cusp interstitium and onto the root adventitia and the endothelial cells inside the lumen, conditioned the living valves in dedicated pulmonary heart valve bioreactors, and pursued orthotopic implantation of autologous cell-seeded valves with 6 months follow-up. Unseeded valves served as controls. Results: Perfusion decellularization yielded acellular pulmonary valves that were stable, no degradable in vivo, cell friendly and biocompatible, had excellent hemodynamics, were not immunogenic or inflammatory, non thrombogenic, did not calcify in juvenile sheep, and served as substrates for cell repopulation. Autologous adipose-derived stem cells were easy to isolate and differentiate into fibroblasts and endothelial-like cells. Cell-seeded valves exhibited preserved viability after progressive bioreactor conditioning and functioned well in vivo for 6 months. At explantation, the implants and anastomoses were intact, and the valve root was well integrated into host tissues; valve leaflets were unchanged in size, non fibrotic, supple, and functional. Numerous cells positive for a-smooth muscle cell actin were found mostly in the sinus, base, and the fibrosa of the leaflets, and most surfaces were covered by endothelial cells, indicating a strong potential for repopulation of the scaffold. Conclusions: Tissue-engineered living valves can be generated in vitro using the approach described here. The technology is not trivial and can provide numerous challenges and opportunities, which are discussed in detail in this paper. Overall, we concluded that cell seeding did not negatively affect tissue-engineered heart valve (TEHV) performance as they exhibited as good hemodynamic performance as acellular valves in this model. Further understanding of cell fate after implantation and the timeline of repopulation of acellular scaffolds will help us evaluate the translational potential of this technology.

Native Aortic Valve Endocarditis Complicated by Splenic Infarction and Giant Mitral-Aortic Intervalvular Fibrosa Pseudoaneurysm-A Case Report and Brief Review of the Literature.

BACKGROUND: Pseudoaneurysm of the mitral-aortic intervalvular fibrosa (P-MAIVF) is an unusual complication related to various injuries or conditions which involve the mitro-aortic region; it communicates with the left ventricular outflow tract and is associated with a high-risk of redoubtable complications or sudden death. The cerebral and splenic localizations are frequently seen as manifestations of systemic embolism in infective endocarditis. Currently, there are no specific recommendations related to the diagnosis, management, treatment, or further evolution of patients with P-MAIVF and concomitant splenic infarction. This paper presents the case of a 43-year-old Caucasian woman with a late diagnosis of mixed bicuspid aortic valve disease, affected by an under-detected and undertreated episode of infective endocarditis leading to asymptomatic P-MAIVF. Prime clinical and imagistic diagnosis of splenic infarction indicated further extended investigations were required to clarify the source of embolism. METHODS: Integrated multimodality imaging techniques confirmed the unexpected diagnosis of P-MAIVF. RESULTS: The case had a fatal outcome following an uncomplicated yet laborious cardiac surgery. Patient death was attributed to a malignant ventricular arrhythmia. CONCLUSION: The present case raises awareness by highlighting an unexplained and unexpected splenic infarction association with P-MAIVF as a result of infective endocarditis related to mixed bicuspid aortic valve disease.

Giant left atrial myxoma - literature review and case presentation.

Primary cardiac tumors are an extremely rare pathology, representing only 5-10% of cardiac neoplasms, but among them, the most common are cardiac myxomas, that appear to originate from multipotent mesenchymal cells of the subendocardial and endocardial stroma. The incidence of cardiac myxomas is higher in females and they are usually diagnosed between the fourth and sixth decade of life. Most often, they are located in the left atrium, having the site of attachment at the level of the interatrial septum, especially at the level of the fossa ovalis and the adjacent limbus. Due to the increased risk of systemic embolization and intracardiac obstruction, cardiac myxomas have a definite indication for emergency surgical treatment. Cardiac myxomas are a very rare cause of transient ischemic attacks and stroke. We present the case of a 38-year-old patient who experienced four recurrent transient ischemic attacks and strokes. At the fourth cerebrovascular event, echocardiography was performed and it revealed a giant tumor located in the left atrium that was surgically removed. Pathological examination confirmed the diagnosis of cardiac myxoma. The postoperative evolution was favorable, both from a neurological and cardiac point of view. Although cardiac myxomas represent a rare cause of transient ischemic attacks and stroke, they must be considered as part of the assessment protocol for cerebrovascular events.

Different Manifestations in Familial Isolated Left Ventricular Non-compaction: Two Case Reports and Literature Review.

Left ventricular non-compaction (LVNC) is a form of cardiomyopathy characterized by prominent trabeculae and deep intertrabecular recesses which form a distinct "non-compacted" layer in the myocardium. It results from intrauterine arrest of the compaction process of the left ventricular myocardium. Clinical manifestations vary from asymptomatic to heart failure (HF), arrhythmias, or thromboembolic events. We present a case of mother and son diagnosed with isolated LVNC (ILVNC). A 4-years-old male patient, diagnosed at 3 months with ILVNC, and NYHA functional class IV HF, was admitted to the Emergency Institute for Cardiovascular Diseases and Transplantation of Targu Mures, Romania, for cardiologic reevaluation, and diagnosis confirmation. ILVNC was confirmed using echocardiography, revealing a non-compaction to compaction (NC/C) ratio of > 2.7. His evolution was stationary until the age of 8 years, when severe pneumonia caused hemodynamic decompensation, and he was listed for heart transplantation (HT). The patient underwent HT at the age of 11 years with favorable postoperative outcome. Meanwhile, a 22-years-old female patient, mother of the aforementioned patient, was also admitted to our institute due to severe fatigue, dyspnea, and recurrent palpitations with multiple implantable cardioverter defibrillator (ICD) shock delivery. Extensive medical history revealed that a presumptive ILVNC diagnosis was established when she was 11 years old. She was asymptomatic until 18 years old, when 3 months post-partum, she developed NYHA functional class III HF, and subsequently underwent ICD implantation. Her diagnosis was confirmed using multi-detector computed tomography angiography, which revealed a NC/C ratio of > 3.3. ICD adjustments were carried out with a favorable evolution under chronic drug therapy. The last evaluation, at 27 years old, revealed that she was in NYHA functional class II HF. In conclusion, ILVNC, even when familial, can present different clinical pictures and therefore requires different medical approaches.

Challenges in Perioperative Animal Care for Orthotopic Implantation of Tissue-Engineered Pulmonary Valves in the Ovine Model.

BACKGROUND: Development of valvular substitutes meeting the performance criteria for surgical correction of congenital heart malformations is a major research challenge. The sheep is probably the most widely used animal model in heart valves regenerative medicine. Although the standard cardiopulmonary bypass (CPB) technique and various anesthetic and surgical protocols are reported to be feasible and safe, they are associated with significant morbidity and mortality rates. The premise of this paper is that the surgical technique itself, especially the perioperative animal care and management protocol, is essential for successful outcomes and survival. METHODS: Ten juvenile and adult female sheep aged 7.8-37.5 months and weighing 32.0-58.0 kg underwent orthotopic implantation of tissue-engineered pulmonary valve conduits on beating heart under normothermic CPB. The animals were followed-up for 6 months before scheduled euthanasia. RESULTS: Based on our observations, we established a guide for perioperative care, follow-up, and treatment containing information regarding the appropriate clinical, biological, and ultrasound examinations and recommendations for feasible and safe anesthetic, surgical, and euthanasia protocols. Specific recommendations were also included for perioperative care of juvenile versus adult sheep. CONCLUSION: The described surgical technique was feasible, with a low mortality rate and minimal surgical complications. The proposed anesthetic protocol was safe and effective, ensuring both adequate sedation and analgesia as well as rapid recovery from anesthesia without significant complications. The established guide for postoperative care, follow-up and treatment in sheep after open-heart surgery may help other research teams working in the field of heart valves tissue regeneration.

Mesangioproliferative glomerulonephritis with extracapillary crescents - unexpected fatal complication in a 17-year-old patient with implanted left ventricular assist device.

The continuous flow left ventricular assist device (cf-LVAD) is the life-saving solution for patients with end-stage global heart failure. We present the case of a young patient with biventricular dilated cardiomyopathy, who had a cf-LVAD implantation and died as result of progressive renal failure. In the first year after implantation, he suffered repeated strokes and episodes of pneumonia with Klebsiella pneumoniae and Escherichia coli. The patient had hypertension, which was kept under control with angiotensin-converting enzyme (ACE) inhibitors and beta-blockers. After multiple bleeding episodes, the patient died at 21 months after the LVAD implant. At autopsy, parenchymatous brain hemorrhage was found to be associated with pulmonary hemorrhages. The unexpected features related to mesangioproliferative and extracapillary glomerulonephritis, with focal glomerulosclerosis. The proliferated parietal cells of Bowman's capsule proved to express cluster of differentiation 44 (CD44), whereas remnant podocytes and mesangial cells showed Wilms tumor 1 (WT1) positivity. Since CD44 might be involved in fibrogenesis, but ACE inhibitors can exert a protective role against glomerular deterioration, we performed a synthesis of literature data which enabled us to propose a hypothesis with a potential clinical impact. We conclude that, in patients with LVAD implants, high blood pressure and high serum level of angiotensin II, the association between ACE inhibitors and anti-CD44 agents might exert glomerular protection and increase the survival time. Experimental studies are necessary to support our hypothesis and to explain the mechanism of possible glomerulopathy installed after LVAD implant.

[Surgical ventricular reconstruction for ischemic left ventricular aneurysm. Early and medium-term outcomes for two surgical techniques]. / Az ischaemiás eredetu balkamra-aneurysma sebészi rekonstrukciója. Két sebészi technika korai és középtávú eredményei.

INTRODUCTION: Left ventricular aneurysm is a severe complication of acute myocardial infarction, which contributes significantly to mortality and morbidity associated with this pathology. Despite the progress of correction techniques, there are still controversies about the optimal approach addressing this pathology. AIM: The aim of this study was to analyse short and medium term outcomes of left ventricular reconstruction for ischemic left ventricular aneurysm using two surgical techniques (endoventricular patch plasty and liniar suture) in order to determine if one of these techniques has supperior results. METHOD: 117 patients were included in the study, 48 patients (41%) underwent left ventricular reconstruction with endoventricular patch (Group 1), 69 patients (59%; Group 2) had linear reconstruction. 113 patients (96.5%) required associated procedures: 108 surgical myocardial revascularization, 18 mitral valvuloplasty and 8 ventricular septal defect closure. Short and medium term morbidity, mortality, alteration of ejection fraction and NYHA class were analysed. RESULTS: Perioperative mortality was 11.11%, 4.2% in the endoventricular patch group, and 15.9% in the linear suture group (p = 0.03). The overall 5-year survival was 78.5% (88.7% in Group 1 and 71.2% in Group 2). The left ventricular ejection fraction and NYHA functional class improved in both groups, with greater improvement in the endoventricular patch group. CONCLUSIONS: Surgical ventricular reconstruction is a procedure performed for the correction of ischemic left ventricular aneurysm with good early and medium-term results, but with better results with the endoventricular patch technique regarding early and medium-term mortality, ejection fraction and NYHA functional class improvement. Orv Hetil. 2018; 159(51): 2167-2174.