Blood and lymphatic vessels contribute to the impact of the immune microenvironment on clinical outcome in non-small-cell lung cancer.

OBJECTIVES: Lymphangiogenesis plays a critical role in the immune response, tumour progression and therapy effectiveness. The aim of this study was to determine whether the interplay between the lymphatic and the blood microvasculature, tumour-infiltrating lymphocytes and the programmed death 1 (PD-1)/programmed death ligand 1 (PD-L1) immune checkpoint constitutes an immune microenvironment affecting the clinical outcome of patients with non-small-cell lung cancer. METHODS: Samples from 50 squamous cell carcinomas and 42 adenocarcinomas were subjected to immunofluorescence to detect blood and lymphatic vessels. CD3pos, CD8pos and PD-1pos tumour-infiltrating lymphocytes and tumour PD-L1 expression were assessed by immunohistochemical analysis. RESULTS: Quantification of vascular structures documented a peak of lymphatics at the invasive margin together with a decreasing gradient of blood and lymphatic vessels from the peritumour area throughout the neoplastic core. Nodal involvement and pathological stage were strongly associated with vascularization, and an increased density of vessels was detected in samples with a higher incidence of tumour-infiltrating lymphocytes and a lower expression of PD-L1. Patients with a high PD-L1 to PD-1 ratio and vascular rarefaction had a gain of 10 months in overall survival compared to those with a low ratio and prominent vascularity. CONCLUSIONS: Microvessels are an essential component of the cancer immune microenvironment. The clinical impact of the PD-1/PD-L1-based immune contexture may be implemented by the assessment of microvascular density to potentially identify patients with non-small-cell lung cancer who could benefit from immunotherapy and antiangiogenic treatment.

International Expert Consensus on Sutureless and Rapid Deployment Valves in Aortic Valve Replacement Using Minimally Invasive Approaches.

OBJECTIVE: To define the benefit of sutureless and rapid deployment valves in current minimally invasive approaches in isolated aortic valve replacement. METHODS: A panel of 28 international experts with expertise in both minimally invasive aortic valve replacement and rapid deployment valves was constituted. After thorough literature review, the experts rated evidence-based recommendations in a modified Delphi approach. RESULTS: No guideline could be retrieved. Thirty-three clinical trials and 9 systematic reviews could be identified for detailed text analysis to obtain a total of 24 recommendations. After rating by the experts 12, final recommendations were identified: preoperative computed tomographic scan as well as intraoperative transesophageal echocardiography are highly recommended. Suitable annular sizes are 19 to 27 mm. There is a contraindication for bicuspid valves only for type 0 and for annular abscess or destruction due to infective endocarditis. The use of sutureless and rapid deployment valves reduces extracorporeal circulation and aortic cross-clamp time and leads to less early complications as prolonged ventilation, blood transfusion, atrial fibrillation, pleural effusions, paravalvular leakages and aortic regurgitation, and renal replacement therapy, respectively. These clinical outcomes result in reduced intensive care unit and hospital stay and reduced costs. The use of sutureless and rapid deployment valves will lead to a higher adoption rate of minimally invasive approaches in aortic valve replacement. Respect should be taken to a necessary short learning curve for both sutureless and minimally invasive programs. CONCLUSIONS: Sutureless and rapid deployment aortic valve replacement together with minimally invasive approaches offers an attractive option in aortic valve placement for patients requiring biological valve replacement.

Minimally invasive aortic valve replacement with a sutureless valve through a right anterior mini-thoracotomy versus transcatheter aortic valve implantation in high-risk patients.

OBJECTIVES: The aim of this study was to compare early outcomes and mid-term survival of high-risk patients undergoing minimally invasive aortic valve replacement through right anterior mini-thoracotomy (RT) with sutureless valves versus patients undergoing transcatheter aortic valve implantation (TAVI) for severe aortic stenosis. METHODS: From October 2008 to March 2013, 269 patients with severe aortic stenosis underwent either RT with perceval S sutureless valves (n = 178 patients, 66.2%) or TAVI (n = 91, 33.8%: 44 transapical and 47 trans-femoral). Of these, 37 patients undergoing RT with the perceval S valve were matched to a TAVI group by the propensity score. RESULTS: Baseline characteristics were similar in both groups (mean age 79 ± 6 years) and the median logistic EuroSCORE was 14% (range 9-20%). In the matched group, the in-hospital mortality rate was 8.1% (n = 3) in the TAVI group and 0% in the RT group (P = 0.25). The incidence rate of stroke was 5.4% (n = 2) versus 0% in the TAVI and RT groups (P = 0.3). In the TAVI group, 37.8% (n = 14) had mild paravalvular leakage (PVL) and 27% (n = 10) had moderate PVL, whereas 2.7% (n = 1) had mild PVL in the RT group (P < 0.001). One- and 2-year survival rates were 91.6 vs 78.6% and 91.6 vs 66.2% in patients undergoing RT with the perceval S sutureless valve compared with those undergoing TAVI, respectively (P = 0.1). CONCLUSIONS: Minimally invasive aortic valve replacement with perceval S sutureless valves through an RT is associated with a trend of better early outcomes and mid-term survival compared with TAVI.

Early and long-term outcomes of minimally invasive mitral valve surgery through right minithoracotomy: a 10-year experience in 1604 patients.

BACKGROUND: To report early and long-term outcomes of patients undergoing minimally invasive mitral valve surgery (MIMVS) through right mini-thoracotomy (RT) over a 10-year period. METHODS: From September 2003 to December 2013, a total of 1604 consecutive patients underwent MIMVS through RT. RESULTS: The mean age was 63 ± 13 years, 770 (48 %) patients were female and 218 (13.6 %) had previous cardiac operations. The most predominant pathology was degenerative disease (70 %), followed by functional mitral valve regurgitation (12 %), rheumatic disease (9.4 %), endocarditis (5 %) and prosthetic dysfunction (3.2 %). Mitral valve repair was performed in 1137 (71 %) patients and 476 (29 %) had mitral valve replacement. Direct aortic cannulation was achieved in 1325 (83 %) patients. Among patients with degenerative disease candidate for repair (n = 958), rate of mitral valve repair was 95 %. Repair techniques included annuloplasty (95 %), leafleat resection (63 %), neochordae implantation (16 %) and sliding plasty (11 %). Concomitant procedures included tricuspid valve repair (14.6 %), atrial fibrillation ablation (9.5 %) and atrial septal defect closure (3.2 %). Overall in-hospital mortality was 1.1 %. Thirty-four patients (2.1 %) had conversion to sternotomy. Incidence of stroke was 2 %. Overall survival at 10 years was 88 ± 2 %. Freedom from reoperation at 10 years was 94 ± 2 % for repair and 80 ± 6 % for replacement. Freedom from recurrent mitral regurgitation >3+ at 10 years was 90 ± 3 %. CONCLUSIONS: Minimally invasive mitral valve surgery is a safe and reproducible approach associated with low mortality and morbidity, high rate of mitral valve repair and excellent late results.

Isolation and Characterization of Human Lung Lymphatic Endothelial Cells.

Characterization of lymphatic endothelial cells from the respiratory system may be crucial to investigate the role of the lymphatic system in the normal and diseased lung. We describe a simple and inexpensive method to harvest, isolate, and expand lymphatic endothelial cells from the human lung (HL-LECs). Fifty-five samples of healthy lung selected from patients undergoing lobectomy were studied. A two-step purification tool, based on paramagnetic sorting with monoclonal antibodies to CD31 and Podoplanin, was employed to select a pure population of HL-LECs. The purity of HL-LECs was assessed by morphologic criteria, immunocytochemistry, flow cytometry, and functional assays. Interestingly, these cells retain in vitro several receptor tyrosine kinases (RTKs) implicated in cell survival and proliferation. HL-LECs represent a clinically relevant cellular substrate to study lymphatic biology, lymphoangiogenesis, interaction with microbial agents, wound healing, and anticancer therapy.

Cardioprotection by Targeting the Pool of Resident and Extracardiac Progenitors.

The adult heart has the capacity to generate new myocytes that are markedly enhanced in acute and chronic heart failure of ischemic and non-ischemic origin. In addition, a pool of blood trafficking progenitor cells able to sense myocardial damage may home to the sites of injury participating to cardiac repair. This new view of myocardial biology leads to an expanding long-term research and therapeutic goals for cardioprotection. A fundamental concept to be analyzed is whether cardiac diseases are influenced by changes in the properties of tissue specific and circulating progenitors. Loss of self-renewal capacity, impaired growth or increased susceptibility to death may lead to a reduction of progenitors and leave myocardial damage unrepaired. Cardiac progenitors generate all myocardial cell lineages, thus impairment in their growth is expected to be critically involved in the structural and functional modifications of the heart. The fact that, in addition to well known effects of anthracyclines, also new drugs that target molecular pathways implicated in cell death and growth can be cardiotoxic further supports our hypothesis. Understanding the role of resident and extracardiac progenitors in the pathogenesis of cardiomyopathies of different etiology will provide not only a better comprehension of cardiac homeostasis but will also open new avenues for therapeutic interventions. The progress toward effective myocardial regeneration based on exploiting the self-renewal potential of the myocardium and the systemic pool of cardiogenic cells should advance the likelihood of efficient cardioprotection and restoration of cardiac function.

Lung mesenchymal cells function as an inductive microenvironment for human lung cancer propagating cells†.

OBJECTIVES: The aim of the present study was to characterize the biological properties and in vivo tumourigenic potential of mesenchymal cells (MCs) obtained from non-small-cell lung cancer (NSCLC) samples. METHODS: NSCLC samples (53 adenocarcinomas and 24 squamous-cell carcinomas) surgically removed from 46 males and 31 females were processed to identify mesenchymal cells from human lung cancer (hLc-MCs). hLc-MCs were separated from neoplastic epithelial cells, expanded and extensively characterized in vitro. Subsequently, female BALB/c nude mice were subcutaneously injected with either 10(6) or 2.5 × 10(6) Calu-3 (human adenocarcinoma cell line able to reproducibly induce xenografted tumours) alone or in combination with equal doses of hLc-MCs. Control animals were injected with the two doses of hLc-MCs only. RESULTS: Primary cultures of hLc-MCs were obtained from >80% of NSCLC specimens. The typical MCs immunophenotype was documented by the expression of CD90, CD105, CD73, CD13 and CD44 at fluorescence-activated cell sorting analysis. CD45, CD14, CD34 and epithelial antigens were negative while CD117 (c-kit) and CD133 (prominin) were partially expressed. Interestingly, nuclear transcription factors octamer-binding transcription factor 3/4 and sex determining region Y-box 2 involved in stemness, thyroid transcription factor 1 in bronchoalveolar commitment, and ETS1 in carcinogenesis, were expressed in hLc-MCs isolated from NSCLC. Specific conditioned media and cocultures confirmed the supportive role of hLc-MCs for cancer cells. In vivo experiments showed that at both doses Calu-3 xenografts doubled in size when hLc-MCs were coinjected. Cell tracking in xenografted tumours, by immunofluorescence combined with fluorescence in situ hybridization analysis, documented hX-chromosome-labelled, Calu-3-derived cytokeratin-positive adenocarcinoma structures surrounded by hLc-MCs. CONCLUSIONS: Tumour-propagating cells require the inductive interaction of resident mesenchymal cells to foster lung cancer development.

Minimally invasive aortic valve replacement with Perceval S sutureless valve: early outcomes and one-year survival from two European centers.

OBJECTIVE: The aim of our study was to evaluate the early outcomes and 1-year survival of patients undergoing minimally invasive aortic valve replacement with the Perceval S sutureless valve for severe aortic stenosis. METHODS: From March 2010 to March 2013, 281 high-risk patients underwent minimally invasive aortic valve replacement with the Perceval S sutureless valve through either right anterior minithoracotomy (n = 164) or upper ministernotomy (n = 117) at 2 cardiac centers. RESULTS: The overall in-hospital mortality was 0.7% (2 patients). The overall median cardiopulmonary bypass and crossclamp time was 81 minutes (interquartile range, 68-98) and 48 minutes (interquartile range, 37-60), respectively. Postoperative stroke occurred in 5 patients (1.8%). The incidence of paravalvular leak greater than 1 of 4 and atrioventricular block requiring pacemaker implantation was 1.8% (5 patients) and 4.2% (12 patients), respectively. No migration occurred, and the mean postoperative gradient was 13 ± 4 mm Hg. At a median follow-up of 8 months (interquartile range, 4-14), the overall survival was 90%. CONCLUSIONS: Minimally invasive aortic valve replacement with the Perceval S sutureless valve in high-risk patients is a safe and reproducible procedure associated with excellent hemodynamic results, postoperative outcomes, and 1-year survival.

Human cardiac and bone marrow stromal cells exhibit distinctive properties related to their origin.

AIMS: Bone marrow mesenchymal stromal cell (BMStC) transplantation into the infarcted heart improves left ventricular function and cardiac remodelling. However, it has been suggested that tissue-specific cells may be better for cardiac repair than cells from other sources. The objective of the present work has been the comparison of in vitro and in vivo properties of adult human cardiac stromal cells (CStC) to those of syngeneic BMStC. METHODS AND RESULTS: Although CStC and BMStC exhibited a similar immunophenotype, their gene, microRNA, and protein expression profiles were remarkably different. Biologically, CStC, compared with BMStC, were less competent in acquiring the adipogenic and osteogenic phenotype but more efficiently expressed cardiovascular markers. When injected into the heart, in rat a model of chronic myocardial infarction, CStC persisted longer within the tissue, migrated into the scar, and differentiated into adult cardiomyocytes better than BMStC. CONCLUSION: Our findings demonstrate that although CStC and BMStC share a common stromal phenotype, CStC present cardiovascular-associated features and may represent an important cell source for more efficient cardiac repair.

Cancer treatment-induced cardiotoxicity: a cardiac stem cell disease?

Cardiovascular diseases and cancer represent respectively the first and second cause of death in industrialized countries. These two conditions may become synergistic when cardiovascular complications of anti-cancer therapy are considered. More than 70% of childhood and 50% of adult cancer patients can be cured, however this important success obtained by the biological and medical research is obfuscated by emerging findings of early and late morbidity due to cardiovascular events. Although anthracyclines are effective drugs against cancer a dose-dependent cardiotoxic effects whose mechanism has not been elucidated resulting in failure of therapeutic interventions limit their use. Unexpectedly, tyrosine/kinase inhibitors (TKIs) aimed at molecularly interfering with oncogenic pathways, have been implicated in cardiac side effects. Possible explanations of this phenomenon have been ambiguous, further strengthening the need to deepen our understanding on the mechanism of cardiotoxicity. In addition to a detailed description of anthracyclines and TKIs-related cardiovascular effects, the present review highlights recent observations supporting the hypothesis that the cellular target of anthracyclines and TKIs may include myocardial compartments other than parenchymal cells. The demonstration that the adult mammalian heart possesses a cell turnover regulated by primitive cells suggests that this cell population may be implicated in the onset and development of cardiovascular effects of anti-cancer strategies. The possibility of preventing cardiotoxicity by preservation and/or expansion of the resident stem cell pool responsible for cardiac repair may open new therapeutic options to unravel an unsolved clinical issue.

Medium-term results of systematic off-pump coronary surgery performed by trainee surgeons.

OBJECTIVE: Our unit has used off-pump coronary artery bypass (OPCAB) surgery since 1998, and has consequently developed teaching methods for surgical trainees. This study aimed to compare the medium-term results of OPCAB performed by experts or supervised trainees. METHODS: We retrospectively analysed the data relating to 1333 OPCAB operations performed between January 1998 and January 2006 (mean patient age: 65.3 + or - 13; M/F ratio: 2.9), and compared the medium-term outcomes of the 977 (73.3%) carried out by three expert surgeons (group A) with the remaining 356 (26.7%) carried out by four supervised trainees (group B). RESULTS: There were no preoperative differences in patient age, gender, angina class, operative priority, extent of coronary artery disease, the presence of a recent myocardial infarction or left main stenosis or European System for Cardiac Operative Risk Evaluation (EuroSCORE) between the two groups. Thirty-day mortality was 1% in group A and 0.6% in group B (p=0.43), and 4-year actuarial survival, respectively, 97.4 + or - 1.1% and 94.3 + or - 4.1% (p=0.41); the freedom from new re-vascularisation rates in the two groups were, respectively, 96 + or - 0.7% and 95.3 + or - 1.4% (p=0.3). CONCLUSIONS: The results of this study reflect our unit's long experience of OPCAB surgery and that its successful re-engineering towards the systematic use of OPCAB was feasible. They also show that, in this context, teaching OPCAB surgery is safe in a non-selected cohort of patients, and that the medium-term outcomes of the patients operated on by trainee or expert surgeons are similar.

[Present and future options for the surgical treatment of patients with advanced heart failure]. / Che novità possiamo attenderci dalla terapia chirurgica dello scompenso cardiaco avanzato.

Despite considerable improvement in the medical treatment of heart failure, cardiac transplantation remains the gold standard for the treatment of end-stage patients. However, organ shortage forces to look for alternative therapies. A number of innovative approaches are being investigated in terms of improved survival and quality of life in patients refractory to medical therapy. The main cause of heart failure is represented by ischemic cardiomyopathy, responsible for up to 65% of its prevalence in the population. Long-term survival of patients affected by advanced heart failure due to ischemic cardiomyopathy is still unsatisfactory, in spite of improved medical therapy. Besides heart transplantation and the implantation of ventricular assist devices, a surgical option is represented by conventional heart surgery, consisting of myocardial revascularization associated with surgical ventricular restoration, correction of mitral valve regurgitation, and cardiac resynchronization therapy. The STICH trial (Surgical Treatment for Ischemic Heart Failure), an international multicenter trial sponsored by the US National Heart Lung and Blood Institute, will provide important information regarding the effectiveness of such surgical treatment. A new therapeutic option could be represented in the next future by the clinical use of intracardiac elastic devices, currently under investigation, which can be implanted at the mitral annulus and at the level of the left ventricular equator.

Toward the development of a fully elastic mitral ring: preliminary, acute, in vivo evaluation of physiomechanical behavior.

OBJECTIVES: The optimal repair of functional mitral regurgitation is still debated. No device is able to simultaneously abolish mitral regurgitation and replicate natural mitral annular dynamics. We have tested a fully elastic mitral ring in an acute animal study with the purpose of evaluating (1) ring design and implantation technique, (2) elastic performance, and (3) acute effects on the native mitral annulus. METHODS: Ten healthy sheep underwent surgical implantation of mitral devices, the elastic component of which is represented by a helicoid metallic spring. Preimplantation and postimplantation echocardiographic parameter measurements to evaluate annular dynamics and ventricular function comprise mitral annular motion, systolic tissue Doppler imaging peak wave, transmitral pressure gradient, peak transmitral flow velocity, and ejection fraction. Postimplantation angiographic analysis allowed measurement of the mitral annular area and perimeter variations by means of segmentation of the radiopaque mitral device contour. RESULTS: No significant difference in terms of ejection fraction (P = .13) and systolic tissue Doppler imaging peak wave (P = .87) was found before and after implantation. Mitral annular motion (1.16 cm) was preserved. The percentage of systolic annular reduction derived from angiographic analysis was 14.1% (range, 7.7%-19.7%) in terms of area and 7.2% (range, 4.9%-10.0%) in terms of perimeter. CONCLUSIONS: A mitral elastic ring, implantable by using a standard technique, acutely preserves mitral annular dynamics, allowing area and perimeter changes. Further chronic study is needed to verify the biocompatibility and durability of the device.

Patch size, shape and orientation affect geometrical outcomes of surgical anterior ventricular restoration.

OBJECTIVES: To verify whether the use of a small, oval-shaped patch limits the trend toward re-dilatation compared to endoventricular circular patch plasty and leads to different geometrical and functional results in surgical anterior restoration. METHODS: Thirty-seven patients with ischemic cardiomyopathy after anterior myocardial infarction end-systolic volume index of > or =45 ml/m2, ejection fraction of < or =35%, and no combined mitral procedures, underwent surgical anterior ventricular restoration between January 2000 and April 2003: 18 patients (group 1) were operated on using the endoventricular circular patch plasty technique (mean patch area 9.6 cm2) and 19 patients (group 2) received a small, obliquely oriented, oval-shaped patch (mean patch area 6.2 cm2). Ten geometrical parameters were studied preoperatively and at least 6 and 12 months after surgery. Data were analyzed using repeated-measures ANOVA, chi2, paired and unpaired Student's t-test, and binary logistic regression. RESULTS: Group 1 showed a worsening over time in systolic and diastolic longitudinal length, end-diastolic volume (P < 0.001), end-diastolic volume index (P = 0.006), end-systolic volume (P = 0.005), and end-systolic volume index (P = 0.03). Group 2 showed an improvement in percentage of akinesia and wall motion score index (P < 0.001) and a worsening only in end-systolic diameter (P = 0.03) and end-diastolic volume (P = 0.04). At 12-month follow-up, ANOVA revealed that the oval patch positively influenced end-diastolic volume (P = 0.03), end-systolic volume (P = 0.03), and end-systolic volume index (P = 0.05), and group 2 had a significantly higher number of patients with an end-systolic volume index of <45 ml/m2 (P = 0.01). CONCLUSION: The use of a small, narrow, obliquely oriented, oval patch may help to prevent adverse ventricular remodeling over time.

Implantation of an elastic ring at equator of the left ventricle influences cardiac mechanics in experimental acute ventricular dysfunction.

OBJECTIVES: We hypothesize that the implantation of an endoventricular elastic ring at the left ventricle (LV) equatorial site will positively affect the cardiac mechanics in an experimental model of acute LV dysfunction. BACKGROUND: Changes in the elastic properties of LV occur in the dilated and failing heart, contributing to overall cardiac mechanical dysfunction. No interventions are as yet specifically designed to improve LV elasticity in failing hearts. METHODS: Acute LV enlargement and dysfunction was induced in 13 healthy sheep via the insertion of a large Dacron patch into the lateral wall. In 6 of these sheep, a customized elastic ring was implanted at the inner surface of the LV equator (ring group), and the remaining 7 served as control subjects (dysfunction group). Systolic and diastolic function was evaluated using echocardiography and pressure-volume (P-V) analysis. RESULTS: In the ring group, both the maximum rate of pressure increase and the slope of end-systolic P-V relationship were significantly different from those without ring (1,718 +/- 726 vs. 1,049 +/- 269 and 1.25 +/- 0.30 vs. 0.88 +/- 0.19; both p < 0.05). Preload recruitable stroke work changed even more prominently (33 +/- 11 vs. 17 +/- 5; p = 0.005), along with stroke volume, ejection fraction, and stroke work. Although ring implantation had no effect on end-diastolic P-V relationship, it positively affected the active component of diastole: the maximum rate of pressure decrease declined significantly (p = 0.037). The time constant of relaxation tended to decrease (37 +/- 8 vs. 44 +/- 6; p = 0.088). CONCLUSIONS: Improving the elastic component of the LV at its equatorial site substantially augments contractility and early relaxation in acute systodiastolic LV dysfunction.

A new shape for an old function: lasting effect of a physiologic surgical restoration of the left ventricle.

BACKGROUND: Long-term morphofunctional outcome may vary widely in surgical anterior left ventricular wall restoration, suggesting variability in post-surgical remodeling similar to that observed following acute myocardial infarction. The aim of this pilot study was to demonstrate that surgical restoration obtained with a particular shape of endoventricular patch leads to steady morphofunctional ventricular improvement when geometry, volume and residual akinesia can be restored as normal as possible. METHODS: This study involved 12 consecutive patients with previous anterior myocardial infarction, dilated cardiomyopathy and no mitral procedures, who underwent left ventricular reconstruction and coronary revascularization between May 2002 and May 2003 using a small, narrow, oval patch aiming at a volume

Factors affecting left ventricular remodeling after valve replacement for aortic stenosis. An overview.

Although a small percentage of patients with critical aortic stenosis do not develop left ventricle hypertrophy, increased ventricular mass is widely observed in conditions of increased afterload. There is growing epidemiological evidence that hypertrophy is associated with excess cardiac mortality and morbidity not only in patients with arterial hypertension, but also in those undergoing aortic valve replacement. Valve replacement surgery relieves the aortic obstruction and prolongs the life of many patients, but favorable or adverse left ventricular remodeling is affected by a large number of factors whose specific roles are still a subject of debate. Age, gender, hemodynamic factors, prosthetic valve types, myocyte alterations, interstitial structures, blood pressure control and ethnicity can all influence the process of left ventricle mass regression, and myocardial metabolism and coronary artery circulation are also involved in the changes occurring after aortic valve replacement. The aim of this overview is to analyze these factors in the light of our experience, elucidate the important question of prosthesis-patient mismatch by considering the method of effective orifice area, and discuss surgical timings and techniques that can improve the management of patients with aortic valve stenosis and maximize the probability of mass regression.