Immunocytometric analysis of COVID patients: A contribution to personalized therapy?

AIMS

This study aims to cast light on immunocytometric alterations in COVID-19, a potentially fatal viral infection with heterogeneous clinical expression and a not completely defined pathophysiology.

METHODS

We studied 35 COVID patients at hospital admission testing by cytofluorimetry a large panel of lymphocyte subpopulations and serum tumor necrosis factor (TNF)-α, interleukin (IL)-6, IL-17A and the soluble receptor of IL-17A (IL-17RA).

KEY FINDINGS

At hospital admission, total lymphocytes and most T and B subpopulations were reduced in 50-80% of patients, with close relationship to disease severity. While activated T helper 1 (TH1) and TH17 cells resulted normal or higher. Serum IL-6 was increased in all patients, while TNF-α and IL-17A were higher in advanced stages. A patient subset with low severity had very high IL-17RA levels. Tocilizumab treatment caused an increase of IL-17A in 3/6 patients and a reduction in 3 others, while the lymphocyte number increased in 3 patients and did not change in the others.

SIGNIFICANCE

Cytofluorimetry revealed a functional exhaustion of most lymphocyte populations in COVID patients not involving activated TH1 and TH17. Consequently, there was a relevant cytokines production that contributes to impair the respiratory inflammation. The increase of TH17 and IL-17 in a subset of cases and the evidence of a significant increase of IL-17RA (that prevents the interaction of IL-17 with the cell receptor) in patients with low severity suggest that some patients could benefit from monoclonal antibodies treatment targeting IL-17 pathway. Immunocytofluorimetric markers may contribute to a personalized therapy in COVID patients.

Covid-19 and the role of smoking: the protocol of the multicentric prospective study COSMO-IT (COvid19 and SMOking in ITaly)

The emergency caused by Covid-19 pandemic raised interest in studying lifestyles and comorbidities as important determinants of poor Covid-19 prognosis. Data on tobacco smoking, alcohol consumption and obesity are still limited, while no data are available on the role of e-cigarettes and heated tobacco products (HTP). To clarify the role of tobacco smoking and other lifestyle habits on COVID-19 severity and progression, we designed a longitudinal observational study titled COvid19 and SMOking in ITaly (COSMO-IT). About 30 Italian hospitals in North, Centre and South of Italy joined the study. Its main aims are: 1) to quantify the role of tobacco smoking and smoking cessation on the severity and progression of COVID-19 in hospitalized patients; 2) to compare smoking prevalence and severity of the disease in relation to smoking in hospitalized COVID-19 patients versus patients treated at home; 3) to quantify the association between other lifestyle factors, such as e-cigarette and HTP use, alcohol and obesity and the risk of unfavourable COVID-19 outcomes. Socio-demographic, lifestyle and medical history information will be gathered for around 3000 hospitalized and 700-1000 home-isolated, laboratory-confirmed, COVID-19 patients. Given the current absence of a vaccine against SARS-COV-2 and the lack of a specific treatment for COVID-19, prevention strategies are of extreme importance. This project, designed to highly contribute to the international scientific debate on the role of avoidable lifestyle habits on COVID-19 severity, will provide valuable epidemiological data in order to support important recommendations to prevent COVID-19 incidence, progression and mortality.

Say-Barber-Biesecker-Young-Simpson syndrome and Genitopatellar syndrome: Lumping or splitting?

The Say-Barber-Biesecker-Young-Simpson variant of Ohdo syndrome (SBBYSS) and Genitopatellar syndrome (GTPTS) are 2 rare but clinically well-described diseases caused by de novo heterozygous sequence variants in the KAT6B gene. Both phenotypes are characterized by significant global developmental delay/intellectual disability, hypotonia, genital abnormalities, and patellar hypoplasia/agenesis. In addition, congenital heart defects, dental abnormalities, hearing loss, and thyroid anomalies are common to both phenotypes. This broad clinical overlap led some authors to propose the concept of KAT6B spectrum disorders. On the other hand, some clinical features could help to differentiate the 2 disorders. Furthermore, it is possible to establish a genotype-phenotype correlation when considering the position of the sequence variant along the gene, supporting the notion of the 2 disorders as really distinct entities.

Lipid-lowering effect of bergamot polyphenolic fraction: role of pancreatic cholesterol ester hydrolase

Bergamot polyphenolic fraction (BPF) has been shown to positively modulate several mechanisms involved in metabolic syndrome, suggesting its use in therapy. In particular, it is able to induce a significant amelioration of serum lipid profile in hyperlipemic patients at different levels. The purpose of our study was to investigate the effect of BPF on cholesterol absorption physiologically mediated by pancreatic cholesterol ester hydrolase (pCEH). An in vitro activity assay was performed to study the effect of BPF on pCEH, whereas the rate of cholesterol absorption was evaluated through in vivo studies. In particular, male, Sprague-Dawley rats (200–225 g) were fed either normal chow or chow supplemented with 0.5% cholic acid, 5.5% peanut oil, and varying amounts of cholesterol (0 to 1.5%). BPF (10 mg/Kg) was daily administrated by means of a gastric gavage to animals fed with lipid supplemented diet for 4 weeks and, at the end of the study, plasma lipids and liver cholesteryl esters were measured in all experimental groups. Our results show that BPF was able to inhibit pCEH activity and this effect was confirmed, in vivo, via detection of lymphatic cholesteryl ester in rats fed with a cholesterol-rich diet. This evidence clarifies a further mechanism responsible for the hypolipemic properties of BPF previously observed in humans, confirming its beneficial effect in the therapy of hypercholesterolemia and in the treatment of metabolic syndrome.

Diagnostic application of a capture based NGS test for the concurrent detection of variants in sequence and copy number as well as LOH

Whole exome sequencing (WES) has made the identification of causative SNVs/InDels associated with rare Mendelian conditions increasingly accessible. Incorporation of softwares allowing CNVs detection into the WES bioinformatics pipelines may increase the diagnostic yield. However, no standard protocols for this analysis are so far available and CNVs in non-coding regions are totally missed by WES, in spite of their possible role in the regulation of the flanking genes expression. So, in a number of cases the diagnostic workflow contemplates an initial investigation by genomic arrays followed, in the negative cases, by WES. The opposite workflow may also be applied, according to the familial segregation of the disease. We show preliminary results for a diagnostic application of a single next generation sequencing panel permitting the concurrent detection of LOH and variations in sequences and copy number. This approach allowed us to highlight compound heterozygosity for a CNV and a sequence variant in a number of cases, the duplication of a non-coding region responsible for sex reversal, and a whole-chromosome isodisomy causing reduction to homozygosity for a WFS1 variant. Moreover, the panel enabled us to detect deletions, duplications, and amplifications with sensitivity comparable to that of the most widely used array-CGH platforms.

SNORD116 deletions cause Prader-Willi syndrome with a mild phenotype and macrocephaly

Prader-Willi syndrome is a complex condition caused by lack of expression of imprinted genes in the paternally derived region of chromosome 15 (15q11q13). A small number of patients with Prader-Willi phenotype have been discovered to have narrow deletions, not encompassing the whole critical region, but only the SNORD116 cluster, which includes genes codifying for small nucleolar RNAs. This kind of deletion usually is not detected by the classic DNA methylation analysis test. We present the case of a male patient with a mild Prader-Willi phenotype and a small deletion including SNORD116, diagnosed by methylation-sensitive multiplex ligation-dependent probe amplification (MLPA. The patient showed neonatal hypotonia, hyperphagia, obesity, central hypogonadism, hypothyroidism, strabismus. Stature and intellectual development are within the normal range. The presence of macrocephaly, observed in other cases of SNORD116 deletions as well, is uncommon for the classic phenotype of the syndrome.

Delayed diagnosis is associated with changes in the clinical and ultrasound features of subcutaneous endometriosis near cesarean section scars

INTRODUCTION

The aim of the present study was to highlight the sonographic and clinical characteristics of large (≥30 mm in diameter) scar endometriomas near Pfannenstiel incisions, assuming that large size is a marker of delayed diagnosis.

METHODS

We compared clinical, ultrasound (US) and color Doppler findings in 13 patients (mean age 31.3 years) with 13 large scar endometriomas (L-SEs) (mean lesion diameter 41.8 mm; range 30-60 mm) and 17 women (mean age 30.7 years) with 19 small scar endometriomas (S-SEs) (mean lesion size 18.3 mm; range 7-26 mm).

RESULTS

Compared with the S-SE group, the L-SE group had a significantly longer mean interval between the last cesarean section and hospital admission (5.5 vs. 3.3 years; p < 0.01) and longer mean duration of symptoms before admission (43 vs. 17.4 months; p < 0.01). The L-SE group also had a significantly higher percentage of patients who had undergone at least one inconclusive diagnostic examination (Computed Tomography, Magnetic Resonance Imaging, fine needle biopsy, or laparoscopy) (39% vs. 0%; p < 0.05). As for US findings, L-SEs more frequently displayed cystic regions and fistulous tracts (p < 0.05), loss of round/oval shape (p < 0.05), and increased vascularity (p < 0.05).

CONCLUSIONS

Delayed diagnosis of scar endometrioma reflected by a longer and more complex medical history results in larger than usual endometriomas with peculiar US findings, which are even more likely to be misinterpreted by physicians and radiologists.

Should octogenarians be denied access to surgery for acute type A aortic dissection?

AIM

Outcomes after surgery for acute type A aortic dissection in the octogenarian are controversial. To analyze this issue further, the authors reviewed their experience in the hope of finding ways to improve results in these high-risk patients.

METHODS

Between April 1990 and November 2006, 319 consecutive patients underwent emergency surgery for acute type A aortic dissection at the San Martino University Hospital of Genoa (Italy). Among them, 23 (7%) patients were aged 80 years or older (mean age 82 years, range 80 to 86 years) and represent the study population. On admission 7 patients (30%) had preoperative shock, 1 needed cardiopulmonary resuscitation, 7 (30%) had a neurological deficit, 2 (9%) had acute renal failure. Deep hypothermic circulatory arrest was performed in 19 patients (83%). Surgical procedures included isolated replacement of the ascending aorta in all patients associated with root replacement in 2 (9%) and total aortic arch replacement in 5 (22%). Median follow up was 4.1 years (range 3 to 83 months).

RESULTS

Hospital mortality was 61% (14 of 23 patients). Late mortality was 11% (1 of 9 survivors). Stepwise logistic regression identified the extension of surgery to the arch as independent risk factors for hospital death. Fourteen patients (61%) had 1 or more postoperative complications. Overall survival was 39+/-10% and 33+/-10% after 1 and 5 years respectively.

CONCLUSIONS

Surgery for acute type A aortic dissection in the octogenarian shows high hospital mortality but satisfactory long-term survival among discharged patients. A less aggressive approach should increase the outcomes of surgically managed patients.

Factors predicting complete necrosis rate after ultrasound-guided percutaneous laser thermoablation of small hepatocellular carcinoma tumors in cirrhotic patients: a multivariate analysis

PURPOSE

To assess factors affecting the effectiveness of percutaneous laser ablation (PLA) under ultrasound (US) guidance in terms of complete ablation achievement.

MATERIAL AND METHODS

The clinical records of 86 hepatocellular carcinoma (HCC) tumors (mean diameter 23.7 mm) in 60 cirrhotic patients (mean age 68.3 years; 36 males; 57 HCV+; 53 Child's class A, seven Child's class B) treated by means of PLA were reviewed. PLA was performed with a continuous-wave Nd:YAG laser by a single operator who positioned two to four 300-microm optic fibers advanced in 21-gauge needles into target lesions under US guidance. Triphasic computed tomography (CT) studies were used to verify treatment effectiveness 1 month after PLA completion. The association between characteristics of the lesion and outcome (complete or incomplete ablation) was evaluated by logistic regression, taking into account the following predictive factors: tumor size, pattern of growth (infiltrating or not) at imaging, location, first diagnosis of HCC (naïve tumors vs. non-naïve tumors), number of sessions (1/ > 1), total delivered energy, and years of treatment in 2001-2002 (first period) vs. 2003-2004 (second period).

RESULTS

Complete ablation was obtained in 62 nodules (72%). Statistically significant predictors of incomplete ablation after the first PLA course at both univariate and multivariate analysis included: infiltrating growth pattern (odds ratio (OR) 12.3, P<0.002), non-naïve tumors (OR 8.7, P<0.001), and first period of treatment (OR 10.3, P<0.002).

CONCLUSION

The effectiveness of US-guided PLA for HCC tumors < or =4 cm turned out to be negatively affected by both operator-related (the beginning of the operator's experience with the technique) and tumor-related factors (non-naïve, infiltrating HCC tumors).

Factors influencing the presentation and outcome of tuberculous meningitis in childhood

Tuberculosis (TB) is an important cause of morbidity and mortality worldwide. Here, we describe our experience of childhood tuberculous meningitis (TBM), focusing on factors influencing presentation and outcome.

PATIENTS AND METHODS

Children aged 0-14 years, with diagnosis of TBM and 24 months of post-therapy follow-up, were evaluated in this retrospective study.

RESULTS

Thirty-two patients with TBM were identified. Fever, nuchal rigidity and vomiting were the main presenting symptoms. Fourteen cases (44%) presented with cranial nerve palsy. Seventeen (53%) patients were in advanced stage of the disease on admission. Cerebrospinal fluid (CSF) examinations showed low glucose, high proteins and pleocytosis. A central nervous system device was placed in 4 cases (13%) because of worsening hydrocephalus. Four (13%) patients died, while 6 (19%) had sequelae. Faster normalization of CSF parameters was associated with better outcome.

CONCLUSION

Early antimycobacterial therapy and close monitoring of TBM in childhood improve the outcome.

Pulmonary aspergillosis with possible cerebral involvement in a previously healthy pregnant woman

Invasive aspergillosis is observed mainly in immunodepressed patients. Here we report a case of pulmonary aspergillosis with CNS involvement in a pregnant woman without other known causes of immunodeficiency.

CASE REPORT

A 23-years old pregnant woman underwent a caesarean because of unexplained seizures. During the subsequent days worsening headache and a deteriorating neurological status were reported suggesting meningitis. Stiffness, right sided hemiparesis and cranial nerve palsies were observed at admission. Radiological findings revealed lesions involving the right pulmonary apex, the right cerebellar hemisphere and the Pterygopalatina fossa. Microbiological studies revealed large colonies of Aspergillus fumigatus. A favorable outcome was observed after administration of liposomal amphotericin B and 5-fluorocytosine and, at improved conditions, when oral uptake of itraconazole was given. The authors conclude that risk of infections sustained by fungal opportunistic agents during pregnancy must be considered. Sequential antifungal administration may be an efficient therapy able to shorten hospitalization.

Influence of chronic coinfection with hepatitis B and C virus on liver histology

BACKGROUND

Few data are available on histological features of chronic hepatitis B (HBV) and C (HCV) virus coinfection.

PATIENTS AND METHODS

We enrolled 142 consecutive patients with viral chronic hepatitis on their first liver biopsy: 27 HBsAg and anti-HCV positive (case BC group), 57 HBsAg positive and anti-HCV negative (control B group) and 58 anti-HCV positive, HBsAg/anti-HBs/anti-HBc negative (control C group).

RESULTS

Patients in the case BC group showed serum HBVDNA (37% vs 71.9%, p < 0.005) and ground-glass hepatocytes (37% vs 66.7%, p < 0.01) less frequently than those in the control B group. The case BC group showed a lower prevalence of patients with detectable HCV-RNA than the control C group (60% vs 92.3%, p < 0.001) and a significantly higher fibrosis score (2.1 +/- 1.2 vs 1.5 +/- 1.1, p < 0.05). Of the 27 patients in the case BC group, 10 lacked serum HCV-RNA and showed significantly higher histological activity index (HAI) and fibrosis scores than those found in the 17 HCV-RNA positive (8.5 +/- 4.4 vs 5.4 +/- 2.4 for HAI, p < 0.05; 3.0 +/- 1.3 vs 1.69 +/- 1.0, p < 0.05 for fibrosis).

CONCLUSION

Liver histology seems to be more severe in chronic coinfection with HBV and HCV than in single infection, particularly when HCV replication is impaired.

[Non post-operative spondylodiskitis. Our experience during the period 1990-2001]

Aim of the study was to evaluate the prevalence and characteristics of non operative spondylodiskitis (SD) in our geographic area.

METHODS

We evaluated retrospectively epidemiological, clinical, laboratory and radiological features of patients with non operative SD observed between 1990 and 2001 in our department of the "D. Cotugno" hospital - Naples.

RESULTS

Eighteen patients with diagnosis of SD were evaluated. Etiologic agent was identified in 17 patients: M. tuberculosis in 5, brucella spp. in 4 and pyogenic bacteria in 8. Ten patients had underlying diseases or risk factors (4 diabetes mellitus, 3 arthrosis, 1 CRF, 1 IVDA and 2 previous back trauma). Symptoms preceded observation between 2 days and 12 months (median value 15 days). Seventeen patients presented fever, 13 back pain, 6 meningitis, 3 were comatous and 2 had severe sepsis. Ten patients showed high white blood cells count with granulocyte prevalence. Eritrosedimentation rate or C reactive protein were elevated in all patients. Diagnosis was confirmed in 8 patients only with radiographs of the spine, while 3 needed a CT and 11 a RMN imaging. Antimicrobial therapy was perfomed for at least 6 months in patients with brucellosis, 12 months in patients with tuberculosis and 2 months in patients with pyogenic SD. Persistent neurological deficit were observed in 2 patients.

CONCLUSIONS

Neurological deficit may be avoid in patients affected by SD only with a carefull diagnosis and an accurate antibiotic therapy.

Atherosclerotic aneurysm of the left main coronary artery. Case report and review of the literature

Coronary artery aneurysms involve the right coronary artery, the left anterior descending and the left circumflex coronary arteries in descending order of frequency; aneurysms involving the main left coronary artery are extremely rare. Atherosclerosis is the most common cause. Only eleven patients surgically treated with atherosclerotic left main coronary artery aneurysms are reported. We observed the twelfth case of atherosclerotic aneurysm of the left main coronary artery, successfully treated. In a 65-year-old man we found a large aneurysm originating at the distal segment of the left main coronary artery. A thromboendarterectomy was per-formed and was extended back into the left main and down the left anterior descending artery. An aneurysmorrhaphy and a three-vessel coronary artery bypass grafting were also performed. Three years later the patient was asymptomatic. Management of these cases is still controversial and based on anedoctal experience rather than controlled trials. Although surgery has been recommended to prevent complications, there are no available data comparing medical and surgical management. We feel that coronary bypasses should be performed in coronary artery aneurysm patients only when indicated by the severity of stenosis or progressive angina despite medical therapy. It is our opinion that anurysmorraphy should preserve native flow as much as possible.

Normothermic versus hypothermic perfusion during cardiopulmonary bypass. A randomized study on 132 patients

BACKGROUND

A prospective randomized trial to compare normothermic CPB with hypothermic CPB has been performed.

METHODS

132 patients undergoing CPB were randomized into two groups: group 1 underwent normothermic CPB and group 2 hypothermic CPB (between 26 and 30 degrees C).

RESULTS

Any significant difference was observed between the groups with regard to hospital mortality, blood transfusions, incidence of neurologic deficits and hematocrit, blood hemoglobin levels, platelet counts, plasma concentrations of glutamic-pyruvic transminase, glutamic-oxaloacetic transaminase, creatine kinase, valued at the 12th and 24th postoperative hour and at the 2nd, 3rd, and 4th postoperative day. A significant difference was observed between the groups with regard to tracheal extubation time, discharge time from the intensive care unit and inotropic drug infusion. The normothermic CPB patients group needed shorter time for tracheal extubation and discharge from the intensive care unit: this difference may be ascribed to a shorter inotropic drug infusion. Any increased surgical risks have been observed.

CONCLUSIONS

In conclusion, we think that normothermic CPB is favourable because it can reduce costs, it can improve the management of a cardiac surgery unit and it is more comfortable for patients.

Left ventricular rupture after mitral valve replacement in a patient with osteogenesis imperfecta tarda

We describe the case of a patient with osteogenesis imperfecta tarda (Lobstein's syndrome) and mitral valve insufficiency. The course after mitral valve replacement was complicated by rupture of the left ventricular posterior wall, which caused massive bleeding and sudden death. The pathologic findings and the operative problems are discussed.

Stanford type A aortic dissection. A new surgical approach

We describe a new surgical technique adopted for the repair of Stanford type A aortic dissection. In order to minimize the risk of malperfusion caused by retrograde flow during cardiopulmonary bypass, we avoid femoral artery cannulation. On the hypothesis that it is best not to interfere with the hemodynamics of the dissection, we cannulate the dissected ascending aorta, in either the true or false lumen. We here report 2 cases of successful surgical treatment of Stanford type A aortic dissection. In both cases, the false lumen was cannulated under deep hypothermic circulatory arrest, without clamping the aorta. While the patient was cooling, a 10-mm GORE-TEX side arm was sutured to a Dacron graft prosthesis. Repair of the aortic arch was carried out 1st. The aortic cannula was inserted into the GORE-TEX side arm, the tubular prosthesis was cross-clamped, and cardiopulmonary bypass was reinstituted. After this, the aortic bulb was repaired as usual and the tubular prosthesis was sutured to the bulb. No postoperative cerebral complication occurred. Our experience must be confirmed by more cases and a longer follow up.

Prognostic role of cyclin D1 in non small cell lung cancer: an immunohistochemical analysis

Lung cancer is a worldwide problem and in many countires it is the most lethal malignancy. Because relapse is frequent after resection of non small cell lung cancer, an urgent need exists to define prognostic factors which could help in choosing the best therapeutic approach. We performed immunohistochemistry on 60 formalin-fixed paraffin-embedded non small cell lung cancer specimens in order to evaluate the frequency of cyclin D1 overexpression, and to relate it to the degree of malignancy of these tumors and to the overall survival time of the patients. All specimens were positive for cyclin D1 immunostaining. We found cyclin D1 overexpression in 30 (50%) of our specimens, with no significant difference among the different histological types. Cyclin D1 overexpression correlates in a statistical manner with short-term patient survival. Mantel-Cox analysis of these data generated a significant P value = 0.003. The mean survival time and the five-year survival rate also differed statistically. We did not find any statistically significant correlation between cyclin D1 overexpression and histological grading, tumor stage or TNM status. We concluded that cyclin D1 overexpression in 30 patients is a frequent event in non small cell lung cancer pathogenesis and may have prognostic relevance.

Subacute left ventricular free wall rupture complicating acute myocardial infarction. Successful surgical repair with a sutureless technique

The high mortality index related to surgical therapy with direct suture of rupture of left ventricular free wall following acute myocardial infarction, suggested we analyze and use alternative techniques. So we applied sutureless technique described by Padro to two patients. We used a Teflon patch fixed to the ventricular wall with a biocompatible synthetic glue, an ethyl-2-cyanoacrylate monomer, without any direct suturing of the infarcted myocardium. The two patients survived the operation and were discharged from the hospital 12 and 14 days after surgery. The sutureless technique allows, in our opinion, a more confident and safe aggressive attitude to subacute left ventricular free wall rupture.

Isolated lung perfusion with platinum in the treatment of pulmonary metastases from soft tissue sarcomas

A multimodality approach including operation and isolated lung perfusion with platinum was used in six patients with lung metastases from soft tissue sarcomas. Staged thoracotomies were used in two patients with bilateral lesions. The inclusion criteria generally applied for surgical excision were adopted in this study. The pulmonary artery and a portion of the left atrium were isolated from systemic circulation and cannulated. The cannulas were then connected to a perfusion circuit and normothermic isolated lung perfusion was done for 60 minutes. The lung was then flushed and metastasectomy was done. Serial blood (systemic and pulmonary), tissue (normal lung and tumor), and urine samples were obtained for platinum content measurement by flameless atomic absorption spectroscopy. Lung damage was assessed by light and electron microscopy examination and by serial respiratory tests. Isolated lung perfusion was accomplished in all patients without any death, operative complication, or systemic toxicity. After operation, interstitial and alveolar edema developed in two patients (48 hours after treatment), necessitating respiratory support in one case. Total platinum concentrations in pulmonary plasma were about 43 times greater than those in systemic plasma. No differences in platinum concentrations between normal lung and metastatic tissue were found. Thus the proposed isolated lung perfusion technique is feasible and safe enough to be offered as a valid model to study combined chemosurgical approaches in the treatment of lung metastases.

Circumferential dissection of the ascending aorta with intimal intussusception. Case report and review of the literature

The present report describes an unusual case (apparently the 10th in the world literature) of a type-A aortic dissection with full circumferential detachment of the ascending aortic intima and intussusception thereof into the aortic arch and descending aorta, partly occluding the arch vessels. Computed tomographic scanning and 2-dimensional echocardiography failed to detect an intimal flap and a false lumen in the ascending aorta. Aortic dissection was visualized by aortography. The ascending aorta was surgically repaired and the aortic valve resuspended. The pertinent literature is reviewed.

Emergency surgical treatment for total left main coronary artery occlusion. A report of 2 cases

Treatment of total left main coronary artery occlusion is rarely reported (84 chronic and acute cases in the world literature), due to the high mortality rate from massive myocardial infarction. Acute occlusions have been treated with intracoronary streptokinase, with percutaneous transluminal coronary angioplasty, or with both. To date, there has been no report of successful surgical revascularization in an acute case. We present 2 cases of surgically treated patients who survived total left main coronary artery occlusion that appears to have been acute, or acutely evolving. Both patients had an 80% or greater stenosis of the right coronary artery, yet have remained in New York Heart Association functional class I or II postoperatively. We attribute this not only to the aggressive surgical approach, which enabled reperfusion to be achieved within 2 hours of total occlusion, but to the protective effect in these patients of right coronary-to-left anterior descending collaterals.

[Primary cardiac rhabdomyosarcoma involving the mitral valve]

Primary cardiac rhabdomyosarcoma is rare and its extension to the mitral valve even rarer. We report a case of left atrial rhabdomyosarcoma involving the mitral valve. The patient was a 62-year-old man who complained of recurrent pre-syncopal episodes, dyspnoea often sudden in onset, asthenia and major weight loss (10 kg in one month). 2-D echocardiography revealed a 4.9 cm2 wide mass attached to the atrial side of the anterior mitral leaflet and to the adjacent inferior interatrial septum, where it seemed to have origin. CT scan and scintigraphy revealed bone, kidney and spleen metastases. The patient underwent emergency cardiac surgery because of increasing pre-syncopal and dyspnoeic episodes due to obstruction by the intracardiac mass. At surgery a tumor was found infiltrating the left atrial wall, the interatrial septum, the mitral anulus and the anterior mitral leaflet up to its tip. Invasion of mitral anulus did not allow mitral valve replacement, so that an excision of the intracardiac mass was performed as extensively as possible. Histology revealed a rhabdomyosarcoma. A post-operative chemotherapy cycle had to be stopped due to onset of atrial fibrillation and dyspnoea. 2-D echo monitoring revealed rapid new growth of the tumor across the basal portion of mitral valve leaflet to the atrioventricular orifice. After several episodes of increasing dyspnoea, the patient had a pulmonary oedema and died.

[Catheter embolism. Method of bloodless extraction]

A detailed review and analysis of world literature on the techniques employed for the retrieval of polythene catheter fragments, metal spindles or Pudenz catheters from the heart or large vessels is presented. Non-surgical retrieval techniques are discussed on the basis of 174 cases reported in the literature. 2 personal cases of the retrieval of foreign bodies from the heart using a Deyhle-Seubert catheter are presented.

[Left endoatrial myxoma. Notes on a case]

A case of left endoatrial mixoma, ecocardiographically discovered and successfully operated, is reported. The usefulness of ecocardiography, especially to discover intracardiac masses, is considered.

[Anti-arrhythmic effects of cardioplegic myocardial protection]

Cardioplegia gave excellent results in a preliminary series of 33 cases in which it was used during surgery. The fact that a sinus rhythm was re-established at the end of extracorporeal circulation in patients in atrial fibrillation suggests that it exerts an antiarrhythmic action at the atrial a level.