Microglia cells treated with synthetic vasoactive intestinal peptide or transduced with LentiVIP protect neuronal cells against degeneration

A common pathological hallmark of neurodegenerative disorders is neuronal cell death, accompanied by neuroinflammation and oxidative stress. The vasoactive intestinal peptide (VIP) is a pleiotropic peptide that combines neuroprotective and immunomodulatory actions. The gene therapy field shows long-term promise for treating a wide range of neurodegenerative diseases (ND). In this study, we aimed to investigate the in vitro efficacy of transduction of microglia using lentiviral gene therapy vectors encoding VIP (LentiVIP). Additionally, we tested the protective effects of the secretome derived from LentiVIP-infected "immortalized human" microglia HMC3 cells, and cells treated with Synthetic VIP (SynVIP), against toxin-induced neurodegeneration. First, LentiVIP, which stably expresses VIP, was generated and purified. VIP secretion in microglial conditioned media (MG CM) for LentiVIP-infected HMC3 microglia cells was confirmed. Microglia cells were activated with lipopolysaccharide, and groups were formed as follows: 1) Control, 2) SynVIP-treated, or 3) LentiVIP-transduced. These MG CM were applied on an in vitro neurodegenerative model formed by differentiated (d)-SH-SY5Y cells. Then, cell survival analysis and apoptotic nuclear staining, besides measurement of oxidative/inflammatory parameters in CM of cells were performed. Activated MG CM reduced survival rates of both control and toxin-applied (d)-SH-SY5Y cells, whereas LentiVIP-infected MG CM and SynVIP-treated ones exhibited better survival rates. These findings were supported by apoptotic nuclear evaluations of (d)-SH-SY5Y cells, alongside oxidative/inflammatory parameters in their CM. LentiVIP seems worthy of further studies for the treatment of ND because of the potential of gene therapy to treat diseases effectively with a single injection.

The role of chest X-ray in coronavirus disease 2019 (COVID-19) infection: findings and correlation with clinical outcome

OBJECTIVE

It is possible to diagnose coronavirus disease 2019 (COVID-19) faster and more accurately with chest X-ray (CXR) and chest computed tomography (CT) than with reverse transcriptase PCR (RT-PCR) tests. The aim of this study was to verify the possibility of reducing the use of CT in diagnosis and follow-up of COVID-19 infection by using CXR.

PATIENTS AND METHODS

A total of 326 COVID-19 patients who were hospitalized in Ankara City Hospital were included in this retrospective study.

RESULTS

A total of 326 patients were RT-PCR positive for COVID-19 infection; 178 were male (54.6%) and 148 were female (45.4%), with a median age of 45. Considering the results, the baseline CXR sensitivity in our experience was approximately 72%. The CXRs of 113 patients with abnormal CT were divided into 2 groups, the CXR normal and abnormal groups, and were then compared. In the 1st group with abnormal CXR, the mean age, the number of patients over 65 years old, and the comorbidity rate were higher. Additionally, it was determined that the number of patients requiring respiratory support and intensive care unit (ICU) admission in this 1st group was higher than in the 2nd group (with normal CXR). Most of the patients who died (91%, 10/11) were in Group 1. In the group with normal CXR, no patients in the critically ill category needed invasive or non-invasive mechanical ventilators.

CONCLUSIONS

CXR can help in detecting clinically moderate and severe cases of COVID-19. CXR can assist clinicians in patient management and treatment planning regarding the clinical course, respiratory support, ICU need, and mortality and can help them prepare for potential negative outcomes.

The impacts of the COVID-19 pandemic on patients with viral hepatitis B infection: follow-up, compliance with antiviral treatment, and vaccine preferences

OBJECTIVE

Elimination programs and interventions for patients with viral hepatitis B (HBV) have been disrupted during the COVID-19 pandemic. This study aimed to evaluate the effects of the COVID-19 pandemic on patients with HBV infection in terms of COVID-19 vaccine preferences, follow-up visits, and antiviral treatment compliance.

PATIENTS AND METHODS

In this retrospective single-center cross-sectional study, 129 patients with viral hepatitis B infection were evaluated. The patients were surveyed at the time of admission. A special form was created for patients with viral hepatitis B infection, and the form contained information about the patients at admission to collect the study data.

RESULTS

A total of 129 participants were included in the study. Of the participants, 49.6% were males and the median age was 50 years. In total, 73 (56.6%) patients had their follow-up visits disrupted because of the COVID-19 pandemic. No newly diagnosed case of HBV infection was detected. Among the 129 patients, 46 had inactive hepatitis B, and 83 had chronic hepatitis B infection and were receiving antiviral treatment. None of the patients had trouble reaching antiviral treatments during the COVID-19 pandemic. A liver biopsy was recommended for 8 patients. Half of these 8 patients did not have follow-up visits during the COVID-19 pandemic. Most of the patients (123/129, 95.3%) received the COVID-19 vaccine and the most frequent vaccine that was used was the Pfizer-BioNTech (n: 92, 71.3%) vaccine. Serious side effects of the COVID-19 vaccines were not detected. Mild side effects were found in 41.9% (13/31) of the patients. The COVID antibody level was found to be statistically and significantly higher in the patients who received the Pfizer-BioNTech vaccine than in those that received the CoronoVac vaccine.

CONCLUSIONS

It was reported that elimination programs and interventions for HBV infection decreased or stopped because of the COVID-19 pandemic. In the present study, no newly diagnosed case of HBV infection was detected. Most of the patients had their follow-up visits disrupted. There were no patients who could not receive antiviral treatment, the vaccination rate of the patients was high, and the vaccines were well tolerated.

Systematic elucidation of genetic mechanisms underlying cholesterol uptake

Genetic variation contributes greatly to LDL cholesterol (LDL-C) levels and coronary artery disease risk. By combining analysis of rare coding variants from the UK Biobank and genome-scale CRISPR-Cas9 knockout and activation screening, we substantially improve the identification of genes whose disruption alters serum LDL-C levels. We identify 21 genes in which rare coding variants significantly alter LDL-C levels at least partially through altered LDL-C uptake. We use co-essentiality-based gene module analysis to show that dysfunction of the RAB10 vesicle transport pathway leads to hypercholesterolemia in humans and mice by impairing surface LDL receptor levels. Further, we demonstrate that loss of function of OTX2 leads to robust reduction in serum LDL-C levels in mice and humans by increasing cellular LDL-C uptake. Altogether, we present an integrated approach that improves our understanding of the genetic regulators of LDL-C levels and provides a roadmap for further efforts to dissect complex human disease genetics.

Systematic elucidation of genetic mechanisms underlying cholesterol uptake

Genetic variation contributes greatly to LDL cholesterol (LDL-C) levels and coronary artery disease risk. By combining analysis of rare coding variants from the UK Biobank and genome-scale CRISPR-Cas9 knockout and activation screening, we have substantially improved the identification of genes whose disruption alters serum LDL-C levels. We identify 21 genes in which rare coding variants significantly alter LDL-C levels at least partially through altered LDL-C uptake. We use co-essentiality-based gene module analysis to show that dysfunction of the RAB10 vesicle transport pathway leads to hypercholesterolemia in humans and mice by impairing surface LDL receptor levels. Further, we demonstrate that loss of function of OTX2 leads to robust reduction in serum LDL-C levels in mice and humans by increasing cellular LDL-C uptake. Altogether, we present an integrated approach that improves our understanding of genetic regulators of LDL-C levels and provides a roadmap for further efforts to dissect complex human disease genetics.

Using CRISPR to understand and manipulate gene regulation

Understanding how genes are expressed in the correct cell types and at the correct level is a key goal of developmental biology research. Gene regulation has traditionally been approached largely through observational methods, whereas perturbational approaches have lacked precision. CRISPR-Cas9 has begun to transform the study of gene regulation, allowing for precise manipulation of genomic sequences, epigenetic functionalization and gene expression. CRISPR-Cas9 technology has already led to the discovery of new paradigms in gene regulation and, as new CRISPR-based tools and methods continue to be developed, promises to transform our knowledge of the gene regulatory code and our ability to manipulate cell fate. Here, we discuss the current and future application of the emerging CRISPR toolbox toward predicting gene regulatory network behavior, improving stem cell disease modeling, dissecting the epigenetic code, reprogramming cell fate and treating diseases of gene dysregulation.

Elucidation of remdesivir cytotoxicity pathways through genome-wide CRISPR-Cas9 screening and transcriptomics

The adenosine analogue remdesivir has emerged as a front-line antiviral treatment for SARS-CoV-2, with preliminary evidence that it reduces the duration and severity of illness1.Prior clinical studies have identified adverse events1,2, and remdesivir has been shown to inhibit mitochondrial RNA polymerase in biochemical experiments7, yet little is known about the specific genetic pathways involved in cellular remdesivir metabolism and cytotoxicity. Through genome-wide CRISPR-Cas9 screening and RNA sequencing, we show that remdesivir treatment leads to a repression of mitochondrial respiratory activity, and we identify five genes whose loss significantly reduces remdesivir cytotoxicity. In particular, we show that loss of the mitochondrial nucleoside transporter SLC29A3 mitigates remdesivir toxicity without a commensurate decrease in SARS-CoV-2 antiviral potency and that the mitochondrial adenylate kinase AK2 is a remdesivir kinase required for remdesivir efficacy and toxicity. This work elucidates the cellular mechanisms of remdesivir metabolism and provides a candidate gene target to reduce remdesivir cytotoxicity.

A Plant-Produced in vivo deglycosylated full-length Pfs48/45 as a Transmission-Blocking Vaccine Candidate against malaria

Pfs48/45 is a leading antigen candidate for a transmission blocking (TB) vaccine. However, efforts to produce affordable, safe and correctly folded full-length Pfs48/45 using different protein expression systems have not produced an antigen with satisfactory TB activity. Pfs48/45 has 16 cysteines involved in disulfide bond formation, and the correct formation is critical for proper folding and induction of TB antibodies. Moreover, Pfs48⁄45 is not a glycoprotein in the native hosts, but contains potential glycosylation sites, which are aberrantly glycosylated during expression in eukaryotic systems. Here, we demonstrate for the first time that full length, Endo H in vivo enzymatic deglycosylated Pfs48/45 antigen is produced at a high level in plants and is structurally stable at elevated temperatures. Sera from mice immunized with this antigen showed strong inhibition in SMFA. Thus, Endo H in vivo enzymatic deglycosylated Pfs48/45 is a promising candidate for the development of an affordable TB vaccine, which may have the potential to save millions.

Acute Bismuth Intoxication: Acute Renal Failure, Tonsillar Ulceration and Posterior Reversible Encephalopathy Syndrome

Consumption and production of bismuth compounds are increasing, however, little information on the toxic effects and effective methods in removal of bismuth compounds are available. Although bismuth intoxication is currently rare, a careful evaluation should be carried out for possible exposure. We reported a16-year-old female who developed acute kidney failure, tonsillar ulceration and posterior reversible encephalopathy syndrome after an ingestion of 19 grams of bismuth subcitrate for suicidal attempt. (Hong Kong j.emerg.med. 2015;22:121-125)

Secondary Intoxication of Emergency Department Personnel with a Flammable and Highly Toxic Gas: A Lethal Aluminum Phosphide Poisoning Case

Aluminum phosphide (AlP) is a relatively low cost and highly toxic pesticide. Besides being lethal to the patient poisoned by AlP, this substance may easily contaminate emergency medicine personnel through the release of toxic gases such as phosphine. Furthermore, these toxic gases are flammable and may explode during certain patient interventions, such as gastric lavage. We present a case of lethal poisoning of a patient caused by the intentional ingestion of AlP and secondary intoxication of emergency medicine personnel with the explosive phosphine gas.

Reprogramming of various cell types to a beta-like state by Pdx1, Ngn3 and MafA

The three transcription factors, PDX1, NGN3 and MAFA, are very important in pancreatic development. Overexpression of these three factors can reprogram both pancreatic exocrine cells and SOX9-positive cells of the liver into cells resembling pancreatic beta cells. In this study we investigate whether other cell types can be reprogrammed. Eight cell types are compared and the results are consistent with the idea that reprogramming occurs to a greater degree for developmentally related cells (pancreas, liver) than for other types, such as fibroblasts. Using a line of mouse hepatocyte-derived cells we screened 13 compounds for the ability to increase the yield of reprogrammed cells. Three are active and when used in combination they can increase the yield of insulin-immunopositive cells by a factor of six. These results should contribute to the eventual ability to develop a new cure for diabetes based on the ability to reprogram other cells in the body to a beta cell phenotype.

Stage specific reprogramming of mouse embryo liver cells to a beta cell-like phenotype

We show that cultures of mouse embryo liver generate insulin-positive cells when transduced with an adenoviral vector encoding the three genes: Pdx1, Ngn3 and MafA (Ad-PNM). Only a proportion of transduced cells become insulin-positive and the highest yield occurs in the period E14-16, declining at later stages. Insulin-positive cells do not divide further although they can persist for several weeks. RT-PCR analysis of their gene expression shows the upregulation of a whole battery of genes characteristic of beta cells including upregulation of the endogenous counterparts of the input genes. Other features, including a relatively low insulin content, the expression of genes for other pancreatic hormones, and the fact that insulin secretion is not glucose-sensitive, indicate that the insulin-positive cells remain immature. The origin of the insulin-positive cells is established both by co-immunostaining for α-fetoprotein and albumin, and by lineage tracing for Sox9, which is expressed in the ductal plate cells giving rise to biliary epithelium. This shows that the majority of insulin-positive cells arise from hepatoblasts with a minority from the ductal plate cells.

Post Traumatic Paediatric Ischaemic Stroke: Case Presentation

Stroke is a disorder, which occurs suddenly as a result of vascular disorders and presents with variable neurological signs. Occlusive vascular diseases in childhood have many causes. Connective tissue disorders such as vasculitis, metabolic disorders, migraine, cyanotic heart diseases, infections, dehydration, nephrotic syndrome, malignancies, haemoglobinopathies, Moya moya disease and trauma are some of these causes. Stroke occurring in children as a result of minor head trauma sustained during falls and sport activities are also reported in the literature. An extensive evaluation is necessary for effective treatment of these children and to show the cause of the infarction. We present a case of a two-year-old patient suffered from acute ischaemic stroke resulting from a short distance fall. (Hong Kong j.emerg.med. 2011;18:169-172)

Coagulopathy parameters in patients with Crimean-Congo hemorrhagic fever and its relation with mortality

BACKGROUND

Crimean-Congo hemorrhagic fever (CCHF) is an acute illness affecting multiple organ systems and characterized by ecchymosis, visceral bleeding, and hepatic dysfunction. In this study, we aimed to investigate the profile of coagulopathy markers (platelet count, activated partial tromboplastin time (aPTT), prothrombin time (PT), international normalized ratio (INR), fibrinogen, protein C, protein S, antithrombin III, activated protein C resistance (APCR), and D-dimer) and their clinical significance in 83 CCHF-infected patients.

SUBJECTS AND METHODS

We studied 83 CCHF patients who were admitted to Ankara Numune Education and Research Hospital during the spring and summer of2007. We compared the coagulopathy markers of fatal CCHF patients (n=9) with nonfatal cases (n=74).

RESULTS

Platelet count, PT, aPTT, INR, and fibrinogen were prognostic factors associated with mortality for CCHF. Especially, platelet count<20 x 10(9) cells/l and aPTT>60 sec were important. Protein C, protein S, APCR, and antithrombin III levels were not associated with mortality.

CONCLUSION

Laboratory tests including classical parameters (platelet count, PT, aPTT, INR, and fibrinogen) of coagulopathy seem to be enough for the followup of CCHF. Protein S, protein C, APCR, and D-dimer levels were not associated with mortality.

Midterm results of left atrial bipolar radiofrequency ablation combined with a mitral valve procedure in persistent atrial fibrillation

INTRODUCTION

The aim of the study was to assess the midterm results of left atrial bipolar radiofrequency ablation combined with a mitral valve procedure in patients with mitral valve disease and persistent atrial fibrillation.

METHODS

Between October 2006 and July 2009, 95 patients with mitral valve disease and persistent atrial fibrillation underwent a mitral valve procedure and left atrial bipolar radiofrequency ablation. The postoperative data of the combined procedure were collected at the time of discharge and at one, three, six and 12 months after the operation.

RESULTS

Hospital mortality rate was 6.3% (six patients). Normal sinus rhythm was achieved in 77.2% of patients during the early postoperative period in hospital, and in 73.3, 72.0 and 75% of patients at three, six and 12 months postoperatively, respectively. Patients were followed up for a mean duration of 14.02 + or - 5.71 months (range: 6-19 months). During this midterm follow-up period, nine patients had late recurrence of atrial fibrillation. No risk factor was identified for late recurrence of atrial fibrillation.

CONCLUSION

Our midterm follow-up results suggest that the addition of left atrial bipolar radiofrequency ablation to mitral valve surgery is an effective and safe procedure to restore sinus rhythm in patients with chronic atrial fibrillation.

Glomerulonephritis associating parvovirus B19 infection

We report a previously healthy, immunocompetent 17-year-old male patient, who developed acute glomerulonephritis during the course of Parvovirus B19 infection and this acute glomerulonephritis did not resolve spontaneously. His renal biopsy showed mild mesangial proliferation and focal segmental sclerosis. Parvovirus B19 DNA was detected in renal tissue by polymerase chain reaction.

Risk factors for ICU-acquired imipenem-resistant Gram-negative bacterial infections

Intensive care units (ICUs) are high-risk areas for infections caused by antibiotic-resistant bacteria. This study investigated the risk factors for ICU-acquired imipenem-resistant Gram-negative infections. It was conducted prospectively in three surgical ICUs and one medical ICU from April to December 2002. ICU-acquired Gram-negative infections were found in 128 patients. Of these, 42 had imipenem-resistant and 86 had imipenem-sensitive Gram-negative bacteria as the cause of infection. According to the univariate analysis results, hospital stay before ICU admission, hospitalization period before ICU admission, length of ICU stay, surgical ICU stay, surgical operation and previous antibiotic use were significant risk factors for the acquisition of imipenem-resistant infections. In the multivariate analysis, length of ICU stay, surgical operation and previous carbapenem use were independently associated with imipenem resistance.

Evaluation of antibiotic use in intensive care units of a tertiary care hospital in Turkey

The object of this study was to evaluate the appropriateness of antibiotic use in relation to diagnosis and bacteriological findings in the intensive care units (ICUs) of a 1100-bed referral and tertiary care hospital with an antibiotic restriction policy in Turkey. Between June and December 2002, patients who received antibiotics in the medical and surgical ICUs were evaluated prospectively. Two infectious diseases (ID) specialists assessed the antibiotics ordered daily. Of the 368 patients admitted to the ICUs, 223 (60.6%) received 440 antibiotics. The most frequently prescribed antibiotics were first-generation cephalosporins (16.1%), third-generation cephalosporins (15.2%), aminoglycosides (12.1%), carbapenems (10.7%) and ampicillin-sulbactam (8.7%). Antibiotic use was inappropriate in 47.3% of antibiotics. ID specialists recommended the use of 47% of all antibiotics. An antibiotic order without an ID consultation was more likely to be inappropriate [odds ratio (OR)=13.2, P<0.001, confidence intervals (CI)=4.4-39.5]. Antibiotics ordered empirically were found to be less appropriate than those ordered with evidence of culture and susceptibility results (OR=3.8, P=0.038, CI=1.1-13.1). Inappropriate antibiotic use was significantly higher in patients who had surgical interventions (OR=3.6, P=0.025, CI=1.2-10.8). Irrational antibiotic use was high for unrestricted antibiotics. In particular, antibiotic use was inappropriate in surgical ICUs. Additional interventions such as postgraduate training programmes and elaboration of local guidelines could be beneficial.

A case of prosthetic mitral valve endocarditis caused by Brucella abortus

Endocarditis is a rare but serious complication of brucellosis. We report here a case of Brucella abortus endocarditis occurring on a prosthetic mitral valve. The diagnosis was established by positive serology, the presence of vegetation on the mitral prosthesis and isolation of B. abortus from the blood and valve cultures. The patient was successfully treated with combined medical and surgical therapy.

Surgical treatment of Brucella endocarditis

BACKGROUND

Brucella endocarditis (BE) is a lethal complication of human brucellosis, which is rarely seen and hardly described.

METHODS

In the present report, six successfully treated cases of BE involving three native aortic valves, two native mitral-aortic valves, and a mitral bioprosthesis are described. The diagnosis of BE was based on clinical features, high brucella serologic titers, and positive blood cultures. Although the blood cultures were positive in all patients, all the resected valve materials and tissue cultures were negative. The patients received rifampicin, streptomycin, and doxycycline (in 3 patients), rifampicin, tetracycline, and cotrimoxazole (in 2 patients), and rifampicin, doxycycline, and cotrimoxazole (in 1 patient). Infected native valves and bioprosthesis were replaced by mechanical valves.

RESULTS

There was no early or late mortality. No recurrent infection developed after management with a combination of antibiotherapy lasting 6 months postoperatively during a mean follow-up of 47 months (range 20 to 84 months).

CONCLUSIONS

This report suggests that the combination of valve replacement and antibiotic therapy produces successful results in the treatment of BE.

Different CABG methods in patients with chronic obstructive pulmonary disease

BACKGROUND

Pulmonary dysfunction is still a major problem in coronary artery bypass grafting (CABG). The purpose of this randomized study was to determine the effect of different CABG techniques on pulmonary function.

METHODS

Fifty eight patients with severe obstructive pulmonary disease had elective isolated coronary surgery. The surgical methods for the patients with chronic obstructive pulmonary disease (COPD) were standard CABG in 18 patients (group 1), beating heart surgery in 19 patients (group 2), and minimally invasive direct coronary artery bypass grafting (MIDCABG) in 21 patients (group 3).

RESULTS

The earliest extubation time was from group 3 (p < 0.001). The average stay in the intensive care unit was significantly longer in group 1 (2.6 +/- 1.5 days) than in groups 2 (1.4 +/- 0.8 days) and 3 (1.1 +/- 0.8 days) (p < 0.05). The most prevalent respiratory morbidity was atelectasis that developed in 6 patients from group 1, in 2 patients from group 2, and in 3 patients from group 3. Forced expiratory volumes in 1 second (FEV1) obtained in the second postoperative month were significantly lower than preoperative values only in group 1 (p < 0.05). Forced vital capacity (FVC) values were significantly lower than the preoperative values in all three groups (p < 0.05).

CONCLUSIONS

Off-pump bypass surgical procedures are more advantageous than on-pump methods for patients with COPD. These patients can be operated on using the beating heart technique or by using MIDCABG to prevent side effects of CPB on pulmonary function and effects of sternotomy.

Mechanical versus biological valve prosthesis in the mitral position: a 10-year follow up of St. Jude Medical and Biocor valves

BACKGROUND AND AIM OF THE STUDY

During the past 30 years, the development of mechanical and biological valves has led to major improvements in patient survival. Here, we present long-term results obtained with both types of prosthesis.

METHODS

At our institution, between 1985 and 1989, 158 patients received a Biocor porcine bioprosthesis, and 100 patients a St. Jude Medical (SJM) mechanical valve. Preoperatively, mean age, male:female ratio, NYHA functional class and pathology of mitral valve disease were similar in both groups.

RESULTS

The 30-day mortality was 4.4% in the Biocor group and 4% in the SJM group, the major cause being congestive heart failure. Late mortality was 17.9% and 15.6% respectively in the two groups, but valve-related mortality was very low in both (1.3% versus 4.2%). Ten-year survival was similar in each group (77.8+/-3.4% versus 81.0+/-3.9%; p = 0.538). Ten-year freedom from anticoagulant-related hemorrhage was higher with Biocor prostheses (99.3+/-0.7% versus 90.9+/-3.1%; p = 0.007). Valve thrombosis was seen only in the SJM group, and structural valve degeneration (SVD) only in the Biocor group. Ten-year freedom from reoperation was lower in the Biocor group (84.9+/-3.2% versus 92.2+/-2.8%; p = 0.206). The significant causes of reoperation were SVD in the Biocor group and valve thrombosis in the SJM group. Freedom from prosthetic valve endocarditis was similar in both groups (96.3+/-1.6% versus 95.5+/-2.2%).

CONCLUSION

As no difference was seen in survival and reoperation rates between patients receiving either bioprostheses or mechanical valves, the valve used will depend on the surgeon's choice and the type of patient, notably elderly patients who are intolerant of anticoagulation, and young women wishing to have children.

A cardiac hydatid cyst involving the basal interventricular septum causing biventricular outflow tract obstruction

We report a case of a 37-year-old sheep-raising man with a cardiac hydatid cyst involving the basal interventricular septum causing biventricular outflow obstruction. He suffered from multi-organ hydatidosis and underwent cerebral hydatid cyst extirpation and right nephrectomy for renal echinococcosis. The diagnosis of the cyst was obtained by echocardiography and magnetic resonance imaging. The diagnosis was confirmed by positive hemagglutination test. He was operated on for cardiac hydatid cyst using enucleation and capitonnage procedure under extracorporeal circulation. The morbidity was complete atrioventricular block, necessitating VDD pacemaker implantation. This was followed by medical treatment with albendazole (400 mg/day).

Three ventriculoplasty techniques applied to three left-ventricular pseudoaneurysms in the same patient

A 59-year-old male patient underwent surgery for triple-vessel coronary artery disease and left-ventricular aneurysm in 1994. Four months after coronary artery bypass grafting and classical left-ventricular aneurysmectomy (with Teflon felt strips), a left-ventricular pseudoaneurysm developed due to infection, and this was treated surgically with an autologous glutaraldehyde-treated pericardium patch over which an omental pedicle graft was placed. Two months later, under emergent conditions, re-repair was performed with a diaphragmatic pericardial pedicle graft due to pseudoaneurysm reformation and rupture. A 3rd repair was required in a 3rd episode 8 months later. Sternocostal resection enabled implantation of the left pectoralis major muscle into the ventricular defect. Six months after the last surgical intervention, the patient died of cerebral malignancy. Pseudoaneurysm reformation, however, had not been observed. To our knowledge, our case is the 1st reported in the literature in which there have been 3 or more different operative techniques applied to 3 or more distinct episodes of pseudoaneurysm formation secondary to post-aneurysmectomy infection. We propose that pectoral muscle flaps be strongly considered as a material for re-repair of left-ventricular aneurysms.

Less invasive approaches for closed mitral commissurotomy

OBJECTIVE

Recently, closed mitral commissurotomy (CMC) has been reexplored due to the concepts of less invasive valvular surgery. The feasibility of closed mitral commissurotomy via port access or limited thoracotomy by aid transesophageal echocardiography (TEE) was investigated in this clinical study.

METHODS

Between August 1996 and April 1998, 42 patients (32 women, ten men with a mean age of 36.2+/-7.8 years) underwent less invasive CMC at the Kosuyolu Heart and Research Hospital. CMC procedure were done through a limited (12-16 cm) thoracotomy incision in 23 patients, a very limited or mini thoracotomy incision (7-8 cm) in 11 patients and port access by aid TEE in eight patients. Preoperative mean mitral valve area was calculated as 1.19+/-0.13 cm2 and mean mitral valve gradient was measured as 14.8+/-3.2 mmHg. TEE provided information about the mitral valve anatomy and functions during the procedure in all patients.

RESULTS

Commissurotomy was successfully performed in all patients. In eight patients, a Tubbs dilator was inserted via port access at the 6th intercostal space from a 3-cm incision. Incision by guidance of TEE and CMC could be performed without thoracotomy in five patients. In three patients of the port access group, a very limited thoracotomy was required to perform CMC by digital guidance. Postoperative mean MVA was 2.37+/-0.29 cm2, minimal mitral gradient was 5.3+/-1.7 mmHg. In eleven patients, minimal mitral regurgitation was observed. The operations and postoperative period were free of complications in all patients. Following an average 12+/-2.8 h intensive care unit period, all patients were discharged after an average of 3.4+/-0.8 days of hospitalization.

CONCLUSION

Limited thoracotomy has less detrimental structural effects in patients. Port access by aid TEE approach to CMC may offer less invasiveness, lower cost effectiveness and be an alternative to percutaneous balloon mitral valvotomy.

An uncommon complication of Behçet's disease: intracardiac thrombosis needing surgical treatment

Behçet's syndrome is a multisystem disorder presenting with recurrent oral and genital ulcerations as well as uveitis often leading to blindness. Although vascular lesions are a common complication of this disease, cardiac involvement is extremely rare. In this unusual case a young man had symptoms primarily related to recurrent right-atrial and right-ventricular thrombi unresponsive to medical treatment. The intracardiac lesion was successfully treated by surgical excision with the use of cardiopulmonary bypass. Surgical treatment should be considered in Behçet's disease complicated by cardiac thrombi, when a thrombus recurs despite medical treatment.