Minimally Invasive Surgical Repair of Vertebral Artery Ostium Stenosis in Patients with Ischemic Stroke: A Single-Center Case Series.

BACKGROUND: Ischemic stroke is the second leading cause of death in North Macedonia. Posterior circulation disease, caused by vertebral artery (VA) ostium (VAo) stenosis, is a common cause of ischemic stroke. We established a treatment approach using surgical revascularization of posterior circulation disease. In the present observational study, we assessed the outcome after surgical revascularization of the posterior circulation ischemia caused by VAo stenosis. METHODS: A retrospective analysis of 20 consecutive patients who had undergone surgery from January 2017 to December 2019. The VA was accessed through a 3-cm incision in the upper medial clavicle. The corrective procedures consisted of resection and anastomosis (15 of 20), VA to subclavian artery transposition (16 of 20), endarterectomy (10 of 20), vein graft interposition techniques (4 of 20), and vein graft bypass (1 of 20). RESULTS: The cohort included 9 acute cases. The mean patient age was 66.5 years (range 46-77). Of the 20 patients, 8 were women and 12 were men. Left-sided VA pathology was present in 75% of the cases. We observed rapid clinical improvement in 19 patients (95%). The total study period was 321 patient-months, with a median follow-up of 18 months (interquartile range, 5-24 months). One patient had died of an unknown cause after 12 months. During the follow-up period, 15 patients (75%) had reported permanent clinical improvement with no significant relapse of symptoms. CONCLUSIONS: Minimally invasive surgical revascularization of the posterior brain circulation is a clinically effective therapeutic approach to manage ischemia caused by VAo stenosis. It can be performed safely, promote long-lasting symptom relief, and prevent recurrent strokes.

Effects of high temperatures and drought during anthesis and grain filling period on wheat processing quality and underlying gluten structural changes.

BACKGROUND: Climate changes do not only affect wheat yield, but also its quality. Information on this topic gathered so far is somewhat contradictory and insufficient. Climate changes also affect wheat indirectly through their influence on the ecosystem, including insects and fungi that affect wheat technological quality. The aim of this study was to examine trends in structural and technological changes of wheat quality under conditions typical of climate changes. With this in mind, three groups of wheat varieties with the same Glu-score were examined in three production years, characterized by different production conditions. RESULTS: A production season characterized by climate change conditions results in lower activity of amylolytic enzymes. What is more, it results in lower content of gluten, higher gluten index value, its decrease after 1 h to 37 °C, lower number of free SH groups and higher content of free amino groups, which result in lower alveograph W, lower farinograph WA and higher extensograph dough resistance. CONCLUSION: Variability in wheat quality produced under different climatic conditions is mainly influenced by the production conditions, including their influence on ecosystem factors. The influence of wheat cultivar genetic predisposition is much less expressed. This indicates that differences among cultivars with different Glu-score might be diminished under the influence of altered production conditions, as a consequence of climate change. © 2017 Society of Chemical Industry.

Transcatheter Closure of Patent Foramen Ovale: A Single Center Experience.

BACKGROUND: Percutaneous transcatheter closure (PTC) of patent foramen ovale (PFO) is implicated in cryptogenic stroke, transitional ischemic attack (TIA) and treatment of a migraine. AIM: Our goal was to present our experience in the interventional treatment of PFO, as well as to evaluate the short and mid-term results in patients with closed PFO. MATERIAL AND METHODS: Transcatheter closure of PFO was performed in 52 patients (67.3% women, mean age 40.7 ± 11.7 years). Patients were interviewed for subjective grading of the intensity of headaches before and after the PFO closure. RESULTS: During 2 years of follow-up, there was no incidence of new stroke, TIA and/or syncope. Follow-up TCD performed in 35 patients showed complete PFO closure in 20 patients (57.1%). Out of 35 patients, 22 (62.9%) reported having a migraine before the procedure with an intensity of headaches at 8.1 ± 1.9 on a scale from 1 to 10. During 2 years of follow-up, symptoms of a migraine disappeared in 4 (18.2%) and the remaining 18 patients reported the significant decrease in intensity 4.8 ± 2.04 (p = 0.0001). In addition, following PFO closure the incidence of the headaches decreased significantly (p = 0.0001). CONCLUSIONS: Percutaneous transcatheter closure of PFO is a safe and effective procedure showing mid-term relief of neurological symptoms in patients as well as significant reduction of migraine symptoms.

The assessment of soil availability and wheat grain status of zinc and iron in Serbia: Implications for human nutrition.

The deficiency of zinc (Zn) and iron (Fe) is a global issue causing not only considerable yield losses of food crops but also serious health problems. We have analysed Zn and Fe concentrations in the grains of two bread wheat cultivars along native gradient of micronutrient availability throughout Serbia. Although only 13% of the soil samples were Zn deficient and none was Fe deficient, the levels of these micronutrients in grain were rather low (median values of 21 mg kg(-1) for Zn and 36 mg kg(-1) for Fe), and even less adequate in white flour. Moreover, excessive P fertilization of calcareous soils in the major wheat growing areas strongly correlated with lower grain concentration of Zn. Our results imply that a latent Zn deficiency in wheat grain poses a high risk for grain quality relevant to human health in Serbia, where wheat bread is a staple food.

Wheat breadmaking properties in dependance on wheat enzymes status and climate conditions.

The objective of this study was to evaluate albumins profile, proteolytic and amylolytic activity level and baking performance of wheat varieties grown in two production years with different climate conditions (2011 and 2012) in four locations. The results of ANOVA showed that variety, location, production year, and their interactions all had significant effects on all tested wheat quality parameters. The enzymatic activity and specific bread volume were mainly influenced by the variety. The samples from 2012 production year, had the lower values of albumin content, proteolytic and amylolytic activity, and bread specific volume. The correlation analysis, performed for 2011 production year, showed that albumin fraction (15-30 kDa) and proteolytic activity were negatively correlated with bread specific volume indicating the role of this fraction on lowering the crucial bread quality parameter. In 2012 production year, albumin fractions (5-15 kDa; 50-65 kDa) showed the most correlations, especially with parameters of bread quality.

Intramuscular cavernous hemangioma in the left soleus muscle: successful surgical treatment.

We describe here the case of a 16-year-old boy successfully treated at our hospital for intramuscular cavernous hemangioma in the left soleus muscle. The patient was diagnosed using magnetic resonance imaging and open biopsy after attempted/failed surgery at another institution. We performed lower leg phlebography in order to identify all the feeding and draining veins of the cavernous hemangioma. Our surgical approach of ligation of the feeding and draining veins of the intramuscular cavernous hemangioma with subsequent thrombosis of the hemangioma proved successful, resulting in cure with no operative or postoperative complications, a minimal hospital stay and a good functional and cosmetic outcome.

Resuscitation after prolonged cardiac arrest: effects of cardiopulmonary bypass and sodium-hydrogen exchange inhibition on myocardial and neurological recovery.

OBJECTIVE: To determine if cardiopulmonary bypass (CPB), together with inhibition of the sodium-hydrogen exchanger (NHE), limits myocardial and neurological injury and improves recovery after prolonged (unwitnessed) cardiac arrest (CA), as NHE inhibition improved recovery after deep hypothermic circulatory arrest. METHODS: Twenty-seven pigs (31-39 kg) underwent 15 min of prolonged (no-flow) CA followed by 10 min of cardiopulmonary resuscitation-advanced life support (CPR-ALS). Subjects with restoration of spontaneous circulation (ROSC) during CPR-ALS received either no drug (n=6) or an inhibitor of the NHE (HOE-642; n=5). In the 16 unsuccessfully resuscitated animals, peripheral normothermic CPB was instituted, and either no drug (n=9) or similar HOE-642 (n=7) therapy started. Hemodynamic data, a species-specific neurological deficit score (0=normal to 500=brain death), and mortality were recorded at 24h, and biochemical variables of organ injury measured. RESULTS: CPR-ALS restored ROSC in 41% (11/27) of animals, but was unsuccessful in 59% (16/27) that required CPB. Without CPB, HOE-642 increased cardiac index and decreased vascular resistance; with CPB, HOE-642 caused higher pump flows (3.4±0.6 l min(-1)m(-2) vs 2.5±0.7 l min(-1)m(-2); p<0.001) and higher post-arrest cardiac index; but animals required more vasopressors (p=0.019) from drug-induced vasodilation. No differences between biochemical markers of oxidative and organ injury and overall 24-h mortality (20%) were found between groups. Neurological score was improved at 24h compared with 4h only after HOE-642 treatment with (150±34 vs 220±43; p=0.003) or without CPB (162±39 vs 238±48; p≤0.001), but failed to reach statistical difference with respect to the untreated group. CONCLUSIONS: CPB is an effective resuscitative tool to treat prolonged CA but there is limited improvement of neurological function. NHE inhibition augments cardiac and neurological function, but its effect was less pronounced than in other studies.

Resuscitation after prolonged cardiac arrest: role of cardiopulmonary bypass and systemic hyperkalemia.

BACKGROUND: The purpose of this study was to determine (1) the role of emergency cardiopulmonary bypass (CPB) after prolonged cardiac arrest and failed cardiopulmonary resuscitation, and (2) the use of systemic hyperkalemia during CPB to convert intractable ventricular fibrillation (VF). METHODS: Thirty-one pigs (34 +/- 2 kg) underwent 15 minutes of cardiac arrest after induced VF, followed by 10 minutes of cardiopulmonary resuscitation-advanced life support. Peripheral CPB was used if cardiopulmonary resuscitation failed to restore stable circulation. Damage was assessed by evaluating hemodynamics, biochemical variables (creatine kinase-MB, neuron-specific enolase), neurologic deficit score, and brain magnetic resonance imaging. RESULTS: Cardiopulmonary resuscitation alone was successful in only 19% (6 of 31 pigs). Cardiopulmonary bypass was initiated in 81% of animals (25 of 31 pigs) either for hypotension (5 of 25 pigs) or intractable VF (20 of 25 pigs). Defibrillation was successful in 7 of 20 animals during the first 10 minutes after initiating CPB. Ventricular fibrillation persisted more than 10 minutes in 13 of 20 pigs, and animals were treated either with repeated defibrillation (6 of 13 pigs) or with a potassium bolus (7 of 13 pigs) to induce transient cardiac arrest. Overall survival at 24 hours was 84% with cardiopulmonary resuscitation (100% of pigs with hypotension; 71% in CPB-VF < 10 minutes). Despite CPB, fatal myocardial failure occurred after VF duration of more than 10 minutes in all pigs treated with electrical defibrillation, whereas hyperkalemia allowed 100% cardioversion and 86% survival. Biochemical variables remained elevated in all groups. Similarly, severe brain injury was present in all animals as confirmed by neurologic deficit score (197 +/- 10) and magnetic resonance imaging. CONCLUSIONS: Emergency CPB after prolonged cardiac arrest improves survival and allows systemic hyperkalemia to convert intractable VF, but fails to reduce neurologic damage.

Dual left anterior descending artery distribution.

Dual left anterior descending (LAD) coronary artery with distribution of the vessels from the left main coronary artery and the right aortic sinus of Valsalva is a rare coronary anomaly. Here, we report such a rare anomaly in a young female with anterior wall myocardial infarction and stenting of the 'short' LAD coronary artery, which was subsequently confirmed in the operating room and by multi-slice cardiac computerized tomography after surgery.

Amplatzer occlusion of paravalvular leak of mitral mechanical prosthesis following a reoperation for thrombosed mitral mechanical prosthesis.

We describe a case of a 46-year-old woman with dehiscence and paravalvular leak of a second-time replaced mitral mechanical prosthesis, successfully treated with Amplatzer occlusion of the paravalvular leak, thus avoiding a second reoperation and improving the patient's symptoms.

Suture line reinforcement using suction-assisted bioglue application during surgery for acute aortic dissection.

Bioglue has been widely and variously applied in treating acute aortic dissection according to the pathological process and surgeon's preference. This publication outlines a new hemostatic technique using suction-assisted bioglue application for aortic suture line reinforcement during surgery on acute aortic dissection. Twenty consecutive patients were treated in our center for acute aortic dissection using this technique. There were no bleeding complications during surgery and there were no re-explorations or early deaths as a result of bleeding. Average daily chest tube drainage was 582+/-150 ml/day, with the duration of drainage of 2+/-0.9 days. In conclusion, this new hemostatic technique is simple to use and demonstrates excellent, immediate and early postoperative results.

The effect of ventricular sequential contraction on helical heart during pacing: high septal pacing versus biventricular pacing.

OBJECTIVE: To investigate the effect of biventricular and high septal pacing on the normal contraction sequence of the helical ventricular myocardial band, and its impact on left ventricular function. METHODS: Ten pigs (25-68 kg) underwent analysis of percent segmental shortening (SS%) by sonomicrometry, with crystals placed along the fiber orientation of the ascending, descending segments, and posterior LV wall within the spatial geometry of the helical heart. Unipolar pacing electrodes stimulated the right atrium (RA) and either the right ventricular apex and left ventricular posterior wall (atrio-biventricular), or the proximal high septum (atrio-high septal). Systemic hemodynamics, QRS-interval, cardiac index (CI), systolic and diastolic LV functions and pressure-dimension loops (P-D) were analyzed and cardiac motion was monitored by video analysis. RESULTS: Pacing increased normal sinus heart rate (NSR) from 77+/-9 beats/min to 98+/-5 beats/min. Atrial pacing did not change the NSR hemodynamic variables. Conversely, atrio-biventricular pacing prolonged the QRS-interval (91+/-14 ms vs 56+/-11 ms at baseline, p<0.05) and decreased mean arterial pressure (50+/-4 mmHg vs 58+/-12 mmHg), CI (3.4+/-0.3 L/(min m2) vs 4.0+/-0.8 L/(min m2)) and PRSW (71+/-25%) compared to NSR (p<0.05). Furthermore, atrio-biventricular pacing decreased SS% in all segments, especially at the LV posterior wall (71% of baseline, p<0.05), and disrupted the NSR shortening sequence (progression from descending to posterior to ascending regions). Changes were characterized by premature stimulation of the posterior wall segment adjacent to the pacer stimulus, with associated (1) decrease of pressure-dimension loop area, (2) desynchronization of P-D loops and (3) consistent loss of the twisting pattern of visible cardiac motion. In contrast, atrio-high septal pacing restored systemic hemodynamics, LV systolic and diastolic functions to baseline values and preserved the normal sequence of shortening of the ventricular myocardial band. CONCLUSIONS: (1) Biventricular pacing disrupts of the natural sequence of shortening of the myocardial band and results in impaired LV function. (2) High septal pacing preserves the sequential shortening pattern of the myocardial band and LV function.

Sequential deformation and physiological considerations in unipolar right or left ventricular pacing.

OBJECTIVE: To determine the effects of ventricular pacing on the normal contraction sequence of the helical ventricular myocardial band, and its' impact on left ventricular function. METHODS: Ten pigs (25-68 kg) underwent analysis of percent segmental shortening (%SS) by sonomicrometry, with crystals placed along the fiber orientation of the ascending and descending segments, and posterior LV wall of the geometry of the helical heart. Unipolar pacing electrodes stimulated either the right atrium (RA), right ventricular apex (RVA) and outflow tract (RVOT), or posterior LV wall. Systemic hemodynamics, QRS-interval, cardiac index (CI), systolic and diastolic LV function and pressure-dimension (P-D) loops were analyzed and cardiac motion was monitored by video analysis. RESULTS: Normal sinus heart rate (NSR) was elevated from 84+/-15 beats/min to 113+/-22 beats/min by pacing (p<0.05). The variables of NSR were not changed by atrial pacing. Conversely, compared with NSR, ventricular pacing (RVA, RVOT, LV) significantly (p<0.05) prolonged the QRS-interval (94-111 ms vs 52+/-7 ms, p<0.05) decreased mean arterial pressure (46-47 mmHg vs 62+/-11 mmHg), CI (2.7-3.4 L/(min m2) vs 4.9+/-0.9L/(min m2)) and systolic LV pressure (56-61 mmHg vs 92+/-10 mmHg). Furthermore, ventricular pacing decreased peak +dP/dt and -dP/dt (p<0.05) and lowered PRSW to 59-77%, with most profound change after RVA pacing (p<0.05). Each ventricular pacing intervention decreased SS% significantly in the descending, ascending, and posterior LV segments compared with NSR. Disruption of the normal NSR sequence of shortening (progression from descending to posterior to ascending regions) followed each pacing intervention. Changes were characterized by premature stimulation of the segment adjacent to the pacer stimulus, with associated (1) decrease of pressure-dimension loop area, (2) desynchronization of P-D loops and (3) consistent loss of the twisting pattern of visible cardiac motion. CONCLUSIONS: Ventricular pacing disrupts the natural sequence of shortening along the myocardial band, and the resultant dyssynchrony impairs LV function.

Septal structure and function relationships parallel the left ventricular free wall ascending and descending segments of the helical heart.

OBJECTIVE: Determine if ventricular septum structure and function relationships parallel the left ventricular free wall descending and ascending segments of the helical heart. METHODS: Forty pigs (30-38 kg) were studied physiologically by sonomicrometer to determine if septal fiber orientation resembled responses in the free wall. Following pilot studies in the non-bypassed heart, a right ventriculotomy was made to place septum crystals with fiber orientations that were either perpendicular to or reflected simultaneous free wall measurements. Postbypass measurements tested responses to positive (dopamine) and negative (esmolol) inotropic agents. RESULTS: Similar oblique fiber directions were found for baseline percent systolic shortening (SS%) in the free wall and septum; free wall descending and ascending SS% were 21+/-3% and 10+/-3%, and 13+/-2% and 12+/-2%, respectively, in the septum. Conversely, impaired shortening occurred when transverse fiber direction was tested. Both oblique areas demonstrated comparable time-delay changes between free wall and septal descending and ascending segment at onset (75+/-11 ms) and termination (86+/-21 ms) of contraction. Dopamine increased heart rate and caused a similar increase of free wall descending and ascending segment SS% to 24+/-2% and 14+/-3% (p<0.05), and septal SS% response to 16+/-2% and 15+/-2% (p<0.05), and comparable decrease of time-delay changes of shortening between ascending and descending segments of 54+/-6 ms and 68+/-10 ms, respectively (p<0.05). Conversely, esmolol decreased heart rate and similarly reduced SS% in left ventricular free wall (descending: 18+/-4%; ascending: 7+/-4%; p<0.05) and septum (descending: 10+/-2%; ascending: 10+/-3%; p<0.05). Time-delay of contraction between segments was increased to 91+/-4 ms (p<0.05), but the hiatus at the end of shortening remained unchanged, due to prolonged endocardial contraction. CONCLUSIONS: Septal structure and function relationships parallel the left ventricular free wall ascending and descending segments, thereby supporting the helical heart fiber spatial relationships. The oblique fiber orientation may make the septum become the 'lion of right ventricular function'.