Natural history of right ventricle: longitudinal study in veteran athletes

Funding Acknowledgements

Type of funding sources: None.

INTRODUCTION

Right ventricular (RV) enlargement is a physiologic adaptation to long lasting athletic training. Its clinical implications for veteran athletes are poorly understood. In recent years, controversial data suggest an association between ultra-endurance exercise and a RV cardiomyopathy similar to arrhythmogenic cardiomyopathy (ACM). In this context, the effects of exercise detraining have not been extensively studied yet.

PURPOSE

The aim of this study was to assess the morphological and functional RV changes in veteran athletes and to evaluate the effect of a long period of detraining.

METHODS

This is a longitudinal study including 22 veteran rowers with at least 10 years of competitive career. We evaluated them with an echocardiographic assessment at baseline and after a minimum of 3 years of detraining (age: 23.2 ± 4.4 and 43 ± 7.4 years), by reducing the weekly training volume from 26 ± 0.7 to 3 ± 2 hours. In this second evaluation we also performed an RV strain analysis and a cardiac magnetic resonance (CMR) study.

RESULTS

RV end diastolic (ED) areas significantly reduced after detraining (31.48 ± 5.8 versus 28.59 ± 6.8; p = 0.001), although remaining larger than normal. RV enlargement was balanced: the ratio between inflow (IT) and outflow tract (OT) (RVIT/RVOT = 1.4 ± 0.1) and the ratio between RV and left ventricle (LV) (RV/LV = 0.81 ± 0.1) were within normal limits. The fractional area change (FAC%) was normal at baseline and increased significantly (41.5 ± 6% versus 45.8 ± 7%; p = 0.011). After detraining, RV longitudinal strain was normal (-19.7 ± 2.7%). CMR assessment showed enlarged RVED volumes (97.9 ± 14 ml/m2) but normal RV ejection fraction (55.5 ± 4.1%).

CONCLUSIONS

RV enlargement in endurance athletes persists after a long period of detraining. However, detraining results in a significant reduction of RV dimensions. Furthermore, the absence of RV dysfunction or disproportionate RV geometry are reassuring findings that suggest a physiological remodeling of the RV.

Significant echo findings. RV ECHO PARAMETERS BASELINE DETRAINING MEAN DIFF. (C.I. 95%) p VALUE RVOT plax (mm) 34.8 ± 4 33.7 ± 14 1.1 (0.18; 2.1) p = 0.011 RVOT psax (mm) 34.9 ± 3.3 33.09 ± 3.5 1.8 (0.9; 2.7) p < 0.001 RV basal diameter (mm) 47.31 ± 5.3 45.86 ± 6.4 1.4 (0.04; 2.8) p = 0.022 RV end-diastolic area (cm²) 31.48 ± 5.8 28.59 ± 6.8 2.8 (1.1; 4.6) p = 0.001 FAC% 41.5 ± 6 45.8 ± 7 0.04 (-0.07; -0.007) p = 0.011 RV inflow/outflow ratio 1.36 ± 0.1 1.36 ± 0.2 -0.003 (-0.06; 0.06) p = 0.454 RV/LV ratio 0.82 ± 0.07 0.81 ±0.1 0.01 (-0.01; 0.04) p = 0.219

Abstract Figure. Comparison in the same veteran athlete.

P1362 Echocardiographic findings and BNP levels in patients with valve-in-valve implantation in small failed mitroflow aortic prosthesis

BACKGROUND

Early structural valve deterioration (SVD) frequently occurs in Mitroflow aortic bioprosthesis, especially for small sizes (19-mm and 21-mm), and it is associated with reduced overall survival. Treatment by percutaneous valve-in-valve (ViV) implantation is considered a challenging procedure. This is mainly due to an elevated risk of coronary ostia obstruction and high residual post-procedural mean gradients (mG), particularly when severe pre-existing patient-prosthesis mismatch (PPM) is present.

PURPOSE

Aim of our study was to assess the feasibility of transfemoral ViV in small Mitroflow aortic valves using supra-annular self-expanding valves, named CoreValve and Evolut R and Acurate neo and report the midterm clinical results by comparing serum natriuretic peptide type B levels (BNP) before the procedure and at a mean follow-up of 2 years.

METHODS

This is an observational study including 11 patients with stenotic-type SVD of small Mitroflow aortic valves, considered at high/prohibitive risk for surgical reoperation, who underwent ViV implantation between July 2012 and March 2018. We performed echocardiographic assessment of valve hemodynamics (according to VARC-2 definitions) before and after the procedure and during the follow-up. We used the BNP ratio (the ratio between measured serum BNP/NT-proBNP level and maximal normal level) to compare BNP results before the procedure and at follow-up. All-cause mortality during the hospitalization and follow-up was also reported.

RESULTS

The Mitroflow size was 19-mm in 4 patients and 21-mm in 7 patients. Pre-existing severe PPM was present in 4 patients and moderate PPM in 7. CoreValve 26 was implanted in 2 patients, EvolutR 23 in 5 and Acurate neo S in 4 patients. We reported no coronary obstruction, deaths or other major events during the hospitalization. At a mean follow-up of 2 years one patient died. The baseline aortic mG of 56 ± 19 mmHg has significantly reduced after the procedure to 16,6 ± 8 mmHg (p < 0.0001) and follow-up 29,6 ± 16 mmHg (p = 0.008). A post-procedural mG≥20, but <40 mmHg, was observed in 3 patients. BNP ratio at baseline was 14,6 ± 12; only one patient had a BNP ratio <3. At follow-up (n = 7 patients), BNP ratio was significantly lowered to 1,5 ± 1,08 (p = 0.01) with only one patient with a BNP ratio >3. Patients with mPG ≥20 mmHg did not show differences in terms of mortality and reduction of serum BNP levels.

CONCLUSIONS

In our experience the ViV procedure on small degenerated aortic Mitroflow bioprosthesis appears to be technically feasible and provides good midterm clinical results with a net reduction in serum BNP levels, although an increase in mG was observed. Even though a post-procedural mG ≥20 mmHg is considered indicative of suboptimal aortic valve hemodynamics (according to VARC-2 criteria), its correlation with worse outcomes remains unclear and deserves further investigations.

Robotic versus open total mesorectal excision for rectal cancer: comparative study of short and long-term outcomes

BACKGROUND

Despite the several series in which the short-term outcomes of robotic-assisted surgery were investigated, data concerning the long-term outcomes are still scarce.

METHODS

The prospectively collected records of 65 consecutive patients with extraperitoneal rectal cancer who underwent robotic total mesorectal excision (RTME) were compared with those of 109 consecutive patients treated with open surgery (OTME). Patient characteristics, pathological findings, local and systemic recurrence rates and 5-year survival rates were compared.

RESULTS

There were no statistically significant differences in postoperative complications, reoperation and 30-day mortality. There were significant differences comparing groups: number of lymph nodes harvested (RTME: 20.1 vs. OTME: 14.1, P < 0.001), estimated blood loss (RTME: 0 vs. OTME: 150 ml, P = 0.003), operation time (RTME: 299.0 vs. OTME: 207.5 min, P < 0.001) and length of postoperative stay (RTME: 6 vs. OTME: 9 days, P < 0.001). The rate of circumferential resection margin involvement and distal resection margin were not statistically different between groups. There were no statistically significant differences at the 5-year follow-up: overall survival, disease-free survival and cancer-specific survival. The cumulative local recurrence rate was statistically lower in the robotic group (RTME: 3.4% vs. OTME: 16.1%, P = 0.024).

CONCLUSION

RTME showed a significant reduction in local recurrence rate and a higher, although not statistically significant, long-term cancer-specific survival with respect to OTME. Prospective randomized studies are needed to confirm or deny significantly better local control rates with robotic surgery.

Short- and medium-term results of totally laparoscopic resection for colorectal liver metastases

BACKGROUND

Laparoscopic surgery for primary colorectal cancer is now commonplace but the uptake of laparoscopic surgery for colorectal liver metastasis (CRLM) has been slow, mainly owing to doubts regarding safety, feasibility and oncological efficiency.

METHODS

Prospectively collected data of all patients treated for CRLM between 2004 and 2009 were reviewed retrospectively. The database was analysed for operative details, hospital stay, postoperative results and medium-term survival.

RESULTS

Over 5 years, 135 patients underwent liver surgery for CRLM. For laparoscopic procedures, the median duration of operation was 220 min and median blood loss was 363 ml; a mean tumour-free resection margin of 17.0 mm was achieved (more than 1 cm in 76 per cent), and no port-site metastasis or surgical-site recurrence was observed. The procedure was converted to open surgery in six patients (two for bleeding). Overall survival for the laparoscopic group approached 90 per cent with median follow-up of 22 months.

CONCLUSION

In this series totally laparoscopic CRLM resection had good short- and medium-term results in terms of mortality, morbidity, resection margins, local recurrence or port-site metastasis, and survival. Compared with contemporaneous open experience, the laparoscopic approach was safe and effective in a highly selected consecutive series.

The finding of vascular and urinary anomalies in the harvested kidney for transplantation

INTRODUCTION

In kidney transplantation, anatomical vascular and excretory anomalies may represent causes of failure. Today's surgical techniques have made the most of the organs with anatomic anomalies and iatrogenic injury successfully used for transplantation.

MATERIALS AND METHODS

From January 2000 to June 2006, we harvested 230 kidneys, of including 88 kidneys (20%) with vascular, urinary, or vascular-urinary anomalies; 64 kidneys were implanted and 15 were sent to other transplantation centers. Only 9 kidneys were not appropriate for transplantation.

RESULTS

All patients who received kidneys with the above-mentioned anomalies were carefully examined after the transplantation and short-term and long-term complications were evaluated with respect to controls without anomalies.

DISCUSSION

Renal anatomic anomalies are frequently observed during kidney transplantation and may produce postsurgical complications. However, the presence of these anomalies does not necessarily imply the impossibility of using the kidney for a transplant, especially because of improved surgical techniques. Our experience in transplantation procedures showed that even if kidneys present the above-mentioned anomalies they can still be considered appropriate for transplantation when we perform a correct harvesting/back-table transplant surgery. So vascular and urinary anomalies have to be considered always an incentive to research new surgical solutions and to perform a careful surgical technique.

Older kidneys donor transplantation: five years' experience without biopsy and using clinical laboratory and macroscopic anatomy evaluation

INTRODUCTION

The exponential increase in organ demand is not associated with a similar increase of available kidneys. This emergency led to expanded criteria to consider a kidney transplantable. The aim of this retrospective study was to explain our use of older donor kidneys without biopsy.

MATERIALS AND METHODS

Between 2000 and 2005, 58 older kidneys were harvested: 27 were transplanted in our center; 13 were discarded; and 18 were transplanted in other centers. We considered 3 factors to define kidney quality: macroscopic anatomy, multiple factors linked to the donor, and clinical-laboratory data. After transplantation, we observed the patients for at least 1 year and up to 6 years.

DISCUSSION

At 1 year, 24/27 (89%) patients had a functional kidney, 2 patients showed an initial renal failure and 1 patient lost the kidney. At maximum follow-up, 19 patients (70%) had functional kidneys, 4 with initial renal failure. These results compared with the kidneys harvested using Standard Donor Kidney Criteria are acceptable. Obviously we need long-term follow-up to increase, the amount of data and obtain a definitive outcome.

CONCLUSION

Biopsy is the gold standard for the definition of an older kidney's quality. When a biopsy is not feasible, the study of the macroscopic anatomy the kidney's donor and of some donor's parameters represent an acceptable biopsy alternative, being able to rescue some organs that would be otherwise lost.

Healing of surgical incision in kidney transplantation: a single transplant center's experience

INTRODUCTION

Impaired healing of the surgical incision represents a common complication after kidney transplantation. We led a retrospective study seeking to understand the factors linked to these complications and reasons for their reduction during the last year.

PATIENTS AND METHODS

From January 2000 to April 2004, 170 consecutive kidney transplantations were performed in a homogenous patient population. We evaluated the influence of following factors to determine impaired healing of the incision: antirejection drugs, overweight/obesity, age, delayed graft function (DGF), diabetes, and abdominal wall reconstruction technique.

RESULTS

Among 165 patients we observed 26 (15.76%) cases of impaired healing of the surgical incision: 17 (65,38%) with first-level and nine with second-level wound complications.

CONCLUSIONS

Impaired healing of the surgical incision influences the outcome of kidney transplant patients. In our study we observed that cyclosporine and tacrolimus similary affected the incision's healing. It was not possible to evaluate the role of basiliximab. A univariate analysis of the factors related to complications revealed overweight and DGF. However, all patients developing second-level complications showed more risk factors. Patients who had not had reconstruction of the muscle layers showed a greater incidence of surgical complications, whereas patients who had skin sutured with an intradermic technique did not show an increased risk.

Transplantation and young surgeons in Italy

The relation between young surgeons and transplantation has always been a "love and hate" one. Until a few years ago this branch of surgery was seen as pioneering, with extreme and and extensive training, and was reserved to few elected members. Nowadays things are different. In this article we try to understand the true reasons that young Italian surgeons avoid transplantation surgery.

[Incidence and significance of heart murmurs in newborn infants admitted to nursery]

In a retrospective study on heart murmurs in healthy newborns we reviewed data concerning all newborns admitted in our nursery in the year 1990 (1387 newborns: male 699, female 688). An heart murmur was recorded in 106 (7.6%); in 32 of these (30%) the murmur was still audible at discharge; in 18 cases (17%) a congenital heart defect was diagnosed. Our data suggest that time of onset and intensity are valuable data for diagnostic approach, as murmurs recorded after the first day of life, and/or of intensity of 2/6 or more, are more likely to be expression of a congenital heart disease and should be further evaluated.

[A case of transient hypertrophic cardiomyopathy in a twin infant of a diabetic mother]

The case is reported of a dizygotic twin infant of a diabetic mother with transient hypertrophic cardiomyopathy. The clinical course and eco-ecg reports are described. The etiopathogenesis is discussed since no evidence of cardiomyopathy was found in the second twin. The importance of a timely diagnosis for a correct therapy is emphasized.

[Adrenal hemorrhage in neonates: three cases with different clinical and echographic findings]

Three cases of neonatal adrenal hemorrhage are described. They presented different clinical findings. Ultrasonography was the investigation of choice. It showed different initial patterns: anechoic in one case, hyperechoic in the others. The literature is reviewed. Usefulness of echography in the diagnosis of adrenal hemorrhage is stressed.

[A case of fetal hydrops due to congenital cardiopathy]

As the frequency of Rh isoimmunization is declining, nonimmune fetal hydrops is becoming the predominant form of hydrops. Authors report a case of hydrops secondary to congenital heart disease and briefly discuss the physiopathology of such condition.

[A case of congenital cytomegalic disease: clinical and virological study]

A case of congenital cytomegalovirus infection is reported and its clinical and diagnostic problems are considered. Perinatal and intrauterine transmission of CMV is discussed.

[Neonatal cystic lymphangioma]

The A.A. reports a case of cystic congenital linphangioma of the face and neck, recently observed on the Neonatal Intensive Care Unit. The therapeutic approach was very difficult and required three times a surgical menagement because of successively relapses. The control and normalization of the compressive and infective complications due to the massa and its removal were hard too. In spite of some aesthetical problems, the results may be considered satisfactory. Our case enphasizes the intrinsec, complex, therapeutical difficulties of the cystic linphangiomas.