Letter to the Editor Ross procedure valve function, clinical outcomes and predictors after 25 years follow up.

The following letter presents an answer of a comment of our work titled "Ross procedure: valve function, clinical outcomes and predictors after 25 years' follow-up," recently published in your journal by Rangwala et al.1 As our colleagues point out, the Ross procedure has excellent survival rates but a significant risk of valve dysfunction and therefore reintervention at follow-up. Although the survival advantage with the Ross procedure appears to be consistent compared with mechanical valve substitutes, this benefit is not as clear compared with biological valve substitutes. However, biological valve substitutes also have significant reintervention rates during follow-up. The different surgical modifications of the Ross procedure have not clearly demonstrated better results in follow-up in terms of autograft reintervention. This procedure can be performed in a medium-volume center with good results as long as adequate patient selection and adequate surgical training are carried out.

Ross procedure: valve function, clinical outcomes and predictors after 25 years' follow-up.

OBJECTIVE: To describe long-term outcomes of the Ross procedure in a single center and retrospective series after 25 years follow-up. METHODS: From 1997-2019 we included all consecutive patients who underwent Ross procedure at our center. Clinical and echocardiographic evaluations were performed at least yearly. Echocardiographic valvular impairment was defined as at least moderate autograft or homograft dysfunction. Reintervention outcomes included surgical and percutaneous approach. RESULTS: 151 Ross procedures were performed (mean age 28±12years, 21 %<16years, 70 %male). After 25 years follow-up (median 18 years, interquartile range 9-21, only 3 patients lost) 12 patients died (8 %); Autograft, homograft or any valve dysfunction were present in 38(26 %), 48(32 %) and 75(51 %), respectively; and reintervention in 22(15%), 17(11%) and 38(26 %) respectively. At 20 years of follow-up, probabilities of survival free from autograft, homograft or any valve dysfunction were 63 %, 60 % and 35 %; and from reintervention, 80 %, 85 % and 67 %, respectively. The learning curve period (first 12 cases) was independently associated to autograft dysfunction (HR 2.78, 95 %CI:1.18-6.53, p = 0.02) and reintervention (HR 3.76, 95 %CI: 1.46-9.70, p = 0.006). Larger native pulmonary diameter was also an independent predictor of autograft reintervention (HR 1.22, 95 %CI:1.03-1.45, p = 0.03). Homograft dysfunction was associated with younger age (HR 5.35, 95 %CI: 2.13-13.47, p<0.001) and homograft reintervention, with higher left ventricle ejection fraction (HR 1,10, 95 %CI:1.02-1.19, p<0.02). CONCLUSIONS: In this 25 years' experience after the Ross procedure, global survival was high, although autograft and homograft dysfunction and reintervention rates were not negligible. Clinical and echocardiographic variables can identify patients with higher risk of events in follow up.

Survival Outcomes of Hepatectomy in Gastric Cancer Liver Metastasis: A Systematic Review and Meta-Analysis.

Gastric cancer liver metastasis (GCLM) is a contraindication for surgical treatment in current guidelines. However, the results of recent studies are questioning this paradigm. We assessed survival outcomes and their predictors following hepatectomy for GCLM in a systematic review of studies published from 2000 to 2022 according to PRISMA guidelines. We identified 42,160 references in four databases. Of these, 55 articles providing data from 1990 patients fulfilled our criteria and were included. We performed a meta-analysis using random-effects models to assess overall survival (OS) and disease-free survival (DFS) at one, three, and five years post-surgery. We studied the impact of potential prognostic factors on survival outcomes via meta-regression. One, three, and five years after surgery, OS was 69.79%, 34.79%, and 24.68%, whereas DFS was 41.39%, 23.23%, and 20.18%, respectively. Metachronous presentation, well-to-moderate differentiation, small hepatic tumoral size, early nodal stage, R0 resection, unilobar compromisation, and solitary lesions were associated with higher overall survival. Metachronous presentation, smaller primary tumoral size, and solitary metastasis were linked to longer DFS. The results of our meta-analysis suggest that hepatectomy leads to favorable survival outcomes in patients with GCLM and provides data that might help select patients who will benefit most from surgical treatment.

Valorization of Chicken Slaughterhouse Byproducts to Obtain Antihypertensive Peptides.

Hypertension (HTN) is the leading cause of premature deaths worldwide and the main preventable risk factor for cardiovascular diseases. Therefore, there is a current need for new therapeutics to manage this condition. In this regard, protein hydrolysates containing antihypertensive bioactive peptides are of increasing interest. Thus, agri-food industry byproducts have emerged as a valuable source to obtain these hydrolysates as they are rich in proteins and inexpensive. Among these, byproducts from animal origin stand out as they are abundantly generated worldwide. Hence, this review is focused on evaluating the potential role of chicken slaughterhouse byproducts as a source of peptides for managing HTN. Several of these byproducts such as blood, bones, skins, and especially, chicken feet have been used to obtain protein hydrolysates with angiotensin-converting enzyme (ACE)-inhibitory activity and blood pressure-lowering effects. An increase in levels of endogenous antioxidant compounds, a reduction in ACE activity, and an improvement of HTN-associated endothelial dysfunction were the mechanisms underlying their effects. However, most of these studies were carried out in animal models, and further clinical studies are needed in order to confirm these antihypertensive properties. This would increase the value of these byproducts, contributing to the circular economy model of slaughterhouses.

Risk assessment of hepatitis E transmission through tissue allografts.

Hepatitis E virus (HEV) is a small non-enveloped single stranded RNA virus whose genotypes 3 and 4 have been associated with zoonotic transmission in industrialized countries. HEV infection is considered the main cause of acute hepatitis worldwide. In some cases, transfusion of blood components or organ transplantation have been reported as the source of infection. We have conducted a literature review on the risk of transmission through cell and tissue allografts. Although no case was found, measures to control this risk should be taken when donor profile (based upon geographical and behavioural data) recommended it. Issues to be considered in donor screening and tissue processing to assess and to reduce the risk of HEV transmission are approached.

Ultrasonographic and Histological Correlation after Experimental Reconstruction of a Volumetric Muscle Loss Injury with Adipose Tissue.

Different types of scaffolds are used to reconstruct muscle volume loss injuries. In this experimental study, we correlated ultrasound observations with histological findings in a muscle volume loss injury reconstructed with autologous adipose tissue. The outcome is compared with decellularized and porous matrix implants. Autologous adipose tissue, decellularized matrix, and a porous collagen matrix were implanted in volumetric muscle loss (VML) injuries generated on the anterior tibial muscles of Wistar rats. Sixty days after implantation, ultrasound findings were compared with histological and histomorphometric analysis. The muscles with an autologous adipose tissue implant exhibited an ultrasound pattern that was quite similar to that of the regenerative control muscles. From a histological point of view, the defects had been occupied by newly formed muscle tissue with certain structural abnormalities that would explain the differences between the ultrasound patterns of the normal control muscles and the regenerated ones. While the decellularized muscle matrix implant resulted in fibrosis and an inflammatory response, the porous collagen matrix implant was replaced by regenerative muscle fibers with neurogenic atrophy and fibrosis. In both cases, the ultrasound images reflected echogenic, echotextural, and vascular changes compatible with the histological findings of failed muscle regeneration. The ultrasound analysis confirmed the histological findings observed in the VML injuries reconstructed by autologous adipose tissue implantation. Ultrasound can be a useful tool for evaluating the structure of muscles reconstructed through tissue engineering.

Analysis of impact on tissue activity during COVID-19 outbreak: a survey of 8 banks in Spain.

On March 19 World Health Organization declare the pandemic situation by outbreak coronavirus disease 2019 in the world. The pressure on the health care system has been very high in several countries. Spanish National Transplant Organization (ONT) have made many efforts in maintaining transplantation activity. Although the impact of the pandemic on organ activity has been analysed, to date, less data exist regarding the impact on tissue activity. The aim of this study has been the evaluation of the possible impact on the procurement, processing and distribution of tissues during the peak period of the pandemic COVID-19 in Spain. For this study, a multicentre analysis has been made with a survey of the tissue banks in Spain, during the period March 1 to April 30, 2020. Our data suggest that the impact of coronavirus in Spain has affected dramatically tissue donation but with a moderate effect on stored tissues such as bone, valves, vessels or skin. Tissue banks should prepare if future next pandemic waves surges so that tissue provision is guaranteed both in urgent and elective surgeries.

In vitro susceptibility of microorganisms isolated from cold stored corneas: increased gentamicin-resistance in cornea banking.

Donor cornea contamination is one of the major risks for corneal transplants. The use of antibiotics in storage media remains as one of the most important security measurements to minimize the contamination risk in corneal preservation. Since antibiotic resistance among microorganisms have been rising gradually, it is important to gain knowledge about the antimicrobial susceptibility pattern for choosing the most suitable antimicrobial agents. Thus, we evaluated the in vitro susceptibility of microorganisms isolated in donor corneas processed at the Center for Blood Transfusion, Tissues and Cells (Córdoba, Spain) during 4 years in order to evaluate the efficiency, and to promote changes for further antibiotics use. Our results show the high rate of resistance to gentamicin, an antibiotic used in corneal preservation media such as Optisol GS and Eusol-C. Conversely, all the analyzed microorganisms were sensitive to vancomycin. This suggests the possibility of replacing gentamicin with another more effective antibacterial agent such as vancomycin.

Histology of skeletal muscle reconstructed by means of the implantation of autologous adipose tissue: an experimental study.

The purpose of this study was to determine the histological characteristics of a skeletal muscle reconstructed by means of the implantation of autologous adipose tissue following an experimentally-induced volumetric muscle loss. A cylindrical piece in the belly of the rat anterior tibial muscle was removed. In the hole, inguinal subcutaneous adipose tissue of the same rat was grafted. Animals were sacrificed 7, 14, 21, 28 and 60 days posttransplantation. Histological, histochemical, immunohistochemical and morphometric techniques were used. At all times analyzed, the regenerative muscle fibers formed from the edges of the muscle tissue showed histological, histochemical and immunohistochemical differences in comparison with the control group. These differences are related to delays in the maturation process and are related to problems in reinnervation and disorientation of muscle fibers. The stains for MyoD and desmin showed that some myoblasts and myotubes seem to derive from the transplanted adipose tissue. After 60 days, the transplant area was 20% occupied by fibrosis and by 80% skeletal muscle. However, the neo-muscle was chaotically organized showing muscle fiber disorientation and centronucleated fibers with irregular shape and size. Our results support the hypothesis that, at least from a morphological point of view, autologous adipose tissue transplantation favors reconstruction following a volumetric loss of skeletal muscle by combining the inherent regenerative response of the organ itself and the myogenic differentiation of the stem cells present in the adipose tissue. However, in our study, the formed neo-muscle exhibited histological differences in comparison with the normal skeletal muscle.

Pulmonary homograft stenosis in the Ross procedure: Incidence, clinical impact and predictors in long-term follow-up.

BACKGROUND: The Ross procedure is used in the treatment of selected patients with aortic valve disease. Pulmonary graft stenosis can appear in the long-term follow-up after the Ross intervention, but the factors involved and its clinical implications are not fully known. AIM: To describe the incidence, clinical impact and predictors of homograft stenosis and reintervention after the Ross procedure in a prospective series in a tertiary referral hospital. METHODS: From 1997 to 2009, 107 patients underwent the Ross procedure (mean age: 30±11 years; 69% men; 21 aged<18 years), and were followed for echocardiographic homograft stenosis (peak gradient>36mmHg) and surgical or percutaneous homograft reintervention. RESULTS: After 15 years of follow-up (median: 11 years), echocardiographic and clinical data were available in 91 (85%) and 104 (98%) patients, respectively: 26/91 (29%) patients developed homograft stenosis; 10/104 (10%) patients underwent 13 homograft reintervention procedures (three patients underwent surgical replacement, three received a percutaneous pulmonary valve and one needed stent implantation). The other three patients underwent two consecutive procedures in follow-up; one died because of a procedure-related myocardial infarction. Rates of survival free from homograft stenosis and reintervention at 1, 5 and 10 years were 96%, 82% and 75% and 99%, 94% and 91%, respectively. Paediatric patients had worse survival free from homograft stenosis (hazard ratio [HR] 3.50, 95% confidence interval [CI]: 1.56-7.90; P=0.002), although there were no significant differences regarding reintervention (HR: 2.01, 95% CI: 0.52-7.78; P=0.31). Younger age of homograft donor was also a stenosis predictor (HR: 0.97, 95% CI: 0.94-0.99; P=0.046). CONCLUSIONS: The probabilities of homograft stenosis and reintervention 10 years after the Ross procedure were 29% and 10%, respectively; only one patient had a reintervention-related death. Younger donor and recipient age were associated with a higher rate of stenosis.

Nucleic acid-amplification testing for hepatitis B in cornea donors.

Careful donor selection and implementation of tests of appropriate sensitivity and specificity are of paramount importance for minimizing the risk of transmitting infectious diseases from donors to corneal allograft recipients. Reported cases of viral transmission with corneal grafts are very unusual. Nevertheless potential virus transmission through the engraftment cannot be ruled out. According to European Guideline 2006/17/EC, screening for antibodies for Hepatitis B core antigen (anti HBc) is mandatory, and when this test is positive, some criteria must be established before using corneas. Despite the continuous progress in screening tests, donors carrying an occult hepatitis B infection (OBI) can cause transplant-transmitted hepatitis B. To date, Nucleic Acid Testing (NAT) is not an obligatory assay in corneal tissue setting neither in our country nor in the rest of European countries. Herein, we report three cornea donors that were rejected with the diagnosis of OBI through the testing of sensitive NAT and the serological profile of Hepatitis B virus. The aim of this report is to emphasize the need to include NAT in new reviews of EU Tissues and Cells Directives in order to increase level of security in tissue donation as well as not to reject a high number of donors with isolated profile of anti HBc in geographical areas with high prevalence of Hepatitis B, that could be rejected without a true criterion of Hepatitis B infection.

Perfil eco-epidemiológico de los accidentes por ofidios en Monagas, Venezuela (2002-2006) / Eco-epidemiological profile of snakebite accidents in Monagas state, Venezuela (2002-2006)

El accidente causado por animales venenosos representa un problema global, especialmente en las áreas subtropicales y tropicales del mundo. En Venezuela, es endémico para varias regiones incluyendo la zona nororiental. Con el objetivo de ampliar y actualizar el perfil eco-epidemiológico del ofidismo en el estado Monagas, se evaluó su comportamiento, en cada municipio, durante 5 años de registro (2002 - 2006). Se contabilizaron 339 accidentes ofídicos (con promedio de 68 anuales). El incidente ocurrió con mayor frecuencia en agricultores, adultos jóvenes y de género masculino, durante sus labores en el campo y en el periodo diurno. La incidencia siguió un patrón estacional bimodal con predominio en épocas de alta y baja pluviosidad. Los envenenamientos botrópicos (28,6%) fueron más frecuentes que los crotálicos (14,5%), con proporción 2:1. El 87,9% recibió sueroterapia específica. La incidencia promedio anual en la entidad se ubicó en 11,30 casos por 100.000 habitantes, siendo Punceres (46,29), Acosta (20,91) y Bolívar (19,52) los municipios con mayor impacto. El estado Monagas presentó un mapa de endemicidad distribuido en municipios de (1) muy alta endemicidad, (2) alta endemicidad, (3) mediana endemicidad, (4) baja endemicidad y (5) muy baja endemicidad. Durante el período analizado no se registró muerte por esta causa en el estado. Los hallazgos sugieren la importancia del accidente por serpientes en Monagas, con especial importancia en la mitad norte de la entidad.

The accidents caused by venomous animals are a global problem, especially in subtropical and tropical regions of the world. In Venezuela, they are endemic in several regions including the northeast. In order to expand and update the ecoepidemiological profile of snake bites in Monagas state, their behavior was assessed in each municipality for 5 years (2002 -2006). There were 339 ophidian accidents (on average 68 per year). The bites occurred more frequently in young adult male farmers, while working in the field and during daytime. The incidence followed a bimodal seasonal pattern with predominance in high and low rainfall periods. Bothropic envenoming (28.6%) were the most frequent followed by Crotalic ones (14.5%), with a 2:1 ratio. 87.9% received specific serum therapy. The annual average incidence in the state was 11.30 cases per 100,000 inhabitants. Punceres (46.29), Acosta (20.91) and Bolivar (19.52) were the municipalities with the highest impact. Monagas state showed an endemicity map with municipalities having (1) very high endemicity, (2) high endemicity, (3) medium endemicity, (4) low endemicity and (5) very low endemicity. In the studied period there were no deaths from this cause in the state. The findings suggest the importance of snake accidents in Monagas, especially in the northern half of the state.

Ascaridíase hepatobiliar complicada por pneumonia lipoídica / Hepatobiliary ascariasis complicated by lipoid pneumonia

OBJETIVO: Apresentar um caso de ascaridíase hepatobiliar complicado por pneumonia lipoídica e discutir as implicações anestésicas envolvidas. DESCRIÇÃO DO CASO: Menina de dois anos de idade com ascaridíase hepatobiliar complicada por pneumonia lipoídica por aspiração e desnutrição grave, advinda de família em condições sociais precárias em zona rural, com quatro irmãos. Foi tratada com sucesso por uma combinação de lavados broncopulmonares sucessivos e cirurgia. COMENTÁRIOS: Ascaridíase biliar corresponde a cerca de 10 por cento dos casos de complicações de ascaridíase. Apenas uma minoria precisa de tratamento cirúrgico. O uso de óleo mineral por via oral é um tratamento tradicional para a suboclusão intestinal pelo Ascaris lumbricoides, mas a broncoaspiração do óleo e a conseqüente pneumonia lipoídica representam um risco alto para o seu uso. Anestesia geral para laparotomia exploradora em pré-escolar desnutrido com pneumonia lipóide e ascaridíase biliar é uma situação pouco contemplada na literatura médica, o que exigiu um planejamento terapêutico específico.

OBJECTIVE: To present a case of hepatobiliary ascariasis complicated by exogenous lipoid aspirative pneumonia and the anesthetic implications involved. CASE DESCRIPTION: We present a case of hepatobiliary ascariasis complicated by exogenous lipoid aspirative pneumonia and severe undernourishment in a two-year-old female from a five-children poor family from the Brazilian rural area. She was successfully treated by the association of repeated bronchopulmonary lavage and surgery. COMMENTS: Biliary ascariasis corresponds roughly to 10 percent of complicated ascariasis cases. Only a minority requires surgery. Mineral oil is a traditional treatment for intestinal Ascaris lumbricoides subocclusion, but oil aspiration and lipoid pneumonia remain a highly morbid risk of this practice. General anesthesia and laparotomy in an undernourished small child with lipoid pneumonia and biliary ascariasis were rarely addressed in the medical literature. Therefore, the therapeutic planning of this case was difficult.

Evaluation of tissue discards after implementation of anti-HBc test in a tissue bank in Spain.

The recent introduction as a minimum test required in The Guide to Safety and Quality Assurance for Organs, Tissues and Cells (Council Europe) and the Directive 2004/23/EC applied to donation, procurement, testing, processing, preservation, storage and distribution of human cells and tissues make necessary the implementation of these markers in all European Tissue Establishments. In this study we have analyzed the impact in tissues discard by introducing anti-HBc in a European Tissue Establishment in a country with a high prevalence of HBV infection. The adoption of this exclusion criteria in this region results in acceptably rejection rates among tissue donors, although some studies are needed on basis a risk assessment to determine the eligibility for clinical use.

Prospective evaluation of aortic valve replacement in young adults and middle-aged patients: mechanical prosthesis versus pulmonary autograft.

BACKGROUND AND AIM OF THE STUDY: The best option for aortic valve replacement (AVR) in young adults and middle-aged patients remains controversial. A longitudinal comparison between the Ross procedure (RP) and mechanical prosthesis (MP) was conducted in this group of patients. METHODS: Between January 1997 and January 2003, 125 consecutive patients (age range: 20-50 years) were submitted for AVR; 62 patients (mean age 37.73+/-7.28 years) were included in the MP group, and 63 (mean age 35.33+/-7.63 years) in the RP group. Gender, etiology, NYHA functional class and other preoperative data were comparable between the two groups. RESULTS: The operative mortality was four (6.5%) in the MP group, and one (1.6%) in the RP group (p = NS). The postoperative complication rate was similar in both groups. Two RO patients required early autograft replacement due to severe regurgitation. There were no late deaths during the follow up period. In the MP group, three patients (4.8%) suffered major bleeding, three (4.8%) were diagnosed with prosthetic endocarditis (one required reoperation), and three (4.8%) suffered valve- or coumarin-related thromboembolic complications. All RP patients were free from bleeding, thromboembolic, or infectious complications, but three suffered severe pulmonary homograft stenosis (one re-replacement, one Palmaz stent, and one under clinical surveillance). The combined freedom from death or major complications was 64.72+/-4.3% in the MP group, and 87.92+/-9.65% in the RP group (p = 0.068). CONCLUSION: Intraoperative and early postoperative morbidity and mortality rates were similar among RP and MP patients, despite a steep learning curve during the early RP cases. Although the follow up was limited, and homograft-related morbidity was seen in the RP group, the overall five-year major complication rate supported use of the pulmonary autograft for AVR in patients aged between 20 and 50 years.

The Ross procedure.

BACKGROUND: The search for the ideal substitute for the aortic valve led Donald Ross to develop the pulmonary autograft concept in 1967. A historical, technical, and scientific review of this surgical option is presented together with our clinical experience. MATERIALS AND METHODS: The literature is reviewed to identify the advantages and pitfalls of the Ross procedure over the last decades. We also present our clinical experience with 92 patients operated between 1997 and May 2003. RESULTS: Of the total, 70.65% (n = 65) were males, mean age was 29.32 +/- 11.9 years, with 20 patients under 16 and 6 patients under 10 years. Twenty-five patients (27.17%) had 31 previous interventions. There were 41 associated procedures in 34 patients. Perioperative mortality was 2.17% (two patients). Eight patients required reexploration for bleeding, one required an aortocoronary bypass, and one a permanent pacemaker. Follow-up was 97% with 2.71 patients/year (average 32.55 +/- 19.01 months). Two patients required autograft replacement, one suffered a 44-mm dilatation of the autograft, and one 13-year-old girl developed autograft endocarditis. Six patients suffered severe homograft stenosis (>50 mmHg), two were treated percutaneously, and one required replacement. Combined freedom from reintervention is 93.56 +/- 2.81% at 5 years. CONCLUSIONS: The Ross procedure is a mature concept with thousands of patients operated worldwide and a cumulative experience of over 30 years. Although we believe that it is the procedure of choice in the pediatric population, women in child-bearing age, and substantial subgroups of adult patients, efforts must continue to minimize the incidence of auto- and homograft failure in the long term.

Nefropatia luética em recém-nascido / Luetic nephropathy in a newborn

Descreve-se um caso de nefropatia luética em recém-nascido, ocorrencia relativamente rara nesta faixa etária. Comentários sobre o quadro clínico, patogenia e evoluçäo