Huge ascending aorta and aortic arch aneurysm in ultra octogenarian.

Giant ascending aorta aneurysms (AAA), which are larger than 10 cm, are rarely been reported (1-7). We hereby present the case of a giant AAA of about 11 cm in a very old women who was successfully operated on for ascending aorta and aortic arch replacement under deep hypothermic circulatory arrest.

Additional applications of the Foley catheter in cardiac surgery.

We describe an additional use of the Foley catheter for preoperative and postoperative evaluation of the regurgitant mitral valve.

Two cases of right atrial myxoma in redo patients. A mere coincidence?

We describe two cases of right atrial myxoma in redo patients who had previously undergone to coronary artery by-pass grafting (CABGs) and mitral valve replacement respectively. Both of patients experienced effort dyspnea and were assessed by trans-thoracic echocardiography, revealing the right atrial masses. They were operated on for myxoma resection and postoperative course was uneventful. Our report deals with the interesting topic of the location of benign masses that are usually more common in the left atrium. Should we hypothesize that the right atrial manipulation during the previous surgery induces the onset of the right atrial mass? It is an interesting matter to debate.

Transcutaneous insertion of the Chitwood® clamp in case of minimally invasive cardiac surgery. Personal experience.

We describe a simple trick consisting of an insertion of a trans-thoracic Chitwood® clamp (Scanlan International, Inc, St Paul, MN, USA) through a small skin incision (<1cm), via the second intercostal space along the anterior axillary line, in case of minimally invasive mitral surgery, through right thoracotomy. This trick has been used in more than 100 patients and no complication or discomfort have been reported so far.

Aortic valve replacement through the upper ministernotomy: preliminary experience with modified technique.

Minimally invasive approach for aortic valve surgery has been developed since 1995, reducing the complications related to the full sternotomy. We have introduced a new method for central cannulation that reduces the length of surgical incision for the aortic valve replacement through upper mini-sternotomy. To improve the surgical view without enlargement of the incision, two small additional incisions are performed for both arterial and atrial cannulation. We have used the modified technique in 60 patients without sternal infection or other surgical complications and with good cosmetic results.

Role of oral sildenafil in the treatment of right ventricular dysfunction after heart transplantation.

OBJECTIVE: Right ventricular dysfunction (RVD) after heart transplantation is a major complication, especially in patients with pulmonary hypertension (PH). Herein we have presented our initial experience with oral sildenafil for RVD following heart transplantation. MATERIALS AND METHODS: From February 2006 to February 2008, 10 patients (7 males and 3 females) of overall mean age of 56.7 +/- 9.5 years suffered from acute RVD immediately after heart transplantation. Preoperative hemodynamic data before and after a vasodilatation test (sodium nitroprusside; NTP) showed: systolic pulmonary arterial pressure (SPAP) 59.5 +/- 12.9 and 44.2 +/- 12.4 mm Hg; cardiac output (CO) 3.3 +/- 0.9 and 3.7 +/- 0.8 L/min; transpulmonary gradient (TPG) 11.7 +/- 3.9 and 8.7 +/- 3.6 mm Hg; and pulmonary vascular resistance (PVR) 3.9 +/- 2.1 and 2.4 +/- 1.3 wood units (WU), respectively. All patients required inotropes and inhaled nitric oxide (iNO) to be weaned from cardiopulmonary bypass (CPB). RESULTS: Intravenous (IV) or inhaled vasodilators could be weaned using oral sildenafil in all patients. The hemodynamic data obtained during IV or inhaled drugs (between postoperative days 5 and 10) compared with those obtained on sildenafil therapy alone (about 1 month after transplantation) showed a significant decrease in SPAP (39.0 +/- 8.2 vs 32.0 +/- 6.5 mm Hg; P = .049). CONCLUSION: These data suggested that oral sildenafil may have a role in the treatment of RVD after heart transplantation.

A prospective study of prevalence of 60-days postoperative wound infections after cardiac surgery. An updated risk factor analysis.

AIM: Postoperative wound infections generally cause considerable extra morbidity, mortality and costs. The prevalence of total wound infections after cardiac surgery, including both sternal wound and donor site infections, ranges from 1.3 to 12.8%. The present study was conducted to identify the incidence of wound infections following cardiac surgery, to identify the risk factors and evaluate the efficacy of present modes of management. METHODS: From September 2004 to May 2005, 493 consecutive patients undergoing cardiac surgery were included in the study and were followed for the prevalence of surgical site infection (SSI) up to 60 days postoperatively. The wound infections were defined according to the Centers for Disease Control and Prevention (CDC) and U.S. National Nosocomial Infections Surveillance (NNIS) system criteria. RESULTS: The total incidence of SSI was 3.9%. Sternal wound infection (SWI) occurred in 17 patients (3.4%). Superficial wound infection was diagnosed in 10 patients (2%) and deep wound infection in 7 patients (1.4%). Donor site infection (DSI) occurred in 2 patients (0.4%). Early reoperation for bleeding, postoperative dialysis and the use of one internal mammary artery were independently associated with an increased risk of SWI. CONCLUSION: Preventing SSI in the operating room is the primary goal of the surgical team. Attention should be paid to antibiotic prophylaxis and Methicillin-resistant Staphylococcus aureus (MRSA) nasal carriage treatment. The identification of risk factors will help to further reduce the incidence of wound infection.

[Severe and prolonged post-dural puncture headache: from pathological basis to therapeutic role and correct timing for epidural blood patch]. / Cefalea da deliquorazione grave e protratta: dal riconoscimento del substrato organico al ruolo terapeutico e alla corretta temporizzazione del blood patch peridurale.

Believed to be due to unbalance between cerebrospinal fluid (CSF) production rate and its loss through the spinal dural puncture hole, post-dural puncture headache (PDPH) is often considered as a physiological syndrome, usually reversible without pathological sequelae after dural hole's closure. The clinical case here presented (incapacitating headache associated with diagnostic dural puncture in a leukaemic young female patient who underwent bone marrow transplantation) shows potentially fatal pathological sequelae following prolonged headache (untreated, due to the severe postransplant immunodeficiency and coagulopathy). The observed RMI lesions suggest interesting conclusions about the clinical indications and correct timing of autologous epidural blood patch (EBP). We also suggest the ways to preventing rebound intracranial hypertension following autologous epidural blood patch in patients suffering from incapacitating and prolonged headache.

The coronary vasculature and the myocardium.

The effect of bradykinin (BK) on myocardial inotropic state was tested on 5 isolated rat heart preparations, in which a proper ballon was placed to record left ventricular pressure, whose developed systolic value was taken as an index of contractility. A reduction of developed left ventricular pressure was observed when BK was added to the perfusion oxygenated Tyrode solution. However, when BK was given after 1-amino-benzotriazole, an inhibitor of Cytochrome P-450 (Cyt P-450), developed pressure did not change. Since Cyt P-450 is known to act on arachidonic acid inducing the production of epoxiecocistrienoic acids (EETs) which hyperpolarizes myocardial fibres, it was argued that the reduction in contractility by bradykinin was the result of the hyperpolarizing effect of EETs. The fact that the concentration of Cyt P-450 is higher in the vascular endothelial cells than in the sarcolemma of the myocytes and the observation that the coronary resistance decreases together with the contractility suggest that the endothelium plays a pivotal role in mediating the negative inotropic effect of BK.

[Evaluation of renal function during orthotopic liver transplantation]. / Valutazione della funzione renale in corso di trapianto ortotopico di fegato.

BACKGROUND: Orthotopic liver transplantation (OLI) is a recognised means of therapy for endstage liver failure (ESLF). Both the preoperative alterations of renal function, closely correlated with the ESLF, and the frequent and abrupt changes of circulating blood volumes occurring during the various phases of OLT are able to significantly alter renal function during the perioperative period. METHODS: In order to define the specific changes of renal function during the various phases of OLT, six postnecrotic cirrhotic patients undergoing their first OLT entered a prospective study protocol. All the patients had standard and anesthetic techniques including the venovenous bypass (VVBP) during the anhepatic phase. At standard intervals (baseline, during hepatic dissection, during the anhepatic phase, following reperfusion, at the end of surgery) together with complete hemodynamic and metabolic profiles, arterial blood and urine samples were obtained to determine electrolytes and creatinine concentrations, blood levels of atrial natriuretic factor, aldosterone and renin activity. Using standard formulas creatinine clearance (Ccreat) and Na absolute and fractional excretions (FeNa%) were calculated. RESULTS: Major changes in the hemodynamic profile occurred during the anhepatic phase in spite of the use of the VVBP (reduced cardiac index, reduced pulmonary wedge pressure, increased systemic vascular resistances). Concomitantly a significant decrease in Ccreat (-67%) and in urinary output, was present while aldosterone and renin activity increased. The changes in Ccreat persisted at the end of surgery in spite of the optimal hemodynamic profile. Aldosterone and renin activity returned to values close to baseline at the end of surgery. CONCLUSIONS: From these data it is possible to conclude that renal function markedly deteriorates during OLT and it has to be considered at increased risk in the immediate postoperative period. The use of VVBP does not seem to prevent the intraoperative renal impairment.

Lactate blood levels in the perioperative period of orthotopic liver transplantation.

To investigate whether early postoperative changes in blood lactate concentration indicate the functional recovery of the newly grafted liver, changes in oxygen supply, oxygen consumption, acid-base equilibrium, and blood lactate concentrations were prospectively studied in a group of 53 postnecrotic cirrhotic patients during the various phases of orthotopic liver transplantation (preanhepatic, anhepatic, neohepatic) and for the first 48 h following reperfusion. The patients were divided into two groups according to the quality of the early graft function, as indicated by alanine aminotransferase, bile flow, and prothrombin activity: group A (49 patients), good immediate graft function and group B (4 patients), immediate graft non-function. Lactate levels rose in the same manner during the preanhepatic and anhepatic stages and peaked after revascularization of the graft. Following reperfusion, however, distinctly different blood lactate profiles were recorded in the two groups of patients. A fall in lactate concentration was recorded in group A patients, whereas a continuous rise occurred in group B patients: the difference becoming significant by the end of surgery (P < or = 0.05). During the first 48 h following revascularization of the graft, opposite trends in lactate concentration, bile flow, alanine aminotransferase, and prothrombin activity were evident in the two groups of patients: 24 h after reperfusion, lactate levels were below 2 mmol/l in 47 of 49 patients from group A, while they plateaued above 4 mmol/l in all patients from group B. Group A patients had lower alanine aminotransferase levels (P < or = 0.001), higher prothrombin activity, (P < or = 0.01), and greater bile flow (P < or = 0.02). If validated in larger series, the blood lactate profile, probably more than the absolute level, appears to be a useful indicator of the early recovery of liver metabolic capacities in the immediate postoperative period of orthotopic liver transplantation.

Circannual rhythmicities of cortisol levels in the peripheral plasma of healthy subjects.

Seasonal variations of endocrine function have been extensively studied both in rodents and in man. However, only few studies have attempted to concomitantly evaluate and compare circadian and circannual components by inferential rhythmometric procedures. We have examined [9] circadian profiles (single cosinor: P less than 0.01) of plasma cortisol obtained from samples drawn at 4-h intervals in healthy adult subjects of both sexes (71 males, 120 females, aged 20-54 years) along a 7-year span, from 1974 to 1980. All subjects were routine synchronized. Circulating cortisol was measured by a competitive protein-binding technique and expressed as microgram/dl; intra-assay coefficient of variation was always less than 5%. Both conventional and rhythmometric analysis were used to evaluate seasonal differences of mesor, amplitude and acrophase. The population-mean cosinor analyses revealed statistically significant differences as a function of the time of the year in both the circadian amplitude and acrophase. Examining data year by year revealed in 5 out of 7 annual cycles an apparent tendency to a delayed acrophase and to a reduced amplitude with advancing months towards winter. No significant changes in mesor values were found. Further fitting to a 365.25-day cosine curve of circadian parameters available for different months of an 'average' year yielded significant circannual rhythmicity for acrophase and amplitude; crest-value resulted in spring and autumn, respectively. Our data extend previous observations and are consistent with the existence of circannual variations in plasma cortisol levels in the human. In Italian people, cortisol secretion is conceivably higher in cold months; seasonal changes, on the other hand, appear to be of minor entity of at least as inferred by transverse sampling on a relatively large population. Effects of lighting regimen and of other climatological variables upon the adrenal cycle have to be considered.

Diurnal variation of prednisolone binding to serum corticosteroid-binding globulin in man.

Serum corticosteroid-binding globulin (CBG, transcortin) binding capacity for prednisolone and for cortisol, and levels of the circulating cortisol were evaluated in healthy adult subjects and in patients under long-term treatment with prednisone. Blood samples were drawn at 4-hr intervals throughout at least 24 hr; the prednisone administration was discontinued 24 hr before starting examination. Circadian fluctuations in the CBG-binding capacity for prednisolone occurred in healthy subjects: maximum binding was at 12 midnight and minimum binding at 8 a.m. The diurnal pattern of prednisolone-binding capacity was characterized by phase shifts of approximately 12 hr and 8 hr compared with those of serum cortisol and cortisol-binding capacity, respectively. There were no diurnal variations of prednisolone- and cortisol-binding capacity in the prednisone-treated patients. Moreover, the levels of both capacities, expressed as micrograms bound steroid/100 ml, were significantly reduced with respect to normal control subjects. Cyclic variations in serum CBG-binding capacity may represent an additional factor accounting for temporal differences in the action of synthetic corticoids which are bound by the transport protein. Synthetic derivatives when chronically administered may interfere not only with the adrenal secretion but also with the serum transport of glucocorticoids.

Hyperprolactinemia in girls with idiopathic precocious puberty under prolonged treatment with cyproterone acetate.

Pasma prolactin response to the acute injection of sulpiride (1.5 mg/k BW im) was measured at 0800-0900h in 4 girls with idiopathic precocious puberty before and after 6 to 11 months of continuous therapy with 50 mg daily of cyproterone acetate (CA) orally administered. Two additional girls were examined after 26 and 28 months of therapy, respectively. Mean baseline prolactin concentrations were significantly higher in untreated girls with precocious puberty as compared to that of normal controls of the same chronological age and of a comparable degree of sexual maturation (14.5 +/- 1.9 SE vs. 7.4 +/- 1.8 SE ng/ml and vs. 9.5 +/- 1.8 ng/ml, respectively; P less than .02). Treatment with CA caused a significant further increase of plasma prolactin concentration (P less than .02 as compared to pre-treatment values); no correlation was observed between prolactin concentration and duration of treatment. No significant change in the integrated areas of prlactin response to sulpiride occurred after prolonged CA therapy. The results suggest that in idiopathic precocious puberty the action of CA upon the hypothalamic-hypophyseal complex is not solely antigonadotropic and that prolactin secretion is enhanced in patients given this drug.