Benefits and medium-term outcome of the Sorin Pericarbon Freedom stentless aortic prosthesis in cases of acute bacterial endocarditis.

OBJECTIVES: The aim of this study is to evaluate the ease of use and the advantages of Sorin Pericarbon Freedom (SPF) stentless valve in cases of acute bacterial endocarditis and to check the intermediate-term results after the implant of SPF with respect to resistance to infection, valve deterioration and durability. METHODS: Between June 2003 and February 2015, 26 patients with active aortic valve bacterial endocarditis underwent aortic valve replacement with SPF pericardial stentless aortic prosthesis. The mean age was 57 ± 18 years; 73% of the patients were in preoperative NYHA class III and VI. Mean Logistic EuroSCORE was 14.2 ± 12.7. Endocarditis occurred in 18 patients with native valves, and in 9 patients with prosthetic valves (4 mechanical aortic valve prostheses; 5 aortic bioprostheses). Aortic root abscesses were observed in 16 cases (61.5%). Surgery was emergent in 3 cases (11.5%). Redo surgery was performed in 9 cases (35%). Cumulative follow-up was 126.8 patient-years (mean 4.9 ± 3.3 years). RESULTS: Operative hospital mortality was 0% for all patients. Residual mean prosthetic gradient at discharge was 9.4 ± 3.6 mmHg. Neither residual aortic incompetence nor residual abscess cavity was observed at discharge. Mean ejection fraction at discharge was 54 ± 8% (Min; Max: 35%; 65%). A total of 4 patients died at follow-up, all for non-cardiac causes. One patient was lost to follow-up. Two patients (8%) underwent non-valve-related reoperation with 0% mortality. Residual mean gradient at follow-up was 7.2 ± 2.1 mmHg. Three patients (17%) presented with mild/moderate aortic incompetence and 89% of patients were in NYHA Class I-II at follow-up. At 9 years, actuarial freedom from valve-related reoperation and from structural valve deterioration was 100%. CONCLUSIONS: The SPF aortic prosthesis is a true pericardial stentless prosthesis suitable for the treatment of acute bacterial endocarditis. Intermediate-time results in terms of freedom from reoperation, structural valve deterioration and resistance to infections are satisfactory. Haemodynamic performances are excellent since a complete exclusion of aortic root abscesses is achieved without any reduction of the aortic annular diameter, usually due to marsupialization or patch closure of the infected cavities.

Inflammatory profile in subcutaneous and epicardial adipose tissue in men with and without diabetes.

In recent years, evidence has emerged indicating that insulin resistance and diabetes mellitus type 2 are associated with inflammation of adipose tissue (AT). Interest has been focused on epicardial AT (EAT) because of its possible involvement with atherosclerosis and cardiovascular diseases. The aim of this study was to characterize adipocyte size and inflammatory profile in subcutaneous (SAT) and EAT among subjects with or without diabetes. Biopsies were collected from SAT and EAT in 34 men undergoing elective cardiac surgery. Weight, height, body mass index, waist circumference, as well as serum levels of glucose, insulin, lipids, adiponectin, and leptin were determined in all subjects. Adiponectin, MCP-1, and CD68 mRNA levels present within cells from AT biopsies were determined by real-time polymerase chain reaction. Adipocyte size was determined by optic microscopy and morphometry. Regarding the experimental group as a whole, gene-expression levels within EAT were significantly lower for adiponectin and higher, albeit not significantly, for MCP-1, when compared with that of SAT. In addition, adipocytes in EAT were significantly smaller than those in SAT. Subjects with diabetes showed lower adiponectin gene-expression levels in both SAT and EAT when compared with subjects without diabetes. By contrast, MCP-1 and CD68 gene-expression levels were higher in both tissue types of diabetic subjects. Adipocyte size in EAT was significantly larger in diabetic subjects than in nondiabetic subjects. Our data revealed a predominantly inflammatory profile in both SAT and EAT in subjects with diabetes in comparison with those without diabetes.

Renal cell carcinoma with invasion of the tricuspid valve apparatus.

A right atrial in-growth of renal carcinoma occurs in 1% of cases. A traditional approach to removal of the tumor using cardiopulmonary bypass (CPB) and deep-hypothermic circulatory arrest (DHCA) has been challenged in favor of techniques that allow tumor removal without CPB and DHCA. To the best of the present authors' knowledge, no report has yet been made of an invasion by the tumor of the tricuspid valve leaflets and subvalvular apparatus. The details of such a case are reported herein, where CPB + DHCA was used to completely remove the neoplasm, and to preserve tricuspid valve competence.

Selective pulmonary pulsatile perfusion with oxygenated blood during cardiopulmonary bypass attenuates lung tissue inflammation but does not affect circulating cytokine levels.

OBJECTIVE: Improved respiratory outcome has been shown after selective pulsatile pulmonary perfusion (sPPP) during cardiopulmonary bypass (CPB). No contemporary study has analysed the impact of sPPP on alveolar and systemic inflammatory response in humans. METHODS: Sixty-four patients undergoing a coronary artery bypass graft (CABG) were randomized to sPPP or standard CPB (32 patients each). An alveolar-arterial oxygen gradient (A-aDO(2)) was measured preoperatively (T0), at ICU arrival (T1), 3 h postoperatively (T2) and postextubation (T3). The bronchoalveolar lavage (BAL) was collected at T0, T1 and T2. White blood cells (WBCs), neutrophils, mononucleates and lymphocytes in BAL infiltrates were compared between the two groups. A cytokine assay for interleukin-1 (IL-1), IL-8, tumour necrosis factor alpha (TNF-α), monocyte chemotactic protein-1 (MCP-1), growth regulated oncogene-alpha (GRO-α) and interferon (IFN)-γ was collected from the BAL and peripheral blood at the same time-points. Repeated-measure analysis of variance and non-parametric statistics were used to assess the between-group and during time differences. RESULTS: The two groups proved comparable for perioperative variables. A-aDO(2) proved better after sPPP (group-P = 0.0001; group time-P < 0.0001). BAL infiltrates after sPPP showed lower WBCs, neutrophils and lymphocytes (group-P = 0.0001, group time-P = 0.0001 for all) together with higher mononucleates (group-P = 0.0001, group time-P = 0.0001). Proinflammatory cytokines and chemokine MCP-1 were lower in BAL after sPPP (group-P = 0.005, 0.034, 0.036 and 0.005, and group time-P = 0.001, 0.009, 0.001 and 0.0001 for IL-1, IL-8, TNF-α and MCP-1, respectively), whereas the immune modulator IFN-γ significantly augmented after sPPP (time-P = 0.0001) but remained stable after the standard CPB (time-P = 0.101, group-P = 001, group time-P = 0.0001). Indeed, serum cytokines were not different in the two groups during the study (P = NS at single time-points and as a function of time). CONCLUSIONS: sPPP attenuates alveolar inflammation, as demonstrated by the lower neutrophilic/lymphocytic alveolar infiltration, and the secretion of anti-inflammatory rather than proinflammatory mediators.

Preliminary experience with a new device for delayed sternal closure strategy in cardiac surgery.

PURPOSE: Open chest management with delayed sternal closure (DSC) is a valuable strategy in the management of patients with postcardiotomy hemodynamic instability or severe coagulopathy. The conventional extemporized material available for off-label sternal stenting however may limit its efficacy. We evaluated outcomes of patients with refractory severe postcardiotomy cardiogenic shock (SPCCS) treated with DSC using a novel temporary sternal spreader (NTSS) which allows myocardial recovery by progressive controlled approximation of the sternal edges. METHODS: Seven patients (4 male, mean age 66.5 ± 5 years) with refractory SPCCS showing acute hemodynamic instability at sternal closure, were implanted with the NTSS, consisting of stainless-steel branches linked to 2 diverging plates of polyether-ether ketone, whose progressive opening/closing mechanism can be controlled from outside the chest with a rotating steel wire. The sternal wound was closed by an elastic membrane to achieve a sterile field. Swan-Ganz monitoring was employed, and clinical outcomes evaluated. RESULTS: The device was successfully implanted in all patients without device-related complications or failures. Progressive approximation of sternal edges, titrated on cardiac index values, was successfully completed allowing subsequent uneventful sternal closure in all. Mean time from SPCCS to sternal closure was 70 ± 21 hours. No patient developed infective complications or late hemodynamic instability after device removal and sternal closure. One patient (14%) died of multiorgan failure on postoperative day 9. CONCLUSIONS: Despite the limited number of patients enrolled, the NTSS proved safe and effective in allowing complete myocardial recovery after SPCCS, avoiding hemodynamic instability related to abrupt sternal closure, with no occurrence of infective complications.

Pulsatile pulmonary perfusion with oxygenated blood ameliorates pulmonary hemodynamic and respiratory indices in low-risk coronary artery bypass patients.

OBJECTIVE: Acute lung injury still accounts for postoperative mortality after cardiopulmonary bypass (CPB). The safety and the efficacy of pulsatile pulmonary perfusion (PPP) during CPB were analyzed. Preliminary results of the first PPP trial in human beings are reported. METHODS: Thirty low-risk coronary artery bypass grafting (CABG) patients were prospectively randomized to receive PPP with oxygenated blood during CPB and aortic cross-clamping (15 patients, PPP-group) or to conventional CPB (15 patients, control group). Alveolo-arterial oxygen gradient (A-aDO(2)) was set as the primary end point and collected preoperatively, at intensive care unit (ICU) arrival (T1), 3h postoperatively (T2), and post extubation (T3). Secondary end points were collected at the same time points and consisted of respiratory indices (partial pressure of arterial oxygen/fraction of inspired O(2) (PaO(2)/FiO(2)), lung compliance, mixed-venous partial pressure of oxygen (pO(2))) and hemodynamic pulmonary parameters (indexed pulmonary vascular resistances (PVRI), pulmonary arterial pressure (PAP), pulmonary capillary wedge pressure (PCWP), and cardiac index (CI)). Bronchoalveolar lavage (BAL) fluid was collected preoperatively, at ICU arrival (T1-BAL) and after 4h. RESULTS: There were no PPP-related complications. Patients undergoing PPP showed a better preserved A-aDO(2) (group-p=0.001) throughout the study period (group × time-p = 0.0001). PaO(2)/FiO(2) and lung compliance were better preserved by PPP (group-p and group × time-p ≤ 0.05 for all). Pulmonary hemodynamic status was positively influenced by PPP, as shown by the higher CI (group-p=0.0001, group × time-p = 0.0001), and the lower PVRI, PAP, and PCWP (group-p ≤0.001, group × time-p=0.0001 for all). Postoperative BAL specimens demonstrated a lower absolute count of white blood cells (group-p=0.0001), a higher percentage of monocytes/macrophages (group-p=0.027), and a lower percentage of neutrophils (group-p=0.015) after PPP. CONCLUSIONS: Oxygenated blood PPP proved safe and significantly ameliorated pulmonary hemodynamic parameters and respiratory indices in low-risk CABG.

Spontaneous rupture of the right sinus of valsalva mimicking an ascending aortic intramural hematoma.

Spontaneous ruptures of the ascending aorta are extremely rare and require emergent surgical intervention. We report a case of a delayed diagnosis of a spontaneous, localized periostial rupture of a nondilated right sinus of Valsalva, which mimicked an intramural hematoma of the ascending aorta. The diagnosis and surgical management of this unusual pathology is the subject of this case report.

Adiponectin gene expression and adipocyte diameter: a comparison between epicardial and subcutaneous adipose tissue in men.

INTRODUCTION: Interest has recently focused on epicardial fat, but little is known about epicardial adipocyte size and its relation with insulin resistance and adipokines. METHODS: Biopsies were collected from subcutaneous, epicardial-, and peritoneal fat from 21 males undergoing elective cardiac surgery either for coronary artery bypass grafting (n=11) or for valve replacement (n=10). We assessed epicardial adipocyte size, comparing it with that from subcutaneous fat and peritoneal fat. The adipocyte size was determined by using collagenase digestion of adipose tissue, separation of adipocytes by centrifugation, methylene blue staining of the nuclei, and measurement of the cell diameter. Patient's weight, height, body mass index, waist, as well as glucose, insulin, homeostatic model assessment index, adiponectin, and leptin serum levels were determined. Adiponectin mRNA levels were determined by real-time polymerase chain reaction on subcutaneous fat and epicardial fat biopsies. RESULTS: Adipocytes in epicardial fat were significantly smaller than those in subcutaneous and peritoneal fat. The adipocyte size in epicardial fat correlated positively with insulin resistance and serum leptin, and correlated negatively with serum and mRNA expression of adiponectin. Adiponectin mRNA expression in epicardial fat was significantly lower than in subcutaneous fat. Adipocyte size in epicardial fat was significantly smaller in valve-replacement patients than in coronary artery bypass graft patients. Adiponectin gene expression was lower in the latter than in the former, although not significantly. CONCLUSIONS: Adipocytes in epicardial fat are smaller than those in peritoneal and subcutaneous fat. Adipocyte size, both in epicardial and in subcutaneous fat, is positively related with insulin resistance, shows negative association with local adiponectin gene expression, and is decreased in subjects with coronary artery disease. Adiponectin gene expression is significantly lower in epicardial- than in subcutaneous fat.