The Effect of Berberine Supplementation on Glycemic Control and Inflammatory Biomarkers in Metabolic Disorders: An Umbrella Meta-analysis of Randomized Controlled Trials

PURPOSE

Several meta-analyses reported berberine (BBR) supplementation improves glycemic parameters and inflammatory marker, but findings remain inconsistent. Therefore, this study was conducted.

METHODS

We systematically searched PubMed, Embase, Web of Science, Scopus, and Google Scholar to identify the relevant meta-analyses up to April 2023.

FINDINGS

BBR supplementation was effective in reducing fasting blood glucose (FBG) (ESWMD: -0.77; 95% CI: -0.90 to -0.63, and ESSMD: -0.65; 95% CI: -0.83 to -0.47), hemoglobin A1C (HbA1C) (ESWMD: -0.57; 95% CI: -0.68 to -0.46), homeostasis model assessment for insulin resistance (HOMA-IR) (ESWMD: -1.04; 95% CI: -1.66 to -0.42, and ESSMD: -0.71; 95% CI: -0.97 to -0.46), insulin (ESWMD: -1.00; 95% CI: -1.70 to -0.30, and ESSMD: -0.63; 95% CI: -0.94 to -0.32), interleukin (IL)-6 (ESSMD: -1.23; 95% CI: -1.61 to -0.85), tumor necrosis factor-α (TNF-α) (ESSMD: -1.04; 95% CI: -1.28 to -0.79), and C-reactive protein (CRP) (ESWMD: -0.62; 95% CI: -0.74 to -0.50, and ESSMD: -1.70; 95% CI: -2.21 to -1.19).

IMPLICATIONS

The finding of our umbrella showed that the supplementation of BBR could be effective in improving glycemic parameters and inflammatory marker in adults.

Prognostic value of red blood cell distribution width and D-Dimer in diffuse large B-cell lymphoma: Systematic review and meta-analysis

BACKGROUND

The significant role of red blood cell distribution width (RDW) and D-Dimer as prognostic factors in patients with some blood malignancies has been reported recently.

AIM

We designed and performed a meta-analysis to investigate the prognostic roles of RDW and D-Dimer in subjects with diffuse large B-cell lymphoma (DLBCL).

MATERIALS AND METHODS

We systematically reviewed PubMed-Medline, SCOPUS, EMBASE, Web of Science Core Collection, and Google Scholar up to the present to look for publications on prognostic effects of RDW and D-Dimer in DLBCL patients. For investigation of the associations between RDW and D-Dimer with the overall survival (OS) and progression-free survival (PFS) of the DLBCL cases, hazard ratio (HR) with 95% confidence intervals (CIs) was used.

RESULTS

We included 13 eligible studies in the present meta-analysis. The results of pooled analysis showed that increased levels of RDW was related to poor OS (HR = 2.01, 95% CI: 1.62-2.48, p value <.01, I2  = 0%) and poor PFS (HR = 1.52, 95% CI: 1.24-1.85, p value <.01, I2  = 16%) among the DLBCL patients. Similarly, a significant relationship was found between increased D-Dimer and poor OS (HR = 2.30, 95% CI: 1.03-5.14, p value <.05, I2  = 95%) of the DLBCL patients as well. In addition, there was no significant heterogeneity in OS (p value H = 0.65) and PFS (p value H = 0.31) related to RDW among studies included in the meta-analysis.

CONCLUSION

Our finding clearly confirmed that elevated RDW levels and D-Dimer were associated with adverse OS and PFS in DLBCL.

The role of 18F-fluorodeoxyglucose PET/computed tomography in the diagnosis and monitoring of large vessel vasculitides - a review article

In the last two decades, advancements in positron emission tomography (PET) technology have increased the diagnostic accuracy of patients with large-vessel vasculitis (LVV). Numerous systematic reviews and meta-analyses have been conducted, and patients suspected of having LVV can be diagnosed earlier with 18F-FDG PET. Two subtypes, giant cell arteritis (GCA) and Takayasu arteritis (TA), will progress when their response to corticosteroids and enhanced immunosuppression is inadequate. In the majority of patients, disease activity cannot be monitored solely through laboratory procedures; consequently, glucose metabolism may be a source of potential biomarkers. In this article, we discuss the current state of 18F-FDG PET/CT imaging standards.

Diagnostic Accuracy of Ultrasonography for Detection of Intussusception in Children; a Systematic Review and Meta-Analysis

Introduction

The diagnosis of intussusception can be challenging in children due to the fact that the findings of clinical evaluations are nonspecific and most of the patients present with unclear history. Therefore, in this systematic review and meta-analysis, we aimed to investigate the diagnostic accuracy of ultrasonography for detection of intussusception and also compare the efficacy of point-of-care ultrasound (POCUS) with radiologist-performed ultrasound (RADUS).

Methods

Two independent reviewers systematically searched different online electronic databases including MEDLINE, Scopus, Web of Science, Google Scholar, Embase, and Cochrane from inception to December 1, 2022 to identify published papers reporting accuracy of ultrasonography for diagnosis of intussusception. The quality assessment of the included studies was investigated using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 tool.

Results

A total of 1446 records were retrieved in the initial search of databases. After screening the titles, a total of 344 studies were retrieved for the detailed assessment of full-text. Finally, 37 studies were included in qualitative and quantitative analysis. The pooled sensitivity and specificity of ultrasonography for diagnosis of intussusception were 0.96 (95% CI: 0.95-0.97) and 0.97 (95% CI: 0.97-0.98), respectively. The pooled positive likelihood ratio (PLR) and negative likelihood ratio (NLR) were 24.57 (95% CI: 8.26-73.03) and 0.05 (95% CI: 0.04-0.08), respectively. The area under the hierarchical summary receiver operating characteristic (HSROC) curve was 0.989. Mete-regression showed that there is no significant difference between diagnostic performance of POCUS and RADUS (p = 0.06 and rDOR (diagnostic odds ratio) = 4.38 (95% CI: 0.92-20.89)).

Conclusion

This meta-analysis shows that ultrasonography has excellent sensitivity, specificity, and accuracy for diagnosis of intussusception in pediatric patients. Moreover, we found that diagnostic performance of POCUS is similar to that of RADUS for diagnosis of intussusception.

Synthetic electrospun nanofibers as a supportive matrix in osteogenic differentiation of induced pluripotent stem cells

Continuous remodeling is not able to repair large bone defects. Bone tissue engineering is aimed to repair these defects by creating bone grafts. To do this, several technologies and biomaterials have been employed to fabricate an in vivo-like supportive matrix. Electrospinning is a versatile technique to fabricate porous matrices with interconnected pores and high surface area, replicating in vivo microenvironment. Electrospun scaffolds have been used in a large number of studies to provide a matrix for bone regeneration and osteogenic differentiation of stem cells such as induced pluripotent stem cells (iPSCs). Electrospinning uses both natural and synthetic polymers, either alone or in combination, to fabricate scaffolds. Among them, synthetic polymers have had a great promise in bone regeneration and repair. They allow the fabrication of biocompatible and biodegradable scaffolds with high mechanical properties, suitable for bone engineering. Furthermore, several attempts have done to increase the osteogenic properties of these scaffolds. This paper reviewed the potential of synthetic electrospun scaffolds in osteogenic differentiation of iPSCs. In addition, the approaches to improve the osteogenic differentiation of these scaffolds are addressed.

Prevalence of Nonalcoholic Fatty Liver Disease in Children with Renal Failure Underwent Treatment with Dialysis

Background

In this study, we aimed to investigate the prevalence of nonalcoholic fatty liver disease (NAFLD) in children with renal failure under treatment with dialysis and its association with biochemical measurements.

Methods

In this cross-sectional study, children aged less than 18 years with chronic kidney disease (CKD) who were under treatment with dialysis at least 3 months ago were enrolled. To evaluate fatty liver in those patients who had no recent liver ultrasonography (last 6 months), liver ultrasonography was performed. The characteristics of patients with renal failure with and without NAFLD based on the ultrasonographic evaluation were compared. The association between NAFLD and the studied variables was evaluated.

Results

In this study, 39 children (31 males and 8 females) with renal failure who underwent treatment with dialysis were included. From the studied population, six (19.4%) had NAFLD based on ultrasonographic evaluation. There were no differences between renal failure patients with and without NAFLD regarding the biochemical and anthropometric characteristics (P > 0.0).

Conclusions

The prevalence of NAFLD in our studied children with renal failure who underwent treatment with dialysis was like the general population and it was not associated with the biochemical and anthropometric characteristics of the patients. Given the importance of NAFLD in renal failure patients as well as its subtle nature, it is recommended to screen patients with CKD for NAFLD.

Antagonizing the CX3CR1 Receptor Markedly Reduces Development of Cardiac Hypertrophy After Transverse Aortic Constriction in Mice

ABSTRACT

Left-ventricular hypertrophy, characterized by cardiomyocyte hypertrophy, interstitial cell proliferation, and immune cell infiltration, is a high risk factor for heart failure and death. Chemokines interacting with G protein-coupled chemokine receptors probably play a role in left-ventricular hypertrophy development by promoting recruitment of activated leukocytes and modulating left-ventricular remodeling. Using the minimally invasive model of transverse aortic constriction in mice, we demonstrated that a variety of chemokine and chemokine receptor messenger Ribonucleic Acid are overexpressed in the early and late phase of hypertrophy progression. Among the chemokine receptors, Cx3cr1 and Ccr2 were most strongly overexpressed and were significantly upregulated at 3, 7, and 14 days after transverse aortic constriction. Ligands of CX3CR1 (Cx3cl1) and CCR2 (Ccl2, Ccl7, Ccl12) were significantly overexpressed in the left ventricle at the early stages after mechanical pressure overload. Pharmacological inhibition of CX3CR1 signaling using the antagonist AZD8797 led to a significant reduction of hypertrophy, whereas inhibition of CCR2 with the RS504393 antagonist did not show any effect. Furthermore, AZD8797 treatment reduced the expression of the hypertrophic marker genes Nppa and Nppb as well as the profibrotic genes Tgfb1 and Col1a1 at 14 days after transverse aortic constriction. These findings strongly suggest the involvement of the CX3CR1/CX3CL1 pathway in the pathogenesis of left-ventricular hypertrophy.

Overexpression of the MSK1 Kinase in Patients With Chronic Lung Allograft Dysfunction and Its Confirmed Role in a Murine Model

BACKGROUND

Chronic lung allograft dysfunction (CLAD) and its obstructive form, the obliterative bronchiolitis (OB), are the main long-term complications related to high mortality rate postlung transplantation. CLAD treatment lacks a significant success in survival. Here, we investigated a new strategy through inhibition of the proinflammatory mitogen- and stress-activated kinase 1 (MSK1) kinase.

METHODS

MSK1 expression was assessed in a mouse OB model after heterotopic tracheal allotransplantation. Pharmacological inhibition of MSK1 (H89, fasudil, PHA767491) was evaluated in the murine model and in a translational model using human lung primary fibroblasts in proinflammatory conditions. MSK1 expression was graded over time in biopsies from a cohort of CLAD patients.

RESULTS

MSK1 mRNA progressively increased during OB (6.4-fold at D21 posttransplantation). Inhibition of MSK1 allowed to counteract the damage to the epithelium (56% restoration for H89), and abolished the recruitment of MHCII+ (94%) and T cells (100%) at the early inflammatory phase of OB. In addition, it markedly decreased the late fibroproliferative obstruction in allografts (48%). MSK1 inhibitors decreased production of IL-6 (whose transcription is under the control of MSK1) released from human lung fibroblasts (96%). Finally, we confirmed occurrence of a 2.9-fold increased MSK1 mRNA expression in lung biopsies in patients at 6 months before CLAD diagnosis as compared to recipients with stable lung function.

CONCLUSIONS

These findings suggest the overall interest of the MSK1 kinase either as a marker or as a potential therapeutic target in lung dysfunction posttransplantation.

Bilateral Internal Thoracic Artery Grafting in Women: A Word of Caution

Background: Despite the superior hemodynamic performance of internal thoracic arteries, total arterial revascularization with exclusive bilateral internal thoracic arteries (BITA) is less frequently used especially in specific subsets of patients, including females. We report our experience with total arterial revascularization with exclusive BITA regardless of sex and analyze the impact of female sex on the early and midterm outcomes. Methods: Total arterial revascularization with exclusive BITA was performed with equal frequency in females (79/99, 80%) and males (392/477, 82%; P = .68) undergoing isolated CABG for 3-vessel disease. Pre, intra and postoperative data were compared between these two groups. Results: Complete revascularization was achieved in 77% of females and 72% of males (P = .08). Early mortality did not differ between the groups (6.3% versus 4.6%, P = .7). The incidence of re-sternotomy for bleeding, postoperative stroke, myocardial infarction, new onset atrial fibrillation, and hemofiltration for renal failure did not differ between the two groups. However, there were significantly more wound revision for combined superficial and deep sternal wound infection in females (26.5% versus 5.1%, P = .0001). Nevertheless, midterm survival, freedom from repeat revascularization, myocardial infarction, stroke, and major adverse cardiovascular and cerebral events at five years were very good and compared favorably between females and males. Conclusions: Our findings suggest that total arterial myocardial revascularization with exclusive internal thoracic arteries in females carries the same midterm benefits as in males. Early outcomes are comparable except for a higher incidence of wound revision for combined superficial and deep sternal wound infections in females compared to males. Benefits of bilateral internal thoracic artery grafting in females should be weighed against increased risk of early wound revision.

Role of cathepsins in Alzheimer's disease: A systematic review

Alzheimer's disease (AD) is a multifactorial disease. In addition to the precipitating of two proteins betaamyloid peptide and neurofebrillary tangles, which are the main mechanisms involved in the pathogenesis ofAD, other factors such as inflammatory mechanisms and changes in lysosomal enzymes play an important part in the pathogenesis of this disease. Increased and decreased lysosomal proteases, such as cathepsin, can lead to functional impairment and gradual death of neurons. The aim of this review was to investigate the role of cathepsins in the pathogenesis of AD. To conduct this review, relevant articles published between 2000 and 2016, and indexed in reliable databases including PubMed, Google Scholar, Scopus and Web of Science were retrieved. After reviewing the articles, 30 articles that directly addressed the subject of this review were included in final analysis. Cathepsins exacerbate intracellular conditions in neurons, by processing beta-amyloid precursor protein and converting it into amyloid beta. They also play a protective role against AD and fight it by catalyzing the decomposition of beta-amyloids and converting them into the cut out forms of the carboxyl C-terminus. In addition, the 24 kDa fragment resulting from the effect of cathepsin D on apolipoprotein E (ApoE) is the second binding to the receptor in the ApoE. This fragment may also be the cause of the pathogenicity of Apo E in AD. Identifying and explaining the mechanisms involved in the pathogenesis of AD can play a significant role in the prevention and treatment of this disease. Since cathepsins play a pivotal role in the decomposition of beta-amyloid and reduction of the risk of AD, further studies can be considered an effective approach to study AD.Journal of Medical and Biomedical Sciences (2018) 7(1), 1 - 10

Technique and Patient Selection Criteria of Right Anterior Mini-Thoracotomy for Minimal Access Aortic Valve Replacement

Aortic valve stenosis has become the most prevalent valvular heart disease in developed countries, and is due to the aging of these populations. The incidence of the pathology increases with growing age after 65 years. Conventional surgical aortic valve replacement through median sternotomy has been the gold standard of patient care for symptomatic aortic valve stenosis. However, as the risk profile of patients worsens, other therapeutic strategies have been introduced in an attempt to maintain the excellent results obtained by the established surgical treatment. One of these approaches is represented by transcatheter aortic valve implantation. Although the outcomes of high-risk patients undergoing treatment for symptomatic aortic valve stenosis have improved with transcatheter aortic valve replacement, many patients with this condition remain candidates for surgical aortic valve replacement. In order to reduce the surgical trauma in patients who are candidates for surgical aortic valve replacement, minimally invasive approaches have garnered interest during the past decade. Since the introduction of right anterior thoracotomy for aortic valve replacement in 1993, right anterior mini-thoracotomy and upper hemi-sternotomy have become the predominant incisional approaches among cardiac surgeons performing minimal access aortic valve replacement. Beside the location of the incision, the arterial cannulation site represents the second major landmark of minimal access techniques for aortic valve replacement. The two most frequently used arterial cannulation sites include central aortic and peripheral femoral approaches. With the purpose of reducing surgical trauma in these patients, we have opted for a right anterior mini-thoracotomy approach with a central aortic cannulation site. This protocol describes in detail a technique for minimally invasive aortic valve replacement and provides recommendations for patient selection criteria, including cardiac computer tomography measurements. The indications and limitations of this technique, as well as its alternatives, are discussed.

Standardized Technique of Aortic Valve Re-implantation for Valve-sparing Aortic Root Replacement

Despite the obvious advantages of the preservation of a normal aortic valve during aortic root replacement, the complexity of valve sparing procedures prevents a number of cardiac surgeons from incorporating them into their practice. The aim of this protocol is to describe a simplified and user-friendly technique of an aortic valve-sparing root replacement (VSRR) procedure by re-implantation of the aortic valve. Proper selection of patients and limitations of the technique are discussed. In 54 consecutive patients, normal appearing aortic valves were re-implanted in a commercially available polyester prosthesis with pre-shaped sinuses by a simplified and standardized technique. Placement of the first row of the proximal suture line, choice of the prosthesis size, and adjustment of the height of the commissures of the patient to the fixed height of the sinus portion of the prosthesis were slightly modified from the reference techniques with the aim of increasing its feasibility for use by other cardiac surgeons. Early mortality and morbidity as well as 5-year survival, freedom from aortic valve reoperation, and freedom from recurrent moderate regurgitation were collected in all patients. Thirty-day mortality, re-sternotomy for bleeding, re-sternotomy for mediastinitis, and the incidence of stroke were very low, 1.8% for each (1 of 54). No patient required permanent pace-maker implantation. At 5 years, survival, freedom from aortic valve reoperation, and freedom from recurrent moderate regurgitation were 97.5%, 95.2%, and 91.6%, respectively. Mid-term results of our standardized technique of re-implantation of the aortic valve for valve-sparing aortic root replacement are very good and compare with more complex techniques reported by experienced surgeons. By following the present protocol of the standardized re-implantation technique, a greater number of cardiac surgeons can perform this procedure with comparable good results.

Technique of Minimally Invasive Transverse Aortic Constriction in Mice for Induction of Left Ventricular Hypertrophy

Transverse aortic constriction (TAC) in mice is one of the most commonly used surgical techniques for experimental investigation of pressure overload-induced left ventricular hypertrophy (LVH) and its progression to heart failure. In the majority of the reported investigations, this procedure is performed with intubation and ventilation of the animal which renders it demanding and time-consuming and adds to the surgical burden to the animal. The aim of this protocol is to describe a simplified technique of minimally invasive TAC without intubation and ventilation of mice. Critical steps of the technique are emphasized in order to achieve low mortality and high efficiency in inducing LVH. Male C57BL/6 mice (10-week-old, 25-30 g, n=60) were anesthetized with a single intraperitoneal injection of a mixture of ketamine and xylazine. In a spontaneously breathing animal following a 3-4 mm upper partial sternotomy, a segment of 6/0 silk suture threaded through the eye of a ligation aid was passed under the aortic arch and tied over a blunted 27-gauge needle. Sham-operated animals underwent the same surgical preparation but without aortic constriction. The efficacy of the procedure in inducing LVH is attested by a significant increase in the heart/body weight ratio. This ratio is obtained at days 3, 7, 14 and 28 after surgery (n = 6 - 10 in each group and each time point). Using our technique, LVH is observed in TAC compared to sham animals from day 7 through day 28. Operative and late (over 28 days) mortalities are both very low at 1.7%. In conclusion, our cost-effective technique of minimally invasive TAC in mice carries very low operative and post-operative mortalities and is highly efficient in inducing LVH. It simplifies the operative procedure and reduces the strain put on the animal. It can be easily performed by following the critical steps described in this protocol.

Full-root Aortic Valve Replacement by Stentless Aortic Xenografts in Patients with Small Aortic Roots

In patients with small aortic roots who need an aortic valve replacement with biological valve substitutes, the implantation of the stented pericardial valve might not meet the functional needs. The implantation of a too-small stented pericardial valve, leading to an effective orifice area indexed to a body surface area less than 0.85 cm²/m², is regarded as prosthesis-patient mismatch (PPM). A PPM negatively affects the regression of left ventricular hypertrophy and thus the normalization of left ventricular function and the alleviation of symptoms. Persistent left ventricular hypertrophy is associated with an increased risk of arrhythmias and sudden cardiac death. In the case of predictable PPM, there are three options: 1) accept the PPM resulting from the implantation of a stented pericardial valve when comorbidities of the patient forbid the more technically demanding operative technique of implanting a larger prosthesis, 2) enlarge the aortic root to accommodate a larger stented valve substitute, or 3) implant a stentless biological valve or a homograft. Compared to classical aortic valve replacement with stented pericardial valves, the full-root implantation of stentless aortic xenografts offers the possibility of implanting a 3-4 mm larger valve in a given patient, thus allowing significant reduction in transvalvular gradients. However, a number of cardiac surgeons are reluctant to transform a classical aortic valve replacement with stented pericardial valves into the more technically challenging full-root implantation of stentless aortic xenografts. Given the potential hemodynamic advantages of stentless aortic xenografts, we have adopted full-root implantation to avoid PPM in patients with small aortic roots necessitating an aortic valve replacement. Here, we describe in detail a technique for the full-root implantation of stentless aortic xenografts, with emphasis on the management of the proximal suture line and coronary anastomoses. Limitations of this technique and alternative options are discussed.

Direct Re-implantation of Left Coronary Artery into the Aorta in Adults with Anomalous Origin of Left Coronary Artery from the Pulmonary Artery (ALCAPA)

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital anomaly which is one of leading causes of myocardial ischemia and infarction in children. If left untreated, it results in a 90% mortality rate in the first year of life. In patients who survive to the adulthood, the coronary steal phenomenon and retrograde left-sided coronary flow provide a substrate for chronic subendocardial ischemia, which may lead to left ventricular dysfunction, ischemic mitral regurgitation, malignant ventricular arrhythmias, and sudden cardiac death. The average age of life-threatening presentation is 33 years and of sudden cardiac death 31 years. Therefore, surgical correction is highly recommended as soon as the diagnosis is made, regardless of age. In adult-type ALCAPA originating from the right-facing sinus of the pulmonary artery, direct re-implantation of the ALCAPA into the aorta is the more physiologically sound repair technique to re-establish the dual-coronary perfusion system and is recommended. This protocol describes the technique of direct re-implantation of adult-type ALCAPA into the aorta.

Kinetic mRNA Profiling in a Rat Model of Left-Ventricular Hypertrophy Reveals Early Expression of Chemokines and Their Receptors

Left-ventricular hypertrophy (LVH), a risk factor for heart failure and death, is characterized by cardiomyocyte hypertrophy, interstitial cell proliferation, and leukocyte infiltration. Chemokines interacting with G protein-coupled chemokine receptors may play a role in LVH development by promoting recruitment of activated leukocytes or modulating left-ventricular remodeling. Using a pressure overload-induced kinetic model of LVH in rats, we examined during 14 days the expression over time of chemokine and chemokine receptor mRNAs in left ventricles from aortic-banded vs sham-operated animals. Two phases were clearly distinguished: an inflammatory phase (D3-D5) with overexpression of inflammatory genes such as il-1ß, tnfa, nlrp3, and the rela subunit of nf-kb, and a hypertrophic phase (D7-D14) where anp overexpression was accompanied by a heart weight/body weight ratio that increased by more than 20% at D14. No cardiac dysfunction was detectable by echocardiography at the latter time point. Of the 36 chemokines and 20 chemokine receptors analyzed by a Taqman Low Density Array panel, we identified at D3 (the early inflammatory phase) overexpression of mRNAs for the monocyte chemotactic proteins CCL2 (12-fold increase), CCL7 (7-fold increase), and CCL12 (3-fold increase), for the macrophage inflammatory proteins CCL3 (4-fold increase), CCL4 (2-fold increase), and CCL9 (2-fold increase), for their receptors CCR2 (4-fold increase), CCR1 (3-fold increase), and CCR5 (3-fold increase), and for CXCL1 (8-fold increase) and CXCL16 (2-fold increase). During the hypertrophic phase mRNA expression of chemokines and receptors returned to the baseline levels observed at D0. Hence, this first exhaustive study of chemokine and chemokine receptor mRNA expression kinetics reports early expression of monocyte/macrophage-related chemokines and their receptors during the development of LVH in rats, followed by regulation of inflammation as LVH progresses.

Diastolic Filling Reserve Preservation Using a Semispherical Dacron Patch for Repair of Anteroapical Left Ventricular Aneurysm

In postinfarction left ventricular aneurysm, abnormal geometry and desynchronized wall motion may cause a highly inefficient pump function. The traditional endoventricular patch plasty according to the Dor technique might result in a truncated and restrictive left ventricular cavity in small adults. We report a modified technique of left ventricular anteroapical aneurysm repair by using a semispherical reshaping patch to restore the left ventricular geometry.

Preparing Allicin Nanocapsules and Determining the Factors Controlling Their Particle Size through Artificial Intelligence

Allicin nanocapsules were prepared via ionotropic pre-gelation. The wall materials were alginate-chitosan biopolymers. Nanocapsules were characterized using Fourier transform infrared spectroscopy (FT-IR) and field emission scanning electron microscopy (FE-SEM). We tried to simulate the effects of three different variables on particle size through artificial intelligence approaches. Feedforward neural networks (FFNN) and adaptive neuro-fuzzy inference system (ANFIS) were employed to model the size of allicin nanocapsules, and the latter was found to be relatively more successful in this regard. Finally, genetic algorithms were employed to determine the optimal values for the variables at which the smallest particles were formed.

Lactic acid bacteria as functional probiotic isolates for inhibiting the growth of Aspergillus flavus, A. parasiticus, A. niger and Penicillium chrysogenum

OBJECTIVE

The aim of this study was to assess the potential of lactic acid bacteria (LAB) such as Lactobacillus acidophilus, L. rhamnosus, L. casei, L. paracasei and Bifidobacterium bifidum to inhibit the outgrowth of some common food-spoiling fungi including Aspergillus niger, A. flavus, A. parasiticus and Penicillium chrysogenum.

METHODS

Bacterial isolates were cultured on Mann Rogosa Sharpe (MRS) broth and liquid cultures and supernatants were prepared. The antifungal activity was tested using the agar well diffusion method.

RESULTS

Both liquid culture and supernatant of L. casei isolate exhibited high antifungal activity, followed by L. acidophilus and L. paracasei isolates. The least activity was recorded for the isolates B. bifidum, while the isolate L. rhamnosus was moderately active against tested fungi. The antifungal activity of the supernatants obtained from all probiotic isolates against fungi was significantly less than that of liquid cultures (P<0.05). Antifungal activity evaluation showed that A. flavus was the most inhibited fungus by probiotic bacteria, followed by P. chrysogenum, A. niger and A. parasiticus.

CONCLUSION

These results suggest that probiotic bacteria strains have the ability to prevent the growth of pathogenic and mycotoxigenic fungi as antifungal agents for various biomedical applications.

Full-root aortic valve replacement with stentless xenograft achieves superior regression of left ventricular hypertrophy compared to pericardial stented aortic valves

BACKGROUND

Full-root aortic valve replacement with stentless xenografts has potentially superior hemodynamic performance compared to stented valves. However, a number of cardiac surgeons are reluctant to transform a classical stented aortic valve replacement into a technically more demanding full-root stentless aortic valve replacement. Here we describe our technique of full-root stentless aortic xenograft implantation and compare the early clinical and midterm hemodynamic outcomes to those after aortic valve replacement with stented valves.

METHODS

We retrospectively compared the pre-operative characteristics of 180 consecutive patients who underwent full-root replacement with stentless aortic xenografts with those of 80 patients undergoing aortic valve replacement with stented valves. In subgroups presenting with aortic stenosis, we further analyzed the intra-operative data, early postoperative outcomes and mid-term regression of left ventricular mass index.

RESULTS

Patients in the stentless group were younger (62.6 ± 13 vs. 70.3 ± 11.8 years, p < 0.0001) but had a higher Euroscore (9.14 ± 3.39 vs.6.83 ± 2.54, p < 0.0001) than those in the stented group. In the subgroups operated for aortic stenosis, the ischemic (84.3 ± 9.8 vs. 62.3 ± 9.4 min, p < 0.0001) and operative times (246.3 ± 53.6 vs. 191.7 ± 53.2 min, p < 0.0001) were longer for stentless versus stented valve implantation. Nevertheless, early mortality (0% vs. 3%, p < 0.25), re-exploration for bleeding (0% vs. 3%, p < 0.25) and stroke (1.8% vs. 3%, p < 0.77) did not differ between stentless and stented groups. One year after the operation, the mean transvalvular gradient was lower in the stentless versus stented group (5.8 ± 2.9 vs. 13.9 ± 5.3 mmHg, p < 0.0001), associated with a significant regression of the left ventricular mass index in the stentless (p < 0.0001) but not in the stented group (p = 0.2).

CONCLUSION

Our data support that full-root stentless aortic valve replacement can be performed without adversely affecting the early morbidity or mortality in patients operated on for aortic valve stenosis provided that the coronary ostia are not heavily calcified. The additional time necessary for the full-root stentless compared to the classical stented aortic valve replacement is therefore not detrimental to the early clinical outcomes and is largely rewarded in patients with aortic stenosis by lower transvalvular gradients at mid-term and a better regression of their left ventricular mass index.

A Three-rooted Mandibular Second Premolar: A Case Report

Presence of extra roots and canals should be considered before initiation of root canal treatment for the success of endodontic treatment. A mandibular second premolar with three separate roots is very rare and its prevalence has been reported to be around 0.1%. This case report explains non-surgical endodontic treatment of a mandibular second premolar with three separate roots and three separate mesiobuccal, midbuccal, and lingual canal orifices. Close attention to anatomic variations, thorough radiographic examinations, thorough evaluation of the pulp chamber floor, and use of magnifying and optical devices have been recommended for the success of endodontic treatment of mandibular second premolars with complicated root canal system anatomy.

Multikinase inhibitor sorafenib prevents pressure overload-induced left ventricular hypertrophy in rats by blocking the c-Raf/ERK1/2 signaling pathway

Background

Left ventricular hypertrophy (LVH) is a potent risk factor for sudden death and congestive heart failure.

Methods

We tested the effect of sorafenib, a multikinase inhibitor (10 mg/kg, given orally, starting 2 days prior to banding, till sacrifice on day 14), on the development of LVH following aortic banding in rats.

Results

The latter resulted in significant LVH caused by both an increase in cardiomyocyte volume and interstitial collagen deposition. The observed LVH was entirely blocked by sorafenib downregulating both of these components. LVH was associated with PDGF-BB and TGFβ1 overexpression, as well as phosphorylation of c-raf and ERK1/2. Additionally, the transcription factors c-myc and c-fos leading to proliferation as well as the hypertrophy-inducing transcription factor GATA4 and its regulated gene ANP were all upregulated in response to aortic banding. All these overexpressions and upregulations were inhibited upon sorafenib treatment.

Conclusion

We show that sorafenib exhibits a regulatory role on the occurrence of LVH following AB in rats by blocking the rise in growth factors PDGF-BB and TGFβ1, activation of the corresponding c-Raf-ERK1/2 signaling pathway and effector mechanisms, including GATA4 and ANP. This effect of sorafenib may be of clinical importance in modulating the maladaptive hypertrophic response to pressure overload.

The effectiveness of education using the health belief model in preventing osteoporosis among female students

This study was conducted to determine the impact of education using the Health Belief Model on preventing osteoporosis among female students. This interventional study (quasi-experimental) was performed on 45 female students aged 15-16 years old who resided in a town near Tehran. The females participated in a threeweek educational programme based on the Health Belief Model. The data collection instrument was a validated and reliable questionnaire in five sections: demographics, knowledge, Health Belief Model constructs, physical activity and consumption of foods containing calcium. The mean scores of students' knowledge were significantly different before and after the educational intervention (P < 0.05). The mean scores of some Health Belief Model structures changed significantly after the intervention (P < 0.05). Also post-intervention, physical activity increased (P = 0.041) but calcium intake did not. The use of an educational intervention on osteoporosis seems to improve knowledge and health beliefs and may positively impact physical activity-related behaviour.

A case of concurrent proteus syndrome and hemophilia a

BACKGROUND

Proteus syndrome is a very rare condition with less than 100 confirmed cases reported worldwide. We report a case of Proteus syndrome in a two-year-old male who has hemophilia A comorbidity.

CASE PRESENTATION

A two-year-old male patient was admitted with the chief complaint of severe bleeding in mouth cavity after trauma for two weeks. At admission he was found to have petechiae on buccal mucosa and fecal discoloration due to GI bleeding. We noted multiple abnormalities in his musculoskeletal system and skin. He had lymph edema in left leg, hemihypertrophy, macrodactyly in both foots and macrocephaly. With the history of severe bleeding and recurrent blood product transfusion, we suspected a hemorrhagic disorder. The reduced level of Factor VIII activity confirmed the diagnosis of hemophilia A. Considering patient's various musculoskeletal abnormalities according to the diagnostic criteria and after ruling out similar disorders the diagnosis of Proteus syndrome was established.

CONCLUSION

Because of the variability of clinical features, Proteus syndrome can be confused with other disorders of multiple tissue overgrowth. Our case of Proteus syndrome, who had hemophilia A comorbidity outlines the challenges in diagnosis of such rare combination of diseases.

Superior flow pattern of internal thoracic artery over saphenous vein grafts during OPCAB procedures

BACKGROUND

The advantages of the use of the internal thoracic artery (ITA) over that of the saphenous vein (SV) for revascularization of the circumflex (Cx) or right coronary artery (RCA) are still debated.

METHODS

Serial intraoperative flow measurements were carried out in 306 consecutive patients (mean age 64 years, mean Euroscore 5.1) undergoing off-pump coronary artery bypass grafting (OPCAB). The LAD was grafted in 302 patients [293 ITA (97%), 9 SV], the Cx in 252 patients [117 ITA (46%), 135 SV], and the RCA in 260 patients [36 ITA (14%), 224 SV].

RESULTS

Averages of 3.7+/-1.0 distal anastomoses/patient were constructed. Mean pulsatile index (PI) was significantly better for the single ITA/Cx-grafts (2.8+/-1.9, n=92) than for the single SV/Cx-grafts (3.3+/-1.7, n=43, p<0.05), whereas the mean flow did not differ (28+/-22 and 31+/-25 mL/min respectively, p=ns). Accordingly, the mean PI was significantly better for the single ITA/RCA-grafts (2.2+/-1.2, n=36) than for the single SV/RCA-grafts (3.4+/-2.6, n=178, p<0.01), whereas the mean flow did not differ (30+/-16 and 32+/-22 mL/min respectively, p=ns). The incidence of perioperative myocardial infarction tended to be lower in patients receiving an ITA to either the Cx or the RCA than in those receiving a SV, but the difference did not reach statistical significance [2/92 of ITA/Cx (2.2%) vs. 2/43 of SV/Cx (4.6%), 1/36 of ITA/RCA (2.8%) vs. 8/178 of SV/RCA (4.5%)].

CONCLUSION

The internal thoracic artery provides superior flow properties than the SV to the Cx and RCA regions with reduced perioperative ischemia. Whether this advantage persists after adjusting for the grade of the proximal coronary stenosis needs further studies.

Ascending aortic dissection after proximal bypass anastomotic device

Ascending aortic dissection is a known complication of cardiac surgery. Different type of devices allowing performance of proximal bypass anastomoses without aortic side-clamping are supposed to reduce the risk for aortic dissection. We report a case in which ascending aortic dissection occurred six months after off-pump coronary artery bypass surgery, with the entry tear arising directly from a proximal anastomosis performed with the Heartstring hemostatic seal system.

Atrium-driven Mitral Annulus Motion Velocity Reflects Global Left Ventricular Function and Pulmonary Congestion During Acute Biventricular Pacing

BACKGROUND

The short-term effect of acute biventricular pacing on cardiac function in patients with chronic heart failure undergoing heart surgery is widely unknown. The present study was designed to determine whether mitral annular tissue Doppler imaging (TDI) is useful to predict acute changes in global systolic function determined by the continuous cardiac output method that was measured postoperatively during various pacing configurations in patients with depressed left ventricular (LV) function.

METHODS

TDI peak velocities of systolic (Sm), early diastolic (Em), and late diastolic (Am) mitral annular motion waves were measured in 17 patients (age 67 +/- 8 years, 10 male) with depressed LV systolic function (LV ejection fraction < or = 35%) and QRS duration > 120 ms undergoing temporary epicardial biventricular pacing after aortocoronary bypass and valve surgery. TDI velocities, QRS duration on surface electrocardiogram, cardiac index (CI), right atrial pressure, pulmonary artery pressure, and pulmonary capillary wedge (PCW) pressure were measured simultaneously during various pacing configurations (right atrial-biventricular, right atrial-LV, right atrial-right ventricular, atrial inhibited, and no pacing).

RESULTS

Univariate linear regression analysis showed a good correlation between Am and CI (r = 0.53, P = .0001) determined in all pacing modes, a weak correlation between Sm and CI (r = 0.31, P = .017), and no correlation between Em and CI (r = 0.21, P = .074). Am > 6 cm/s predicted a CI of 2.5 L/min/m(2) or more with a sensitivity of 95% and a specificity of 30%. All TDI values correlated negatively with PCW (r = -0.53, P = .0001 for Sm; r = -0.34, P = .01 for Em; r = -0.50, P = .0001 for Am). Am greater than 6 cm/s predicted a PCW of 16 mm Hg or less with a specificity of 100% and a sensitivity of 34%. Mean values of TDI velocities and hemodynamic parameters were not significantly different between each pacing configuration.

CONCLUSIONS

Peak Am mitral annular velocity correlates well with CI and PCW, respectively, thus providing an easy means to assess LV systolic function and pulmonary congestion during cardiac pacing in chronic heart failure.

Kaolin-Based Activated Coagulation Time Measured by Sonoclot in Patients Undergoing Cardiopulmonary Bypass

OBJECTIVES

In vivo data for the kaolin-based ACT test from the Sonoclot Analyzer (SkACT, Sienco Inc, Arvada, CO) are lacking. The aim of this study was to compare SkACT with an established kaolin-based ACT from Hemochron (HkACT) and anti-Xa activity in patients undergoing cardiopulmonary bypass (CPB).

DESIGN

Prospective observational study.

SETTING

Community hospital.

PARTICIPANTS

Fifty patients scheduled for elective cardiac surgery.

INTERVENTIONS

Blood samples were taken before CPB at baseline (T0) and after heparinization (T1 and T2), on CPB after administration of aprotinin (5, 15, 30, 60 minutes; T3-T6), and at the end after protamine infusion (T7).

MEASUREMENTS AND MAIN RESULTS

A total of 375 blood samples were analyzed. ACT measurements were comparable for SkACT and HkACT at each measurement time point. Overall bias +/- standard deviation between SkACT and HkACT was -19 +/- 75 seconds (-2.4% +/- 11.7%). Mean bias between SkACT and HkACT at each time point ranged from -35 to 3 seconds (-4.5% to 2.6%) and showed no statistical significance over time. Heparin sensitivity of SkACT and HkACT, defined as (ACT(Tx)-ACT(T0))/(anti-Xa(Tx)-anti-Xa(T0)), significantly increased for measurements during CPB (p < 0.001) but without significant difference between the 2 methods. Test variability was comparable for both ACT measurement techniques. Overall test variability was 7.5% +/- 7.4% for SkACT and 7.8% +/- 11% for HkACT.

CONCLUSIONS

Accuracy and performance of SkACT and HkACT were comparable for heparin monitoring in patients undergoing CPB for elective cardiac surgery. However, both tests were affected significantly after initiating CPB and aprotinin infusion.

Acute biventricular pacing after cardiac surgery has no influence on regional and global left ventricular systolic function

BACKGROUND

Cardiac resynchronization therapy has been shown to improve systolic function in patients with advanced chronic heart failure and electromechanical delay (QRS width > 120 ms). However, the effect of acute biventricular (BiV) pacing on perioperative haemodynamic changes is not well defined. In the present study, acute changes in regional left ventricular (LV) systolic function determined by tissue Doppler imaging (TDI) and global LV systolic function determined by the continuous cardiac output method were measured during various pacing configurations in patients with depressed LV systolic function undergoing heart surgery.

METHODS

Twenty-six patients (age 68 +/- 8 years, 15 males) with depressed systolic LV function (LV ejection fraction <or=35%), symptomatic heart failure, and a QRS duration of > 120 ms undergoing temporary epicardial BiV pacing after aortocoronary bypass and valve surgery were included. QRS duration on surface electrocardiogram (ECG), TDI (systolic velocities of septal and lateral mitral annulus), cardiac index (CI), right atrial pressure, pulmonary artery pressure (PAP), and pulmonary capillary wedge pressure (PCW) were measured during various pacing configurations [no pacing (intrinsic rhythm), right atrial-biventricular (RA-BiV pacing), right atrial-left ventricular (RA-LV), right atrial-right ventricular (RA-RV), and AAI pacing].

RESULTS

There were no differences in QRS duration during intrinsic rhythm, RA-BiV pacing, and AAI pacing. However, RA-LV and RA-RV stimulations showed a longer QRS duration (P < 0.01 vs. intrinsic rhythm, RA-BiV pacing, and AAI, respectively). Tissue Doppler velocities of the septal and lateral mitral annulus were comparable in all pacing modes. Neither CI nor PAP or PCW showed significant differences during the various pacing configurations. There was a positive correlation between regional (TDI) and global (CI) parameters of LV systolic function. Conclusions Biventricular pacing after heart surgery does not improve parameters of regional and global LV systolic function acutely in patients with heart failure and intraventricular conduction delay and, thus, may not reflect changes observed with chronic BiV pacing.

Gene Regulatory Control of Myocardial Energy Metabolism Predicts Postoperative Cardiac Function in Patients Undergoing Off-pump Coronary Artery Bypass Graft Surgery

Background

Anesthetic gases modulate gene expression and provide organ protection. This study aimed at identifying myocardial transcriptional phenotypes to predict cardiovascular biomarkers and function in patients undergoing off-pump coronary artery bypass graft surgery.

Methods

In a prospective randomized trial, patients undergoing elective off-pump coronary artery bypass graft surgery were allocated to receive either the anesthetic gas sevoflurane (n = 10) or the intravenous anesthetic propofol (n = 10). Blood samples were collected perioperatively to determine cardiac troponin T, N-terminal pro-brain natriuretic peptide, and pregnancy-associated plasma protein A. Cardiac function was measured with transesophageal echocardiography and pulmonary artery thermodilution. Atrial biopsies were collected at the beginning and end of bypass surgery to determine gene expression profiles.

Results

N-terminal pro-brain natriuretic peptide and pregnancy-associated plasma protein A blood levels were decreased with sevoflurane treatment. Echocardiography showed preserved postoperative cardiac function in sevoflurane patients, which paralleled higher cardiac index measurements. N-terminal pro-brain natriuretic peptide release was predicted by sevoflurane-induced transcriptional reduction in fatty acid oxidation, whereas changes in cardiac index were predicted by preoperative gene activity of the peroxisome proliferator-activated receptor gamma coactivator-1alpha pathway. Sevoflurane-mediated attenuation of transcripts involved in DNA-damage signaling and activation of the granulocyte colony-stimulating factor survival pathway predicted improved postoperative cardiac index and diastolic heart function, respectively.

Conclusions

Anesthetic-induced and constitutive gene regulatory control of myocardial substrate metabolism predicts postoperative cardiac function in patients undergoing off-pump coronary artery bypass graft surgery. The authors' analysis further points to novel cardiac survival pathways as potential therapeutic targets in perioperative cardioprotection.

Monitoring activated clotting time for combined heparin and aprotinin application: in vivo evaluation of a new aprotinin-insensitive test using Sonoclot☆

OBJECTIVE

Kaolin-based activated clotting time assessed by HEMOCHRON (HkACT) is a clinical standard for heparin monitoring alone and combined with aprotinin during cardiopulmonary bypass (CPB). However, aprotinin is known to prolong not only celite-based but also kaolin-based activated clotting time. Overestimation of activated clotting times implies a potential hazardous risk of subtherapeutic heparin anticoagulation. Recently, a novel 'aprotinin-insensitive' activated clotting time test has been developed for the SONOCLOT analyzer (SaiACT). The aim of our study was to evaluate SaiACT in patients undergoing CPB in presence of heparin and aprotinin.

METHODS

Blood samples were taken from 44 elective cardiac surgery patients at the following measurement time points: baseline (T0); before CPB after heparinization (T1 and T2); on CPB, before administration of aprotinin (T3); 15, 30, and 60 min on CPB after administration of aprotinin (T4, T5, and T6); after protamine infusion (T7). On each measurement time point, activated clotting time was assessed with HkACT and SaiACT, both in duplicate. Furthermore, the rate of factor Xa inhibition and antithrombin concentration were measured. Statistical analysis was done using Bland and Altman analysis, Pearson's correlation, and ANOVA with post hoc Bonferroni-Dunn correction.

RESULTS

Monitoring anticoagulation with SaiACT showed reliable readings. Compared to the established HkACT, SaiACT values were lower at all measurement time points. On CPB but before administration of aprotinin (T3), SaiACT values (mean+/-SD) were 44+/-118 s lower compared to HkACT. However, the difference between the two measurement techniques increased significantly on CPB after aprotinin administration (T4-T6; 89+/-152 s, P=0.032). Correlation of ACT measurements with anti-Xa activity was unchanged for SaiACT before and after aprotinin administration (r2=0.473 and 0.487, respectively; P=0.794), but was lower for HkACT after aprotinin administration (r2=0.481 and 0.361, respectively; P=0.041). On CPB after administration of aprotinin, 96% of all ACT values were classified as therapeutic by HkACT, but only 86% of all values were classified therapeutic if ACT was determined by SaiACT. Test variability was comparable for SaiACT and HkACT.

CONCLUSIONS

The use of SaiACT may result in more consistent heparin management that is less affected by aprotinin and a corresponding increase in heparin administration for patients receiving aprotinin.

Electroporation-mediated interleukin-10 overexpression in skeletal muscle reduces acute rejection in rat cardiac allografts

OBJECTIVES

Human interleukin 10 (hIL-10) may reduce acute rejection after organ transplantation. Our previous data shows that electroporation-mediated transfer of plasmid DNA to peripheral muscle enhances gene transduction dramatically. This study was designed to investigate the effect of electroporation-mediated overexpression of hIL-10 on acute rejection of cardiac allografts in the rat.

METHODS

The study was designed to evaluate the effect of hIL-10 gene transfer on (a) early rejection pattern and (b) graft survival. Gene transfer was achieved by intramuscular (i.m.) injection into the tibialis anterior muscle of Fischer (F344) male recipients followed by electroporation 24 h prior to transplantation. Heterotopic cardiac transplantation was performed from male Brown Norway rat to F344. Four groups were studied (n = 6). Treated animals in groups B1 and B2 received 2.5 microg of pCIK hIL-10 and control animals in groups A1 and A2 distilled water. Graft function was assessed by daily palpation. Animals from group A1 were sacrificed at the cessation of the heart beat of the graft and those in group B1 were sacrificed at day 7; blood was taken for ELISA measurement of hIL-10 and tissue for myeloperoxidase (MPO) measurement and histological assessment. To evaluate graft survival, groups A2 and B2 were sacrificed at cessation of the heart beat of the graft.

RESULTS

Histological examination revealed severe rejection (IIIB-IV) in group A1 in contrast to low to moderate rejection (IA-IIIA) in group B1 (p = 0.02). MPO activity was significantly lower in group B1 compared to group A1 (18 +/- 7 vs. 32 +/- 14 mU/mg protein, p = 0.05). Serum hIL-10 levels were 46 +/- 13 pg/ml in group B1 vs. 0 pg/ml in group A1. At day 7 all heart allografts in the treated groups B1 and B2 were beating, whereas they stopped beating at 5 +/- 2 days in groups A1 and A2 vs. 14 +/- 2 days in group B2 (p = 0.0012).

CONCLUSIONS

Electroporation-mediated intramuscular overexpression of hIL-10 reduces acute rejection and improves survival of heterotopic heart allografts in rats. This study demonstrates that peripheral overexpression of specific genes in skeletal muscle may reduce acute rejection after whole organ transplantation.

Respiratory dependent compression of a venous bypass: therapy by stenting

Although coronary artery bypass surgery has provided major advances in the treatment of coronary artery disease, narrowing of bypass vessels still constitutes a drawback of this therapy. Although this event is most frequently caused by intraluminal processes, obstruction from external structures is extremely rare. We report such a case in which external bypass compression was provoked by deep inspiration causing typical anginal symptoms. Percutaneous coronary intervention including stent placement provided bypass patency independent from the patient's respiratory phase. Disappearance of symptoms and absence of myocardial ischemia in perfusion scans confirmed successful treatment.

Off-Pump Coronary Artery Bypass Grafting: The Zurich Experience

Coronary artery bypass grafting (CABG) is the surgical procedure of choice for treatment of multi-vessel coronary artery disease. The rising risk profile of the patients requiring isolated CABG and the economic pressure have prompted us to devise new operative strategies to treat these patients. Elimination of the cardiopulmonary bypass is one possible answer to the dilemma of maintaining the quality of care and reducing the exploding costs of our health system. Therefore, we developed the off-pump coronary artery bypass grafting (OPCAB) for patients requiring isolated CABG. In our experience the key to successful OPCAB relies on the order of revascularization of the myocardial walls (anterior, inferior, lateral), use of intracoronary shunt, no-touch technique for the proximal aortic anastomosis with heart string â (Guidant, IN, USA), close collaboration with the anesthesiologists, early and aggressive administration of anti-platelet therapy, endoscopic vein harvest by perfusionists, and improved body temperature control. Following these concepts, we have been able to offer the OPCAB procedure to over 90% of our patients and to reduce perioperative morbidity and global costs.

Aortic Dissection With Potential Origin From a Mechanical Bypass Anastomosis

Ascending aortic dissection is a known complication of cardiac surgery. Off-pump coronary artery bypass surgery seems to be associated with a higher risk for this event as compared with on-pump bypass surgery. This increased risk may result from aortic side-clamping under pulsatile flow as opposed to continuous flow in conventional bypass surgery. Mechanical devices allowing performance of proximal bypass anastomoses without aortic side-clamping are supposed to reduce the risk for aortic dissection. We report a case in which ascending aortic dissection occurred 8 days after off-pump bypass surgery, most likely arising from a mechanically performed proximal bypass anastomosis.

Influence of body core temperature on blood loss and transfusion requirements during off-pump coronary artery bypass grafting: a comparison of 3 warming systems

BACKGROUND

The aim of this prospective randomized trial was to evaluate the efficacy of 3 intraoperative warming systems (Warm-Touch, Thermamed SmartCare OP system, and Allon 2001) on maintenance of normothermia and to investigate their effects on perioperative bleeding and transfusion requirements in patients undergoing off-pump coronary artery bypass grafting.

METHODS

With institutional approval/patient informed consent, 90 patients presenting for elective multiple off-pump coronary artery bypass grafting were randomly assigned to 1 of the 3 warming systems. Active warming was started after the induction of anesthesia. Perioperative transfusion was based on international guidelines. Body core temperature was recorded every 30 minutes during operation. Perioperative blood loss, autotransfusion, and allogenic transfusions were recorded. Analysis of variance was performed with post hoc Scheffé tests and chi 2 tests.

RESULTS

Normothermia could be sufficiently maintained during operation by the Allon 2001 only. Final body core temperature was 34.7 degrees C +/- 0.9 degrees C (Warm-Touch), 35.6 degrees C +/- 0.8 degrees C (Thermamed SmartCare OP), and 36.5 degrees C +/- 0.4 degrees C (Allon 2001; P < .001, Warm-Touch vs Thermamed SmartCare OP, Warm-Touch vs Allon 2001, and Thermamed SmartCare OP vs Allon 2001). Perioperative blood loss was 2683 +/- 1049 mL (Warm-Touch), 2300 +/- 788 mL (Thermamed SmartCare OP), and 1497 +/- 497 mL (Allon 2001; P = .195, Warm-Touch vs Thermamed SmartCare OP; P < .001, Warm-Touch vs Allon 2001; P = .001, Thermamed SmartCare OP vs Allon 2001). Transfusion requirements were 1097 +/- 874 mL (Warm-Touch), 986 +/- 744 mL (Thermamed SmartCare OP), and 431 +/- 387 mL (Allon 2001; P = .838, Warm-Touch vs Thermamed SmartCare OP; P = .003, Warm-Touch vs Allon 2001; P = .013, Thermamed SmartCare OP vs Allon 2001). Free of allogenic transfusion were 15 (51.7%; Warm-Touch), 18 (60%; Thermamed SmartCare OP), and 24 (82.8%; Allon 2001) patients ( P = .037).

CONCLUSIONS

The goal of normothermia during off-pump coronary artery bypass grafting was best achieved by the Allon system. With this concept, overall blood loss and transfusion requirements were reduced, hence indicating improved quality of perioperative care.