A Structured Training for Trans Anal Irrigation in Pediatric Patients Improves Outcomes and Reduce Failures: Results of an Interventional Multicenter Prospective Study

BACKGROUND

Continence issues due to organic causes including previous colorectal surgery or neurological issues might benefit from Transanal irrigation (TAI) that proved to be highly effective but with a number of limitations including a relatively high discontinuation rates. Our study was aimed at evaluating the efficacy of an advanced protocol tailored to each patient to prevent dropout and increase satisfaction, independence, and quality of life.

MATERIALS AND METHODS

This was a prospective, interventional, multicenter, nonrandomized study involving children aged 4-18 years with bowel dysfunction unresponsive to conventional treatments who required TAI. TAI was performed in accordance to the best standards of care with a total irrigation volume that was determined based on low emission X-Ray barium enemas performed at the very beginning of the study. All patients underwent training and assessments of continence, patients' perspectives and quality of life were performed at different timepoints from enrollment (T0) up to 6 months since TAI was introduced (T3).

RESULTS

A total of 78 patients were enrolled. Male to female ratio was 1.4:1. Mean age at enrollment was 106.1 ± 42.8 months. Discontinuation was reported by 3 patients (3.8 %). Continence, satisfaction and a number of other outcome measures increased from baseline (T0) to the last visit (T3). In particular, mean Rintala total score increased linearly from 7.8 to 14.8 during the study period (T0 to T3 timepoints). On a multivariate analysis, the only parameter that proved to be inversely associated with continence as well as with other outcome measures was the use of laxatives at enrollment and during the study.

CONCLUSIONS

This study has demonstrated the high efficacy of this innovative patient-tailored TAI protocol across all assessed scores. Of note, given the negative impact of laxatives, our findings suggest limiting their use in this patient population to further increase the efficacy of the procedure.

Acute appendicitis in elderly during Covid-19 pandemic

PURPOSE

During the past months, the Italian Government has reduced the restrictions and access to hospitals. Since then, up to 40% of non-traumatic abdominal emergencies have had unusual delayed treatment. Given the rapidly evolving situation and the absence of evidence to support recommendations during the pandemic, it is useful to assess how the current situation is influencing the management of elderly with acute appendicitis.

METHODS

Between February 2020 and December 2020, all patients older than 68 years old undergone appendectomy were included. Surgical approach, hospital stay, post-operative complications, radiology reports, and histologic examination were included in the retrospective analysis and compared with a same sample of the same period before the pandemic.

RESULTS

Twenty-seven patients underwent appendectomy for acute appendicitis during the pandemic and 34 patients in the pre-outbreak period. Laparoscopic approach was completed in 51.8% of the cases, while conversion to laparotomy in 22.3% of patients and open procedure in the 25.9%, before the pandemic 73.6%, 14.7%, and 11.7%, respectively. During the pandemic, complicated appendicitis occurred in 59.3% of the cases (26.5% before the outbreak). One patient was treated for a pelvic abscess, while no minor complications were detected. No mortality rate was reported, with a mean hospital stay of 5.64 days during the outbreak and 4.21 days before the pandemic.

CONCLUSION

Our data highlighted a partial delay in diagnosis in the elderly group, and an increase in complicated appendicitis also demonstrated by the need for conversion to laparotomy.

Left atrial strain as a pre-operative prognostic marker for patients with severe primary mitral regurgitation

Background

For patients with severe mitral regurgitation (MR), new indices are needed to optimize surgical timing before irreversible myocardial dysfunction.

Purpose

We investigated the prognostic role of left atrial (LA) strain by speckle tracking echocardiography after mitral surgery for severe MR, and its association with LA fibrosis.

Methods

70 patients with primary severe MR undergoing echocardiography before mitral surgery were enrolled. Patients with other valvular disease > moderate, left bundle branch block, coronary artery disease, heart failure (HF), pacemaker implantation, heart transplantation, poor acoustic window, were excluded. The primary composite endpoint included HF and mortality; the secondary endpoint was post-operative functional capacity (NYHA and Borg CR10). LA fibrosis was assessed by atrial biopsy specimens.

Results

Of 62 patients eligible, 32 had composite events (medium follow-up: 3.3±2.5 years for event-group, 7.6±1 years for non-event group). Characteristics of our study population are summarized in Table 1. With Kaplan-Meier analysis (Fig. 1), PALS provided a good risk stratification; it also was an independent and incremental predictor of outcome in four multivariate Cox adjusted models. There was a strong association between PALS and secondary endpoint (NYHA: r2=0.11, p=0.04; Borg CR10: r2=0.10, p=0.02) and an inverse correlation between PALS <21% and LA fibrosis (r2=0.80; 76.6±20.7% vs 31.9±20.8%; p<0.0001).

Conclusions

Global PALS emerged as a reliable predictor of outcome and functional capacity for severe primary MR, and as a marker of LA fibrosis.

Figure 1

Funding Acknowledgement

Type of funding source: None

Sphinkeeper™ for faecal incontinence: a preliminary report

AIM

A new artificial anal sphincter placed into the intersphincteric space, SphinKeeper™, has recently been proposed to improve outcomes in the treatment of faecal incontinence (FI). We report our preliminary results with short-term follow-up, comparing preoperative and postoperative data after implant of SphinKeeper™ in patients suffering from FI.

METHODS

All patients older than 18 years were included with FI of at least 6 months, incontinence episodes occurring more than once a week and resistance to other conservative treatments. Anorectal manometry, endoanal ultrasound, Cleveland Clinic FI Score, FI Quality of Life score and total number of episodes of FI per week were recorded preoperatively and at the end of the 6-month follow-up period.

RESULTS

Thirteen consecutive patients were treated with SphinKeeper™. No intra-operative nor postoperative complications were reported. Two cases of prosthesis extrusion occurred, and in one case an anterior dislocation was detected. Maximum resting pressure, total number of episodes of FI per week and Cleveland Clinic FI Score were improved after 6 months (P < 0.05).

CONCLUSIONS

SphinKeeper™ could be a minimally invasive procedure for FI with good postoperative outcomes. If these results are confirmed by studies with more patients and longer follow-up, it could be a first-line approach in FI.

Longitudinal Strain Stress-Echo Evaluation of Aged Marginal Donor Hearts: Feasibility in the Adonhers Project

BACKGROUND

The Adonhers (aged donor heart rescue by stress-echo protocol) Project was created to resolve the current shortage of donor hearts. One of the great limits of stress echo is the operator dependency. Speckle-tracking echocardiography (STE), offering a quantitative objective analysis of myocardial deformation, may help to overcome this limit. This study aimed to verify feasibility of a stress-strain echo analysis in selection of aged donor hearts for heart transplant.

METHODS

From February 2014 to October 2015, 22 marginal candidate donors (16 men) ages 58 ± 4 years were initially enrolled. After legal declaration of brain death, all marginal donors underwent bedside echocardiography, with baseline and (when resting echocardiography was normal) dipyridamole (0.84 mg/kg in 6 minutes) stress echo. In all patients, left ventricular (LV) longitudinal myocardial deformation was obtained by STE in the 4-, 2-, and 3-chamber views, obtaining the average global longitudinal strain (GLS). GLS was assessed at baseline and at the peak of stress echo.

RESULTS

Baseline echocardiography showed wall motion abnormalities in 9 patients (excluded from donation). Stress echocardiography was performed in the remaining 13 patients. Results were normal in 8, who were uneventfully transplanted in marginal recipients. Stress results were abnormal in 5 (excluded from donation). STE was obtained in all cases (100% feasibility) and ΔGLS was significantly different between normal and pathological stress-echo (+13.2 ± 5.2 versus -6.1% ± 3.1%, P = .0001, respectively).

CONCLUSIONS

STE showed an excellent feasibility in analysis of LV myocardial longitudinal strain at baseline and at the peak of stress echo of marginal heart donors. Further experience is needed to confirm STE as a valuable additional mean to better interpret stress echo in marginal donors.

Neuroimaging Biomarker of Major Depressive Disorder

Introduction

Recent studies have shown that it is important to understand the brain mechanism specifically by focusing on the common and unique functional connectivity in each disorder including depression.

Objectives

To specify the biomarker of major depressive disorder (MDD), we applied the sparse machine learning algorithm to classify several types of affective disorders using the resting state fMRI data collected in multiple sites, and this study shows the results of depression as a part of those results.

Aims

The aim of this study is to understand some specific pattern of functional connectivity in MDD, which would support diagnosis of depression and development of focused and personalized treatments in the future.

Methods

The neuroimaging data from patients with major depressive disorder (MDD, n = 100) and healthy control adults (HC: n = 100) from multiple sites were used for the training dataset. A completely separate dataset (n = 16) was kept aside for testing. After all preprocessing of fMRI data, based on one hundred and forty anatomical region of interests (ROIs), 9730 functional connectivities during resting states were prepared as the input of the sparse machine-learning algorithm.

Results

As results, 20 functional connectivities were selected with the classification performance of Accuracy: 83.0% (Sensitivity: 81.0%, Specificity: 85.0%). The test data, which was completely separate from the training data, showed the performance accuracy of 83.3%.

Conclusions

The selected functional connectivities based on the sparse machine learning algorithm included the brain regions which have been associated with depression.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Paediatric ulcerative colitis surgery: Italian survey

BACKGROUND AND AIMS

Recent epidemiological studies showed an increase in ulcerative colitis among children, especially in its aggressive form, requiring surgical treatment. Although medical therapeutic strategies are standardized, there is still no consensus regarding indications, timing and kind of surgery. This study aimed to define the surgical management of paediatric ulcerative colitis and describe attitudes to it among paediatric surgeons.

METHODS

This was a retrospective cohort study. All national gastroenterology units were invited to participate. From January 2009 to December 2013, data on paediatric patients diagnosed with ulcerative colitis that required surgery were collected.

RESULTS

Seven units participated in the study. Seventy-one colectomies were performed (77.3% laparoscopically). Main surgical indications were a severe ulcerative colitis attack (33.8%) and no response to medical therapies (56.3%). A three-stage strategy was chosen in 71% of cases. Straight anastomosis was performed in 14% and J-pouch anastomosis in 86% of cases. A reconstructive laparoscopic approach was used in 58% of patients. Ileo-anal anastomosis was performed by the Knight-Griffen technique in 85.4% and by the pull-through technique in 9.1% of patients. Complications after colectomy, after reconstruction and after stoma closure were reported in 12.7, 19.3 and 35% of cases, respectively.

CONCLUSIONS

This study shows that there is general consensus regarding indications for surgery. The ideal surgical technique remains under debate. Laparoscopy is a procedure widely adopted for colectomy but its use in reconstructive surgery remains limited. Longer follow-up must be planned to define the quality of life of these patients.

Complex anal fistula remains a challenge for colorectal surgeon

AIM

Anal fistula is a common proctological problem to both patient and physician throughout surgical history. Several surgical and sphincter-sparing approaches have been described for the management of fistula-in-ano, aimed to minimize the recurrence and to preserve the continence. We aimed to systematically review the available studies relating to the surgical management of anal fistulas.

MATERIAL AND METHODS

A Medline search was performed using the PubMed, Ovid, Embase, and Cochrane databases to identify articles reporting on fistula-in-ano management, aimed to find out the current techniques available, the new technologies, and their effectiveness in order to delineate a gold standard treatment algorithm.

RESULTS

The management of low anal fistulas is usually straightforward, given that fistulotomy is quite effective, and if the fistula has been properly evaluated, continence disturbance is minimal. On the contrary, high complex fistulas are challenging, because cure and continence are directly competing priorities.

CONCLUSIONS

Conventional fistula surgery techniques have their place, but new technologies such as fibrin glues, dermal collagen injection, the anal fistula plugs, and stem cell injection offer alternative approaches whose long-term efficacy needs to be further clarified in large long-term randomized trials.

Right ventricular longitudinal strain and right ventricular stroke work index in patients with severe heart failure: left ventricular assist device suitability for transplant candidates

BACKGROUND

Right ventricular (RV) systolic function has a critical role in determining the clinical outcome and the success of using left ventricular assist devices in patients with refractory heart failure. RV deformation analysis by speckle tracking echocardiography (STE) has recently allowed the analysis of RV longitudinal function. Using cardiac catheterization as the reference standard, this study aimed to explore the correlation between RV longitudinal function by STE and RV stroke work index (RVSWI) among patients referred for cardiac transplantation.

METHODS

Right heart catheterization and transthoracic echo-Doppler were simultaneously performed in 47 patients referred for cardiac transplant assessment due to refractory heart failure (ejection fraction 25.1 ± 4.5%). Thermodilution RV stroke volume and invasive pulmonary pressures were used to obtain RVSWI. RV longitudinal strain (RVLS) by STE was assessed averaging RV free-wall segments (free-wall RVLS). We also calculated. Tricuspid S' and tricuspid annular plane systolic excursion (TAPSE).

RESULTS

No significant correlation was observed for TAPSE on tricuspid S' with RV stroke volume (r = 0.14 and r = 0.06, respectively). A close negative correlation between free-wall RVLS and RVSWI was found (r = -0.82; P < .0001). Furthermore, free-wall RVLS showed the highest diagnostic accuracy (area under the curve of 0.90) with good sensitivity and specificity of 95% and 91%, respectively, to predict depressed RVSWI using a cutoff value less than -11.8%.

CONCLUSIONS

Among patients referred for heart transplantation, TAPSE and tricuspid S' did not correlate with invasively obtained RVSWI. RV longitudinal deformation analysis by STE correlated with RVSWI, providing a better estimate of RV systolic performance.

Serum Cystatin C as a Reliable Marker of Changes in Glomerular Filtration Rate in Children With Urinary Tract Malformations

PURPOSE

Cystatin C has been suggested as a simple method of estimating GFR more accurately than creatinine in children. We compared the diagnostic accuracy of cystatin C with serum creatinine and the Schwartz formula for estimating GFR in patients with UTMs.

MATERIALS AND METHODS

We prospectively compared 72 patients with UTMs (20 days to 36 months old, 58 males and 14 females) with a group of 72 healthy controls (10 days to 48 months old, 53 males and 19 females). All patients underwent nuclear medicine clearance investigations with (99m)Tc DTPA.

RESULTS

Serum concentration of cystatin C revealed a higher correlation with (99m)Tc DTPA (r = 0.62, p <0.001) than serum concentration of creatinine (r = 0.30, p <0.01) or Schwartz formula (r = 0.51, p <0.001). These results were more evident in patients with uropathy (19) with mild renal impairment. Agreement between methods was assessed using Bland Altman analysis. Mean differences between GFR calculated with (99m)Tc DTPA and cystatin C based GFR estimation or Schwartz formula were -2.6% +/- 46.7% and -73.4% +/- 53.6%, respectively. Diagnostic accuracy in identifying decreased GFR measured as AUC was always highest for cystatin C but hardly sufficient for the 3 variables. Cystatin C performed better in the 0 to 6-month-olds (0.70 +/- 0.08 for cystatin C, 0.58 +/- 0.07 for Schwartz estimate) and patients older than 12 months (0.82 +/- 0.09 for cystatin C, 0.65 +/- 0.11 for Schwartz estimate).

CONCLUSIONS

Cystatin C proved to be a superior marker rate over serum creatinine in estimating glomerular filtration in children younger than 3 years with UTMs and mild renal impairment, thus, offering a more specific and practical measure for monitoring GFR.

C2 and C0 Values for Monitoring Cyclosporine Therapy in Stable Heart Transplant Recipients

INTRODUCTION

We sought to evaluate the behavior of C2 values and their correlation with acute rejection episodes and cyclosporine (CyA) side effects in heart transplant patients whose immunosuppressive therapy, was monitored with C0 trough levels.

METHODS

Sixty stable patients who had received heart transplants from 3 months to 60 months prior were randomly observed from September 2001 to June 2004. Four area under the concentration-time curves (AUC) were performed on each patient, a total of 240 AUC curves.

RESULTS

Regarding the variability of CyA absorption, two groups of patients were distinguished: group A, "constant absorbers," namely, low variability (<15%) of CyA absorption; group B, "inconstant absorbers" patients with higher (>15%) variability of absorption. Group B patients showed more acute rejection episodes (41%) than group A (19%). CyA side effects were more serious in patients with higher variability of absorption: systemic hypertension, neurological disorders, hyperlipidemia, and gum hyperplasia; Group B patients who developed CyA side effects showed higher maximum and mean C2 levels (P < .05) than group A patients. No differences were found with regard to renal dysfunction between the two groups: all patients showed a mean increase of serum creatinine by at least 50% compared to the baseline value.

CONCLUSION

Higher C2 levels were not sufficient to predict acute rejection compared to lower but constants, C2 levels. Patients with inconstant absorption were more often overexposed to CyA than underexposed, developing more side effects than patients with lower variability of absorption. Monitoring CyA therapy with C0 and C2 may prevent over- or underexposure to the drug.

Risk factors for smoking abuse after heart transplantation

Patients (n = 103) were studied before heart transplantation with regard to smoking habits by means of a clinical interview, and 81 were submitted to Minnesota Multiphasic Personality Inventory (MMPI). After a mean time of 50.8 +/- 24.2 months from transplant, they were once again interviewed to ascertain their smoking habits after intervention. Nonsmokers (35 of 103) were still nonabusers. Of the remaining 68 patients who ceased smoking before heart transplant, 12 (17.6%) had returned to tobacco abuse. Dividing these 68 patients into two groups based upon the length of smoking cessation before heart transplant (less than 1 year: short term [ST] more than 1 year: long term [LT]), we noticed that the ST group showed a much greater rate of reabuse (8 of 20, 40%) than the LT group (4 of 48, 8.3%, P =.006). Analyzing six scales of MMPI, we found a statistically different score for self-control ability (scale K) in ST and LT smokers compared to nonsmokers (45.5 and 45.5 vs 51.2, P =.026), and for difficult adaptation (scale Ma) in ST compared both to LT smokers and nonsmokers (ST 57, LT 50.5, NS 47.6; P =.042 LT vs ST, P =.0005 ST vs NS). We concluded that patients who have recently decided to stop smoking and show after MMPI compilation a score of >50 for K and <50 for Ma scale have a higher risk of reabuse and need a greater effort by the transplant team to reinforce their will to stop smoking.

Transumbilical laparoscopic-assisted appendectomy (TULAA): a safe and useful alternative for uncomplicated appendicitis

AIM

To compare transumbilical laparoscopic-assisted appendectomy (TULAA) and open appendectomy (OA) in cases of acute uncomplicated appendicitis.

METHODS

58 TULAA and 65 OA in patients with a preoperative diagnosis of acute uncomplicated appendicitis are compared. Pneumoperitoneum was obtained with a transumbilical 10 mm trocar (telescope access) and a 5 mm operative channel introduced in the left iliac fossa. Appendectomy was performed outside the abdomen, after the exteriorisation of the appendix through the transumbilical incision.

RESULTS

In the TULAA group, operative time and hospital stay were reduced. Conversion was necessary in one case (1.7 %), and in one case (1.7 %), an additional 5 mm operative channel was introduced. Neither intra- or postoperative complications were found in the TULAA group, with excellent cosmetic results. In the OA group we had a wound infection (1.5 %) and in 8 cases (12.3 %) an enlargement of the incision was necessary.

CONCLUSIONS

TULAA is the best approach in uncomplicated appendicitis. It is less invasive and traumatic, permits a complete evaluation of the peritoneal cavity with superior cosmetic results, especially in obese patients and in cases of ectopic appendicitis.

Enhanced apoptosis of peripheral blood mononuclear cells in cardiac transplanted patients undergoing chronic immunosuppressive treatment

Apoptosis plays a major role in tissue transplantation because intact T-cell-apoptosis pathways are required for the induction of tolerance to allografts. Moreover, immunosuppressive agents commonly used in clinical transplantation medicine promote lymphocyte apoptosis inhibiting the expression and production of cytokines involved in lymphocyte survival. The aim of our study was to evaluate peripheral blood mononuclear cells (PBMC) spontaneous apoptosis in patients undergoing chronic immunosuppressive treatment after cardiac transplantation. PBMC obtained from patients (n = 31) and controls matched for age and sex (n = 25) were cultured for 72 h and apoptosis was evaluated by quantification of fragmented DNA, staining with Hoechst 33258 dye and annexin V binding. We also investigated Fas expression and FasL mRNA expression as well as the ability of an IgM anti-Fas antibody to induce apoptosis. Finally, we evaluated IL2 production induced by PHA and the ability of IL2 to prevent apoptosis. In patients, PBMC underwent enhanced spontaneous apoptosis in comparison with controls. However, we could not find any difference between patients and normals as regards the expression of Fas and of FasL mRNA, even if the cross-linking of the Fas molecule induced apoptosis in PBMC from patients, whereas it failed to induce cell death in normals. We also found that IL2 production was significantly decreased in patients and that the addition of IL2 to the culture medium reduced PBMC spontaneous apoptosis. Our findings suggest that in cardiac transplanted patients PBMC undergo enhanced spontaneous apoptosis, which may contribute to prevent allograft rejection.

A primary intracavitary right atrial neurilemoma

Primary cardiac neurilemoma, a benign tumor, is extremely uncommon. To our knowledge only eight cases have been reported in the literature. We report a case of a 72-year-old man who presented with complaints of progressive shortness of breath and chest pain, seven years after a right nephrectomy for renal adenocarcinoma. An intra-right atrial tumor was surgically removed; the lesion was found to be a neurilemoma of the right atrium. This case report describes the surgical removal and rarity of neurilemomas, their predisposition to be right-sided in the heart and their coincidental association with other types of cancer.

Electrophysiologic effects of lercanidipine on repolarizing potassium currents

Blockade of cardiac repolarizing potassium channels by drugs may result in QT-interval prolongation, eventually degenerating into "torsades de pointes," a life-threatening arrhythmia. Lercanidipine (LER) is a recently introduced lipophilic calcium antagonist with no cardiodepressant activity and long-lasting antihypertensive action. Its chemical structure is characterized by the presence of a diphenylpropylaminoalkyl group, which is present in some of the drugs that have been reported to cause QT-interval prolongation. Our previous data demonstrated that LER blocks L-type calcium channels without affecting sodium current; however, no data are available concerning its effects on cardiac potassium channels. Transient outward (I(to)), delayed rectifier (I(K)), background currents, and action potential (AP) profile were measured from patch-clamped ventricular myocytes isolated from rat, guinea pig, or human hearts using enzymatic dissociation procedures. LER did not affect I(K) (and I(Kr)) density and activation curve in guinea pig myocytes; the reversal potential of the background current (I(K1)) and its slope were not changed by the drug. Maximal diastolic potential (MDP) and duration of the AP measured at -60 mV (APD(-60)) were not significantly changed. I(to) density and activation curves measured in rat myocytes were similar in the absence and presence of 1 or 10 microM LER. Finally, the effect of LER was tested in human ventricular myocytes: superfusion with 1 microM LER did not affect MDP and APD(-60). I(to) density and the midpoint of activation and inactivation curves were similar in the absence and presence of LER. In conclusion, our data demonstrate that LER does not affect repolarizing potassium currents and action potential profile recorded from guinea pig, rat, and human ventricular myocytes. It is unlikely that LER could cause QT prolongation in vivo.

Capillary electrophoresis in the evaluation of ischemic injury: simultaneous determination of purine compounds and glutathione

An understanding of tissue energy metabolism and antioxidant status is of major interest in the field of organ preservation for transplantation. Nucleotide and glutathione are indicators of cell damage occurring during ischemia and reperfusion. A high performance capillary electrophoresis (HPCE) method with UV detection (185 nm) for the simultaneous analysis of intracellular free ribonucleotides, nucleosides, bases and glutathione (oxidized and reduced form) in myocardial tissues is described. The method does not involve thiol derivatization. The separations were carried out in an uncoated fused-silica capillary, 60 cm long, 52.5 cm to detector, 75 microm ID, with 20 mM Na-borate buffer, pH 10.00, at 20 kV voltage and reading at 185 nm. Injection was hydrostatic for 12 s and total analysis time was 20 min. The technique enables optimum separation of all the compounds examined and has a resolution similar to that of HPLC analysis, with the advantage of fast simultaneous measurement of cell nucleotide metabolism and redox state, not possible with HPLC.

Iatrogenic right ventricular laceration: delayed presentation after abdominal surgery

A 69-year-old man presented at our emergency department in marginal hemodynamic condition due to hemorrhagic shock and cardiac tamponade. Two months earlier, he had undergone total gastrectomy and left lobe hepatectomy for invasive gastric cancer. Delayed iatrogenic laceration of the right ventricle, consequent to the abdominal procedure, was the uncommon cause of the massive hemopericardium. To our knowledge, this is only the 2nd case in the literature of a cardiac laceration after abdominal surgery.

Endothelin receptors in adult human and swine isolated ventricular cardiomyocytes

The present study aimed to investigate endothelin-1 (ET-1) receptors in human and swine cardiomyocytes with binding studies using ET(A) and ET(B) selective receptor antagonists (BMS-182874 and BQ-788, respectively). Cell distribution of mRNA expression for ET(A) and ET(B) subtypes was investigated by in situ hybridization using specific cDNA probes. The 1251-ET-1 binding, which reached equilibrium in about 120 min (Kobs = 0.051+/-0.003 min(-1)), was only partially displaceable by the addition of a large excess of ET-1 (about 15% with a half-life of 20 min). In equilibrium binding studies, 125I-ET-1 had a Kd of 0.43+/-0.08 nM and a maximum binding (Bmax) of 42.8+/-6.6 fmol/mg protein. ET(A) and ET(B) receptors are represented in human and swine cardiomyocytes with an 85:15 ratio as indicated by the biphasic pattern of competition of both BMS-182874 and BQ-788. In situ hybridization studies confirmed that myocytes mainly expressed mRNA for ET(A), whereas expression of mRNA for the ET(B) subtype was documented in non-myocyte cells. These results showed that ET-1 binds with high affinity and poor reversibility to specific receptors, in both human and swine isolated ventricular cardiomyocytes, without significant species differences.

Combined use of single and double-cross steel wires for closure of midline sternotomy

BACKGROUND

We describe an improved technique for sternal closure which is performed using combined single and double-cross steel wires. We made a mechanical study of these single and double-cross shapes considering the effects of applied transverse and longitudinal shearing forces.

METHODS

We used this technique in 80 patients who underwent coronary surgery with the use of bilateral internal mammary arteries.

RESULTS

Among them no major wound complications occurred, and in all cases a firm stabilization of the sternum was achieved.

CONCLUSIONS

We therefore consider this technique of sternal closure easy, safe and effective, also in patients considered at risk for sternal dehiscence.

Nonpenetrating stapling: a valuable alternative for coronary anastomoses?

BACKGROUND

The safe development of minimally invasive coronary artery bypass operations might require alternatives to conventional suture-based anastomotic techniques. In this setting, nonpenetrating stapling is an attractive option because of its simplicity of use and potential for improved endothelial preservation.

METHODS AND RESULTS

In the experimental part of this study, porcine internal mammary arteries were anastomosed to left anterior descending coronary arteries using either an 8-0 polypropylene running suture or nonpenetrating microclips (7 anastomoses in each group). The endothelium-dependent relaxations to bradykinin of the arterial rings bearing the anastomosis and of noninstrumented rings were compared in organ chamber experiments. There were no significant differences in maximal relaxations (mean +/- SEM) between the microclipped and sutured anastomoses (81%+/-7% versus 74%+/-10%), which were both significantly lower than those of control coronary rings (98%+/-2%, p = 0.001 versus the two anastomosed groups). Histologic examination showed a comparable preservation of the coronary and graft endothelium with both techniques. The clinical part of the study comprised 7 patients in whom the left internal mammary artery was conventionally sutured to the left anterior descending whereas 13 saphenous vein grafts were anastomosed to their target vessels by nonpenetrating staples. There were no clip-related complications. An angiographic assessment of the venous grafts was performed within 10 days postoperatively in all patients. One graft is presumably occluded. The 12 remaining conduits were patent with stapled anastomoses featuring a widely open "shark-mouth" configuration.

CONCLUSIONS

These preliminary data suggest that non-penetrating stapling is an easy-to-use technique that competes well with conventional suturing, at least in terms of immediate results. Further studies are warranted to better define its potential place within the armamentarium of minimally invasive coronary artery bypass techniques.

Reduction of oxidative stress does not affect recovery of myocardial function: warm continuous versus cold intermittent blood cardioplegia

OBJECTIVE

To compare oxidative stress after cardiac surgery in patients treated with two different methods of myocardial protection: warm continuous versus cold intermittent blood cardioplegia. To correlate oxidative stress with postoperative myocardial dysfunction.

DESIGN

Prospective, randomised, double blind, trial.

SETTING

Institutional centre of cardiovascular surgery.

PATIENTS

20 patients were selected for coronary artery bypass surgery (CABG) on the following basis: stable angina, ejection fraction > 50%, double or triple vessel disease, no previous CABG or associated disease. Patients were randomised to two groups of 10 patients each.

INTERVENTIONS

Patients underwent CABG with one of two different methods of myocardial protection and cardiopulmonary bypass. CBC group: intermittent cold blood antegrade-retrograde cardioplegia with moderate hypothermic cardiopulmonary bypass; WBC group: continuous warm blood antegrade-retrograde cardioplegia with mild hypothermic cardiopulmonary bypass.

MAIN OUTCOME MEASURE

The index of oxidative stress used was the alteration of whole blood and plasma glutathione redox status. Samples were collected from the coronary sinus and peripheral vein before anaesthesia (T1), before aortic unclamping (T2), 15 minutes (T3), and 30 minutes (T4) after unclamping. Haemodynamic parameters were measured with thermodilution techniques.

RESULTS

Oxidised glutathione and glutathione-cysteine mixed disulphide significantly increased in the coronary sinus plasma in the CBC group, and the overall redox balance of glutathione was decreased (P < 0.01) at T2-T4 versus T1, and compared with the WBC group. Comparable results were obtained for coronary sinus blood. There was no correlation between postoperative haemodynamic measurements and oxidative stress markers.

CONCLUSIONS

Oxidative stress was significant in patients undergoing CABG using cold blood cardioplegia, while the warm technique minimised the effects of ischaemia. However, oxidative stress was not correlated with myocardial dysfunction following CABG.

Total arterial myocardial revascularization without cardiopulmonary bypass

The risks associated with cardiopulmonary bypass have led to an interest in coronary surgery without the use of such a bypass. Six patients of mean(s.d.) age 62.0(8.0) (range 52-71) years were selected for elective coronary surgery without cardiopulmonary bypass. In five cases a midline sternotomy and in one case a small anterolateral thoracotomy were performed; in the latter case the harvesting of the proximal end of the left internal mammary artery was video-assisted by thoracoscopy. The left internal mammary artery was used in all cases; the right internal mammary artery was used in one case, the radial artery in four, the inferior epigastric artery in two and the right gastroepiploic artery inn one. No patient died or had a stroke. There were no postoperative episodes of low cardiac output syndrome or perioperative myocardial infarction. All patients were extubated within a few hours after surgery. The mean(s.d.) intensive care unit and hospital stays were 1.3(0.5) and 5.0(0.9) days, respectively. Total arterial myocardial revascularization without cardiopulmonary bypass using composite grafts, is a new and promising technique that is feasible with low risks and good early results in selected cases.

Arterial myocardial revascularization without cardiopulmonary bypass through a small thoracotomy

The opportunity to obviate the risks associated with cardiopulmonary bypass (CPB) while maintaining the long-term survival previously demonstrated with the use of arterial grafts, led us to perform myocardial arterial revascularization without CPB, using a small left thoracotomy as the surgical approach. One patient was operated on with this technique grafting the left anterior descending artery with the left internal mammary artery and grafting sequentially the first diagonal branch and the first marginal branch with a T-graft of radial artery. A small anterolateral thoracotomy was performed and the proximal harvesting of the left internal mammary artery was video-assisted by thoracoscopy. No hemodynamic deterioration occurred during the procedure. The patient was discharged on postoperative day 5 and the postoperative course was uneventful.

Coronary surgery without cardiopulmonary bypass

The need to obviate the risks associated with cardiopulmonary bypass (CPB) in coronary surgery has led to an interest in coronary artery bypass grafting without CPB. From November 1994 to May 1995, 58 patients (49 males and 9 females, mean age 61.8 +/- 9.3 years, range 40-74) were selected for coronary artery bypass grafting without CPB. Three patients had left main stenosis and 6 had left ventricular dysfunction (ejection fraction < 40%). Stable angina was present in 42 patients (27 with low threshold angina) and unstable angina in 16. In 44 patients a routine median sternotomy and in 14 cases a small anterior thoracotomy were performed: in the latter the proximal harvesting of the left internal mammary artery was video-assisted by thoracoscopy. The left internal mammary artery was used in 53 cases; the saphenous vein was used in 36 cases; the radial artery was used in 4 cases; the inferior epigastric artery was used in 2 cases and the right gastroepiploic artery in 1 case. We recorded 1 death (1.7%) and 1 case of postoperative low cardiac output syndrome requiring counterpulsation (1.7%). Perioperative myocardial infarction occurred in 3 cases (5.8%). We did not record noncardiac complications (cerebrovascular, renal failure, prolonged ventilatory support over 24 hours or sternal wound complications). Supraventricular and ventricular arrhythmias were never detected. Mean intensive care unit and hospital stay were 1.1 +/- 0.5 and 5.1 +/- 1.7 days, respectively. In conclusion, according to our experience, "beating heart" coronary surgery is a new promising technique that can be considered alternative in most cases to percutaneous transluminal coronary angio and complementary to conventional coronary surgery.

Warm heart surgery eliminates diaphragmatic paralysis

Since January 1992, we adopted a new method of myocardial protection: warm blood cardioplegia with continuous ante-retrograde combined delivery during normothermic cardiopulmonary bypass, (CPB) instead of cold blood intermittent cardioplegia plus topical ice slush in hypothermic CPB. We have compared postoperative chest X-rays of 50 patients who underwent elective coronary artery bypass with normothermic CPB to postoperative chest X-rays, of 50 patients operated upon with hypothermia. In the cold group transitory diaphragmatic paralysis, as well as pleural effusions and thoracentesis related to the hypothermia, and topical cooling, were statistically increased over that of warm group. The data suggest that topical cooling with slush ice is responsible for phrenic nerve injury and that warm heart surgery has no associated incidence of diaphragmatic injury.

Subacute left ventricular free wall rupture. Surgical repair prompted by echocardiographic diagnosis

Subacute cardiac rupture may occur in patients with electrocardiographic and enzyme evidence of transmural myocardial infarction. In the unusual case we encountered, these changes were absent. The echocardiographic observation of an echo-dense area within the pericardial space, due to an organized thrombus, provided early diagnosis of cardiac rupture and prompted surgery.

[Post-infarction pseudoaneurysm of the left ventricle as a cause of heart failure. Presentation of a surgically treated case]

Pseudoaneurysm of the left ventricle is an unusual complication of myocardial infarction. Surgical resection is justified by the high risk of rupture. Patients may be asymptomatic, more often a clinical state of chronic heart failure is present. We report on a patient who successfully underwent urgent resection of a large pseudoaneurysm which was the cause of acute heart failure.