Perioperative dental screening and treatment in patients undergoing cardiothoracic surgery and interventional cardiovascular procedures. A consensus report based on RAND/UCLA methodology.

AIM: To reach a consensus on a consistent strategy to adopt when screening patients for dental/periodontal infections and on the feasibility of providing dental treatment before cardiothoracic surgery, cardiovascular surgery or other cardiovascular invasive procedures. METHODOLOGY: A panel of experts from six Italian scientific societies was created. The deliberations of the panel were based on the RAND method. From an initial systematic literature review, it became clear that a consensually validated protocol for the reproducible dental screening of patients awaiting cardiac interventions was considered mandatory by professionals with expertise in the dental, cardiologic and cardiac surgery areas. However, a systematic review also concluded that the treatment options to be provided, their prognosis and timing in relation to the physical condition of patients, had never been defined. Following the systematic review, several fundamental questions were generated. The panel was divided into two working groups each of which produced documents that addressed the topic and which were subsequently used to generate a questionnaire. Each member of the panel completed the questionnaire independently, and then, a panel discussion was held to reach a consensus on how best to manage patients with dental/periodontal infections who were awaiting invasive cardiac procedures. RESULTS: A high level of agreement was reached regarding all the items on the questionnaire, and each of the clinical questions formulated were answered. Three tables were created which can be used to generate a useful tool to provide standardized dental/periodontal screening of patients undergoing elective cardiovascular interventions and to summarize both the possible oral and cardiovascular conditions of the patient and the timing available for the procedures considered. CONCLUSIONS: Upon publication of this consensus document, the dissemination of the information to a wide dental and cardiac audience should commence. The authors hope that this consensus will become a model for the development of a dedicated protocol, ideally usable by heart and dental teams in the pre-interventional preparation phase.

Perioperative dental screening and treatment in patients undergoing cardio-thoracic surgery and interventional cardiovascular procedures. A consensus report based on RAND/UCLA methodology.

AIM: To reach a consensus on a consistent strategy to adopt when screening patients for dental/periodontal infections, and on the feasibility of providing dental treatment before cardiothoracic surgery, cardiovascular surgery or other cardiovascular invasive procedures. METHODOLOGY: A panel of experts from six Italian scientific societies was created. The deliberations of the panel were based on the RAND method. From an initial systematic literature review, it became clear that a consensually validated protocol for the reproducible dental screening of patients awaiting cardiac interventions was considered mandatory by professionals with expertise in the dental, cardiologic and cardiac surgery areas. However, systematic review also concluded that the treatment options to be provided, their prognosis and timing in relation to the physical condition of patients had never been defined. Following the systematic review several fundamental questions were generated. The panel was divided into two working groups each of which produced documents that addressed the topic and which were subsequently used to generate a questionnaire. Each member of the panel completed the questionnaire independently and then a panel discussion was held to reach a consensus on how best to manage patients with dental/periodontal infections who were awaiting invasive cardiac procedures. RESULTS: A high level of agreement was reached regarding all the items on the questionnaire, and each of the clinical questions formulated were answered. Three tables were created which can be used to generate a useful tool to provide standardized dental/periodontal screening of patients undergoing elective cardiovascular interventions, and to summarize both the possible oral and cardiovascular conditions of the patient and the timing available for the procedures considered. CONCLUSIONS: Upon publication of this consensus document, the dissemination of the information to a wide dental and cardiac audience should commence. The authors hope that this consensus can become a model for the development of a dedicated protocol, ideally usable by heart and dental teams in the pre-interventional preparation phase.

On-pump Cardiac Surgery Enhances Platelet Renewal and Impairs Aspirin Pharmacodynamics: Effects of Improved Dosing Regimens.

On-pump cardiac surgery may trigger inflammation and accelerate platelet cyclooxygenase-1 renewal, thereby modifying low-dose aspirin pharmacodynamics. Thirty-seven patients on standard aspirin 100 mg once-daily were studied before surgery and randomized within 36 hours postsurgery to 100 mg once-daily, 100 mg twice-daily, or 200 mg once-daily for 90 days. On day 7 postsurgery, immature and mature platelets, platelet mass, thrombopoietin, glycocalicin, leukocytes, C-reactive protein, and interleukin-6 significantly increased. Interleukin-6 significantly correlated with immature platelets. At day 7, patients randomized to 100 mg once-daily showed a significant increase in serum thromboxane (TX)B2 within the 24-hour dosing interval and urinary TXA2 metabolite (TXM) excretion. Aspirin 100 mg twice-daily lowered serum TXB2 and prevented postsurgery TXM increase (P < 0.01), without affecting prostacyclin metabolite excretion. After cardiac surgery, shortening the dosing interval, but not doubling the once-daily dose, rescues the impaired antiplatelet effect of low-dose aspirin and prevents platelet activation associated with acute inflammation and enhanced platelet turnover.

Vascular Complications following Isolated Limb Perfusion for Local Recurrence of Extremity Melanoma: A Case Report and Literature Review.

Introduction. To evaluate the role of hyperthermic isolated limb perfusion (HILP) in arterial thrombosis following melanoma-soft tissue sarcoma chemotherapy. Report. Here is presented one case of iliac-common femoral artery subacute thrombosis and a review of the appropriate literature performed using a MEDLINE search. Acute/subacute arterial occlusion is one of the most feared vascular complications of HILP, located nearly always in the external iliac-femoral artery axis, being those vessels cannulated for perfusion. Conclusions. The small number of reported cases indicates either the rarity of this complication or unawareness of its existence. The true incidence of this complication is probably underreported.

Tissue factor induction by protease-activated receptor 1 requires intact caveolin-enriched membrane microdomains in human endothelial cells.

BACKGROUND: Protease-activated receptors (PARs) comprise a family of G-protein-coupled receptors with a unique mechanism of proteolytic activation. PARs regulate a broad range of cellular functions and are active in the pathogenesis of disorders characterized by chronic inflammation or activation of the coagulation cascade. Signaling through PAR1 and PAR2 shifts the endothelium towards a prothrombotic phenotype, thereby exacerbating the initial pathophysiologic condition. OBJECTIVES: This study aimed to analyze the localization of PARs in the cell membrane and how their compartmentalization affects tissue factor (TF) in human endothelial cells. METHODS: TF expression was determined by quantitative real-time polymerase chain reaction analysis and by activity assays. The interaction of PARs with caveolin was investigated through: (i) caveolin-1 gene knockdown performed by transfection with specific small interfering RNA (siRNA); (ii) caveolin-enriched membrane microdomain disruption; and (iii) coimmunoprecipitation assay. RESULTS: We have shown that PAR1, but not PAR2, is present in endothelial caveolin-enriched membrane microdomains, where it is bound to caveolin-1, and that these structures must be intact if PAR1-induced signaling is to increase TF activity. Cholesterol depletion of endothelial cells by cholesterol-sequestering agents caused the PAR1 to relocate to high-density membranes, and impaired the induction of TF (P < 0.01) without affecting the PAR2-mediated procoagulant effect. In addition, siRNA directed against caveolin-1 inhibited TF activation by PAR1 (P < 0.01 and P < 0.01, respectively). CONCLUSIONS: PAR1 localization in the caveolin-enriched membrane microdomain, bound to caveolin-1, represents a crucial requirement for TF induction in endothelial cells.

First report of an unusual, rare complication of pregnancy: rupture of multiple lienal vein aneurysms.

Lienal vein aneurysms are a very unusual pathology. Usually they are extremely rare incidental findings, associated with many diseases as hepatic cirrhosis, portal hypertension and other conditions as pregnancy. We report here the case of death of a mother and her fetus at the third trimester of her third pregnancy due to haemoperytoneum for rupture of aneurysm. The autoptic examination revealed the presence of three fusiform and saccular aneurysms of the lineal vein. The histopathological features of aneurysms' wall are described. The aetiopathogenetic hypothesis of the lesion is discussed. To our knowledge this is the first case report describing the sudden death of pregnant woman and fetus from a rupture of maternal lineal vein aneurysm, complication of multiple aneurysms.

Distinct roles for PAR1- and PAR2-mediated vasomotor modulation in human arterial and venous conduits.

BACKGROUND: Patency rates after coronary artery bypass grafting (CABG) are better if the internal mammary artery (IMA) is used rather than the greater saphenous vein (GSV), and may be related to the endothelial release of vasodilators antagonizing vascular contraction. It has recently been shown that a family of protease-activated receptors (PARs) modulate endothelium-dependent vasodilatation. OBJECTIVE AND METHODS: The aim of this study was to evaluate the presence and functional role of protease-activated receptor 1 (PAR1) and protease-activated receptor 2 (PAR2) in mediating vascular tone in IMAs and GSVs from patients undergoing CABG by means of real time-PCR and isometric tension measurements. RESULTS: PAR1 mRNA levels were higher than those of PAR2 mRNA in both vessels. A selective PAR2-activating peptide (PAR2-AP), SLIGKV-NH(2) (0.01-100 micromol L(-1)), failed to induce vasorelaxation in precontracted IMA and GSV rings, whereas the selective PAR1-AP, TFLLR-NH(2) (0.001 to 10 micromol L(-1)), caused greater endothelium-dependent relaxation in the IMAs (pD(2) values 7.25 +/- 0.6 vs. 7.86 +/- 0.42, P < 0.05; E(max) values 56.2 +/- 17.3% vs. 29.7 +/- 13.4%, P < 0.001). Preincubation with TNFalpha (3 nmol L(-1)) induced vasorelaxation in IMAs in response to PAR2-AP (P < 0.05 vs. non-stimulated vessels); the response to PAR1-AP was unchanged. The relaxation induced by both PAR-APs was NO- and endothelium-dependent. CONCLUSION: These data show that functionally active PAR1 and PAR2 are present in IMAs and GSVs, and that inflammatory stimuli selectively enhance endothelium-dependent relaxation to PAR2-AP in IMAs.

Plexiform lipoleiomyoma of the uterus: first case report.

We describe the first report of plexiform lipoleiomyoma with amyloid stroma. A 57-year-old woman underwent an abdominal hysterectomy for methrorragia. The hysterectomy specimen exhibited a soft, rubbery, encapsulated 11 cm ovoid mass with aciniform, white cut surface on the right edge of the uterus. The histology was distinctive and typical of plexiform lipoleiomyoma: long cords, strands and small nests of cells embedded in a collagenous matrix. The neoplastic cells showed eosinophilic cytoplasm, crumpled, bland nuclei. Scattered islands of mature adipocytes were distributed throughout the leiomyomatous proliferation. Immunohistochemistry showed positivity for smooth muscle actin in the plexiform component, and for S100 in the adipocytes. Histogenesis and origin of the cellular neoplastic component are discussed.

Coronary blood flow, metabolism, and function in dysfunctional viable myocardium before and early after surgical revascularisation.

OBJECTIVES: To assess the link between perfusion, metabolism, and function in viable myocardium before and early after surgical revascularisation. DESIGN: Myocardial blood flow (MBF, thermodilution technique), metabolism (lactate, glucose, and free fatty acid extraction and fluxes), and function (transoesophageal echocardiography) were assessed in patients with critical stenosis of the left anterior descending coronary artery (LAD) before and 30 minutes after surgical revascularisation. SETTING: Tertiary cardiac centre. PATIENTS: 23 patients (mean (SEM) age 57 (1.7) years with LAD stenosis: 17 had dysfunctional viable myocardium in the LAD territory, as shown by thallium-201 rest redistribution and dobutamine stress echocardiography (group 1), and six had normally contracting myocardium (group 2). RESULTS: LAD MBF was lower in group 1 than in group 2 (58 (7) v 113 (21) ml/min, p < 0.001) before revascularisation and improved postoperatively in group 1 (129 (133) ml/min, p < 0.001) but not in group 2 (105 (20) ml/min, p = 0.26). Group 1 also had functional improvement in the LAD territory at intraoperative echocardiography (mean regional wall motion score from 2.6 (0.85) to 1.5 (0.98), p < 0.01). Oxidative metabolism, with lactate and free fatty acid extraction, was found preoperatively and postoperatively in both groups; however, lactate and free fatty acid uptake increased after revascularisation only in group 1. CONCLUSIONS: MBF is reduced and oxidative metabolism is preserved at rest in dysfunctional but viable myocardium. Surgical revascularisation yields immediate perfusion and functional improvement, and increases the uptake of lactate and free fatty acids.

Off-pump redo coronary artery bypass grafting: technical aspects and early results.

BACKGROUND: Redo coronary artery bypass grafting (CABG) represents an high-risk surgical procedure, because of an increased incidence of perioperative death, myocardial infarction and stroke. Theoretically, the avoidance of cardiopulmonary bypass may reduce surgical traumatism and ameliorate early results. MATERIALS AND METHODS: From January 1995 to May 2001, we performed 123 redo CABGs, of which 53 (44%) off-pump. Off-pump procedure represented respectively 90% of redo CABG in the period 2000-2001 versus 30% in the 1995-1999 period. The mean age was 66.4 years, males were 39 (73%). The mean 2D-echo ejection fraction was 56% and in 9 cases (17%) was less than 40%. Three operations (5.6%) were performed on an urgent base. The access was median sternotomy in all cases. The mean number of grafts per patient was 1.9 (1.7 in the period 1995-99 vs. 2.3 in the period 2000-01, p=0.01). In 20 cases (38%) we grafted the circumflex artery branches (19% in the period 1995-99 vs. 55.5% in the period 2000-01, p=0.015). Improvements in surgical techniques were achieved over time. The current operative strategy includes the use of deep traction stitches in the posterior pericardium and wall stabilizers to expose target vessels, coronary intraluminal shunts during construction of the anastomoses and continuous trans-esophageal echocardiographic monitoring. Urgent conversion to on-pump procedure was not required in any case. RESULTS: We recorded no in-hospital death, one perioperative myocardial infarction (1.9%), one fifth postoperative day-stroke (1.9%) and 9 atrial fibrillations (17%). Mediastinal re-exploration for bleeding was performed in no one patient; 13 patients (24.5%) required postoperative blood transfusion. The mean length of postoperative stay was 7.5 days, ranging from 6 to 18 days. CONCLUSIONS: In our experience off-pump redo CABG is a safe and effective alternative to on-pump procedure and now off-pump is our first choice-technique in redo CABG. A complete revascularization is technically feasible with a low incidence of perioperative complications.

[Banks of vascular homografts]. / Banking degli omoinnesti vascolari.

We define as Banking of the tissues all the procedures that include the finding, preparation, conservation and distribution of the homograft. The vascular homografts are taken and put into a solution of transportation at +4 degrees C and kept at this temperature till their arrival at the Bank. The following step is the dissection of the homograft which will have to be performed as quickly as possible at most 24 hours after the taking in conditions of maximum sterility. At the Italian Homograft Bank at Centro Cardiologico, the vascular homografts are kept at +4 degrees C for 96 hours on average with antibiotics. After a phase of sterilization at +4 degrees C the tissue is frozen according to a homogeneous and controlled thermic decrease and stored at -150 degrees C/-180 degrees C in fumes of liquid nitrogen till the moment of their employment allowing a long term conservation. The aim of all these procedures of cryopreservation is to keep the structural and functional integrity of cells and tissues. The thermic decrease of the tissues must occur so that to avoid all the damages of the cellular vitality and functionality and especially of the tissue structure in toto. In order to limitate these events some cryoprotector agents are employed because they reduce the concentration of the solutes, the cellular dehydration, the formation of micro-macro crystals. Another step to establish if the homograft is proper is the study of bacteriological and viral aspects. The viral screenings are performed on the donor's blood and the bacteriological tests are performed on the tissue and on the liquids. For each phase of the banking a series of information about the donor and about the tissues are recorded and filed both on paper and database so that to grant always a right conduct of the material.

[Myocarcial revascularisation without extracorporeal circulation: current indications, surgical technique and results]. / La rivascolarizzazione coronarica senza circolazione extracorporea. Indicazioni attuali, tecnica chirurgica e risultati.

BACKGROUND: This study was undertaken to assess our experience of the evolution, over time, of beating heart surgery in the Cardiologic Center Foundation Monzino. METHODS: From March 1995 to June 2000, 506 patients underwent myocardial revascularization on beating heart: 313 until May 1999, and 193 between June 1999 and June 2000, after the advent of coronary artery stabilizers and shunts, to keep the surgical field bloodless, with minimal motion and continuous myocardial perfusion. Surgical accesss was via a median sternotomy for 408 cases and via a left anterior thoracotomy for 98 cases. RESULTS: The indications by choice increased, from I to II period, from 61% to 83% with special situations in which patients had three-vessel coronary artery disease raised from 33% to 50%, concerning also bypass grafts performed on circumflex artery and right coronary increased. Postoperative mortality in hospital decreased from 1.3% to 0.5% and perioperative IMA (acute myocardial infarction) from 3.8% to 0.5% in patients undertaken to median thoracotomy. Hospital stay decreased from 8 to 7 days about [no significant differences with patients who underwent CPB (cardiopulmonary bypass)]; in patients who underwent to MTS (left anterior minithoracotomy) there was no deaths, IMA decreased from 3.9% to 0% and hospital stay from 6 to 5 days. Grafts patency increased from 92.3% to 100%. CONCLUSIONS: To perform completed revascularisations is possible now even on the beating heart, and also to make precise anastomosis as on pump CABG, in a reproducible and easy way. The beating heart procedure, that is also more economical, might be expanded to all patients, not only high risk patients.

A preoperative index of mortality for patients undergoing surgery of type A aortic dissection.

BACKGROUND: The aim of this study was to identify and stratify the most important preoperative factors for in-hospital death after surgery for type A aortic dissection. METHODS: From January 1985 to June 1998, 108 patients underwent surgery for type A aortic dissection. 89.9% of the patients had an acute type A dissection (AD), whereas 11.1% had a chronic dissection (CD). Cardiac tamponade and shock occurred in 22% and 14.8% of the patients, respectively. The location of the primary intimal tear was in the ascending aorta in 71.2% of the cases, in the arch in 16.6% and in the descending aorta in 7.4%. Univariate and multivariate analyses were conducted to identify non-embolic variables independently correlated to in-hospital death. A predictive model of in-hospital mortality was then constructed by means of a mathematical method with the variables selected from logistic regression analysis. RESULTS: The overall in-hospital mortality rate was 20.3% (22/108 patients), being 9% for CD and 21.6% for AD. Emergent procedures had an in-hospital mortality rate of 47.6%, whereas non-emergent operations had an in-hospital mortality rate of 13.7% (p<0.01). Univariate analysis revealed among 39 preoperative and operative variables, age (years), age >70 years, remote myocardial infarction, cerebrovascular dysfunction, diabetes, preoperative renal failure, shock, cardiopulmonary bypass time (minutes), emergency operation as factors associated to in-hospital death (p<0.05). Stepwise logistic regression analysis selected as independent predicting variables (p<0.05), remote myocardial infarction (p=0.006), preoperative renal failure (p=0.032), shock (p=0.001), age >70 years (p=0.007). Finally, a probability table of death risk was obtained with the logistic regression coefficients. The lower death probability (10.6%) was calculated in absence of risk variables; the higher one in presence of all of them (79.7%). Between these extremes, a total of 64 combinations of death risk were obtained. CONCLUSIONS: Increasing age, shock, coronary artery disease and renal failure are variously associated to a high risk of in-hospital death after surgical correction of type A aortic dissection. This predictive model of death probability allows to collocate preoperatively patients with type A aortic dissection at different levels of risk for in-hospital death.

[Inflammatory abdominal aortic aneurysms]. / Aneurismi infiammatori dell'aorta addominale.

The authors present a review of the literature on inflammatory abdominal aortic aneurysms. These aneurysms represent from 3 to 10% of all abdominal aortic aneurysms. Progress has occurred in the technical approach to these aneurysms, and operative morbidity and mortality have been remarkably reduced. However, the pathogenesis remains poorly understood. Early reports have considered the inflammatory aneurysm as a distinct clinical and pathological entity, whereas recent evidences suggest a common etiopathogenetic mechanism for both atherosclerotic and inflammatory aneurysms. Finally, genetic and environmental factors, such as tobacco use, may predispose certain persons to the development of non-inflammatory aneurysms and others to a wide spectrum of inflammatory reactions until inflammatory aneurysms development. The most common clinical features of these aneurysms are represented by symptoms, such as abdominal or back pain, obstructive uropathy and by an elevated erythrocyte sedimentation rate. Computed tomography (CT) allows a specific diagnosis by the typical image of soft tissue surrounding the aortic wall enhancing with contrast administration. Ultrasonography is less sensitive whereas nuclear magnetic resonance (RNM) is a promising technique. Excretory urography may suggest the diagnosis by demonstration of ureter entrapment. Surgical therapy, by a technique of limited dissection represents the definitive treatment. Evolution of fibrosis after surgery is still debated because some studies have reported complete regression of inflammation and other partial regression or persistence of fibrotic process. At present, endovascular treatment of these aneurysms is occasionally reported, although preliminary results appear satisfactory.

Centrifugal pump and reduction of neurological risk in adult cardiac surgery.

This study was performed to assess if the kind of pump used for CPB (roller vs. centrifugal) can influence neurological outcomes of adult cardiac surgery patients. Between 1994 and 1998, 3438 patients underwent coronary and/or valve surgery at our hospital; of these, 1805 (52.5%) underwent surgery with the use of a centrifugal pump, and 1633 (47.5%) were operated with a roller pump. The effect of the type of the pump and of common preoperative and intraoperative risk factors for five different neurological outcomes (permanent neurological deficit, coma, delirium, transient neurological deficit, overall neurological complications) were assessed with univariate and multivariate analyses in the whole patients population, in patients > or = 75 years old and in patients with histories of previous neurological events. Centrifugal pump use was the only protective factor for perioperative permanent neurological deficit in multivariable models developed for the whole patient population and for patients > or = 75 years old. In addition, it resulted as the only protective factor for perioperative coma occurrence in multivariable models developed for patients > or = 75 years old, and for patients with histories of previous neurological events. The use of the centrifugal pump provided a risk reduction for the considered events ranging from 23 to 84%. Centrifugal pump use can be helpful in reducing the occurrence of some of the most feared neurological complications of adult cardiac surgery patients.

Effect of valsartan on angiotensin II-induced plasminogen activator inhibitor-1 biosynthesis in arterial smooth muscle cells.

Previous studies have shown that angiotensin II stimulates the synthesis of plasminogen activator inhibitor-1 in cultured vascular cells, which suggests that activation of the renin-angiotensin system may impair fibrinolysis. We have investigated the effects of angiotensin II and of valsartan, a recently developed angiotensin II antagonist that is highly specific and selective for the angiotensin II subtype 1 receptor, on plasminogen activator inhibitor-1 secretion by smooth muscle cells isolated from rat and human vessels. Angiotensin II induced a time- and concentration-dependent increase of plasminogen activator inhibitor activity in supernatants of rat aortic cells, which reached a plateau after 6 hours of incubation with 100 nmol/L angiotensin II (2.4+/-0.6-fold over control value; P:<0.001). The angiotensin II-induced plasminogen activator inhibitor activity was inhibited, in a concentration-dependent manner, by valsartan with an IC(50) value of 21 nmol/L. Valsartan fully prevented the angiotensin II-induced increase in plasminogen activator inhibitor-1 protein and mRNA. Furthermore, angiotensin II doubled the secretion of plasminogen activator inhibitor-1 by smooth muscle cells obtained from human umbilical and internal mammary arteries, and valsartan fully prevented it. Angiotensin II did not affect the secretion of tissue plasminogen activator antigen by any of the cell systems tested. Thus, valsartan effectively inhibits angiotensin II-induced plasminogen activator inhibitor-1 secretion without affecting that of tissue plasminogen activator in arterial rat and human smooth muscle cells.