Annual changes in seminal variables of golden lanchead pitvipers (Bothrops insularis) maintained in captivity.

Bothrops insularis is an endemic and critically endangered snake with an estimated population of 2000 individuals restricted to Queimada Grande Island, in southeastern Brazil. Brazilian researchers established a captive breeding program for the species that includes the application of assisted reproductive technologies. The present study, therefore, aimed to evaluate semen samples from captive B. insularis throughout the year to ascertain seasonal differences in semen traits as well as correlations with body size and weight. Eighteen males with snout-vent length (SVL) ranging from 43.5 to 73.7 cm were collected at quarterly basis between August 2012 and May 2013. Macroscopic analysis revealed semen volumes ranging from 0.5 to 6.0 µL with samples featuring whitish to yellowish color and creamy and thick consistency. Viable sperm was obtained from all males indicating that individuals with SVL equal to or greater than 43.5 cm are sexually developed. However, adult and immature males (estimated by SVL) exhibited different seasonal profiles for motility and progressive motility. Adult males had a decrease in sperm motility and progressive motility during summer and spring, respectively, whereas the same variables did not vary throughout the year in immature snakes. Sperm concentration in all individuals was less (0.5 × 10(9) µL) during the winter, but no seasonal fluctuations were detected in semen volume. These findings are of particular importance to the development of reproductive tools such as male selection, artificial insemination and sperm freezing for the genetic management of this critically endangered snake.

Revascularization of hibernating myocardium: rate of metabolic and functional recovery and occurrence of oxidative stress.

BACKGROUND: Left ventricular (LV) dysfunction due to coronary artery disease (CAD) may improve after revascularization in patients with hibernating myocardium (HM). METHODS AND RESULTS: We compared the rate of metabolic (arterial-great cardiac vein differences of lactate, glucose and pyruvate) and functional (intra-operative transesophageal and epicardial echocardiography) recovery and occurrence of oxidative stress (myocardial release of oxidized glutathione (GSSG)) early after surgical revascularization, in patients with CAD, LV dysfunction and HM (n=16) vs those with preserved LV function (n=15). By comparing the two groups, we observed that, after de-clamping, in patients with HM (a) the kinetic of lactate production was converted to extraction (P<0.01 at 1, 5, 10 and 20 min after revascularization), (b) myocardial extraction of pyruvate increased (P<0.01 during the first 5 min after revascularization), (c) GSSG release was less and of shorter duration (P<0.01 at all times), (d) segmental wall motion score improved from 2.4+/-0.3 to 1.7+/-0.5 (P<0.01) as did the thickening of the akinetic territories corresponding to the antero-distal septum and to the distal anterior wall regions (to 36+/-23%, and to 36+/-13%, respectively). There was a correlation between the rate of recovery of metabolic and functional indices. CONCLUSIONS: The contractile and metabolic recovery of HM is more rapid than that of non-HM, and it is not accompanied by oxidative stress.

Transperitoneal approach for pericardial drainage.

A variety of surgical approaches for pericardial drainage have been proposed. The choice of the best approach can be, therefore, oriented depending on the cause of the pericardial effusion. Recently a different approach, for neoplastic or post-traumatic pericardial effusion, has been proposed, in order to create a peritoneal-pericardial window avoiding the insertion of a tube. We report a case of late postoperative cardiac tamponade in a patient with a previous coronary surgery in which, due to extensive adhesion of the anterior wall a modified transperitoneal approach to the pericardium, was used.

Combined surgical approach for carotid and coronary stenosis. Sixty-four patients and review of literature.

BACKGROUND: The proper role of combined carotid endarterectomy (CEA) and coronary bypass (CABG) is still controversial. We contribute to the discussion through the critical evaluation of 64 consecutive patients, whose data have been collected in a prospective way. METHODS: Between 1990 and 1999, 64 patients presenting a critical coronary disease (unemendable by PTA) associated with severe carotid stenosis (= or >70% if symptomatic, = or >80% if asymptomatic), underwent combined CEA-CABG. Cardiological symptoms were evident in 90.6% of cases. Thirty-five patients (54.7%) had a three-vessel coronaropathy, 18 (28.1%) a two-vessel disease and 11 (17.2%) severe stenosis of the common trunk; furthermore 7 patients (10.9%) had a low ejection fraction (<50%). A positive neurologic history was present in 22 (44%) patients. Thirty-four patients (55%) had a carotid stenosis >90%; a significant disease of the contralateral carotid axis was observed in 53% of cases: stenosis >50% in 30 patients and thrombosis in 4. CEA was performed with somato-sensorial evoked potential monitoring. RESULTS: The hospital mortality rate was 6.2% (4 patients). The cause of death was cardiac in 2 cases (1 early bypass thrombosis and 1 irreversible coronary spasm) and related to a multiorgan failure in 2. The neurologic morbidity rate was 0%. CONCLUSIONS: Our data highlight that in these high-risk patients the combined approach dramatically reduces the stroke risk although the mortality rate is still higher than that observed after CEA or CABG.

Reinforced sternal closures for prevention of sternal dehiscence in high risk patients.

BACKGROUND: Sternal dehiscence is still a frequent complication after cardiac surgery procedures, performed through midline sternotomy. Its cumulative incidence has been reported to be around 2.5%, but several risk factors for increased incidence have also been identified. In past years several techniques have been proposed to achieve reinforced sternal approximation, mainly considered for the treatment of sternal dehiscence, more than for its prevention. The objective of this paper is the evaluation of the results, in terms of prevention of sternal dehiscence in high-risk patients, using reinforced closure techniques compared to standard technique. METHODS: Our study population included 212 patients who underwent cardiac surgery procedure and presented at least one of the increased risk factor for sternal dehiscence. Fifty-six patients (26.4%) received a reinforced sternal closure technique (RC group), 156 patients (73.6%) received a conventional sternal closure (CC group). RESULTS: The cumulative incidence of sternal refixation, in this selected population, was 5.6% with a statistically significant difference in favour of the RC group. The results of this study clearly show that the appropriate utilisation and selection of one of the several techniques of reinforced sternal closures can be effective in the reduction of sternal dehiscence in high risk patients. CONCLUSIONS: A reinforced technique should therefore be utilised in all patients undergoing cardiac surgery, presenting one or more risk factors for increased incidence of sternal dehiscence.

Treatment of giant aortic aneurysm with tracheal compression and sternal erosion without circulatory arrest.

Treatment of huge aneurysms involving the ascending aorta and the aortic arch with compression of the surrounding structures represents a surgical challenge. The case of a patient affected by respiratory insufficiency and sternal erosion caused by chronic giant aortic aneurysm is reported. The use of a stepwise approach and selective cerebral arterial perfusion ensured successful operative management, avoiding circulatory arrest and enabling an expeditious postoperative recovery.

Mitral valve repair for isolated prolapse of the anterior leaflet: an 11-year follow-up.

OBJECTIVE: Mitral valve insufficiency (MVI) because of involvement of the anterior mitral leaflet may pose additional risks for late outcome after mitral valve repair, because of more complex techniques. We retrospectively reviewed our experience in patients operated on for isolated anterior mitral leaflet prolapse approached by various techniques. METHODS: Between 1986 and 1997, 616 patients underwent mitral valve repair at our Institution. Isolated pathology of the anterior mitral leaflet was the cause of MVI in 84 patients (13.6%). Age ranged from 23 to 74 years (mean 50 +/- 14). Etiology of MVI was predominantly degenerative (57 patients, 67.8%), and the mechanism of the regurgitation was mainly due to a chordal rupture (58 patients, 69%). Annular dilatation was present in 75 patients (89.5%). A variety of surgical techniques were applied including chordal shortening (five patients, 5.9%), chordal transposition (three patients, 3.5%), artificial chordae (11 patients, 13%). Since 1992, however, the majority of procedures was performed using the 'edge to edge' technique (52 patients, 51.9%). Annular dilatation was treated mainly by means of a prosthetic ring (46 patients, 61.3%) whereas 18 patients (24%) underwent posterior annuloplasty using gluteraldehyde-treated native pericardium. RESULTS: Follow-up ranged from 3 to 122 months (mean 46 +/- 24 months). There were three hospital deaths (3.5%) and five late deaths (5.9%) for a Kaplan-Meier estimated survival of 87.6% at 8 years. Three patients underwent early reoperation within 30 days (3.5%), and six patients underwent late reoperation (7.1%), for a cumulative freedom from reoperation of 85.4% at 8 years. Seventy-four percent of the survivors (50 patients) are still in New York Heart Association Class I, and 92% of survivors (62 patients) have no or trivial (1+) residual mitral regurgitation at echocardiographic follow-up. CONCLUSION: In spite of the greater complexity, conservative surgery to correct anterior mitral valve prolapse pertains high success rate of long term. Recent technical modifications ('edge-to-edge' technique) may allow more expeditious and reproducible procedures with expected favorable influence of mitral valve repair applicability.

[A rare case of massive pulmonary embolism and in transit cardiac thrombosis]. / Un caso insolito di embolia polmonare massiva e trombo in transito cardiaco.

The case of a patient affected with acute pulmonary embolism and concomitant cerebral thromboembolism is described. The patient was admitted to our Coronary Care Unit with aphasia and hemiplegia. Five days before, he had undergone a hip replacement. A lung scan showed bilateral embolism; transthoracic echocardiogram revealed signs of pulmonary hypertension and the presence of a large, elongated, highly mobile "in-transit" thrombus entrapped into a patent foramen ovalis, and prolapsing into the right and left ventricle during diastole. The patient underwent surgical removal of the thrombus, with closure of the patent foramen. We did not treat the patient with thrombolysis, fearing the damage that a new embolism might produce. After surgery, the patient had a lengthy hospital stay because of renal failure and infection due to Pseudomonas aeruginosa. The patient was discharged from the hospital three months later on dialytic treatment and although he was still aphasic, there was partial recovery of motor function. Nevertheless, normalization of renal function and regression of aphasia occurred during the following months, with a residual mild motor defect of the right hand. This case report represents a starting point for discussing treatment of "in-transit" thrombi during pulmonary embolism.

The edge-to-edge technique: a simplified method to correct mitral insufficiency.

OBJECTIVE: Repair of mitral regurgitation (MR) is more demanding in case of prolapse of the anterior leaflet, posterior leaflet with calcified annulus, or prolapse of both leaflets. We evaluated a repair which consists of anchoring the free edge of the prolapsing leaflet to the corresponding free edge of the facing leaflet: the 'edge-to-edge' (E-to-E) technique. The correction results in a double orifice valve when the prolapse is in the middle portion of the leaflet and in a smaller valve orifice when the prolapse is close to a commissure. METHODS: Out of 432 patients with MR submitted to valve repair between January 1991 and September 1997, 121 (mean age 56 +/- 15.8 years) underwent E-to-E correction. The most prevalent etiology was degenerative disease (82 patients, 68%). The mechanism of MR was anterior leaflet prolapse (61 patients), posterior leaflet prolapse (24 patients), prolapse of both leaflets (28 patients) and other complex mechanisms (8 patients). In 72 patients, a double orifice was created, the paracommissural repair was done in 49 patients. RESULTS: Hospital mortality was 1.6%. Overall survival was 92 +/- 3.1% at 6 years with 95 +/- 4.8% freedom from reoperation. Mortality was unrelated to the type of repair. Mitral stenosis was never observed after the correction. At the follow-up (mean 2.2 +/- 1.5 years), all patients but 15 are class I or II. Symptoms at the follow-up are not related to residual MR. CONCLUSIONS: Midterm results of this alternative repair technique are promising, considering the high prevalence of complex anatomical lesions. The technique is simple, easily reproducible and rapidly feasible also when mitral exposure is suboptimal.

"Double-orifice" technique to repair extensive mitral valve excision following acute endocarditis.

The use of conservative surgical techniques to treat mitral valve regurgitation secondary to acute endocarditis is controversial. Reconstruction of the anterior leaflet may represent an additional challenge in such a setting. We report a case of mitral valve repair where extensive excision of the anterior leaflet and related chordae tendinea was necessary because of large vegetation secondary to acute endocarditis. The "double-orifice" technique was performed and allowed the salvage of the native valve. There was no recurrent infection at 6 months from surgery, with optimal hemodynamic results.

Cardiomyoplasty and implantable cardioverter defibrillator: efficacy and safety of concomitant device implantation: sudden death and cardiomyoplasty.

Sudden death represents a common event in the natural history of patients affected by chronic heart failure. Such an outcome also has been shown to characterize the follow-up of the cardiomyoplasty procedure. We report two cases of patients who had cardiomyoplasty and experienced witnessed episodes of ventricular arrhythmia at variable times after surgery (2 years and 2 months, respectively). In the first case, an implantable cardioverter defibrillator (ICD) was implanted subsequent to the arrhythmic episode, whereas the second patient had a combined cardiomyoplasty and ICD implantation procedure. In particular, this patient underwent a modified wrapping technique, herein described, because of a large left ventricular dilatation. In both cases, ventricular defibrillation did not affect the correct functioning of the implanted cardiomyostimulator. Our article confirms that ventricular arrhythmia is common in cardiomyoplasty patients. The combined use of a skeletal muscle stimulator and implantable defibrillator may therefore be effective in preventing arrhythmia-related sudden death without any concurrent effect on the correct functioning of the wrapped muscle/heart circuit, with likely benefit on long-term cardiomyoplasty patient survival.

Surgical management of left ventricular free wall rupture after acute myocardial infarction.

Left ventricular rupture after acute myocardial infarction occurs more often than suspected and diagnosis is rarely made before death. Left ventricular rupture has been reported to contribute to the overall in-hospital mortality after acute myocardial infarction in up to 24% of cases and to be present in 40% of patients dying within the first week after infarction. Only prompt diagnosis and aggressive surgical treatment can be lifesaving under these circumstances. Between February 1991 and August 1993 five patients underwent emergency operation for left ventricular rupture after acute myocardial infarction using exclusively transoesophageal echocardiography as a diagnostic tool. All patients had evidence of cardiac tamponade and electrocardiography showed signs of anterolateral acute myocardial infarction in one, inferolateral acute myocardial infarction in three and lateral acute myocardial infarction in one. In two cases the infarcted area was debrided and an interrupted pledgetted 2/0 polypropylene suture was placed from inside of the ventricle outward to the epicardial surface and then through the pericardial patch. In the other three cases an original technique was used: an autologous glutaraldehyde-stiffened pericardial patch was sealed over the infarcted area using fibrin glue and fixed with running suture on the surrounding healthy myocardium. One patient died in the operating room because of low cardiac output syndrome which was possibly the result of an excessively extended area of infarction. Left ventricular rupture is a catastrophic complication of acute myocardial infarction and prompt diagnosis with transoesophageal echocardiography followed by emergency operation can be lifesaving.(ABSTRACT TRUNCATED AT 250 WORDS)

Dynamic cardiomyoplasty as an effective therapy for dilated cardiomyopathy.

Nine male patients with dilated cardiomyopathy unresponsive to maximal medical therapy were submitted to dynamic cardiomyoplasty according to the technique described by Carpentier and Chachques, and preliminary postoperative results are reported. Seven patients were in New York Heart Association (NYHA) Class III and two were in intermittent Class IV. The mean age was 56 years (range 51 to 61 years). Preoperative ejection fraction (EF) by multiple gated acquisition ranged from 14% to 28% (mean 20.7%). No additional surgery was performed. Transesophageal echocardiographic monitoring was used during surgery to guide the wrapping procedure. There was no operative mortality. There was one early death (1 month). One late death (sudden death) occurred 7 months after surgery despite significant clinical improvement. Follow-up ranges from 2 to 16 months. Six patients were submitted to hemodynamic evaluation from 4 to 6 months after surgery by transthoracic and transesophageal echo-Doppler assessment. Effective latissimus dorsi support was clearly documented in all patients by comparing postoperative basal hemodynamic values (Cardiomyostimulator [Medtronic, Inc.] switched off) and data obtained during assisted beats (EF increased from 19.4% +/- 8.6% to 32.6% +/- 13.8%, p = 0.043; and stroke volume increased from 51.6 +/- 20.6 mL to 63.0 +/- 22.0 mL, p = 0.014). All patients who completed the latissimus dorsi training protocol were in NYHA Class I or II. A significant reduction in postoperative medical therapy was achieved in all patients. Our preliminary results confirm that the cardiomyoplasty procedure is to be considered a safe and valuable mean for treating selected patients with dilated cardiomyopathy refractory to maximal pharmacological treatment.

Recovery of myocardial function. The ultimate target of coronary revascularization.

Recovery of myocardial contraction represents an important target of coronary revascularization and the preoperative recognition of viable akinetic (hibernating) myocardium is a crucial point of the preoperative investigation of patients with chronically depressed left ventricular function. In 14 patients dobutamine infusion during echocardiography was utilized to evoke the contractile reserve retained by viable akinetic segments. Redistribution of thallium(TI)-201 after the rest injection was also used to assess the viability of akinetic areas. The wall motion response to dobutamine infusion predicted immediate postoperative improvement in 85 of 93 segments (sensitivity 91.3%) and identified 25 of the 32 segments which did not exhibit early postoperative improvement (specificity 78.1%). Rest redistribution of TI-201 demonstrated high sensitivity (93.0%) but low specificity (43.7%) for predicting the early recovery of regional wall motion. When late recovery was also considered, the specificity of this method increased to 64.0%. Rest distribution of TI-201 identifies viability which is not necessarily associated with the early recovery of function postoperatively. When the echo-dobutamine test is positive, on the other hand, the recovery of function usually occurs immediately after revascularization and the operative risk is expected to be low even in the presence of severely compromised left ventricular function.

[Reconstructive surgery of pure mitral insufficiency. Operative results and follow-up in 128 patients]. / Chirurgia ricostruttiva nell'insufficienza mitralica pura. Risultati operatori e follow-up in 128 pazienti.

Short and long-term results of valve repair for pure mitral insufficiency are reported in 128 consecutive patients with a mean age of 49 years (range 4-75). The etiology of the mitral valve dysfunction was degenerative in 54% of the cases, rheumatic in 30%, ischemic in 9.5%, endocarditic in 6.5%. Preoperatively, 91% of the patients were in NYHA class II or III. The anatomic lesions and the mechanism of mitral regurgitation were identified preoperatively by transthoracic and/or transesophageal echocardiography. Cardiac catheterization was performed only in patients with multiple valvular dysfunction and/or with evidence of concomitant coronary artery disease. Mitral repair was performed according to the techniques proposed by Carpentier. Only one patient died in the hospital (operative mortality: 0.8%). By actuarial methods, 96% of the patients were alive 4 years postoperatively, and 84% were reoperation free. Freedom from reoperation was significantly higher in patients who received a prosthetic ring than in those who had other types of anuloplasty (96% vs 67%; p < 0.05). During the follow-up period no patient had thromboembolic episodes. Ninety-seven per cent of the 112 patients who survived the operation and were not reoperated were in NYHA class I or II. These results confirm the validity of reconstructive surgery in pure mitral insufficiency. The use of a prosthetic ring gives stability to the repair and improves long-term results.

Postinfarction left ventricular free wall rupture: original management and surgical technique.

A case of postinfarction left ventricular free wall rupture is successfully treated. Prompt diagnosis was provided by echocardiography and an emergency operation was carried out. Following sternotomy, hemodynamic stabilization was obtained by gradually evacuating blood from the pericardium, while the femoral vessels were cannulated and the extracorporeal circulation was established. An autologous glutaraldehyde stiffened pericardial patch was sealed over the infarcted area using fibrin glue and fixed with a running suture on the surrounding healthy myocardium.

Intra- and paraprosthetic valve regurgitation. A color Doppler echocardiographic study.

We prospectively followed a cohort of 64 patients bearing an aortic or mitral prosthetic valve (mean follow-up 5.2 +/- 3.2 months) in order to evaluate if color-coded two-dimensional Doppler echocardiography (CFD) could provide some major advantages with respect to pulsed (PW) and continuous wave (CW) Doppler in the diagnostic accuracy of detection of intra-, and paraprosthetic leaks. During follow-up 4 cases of pathologic prosthetic regurgitation ensued and were all correctly and easily identified by CFD while one of them was missed both by PW and CW Doppler. Based on our results we conclude that CFD is the best noninvasive tool actually available for the correct identification of prosthetic valvular regurgitation because it can provide useful accessory information difficult to obtain with other echocardiographic techniques.

Optimal exposure of the mitral valve through an extended vertical transeptal approach.

The mitral valve was approached through a vertical transeptal incision extended into the roof of the left atrium in 111 patients. Good exposure was invariably provided even in unfavorable situations such as a small left atrium combined with right ventricular hypertrophy or a previously implanted aortic prosthesis. The only hospital death in the entire series was not related to this approach to the mitral valve. Due to breakage of the suture in the roof of the left atrium and to incomplete reconstruction of the atrial septum resulting in a large left-to-right shunt, 2 patients required reinstitution of cardiopulmonary bypass. Both had a smooth postoperative course. Other intra- or postoperative complications related to the incision did not occur. Duration of cardiopulmonary bypass and aortic occlusion was not significantly different from that of patients operated upon through the conventional left atrial approach in the year preceding the experience embraced by this study. Only 3 of 52 patients who were preoperatively in sinus rhythm were discharged in atrial fibrillation. Enhanced atrial vulnerability was demonstrated preoperatively in all 3. These data support a wide application of the extended vertical transeptal approach in mitral valve surgery.