Frozen Elephant Trunk: Technical Overview and Our Experience with a Patient-Tailored Approach.

Ever since the first hybrid prosthesis was used for a total aortic arch replacement, many other techniques have been developed to comply with the need for the treatment of a wide spectrum of patients and their clinical pictures. We hereby provide an overview of the most popular surgical techniques to perform a frozen elephant trunk, including our tailored approach revolving around the antegrade deployment of a Gore C-TAG endovascular stent graft sutured to a four-branched vascular prosthesis. This technique was applied to three cases of acute type A aortic dissection. Although our small series of patients consists of acute aortic dissections only, this technique could be applied to any other aortic arch pathology, such as chronic dissections or aneurysms. Moreover, we believe that, because of the individually tailored approach and widespread availability of the necessary materials, this technique can reveal itself useful in many different operative scenarios.

Digital PCR for Genotype Quantification: A Case Study in a Pasta Production Chain.

Digital polymerase chain reaction (dPCR) is a breakthrough technology based on the partitioning of the analytical sample and detection of individual end-point amplifications into the separate compartments. Among the numerous applications of this technology, its suitability in mutation detection is relevant and characterized by unprecedented levels of precision. The actual applicability of this analytical technique to quantify the presence of a specific plant genotype, in both raw materials and transformed products, by exploiting a point polymorphism has been evaluated. As proof of concept, an Italian premium pasta production chain was considered and a dPCR assay based on a durum wheat target variety private point mutation was designed and evaluated in supply-chain samples. From the results obtained, the assay can be applied to confirm the presence of a target variety and to quantify it in raw materials and transformed products, such as commercial grain lots and pasta. The performance, costs, and applicability of the assay has been compared to analytical alternatives, namely simple sequence repeats (SSRs) and genotype-by-sequencing based on Diversity Arrays Technology sequencing (DArTseqTM).

Spectrophotometry and pharmaceutical PAT/RTRT: Practical challenges and regulatory landscape from development to product lifecycle.

European Pharmacopoeia includes dedicated chapters for Raman, NIR and Chemometrics, as well as there is a lot of Academia research on the matter. Despite that, the word innovation is often associated to such tools and there is a still slow implementation at industry. The paper is the outcome of the Associazione Farmaceutici dell'Industria (AFI) Study Group on Process Innovation and Product Lifecycle; the aim is to describe some case studies referring to practical approaches in pharmaceutical industry, in order to depict challenges and opportunities for the implementation of spectroscopic techniques. Case studies include: feasibility and pre-screening evaluations, chemometric model development approaches, way for the method maintenance during commercial manufacturing, challenges for implementation on existing equipment and on sterile processes. Case studies refer to oral solid products, liquid products and sterile Active Pharmaceutical Ingradient (API) manufacturing. There are already successful and robust spectroscopic applications in pharmaceutical industry and the technology is mature: this is the outcome of a strong applied research performed at pharmaceutical production departments. It is necessary to acknowledge efforts done by industry as Research for strengthening the cooperation with Academia, so that advantage of process innovation might reach the patients in a fastest way.

Ultra-rapid regrowth of urothelial cardiac metastasis after debulking surgery.

Cardiac metastases of urothelial carcinoma are a rare manifestation, and most of them are asymptomatic or autoptic findings. We report a case of a 64-year-old Caucasian man fully asymptomatic, who has been accidentally diagnosed with a right atrial mass during his routine follow up for previous urothelial cancer. Endomyocardial biopsy, and histological examination of the mass were crucial to reach a definitive diagnosis of urothelial metastasis. He underwent a debulking surgery of the mass to avoid cardiac life-threatening complications. Despite effective removal of the atrial metastasis, after 45 days the patient experienced an ultra-rapid regrowth of the mass in the same position. This case demonstrates how rapidly a urothelial cardiac metastasis can grow back, and that surgery does not avoid by itself early recurrence.

A new cannula for antegrade selective cerebral perfusion.

OBJECTIVE: Our aim was to perform antegrade selective cerebral perfusion with a different surgical technique using a new type of cannula. METHODS: This cannula has been designed to be introduced in the supra-aortic vessels directly using a standard guidewire technique (Seldinger technique). The cannula can also be inserted from the ostia of a vessel if preferred. Furthermore, this device can be introduced before the institution of hypothermic circulatory arrest and opening the aortic arch. RESULTS: We have performed operations on 5 patients so far using this cannula. No stroke or spinal cord injuries were detected. At the moment, both intraoperatively and at computed tomography scan follow-up, no significant stenosis of the cannulation sites were noted. Follow-up at 2 years found that patients are alive and free from new major neurological events. CONCLUSIONS: Transarterial introduction using the Seldinger technique of our cannula (AV Flow; MedEurope Srl, Bologna, Italy) represents an alternative to the current well-established techniques. The major advantages we describe are complete cerebral protection throughout the hypothermic circulatory arrest and easier arch vessels reimplantation or hemiarch operations.

Performing Antegrade Selective Cerebral Perfusion Using the AV Cannula: A Novel Approach.

Antegrade selective cerebral perfusion has become the preferred choice for brain protection during aortic arch surgery. To perform antegrade selective cerebral perfusion, cannulas have been introduced directly into the ostia of the supra-aortic vessels (SAV) after institution of hypothermic circulatory arrest and opening the aortic arch. We describe a different surgical technique with a new type of cannula for antegrade selective cerebral perfusion. This cannula, called AV (Andrea Venturini) cannula, has been designed to be introduced in the SAV directly using a standard guidewire technique (Seldinger's technique). The AV cannula can also be introduced from the ostia of the SAV if preferred. The AV cannula can be introduced before the institution of hypothermic circulatory arrest and before opening the aortic arch. One great advantage of this technique is that the ostia of the SAV remain free from a cannula, allowing the operator easier access and a faster anastomosis or reimplantation.

High resolution crystal structures of the Cerebratulus lacteus mini-Hb in the unligated and carbomonoxy states.

The nerve tissue mini-hemoglobin from Cerebratulus lacteus (CerHb) displays an essential globin fold hosting a protein matrix tunnel held to allow traffic of small ligands to and from the heme. CerHb heme pocket hosts the distal TyrB10/GlnE7 pair, normally linked to low rates of O(2) dissociation and ultra-high O(2) affinity. However, CerHb affinity for O(2) is similar to that of mammalian myoglobins, due to a dynamic equilibrium between high and low affinity states driven by the ability of ThrE11 to orient the TyrB10 OH group relative to the heme ligand. We present here the high resolution crystal structures of CerHb in the unligated and carbomonoxy states. Although CO binds to the heme with an orientation different from the O(2) ligand, the overall binding schemes for CO and O(2) are essentially the same, both ligands being stabilized through a network of hydrogen bonds based on TyrB10, GlnE7, and ThrE11. No dramatic protein structural changes are needed to support binding of the ligands, which can freely reach the heme distal site through the apolar tunnel. A lack of main conformational changes between the heme-unligated and -ligated states grants stability to the folded mini-Hb and is a prerequisite for fast ligand diffusion to/from the heme.

A novel approach to ventricular rupture: clinical needs and surgical technique.

Cardiac rupture is a life-threatening event that often occurs after myocardial infarction and is often associated with significant death. Pericardiocentesis provides hemodynamic short-term improvement; however, patients with cardiac rupture require an emergency operation. This report describes a new procedure used to repair left ventricle free wall rupture after myocardial infarction. The technique described repairs the rupture off-pump and without the need for suturing. Midterm results demonstrate the feasibility and durability of this procedure.

Mitral valve repair complicated by iatrogenic coronary artery lesion treated with percutaneous coronary intervention.

We report a case of mitral valve repair complicated by iatrogenic coronary artery lesion. This rare coronary injury caused an acute ST-elevation myocardial infarction and it was treated successfully with a percutaneous coronary intervention.

Diagnosing left ventricular aneurysm from pseudo-aneurysm: a case report and a review in literature.

Rupture of the free wall of the left ventricle (LV) is a catastrophic complication occurring in 4% of patients after myocardial infarction (MI) and in 23% of those who die of MI. Rarely the rupture is contained by an adherent pericardium creating a pseudo-aneurysm. This clinical finding calls for emergency surgery. If no ruptures are detectable and myocardium wall integrity is confirmed, we are in the presence of a true aneurysm, which can be treated by means of elective surgery. Differentiation between these two pathologies remains difficult. We report the case of a patient with a true aneurysm, initially diagnosed as pseudo-aneurysm at our institution; we have reviewed the literature on this difficult diagnosis and outlined characteristic findings of each clinical entity.

Unexpected limited chronic dissection of the ascending aorta.

We report a rare case of a limited chronic dissection of the ascending aorta that was accidentally discovered at operation performed for severe aortic stenosis and moderate to severe dilatation of the ascending aorta. Preoperative investigations such as transoesophageal echocardiography and cardiac catheterization missed the diagnosis of dissection. Intraoperative findings included a 3.5 cm eccentric bulge of the ascending aorta and a 5 mm circular shaped intimal tear comunicating with a limited hematoma or small dissection of the media layer. (The rarety of the report is that the chronic dissection is limited to a small area (approximatively 3.5 x 2.5 cm) of the ascending aorta).

Novel repair for late posttraumatic aortic valve injury and root pseudoaneurysm.

We report a case of posttraumatic aortic valve regurgitation and pseudoaneurysm of the aortic root diagnosed 22 months after a road traffic accident. The surgical treatment consisted of exclusion of the pseudoaneurysm with direct closure of the entry tear in the right coronary sinus followed by insertion of a Toronto stentless prosthesis (St. Jude Medical, St. Paul, MN). This surgical approach aimed to cover the repaired entry tear ensuring exclusion of the site. Recovery was uneventful and 12 month follow-up was unremarkable.

Intraoperative microwave ablation in patients undergoing valvular surgery: midterm results.

AIM OF THE STUDY: To assess the safety and efficacy of intraoperative microwave ablation to restore sinus rhythm and systolic atrial function in patients undergoing valvular surgery. METHODS: Forty-one patients with atrial fibrillation (AF) underwent operations. The mean age was 61 years (range, 45- 76 years). AF was permanent in 30 patients and paroxysmal in 11. Associated cardiac procedures were mitral valve repair in 10 patients, mitral valve replacement in 12, and mitro-aortic valve replacement in 19. The microwave procedure (FLEX, AFx inc.) was performed to create an endocardial bilateral encircling isolation of the ostia of the pulmonary veins. RESULTS: There was no hospital mortality or morbidity. The mean follow-up period was 14.2 months. At follow-up, sinus rhythm was found in 34 patients (82.9%). Echocardiography results at follow-up showed no major or minor left atrial thrombosis and only a mild impairment of the systolic left atrial function. CONCLUSION: Intraoperative microwave ablation is a safe and effective treatment to restore sinus rhythm and a mildly impaired left atrial function in patients with AF undergoing cardiac surgery.