Surgical "elephant trunk" arch replacement with a branched arch prosthesis: two alternative operative techniques

Introduction: Elephant trunk repair of the aortic arch cannot be performed with a branched prosthesis. Aim: We conceived two different modifications of the original technique to perform an arch replacement with a branched graft, while arranging an adequate landing zone for a subsequent thoracic endovascular aortic repair, without the need of dedicated material. Material and methods: Eight consecutive patients underwent arch replacement with one of our techniques. Five were emergency patients with acute aortic dissection, and 3 suffered chronic expansive disease. The "modified elephant trunk" includes a separate anastomosis of an endo-luminal prosthetic segment in the descending aorta. Subsequently, the branched arch prosthesis is anastomosed to the distal aortic stump with the attached trunk. In the "prophylactic debranching", a tail is left on the distal end of the arch prosthesis, so that the branches for the supra-aortic vessels will remain displaced proximally, allowing a "zone 1" available for landing. Results: Three patients experienced transient cerebral deficits (1 transient ischemic attack and post-operative delirium in 2 cases), 1 required re-operation for bleeding and 2 needed prolonged intubation. One died of multi-organ failure. Conclusions: Both techniques proved to be easily reproducible, and allow an adequate landing zone for a subsequent endovascular procedure, while retaining the advantages of using a tetra-furcated prosthesis. They are a viable alternative when a hybrid prosthesis cannot be implanted

Imaging and monitoring in minimally invasive valve surgery using an intra-aortic occlusion device: A single center experience

Background: Minimally invasive approach through a right mini-thoracotomy is a world-wide used procedure for mitral valve surgery. We performed a retrospective analysis based on our center experience in order to propose an effective, safe and reproducible method using an intra-aortic occlusion device.Methods: This is a retrospective analysis on 48 consecutive patients undergoing mitral valve surgery through a right anterolateral mini-thoracotomy in our center. An intra-aortic occlusion device was used for aortic clamping and cardioplegia delivery. Simultaneous multi-plane three-dimensional echocardiography imaging was acquired to detect the venous cannulas position, the intra-aortic device location in the ascending aorta, the balloon inflation, the complete occlusion of the aorta, the cardioplegia delivery, the origin and the blood flow in the right coronary artery. Aortic root pressure was measured by the tip of the intra-aortic occlusion device. A bilateral upper extremity invasive arterial pressure monitoring was detected. Neuromonitoring was performed through bilateral cerebral oximetry.Results: The analysis has shown no aortic dissection, neurological damage type 1 and myocardial ischemia in the study population. In 3 cases a distal displacement of the intra-aortic occlusion device was promptly detected by the combined use of echocardiographic imaging and by a drop of the right cerebral oximetry saturation and of the right radial artery pressure.Conclusions: The combined use of transesophageal simultaneous multi- plane three- dimensional echocardiography imaging, bilateral upper extremity invasive arterial pressure monitoring, aortic root pressure and cerebral oximetry is an effective, safe and reproducible method in patients undergoing minimally invasive valve surgery using an intra-aortic occlusion device

Mid-term results of mitral valve replacement and repair: current clinical experience, technical aspects, and risk factor analysis

Aim: we evaluated the short- and mid-term results of mitral valve replacement (MVR) and mitral valve repair (MV-repair). Methods: in total, 168 patients (mean age 67 ± 11 years) underwent MVR (n = 104) and MV-repair (n = 64). To treat posterior leaflet disease, MV-repair techniques included triangular or quadrangular resection (n = 38), P1-P2 plication (n = 4), side-to side P1-P2 (n = 1), posterior-medial commissure-plasty (n = 1), and annuloplasty (n = 20). A prosthetic ring was implanted in all patients. In the presence of degenerative disease involving the anterior leaflet, extensive myxomatous and/or prolapsing pathology of the entire valve, and/or rheumatic and endocarditis degeneration, surgical orientation was to perform MVR directly. When possible, the sub-valvular apparatus with its papillary muscle was partially preserved. The mean follow-up was 38 ± 22 months. Results: operative mortality (0.96% vs. 1.56%) and six-year survival (94% vs. 100%) were similar in MVR and MV-repair. The only independent predictor of late survival was advanced age at the operation (79.2 years vs. 66.4 years; P = 0.012). Freedom from redo-operation was 100%. Partial preservation of the sub-valvular apparatus with its papillary muscle during MVR allowed postoperatively a better left ventricular function with similar values achieved with MV-repair (P = 0.05), and it was a protective factor against the development of left ventricular dysfunction during follow-up (P = 0.01). Conclusion: MVR and MV-repair are associated with satisfactory results in the short and medium term. MV-repair to treat posterior leaflet disease is associated with a stable and long-lasting result; MVR allows equally satisfactory results in the presence of more extensive and more complex mitral valve disease. Partial preservation of the subvalvular apparatus favors a better left ventricular systolic function

Percutaneous transfemoral-transseptal implantation of a second-generation CardiAQ™ mitral valve bioprosthesis: first procedure description and 30-day follow-up

Transcatheter mitral valve implantation for mitral valve regurgitation is in the very early phase of development because of challenging anatomy and device dimensions. We describe the procedure of a transfemoral-transseptal implantation of the second-generation CardiAQ™ mitral valve bioprosthesis and 30-day follow-up

The effects of DeBakey type acute aortic dissection and preoperative peripheral and cardiac malperfusion on the outcomes after surgical repair

Introduction: Emergent surgical repair of DeBakey type I and II acute aortic dissection represents the standard of care to prevent lethal complications. Aim: Evaluation of the effect of extension of aortic dissection (AAD) according to DeBakey classification, type I and II AAD, and the relationship with preoperative peripheral and myocardial malperfusion on early outcome and the mid-term follow-up period. Material and methods: A total of 135 patients who underwent AAD surgery between January 2015 and October 2019 were analysed. Results: In total 103 patients were affected by DeBakey type I AAD and 32 by DeBakey type II; 56 patients preoperatively showed peripheral, cardiac malperfusion, or both. Intra-operative mortality was 11%. Postoperative peripheral, cardiac malperfusion, and intraoperative and postoperative mortality were lower for type II AAD. The protective factor for intra- and postoperative 60-day mortality was type II AAD (RR = 0.03, p = 0.001); independent predictors were hypertension, and preoperative cardiac and renal-visceral malperfusion. At 5 years the overall survival was 74 ±6.9%. Independent predictors of reduced survival were major extension of type I AAD (RR = 5.37, p < 0.05) and preoperative cardiac malperfusion (RR = 5.78, p < 0.05). Five-year freedom from cardiac death, redo surgical operation, and new vascular procedures on the thoracic and abdominal aorta was 92 ±5.7%, 99 ±1.2%, and 81 ±7.2%, respectively. Extension of DeBakey type I AAD into the thoracic-abdominal aorta segment was also a predictor of the need for new vascular procedures (RR = 1.66, p = 0.05). Conclusions: A more favourable anatomy of DeBakey type II AAD is associated with better early and late outcomes after aortic repair. This is due to a lower incidence of peripheral and cardiac malperfusion

The impact of dual antiplatelet therapy administration on the risk of bleeding complications during coronary artery bypass surgery

Introduction: Dual antiplatelet therapy reduces the risk of cardiovascular death, myocardial infarction and recurrence of adverse ischemic events in patients affected by acute coronary syndromes, but in patients urgently needing coronary artery surgery it can increase the risk of severe perioperative bleeding complications. Aim: We evaluated the impact of dual antiplatelet therapy (DAPT) based on acetylsalicylic acid plus clopidogrel or ticagrelor in patients undergoing coronary artery bypass grafting (CABG). Material and methods: Three hundred and thirty-three patients underwent coronary artery bypass grafting with DAPT discontinuation > 72 hours or 3-4 days (group A, n = 159), 48-72 hours or 2-3 days (group B, n = 126), < 24 hours or 0-1 day (group C, n = 24) prior to CABG. Results: Operative mortality was 1.87% (group A), 0.79% (group B), absent (group C). The incidence of mediastinal re-exploration was 1.25% or 2 patients (group A), 1.59% or 2 patients (group B), 8.33% or 4 patients (group C) (p = 0.01). Group C showed postoperatively a greater incidence of a blood loss greater than 500 ml at 6 hours and a blood loss from chest tube drainages significantly higher at 6 and 24 hours (p < 0.01). Multivariate analysis showed that ongoing ticagrelor intake in group C (HR = 42.4; p = 0.02) and group C (HR = 6.9; p = 0.04) were the only independent predictors of surgical re-exploration. In group C, surgical re-exploration was 2.56% or 1/39 patients taking clopidogrel, 33.3% or 3/9 patients taking ticagrelor (p = 0.002). Conclusions: Dual antiplatelet therapy ongoing until 1 day or 24 hours before CABG showed a significantly increased risk of bleeding complications in comparison with its discontinuation at 2-3 and > 3-4 days before, respectively. Major blood loss and surgical re-exploration were not associated with increased risk of operative all-cause or bleeding-related mortality. As expected, taking ticagrelor compared with clopidogrel in the short interval confers a higher risk of bleeding complications

Early and mid-term results in patients undergoing primary CABG in comparison with patients with PCI prior to CABG

Aim: We evaluated the impact of prior percutaneous coronary intervention (PCI) on early and mid-term results in patients undergoing coronary artery bypass grafting (CABG). Methods: Between 2015 and 2020, 938 consecutive patients (mean age 67.4 ± 9.11 years) underwent CABG with prior PCI (n = 121) or primary CABG (n = 817). The mean follow-up was 37 ± 25 (median 36) months. Kaplan- Meier estimates were used to assess survival rates, while Logistic and Cox model analysis regressions assessed the risk of prior PCI and other variables. Results: Six-year survival including in-hospital mortality was 79% ± 6% in CABG with prior-PCI patients vs. 88% ± 2% in primary CABG (P = 0.002). As compared with primary CABG, in prior-PCI patients, clinical presentation (acute coronary syndrome, reduced left ventricular ejection fraction, and previous myocardial infarction, P ≤ 0.01, for all comparisons) was worse, comorbidity increased (Euroscore-2, severe chronic renal dysfunction, P < 0.01), and in-hospital mortality was higher (6.6% or 8 patients vs. 1.6% or 13 patients, P < 0.001). Prior PCI was found to be an independent predictor of mortality (HR = 4.23; P = 0.01). Six-year freedom from late all-cause death and cardiac death were 84% ± 6% vs. 90% ± 2% (P = 0.2) and 96% ± 2% vs. 96% ± 1% (P = 0.5), respectively. Independent predictors of all-cause death were advanced age at the operation (P < 0.0001), reduced left ventricular ejection fraction (P = 0.01), severe chronic renal dysfunction (P = 0.02), prior PCI (P = 0.03), and Euroscore-2 (P = 0.05). Prior PCI did not negatively affect late cardiac death (P = 0.5). Conclusion: Patients undergoing CABG after prior PCI have worse perioperative outcomes. Mid-term reduced survival in the prior-PCI patients is mainly due to the concomitant presence of worse clinical presentation and increased comorbidity. Freedom from cardiac death is comparable and satisfactory in both cohorts, highlighting the positive protective effect of CABG over time

Comment on PP2A inhibition sensitizes cancer stem cells to ABL tyrosine kinase inhibitors in BCR-ABL human leukemia

LB100 does not sensitize CML stem cells to tyrosine kinase inhibitor–induced apoptosis

Biomechanical properties and histomorphometric features of aortic tissue in patients with or without bicuspid aortic valve

Background: We sought to investigate and compare biomechanical properties and histomorphometric findings of thoracic ascending aorta aneurysm (TAA) tissue from patients with bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) in order to clarify mechanisms underlying differences in the clinical course. Methods: Circumferential sections of TAA tissue in patients with BAV (BAV-TAA) and TAV (TAV-TAA) were obtained during surgery and used for biomechanical tests and histomorphometrical analysis. Results: In BAV-TAA, we observed biomechanical higher peak stress and lower Young modulus values compared with TAV-TAA wall. The right lateral longitudinal region seemed to be the most fragile zone of the TAA wall. Mechanical stress-induced rupture of BAV-TAA tissue was sudden and uniform in all aortic wall layers, whereas a gradual and progressive aortic wall breakage was described in TAV-TAA. Histomorphometric analysis revealed higher amount of collagen but not elastin in BAV-TAA tunica media. Conclusions: The higher deformability of BAV-TAA tissue supports the hypothesis that increased wall shear stress doesn't explain the increased risk of sudden onset of rupture and dissection; other mechanisms, likely related to alteration of specific genetic pathways and epigenetic signals, could be investigated to explain differences in aortic dissection and rupture in BAV patients

Speaker-independent emotion recognition exploiting a psychologically-inspired binary cascade classification schema

In this paper, a psychologically-inspired binary cascade classification schema is proposed for speech emotion recognition. Performance is enhanced because commonly confused pairs of emotions are distinguishable from one another. Extracted features are related to statistics of pitch, formants, and energy contours, as well as spectrum, cepstrum, perceptual and temporal features, autocorrelation, MPEG-7 descriptors, Fujisakis model parameters, voice quality, jitter, and shimmer. Selected features are fed as input to K nearest neighborhood classifier and to support vector machines. Two kernels are tested for the latter: Linear and Gaussian radial basis function. The recently proposed speaker-independent experimental protocol is tested on the Berlin emotional speech database for each gender separately. The best emotion recognition accuracy, achieved by support vector machines with linear kernel, equals 87.7%, outperforming state-of-the-art approaches. Statistical analysis is first carried out with respect to the classifiers error rates and then to evaluate the information expressed by the classifiers confusion matrices. © Springer Science+Business Media, LLC 2011