Safety and Feasibility of MitraClip Implantation in Patients with Acute Mitral Regurgitation after Recent Myocardial Infarction and Severe Left Ventricle Dysfunction

Patients with severe mitral regurgitation (MR) after myocardial infarction (MI) have an increased risk of mortality. Transcatheter mitral valve repair may therefore be a suitable therapy. However, data on clinical outcomes of patients in an acute setting are scarce, especially those with reduced left ventricle (LV) dysfunction. We conducted a multinational, collaborative data analysis from 21 centers for patients who were, within 90 days of acute MI, treated with MitraClip due to severe MR. The cohort was divided according to median left ventricle ejection fraction (LVEF)-35%. Included in the study were 105 patients. The mean age was 71 ± 10 years. Patients in the LVEF \u3c 35% group were younger but with comparable Euroscore II, multivessel coronary artery disease, prior MI and coronary artery bypass graft surgery. Procedure time was comparable and acute success rate was high in both groups (94% vs. 90%, p = 0.728). MR grade was significantly reduced in both groups along with an immediate reduction in left atrial V-wave, pulmonary artery pressure and improvement in New York Heart Association (NYHA) class. In-hospital and 1-year mortality rates were not significantly different between the two groups (11% vs. 7%, p = 0.51 and 19% vs. 12%, p = 0.49) and neither was the 3-month re-hospitalization rate. In conclusion, MitraClip intervention in patients with acute severe functional mitral regurgitation (FMR) due to a recent MI in an acute setting is safe and feasible. Even patients with severe LV dysfunction may benefit from transcatheter mitral valve intervention and should not be excluded

The risk of stroke recurrence in patients with atrial fibrillation and reduced ejection fraction

Abstract Background: Atrial fibrillation (AF) and congestive heart failure often coexist due to their shared risk factors leading to potential worse outcome, particularly cerebrovascular events. The aims of this study were to calculate the rates of ischemic and severe bleeding events in ischemic stroke patients having both AF and reduced ejection fraction (rEF) (⩽40%), compared to ischemic stroke patients with AF but without rEF. Methods: We performed a retrospective analysis that drew data from prospective studies. The primary outcome was the composite of either ischemic (stroke or systemic embolism), or hemorrhagic events (symptomatic intracranial bleeding and severe extracranial bleeding). Results: The cohort for this analysis comprised 3477 patients with ischemic stroke and AF, of which, 643 (18.3%) had also rEF. After a mean follow-up of 7.5 ± 9.1 months, 375 (10.8%) patients had 382 recorded outcome events, for an annual rate of 18.0%. While the number of primary outcome events in patients with rEF was 86 (13.4%), compared to 289 (10.2%) for the patients without rEF; on multivariable analysis rEF was not associated with the primary outcome (OR 1.25; 95% CI 0.84–1.88). At the end of follow-up, 321 (49.9%) patients with rEF were deceased or disabled (mRS ⩾3), compared with 1145 (40.4%) of those without rEF; on multivariable analysis, rEF was correlated with mortality or disability (OR 1.35; 95% CI 1.03–1.77). Conclusions: In patients with ischemic stroke and AF, the presence of rEF was not associated with the composite outcome of ischemic or hemorrhagic events over short-term follow-up but was associated with increased mortality or disability

Trattamento chirurgico del paziente con gozzo tiroideo immerso

Il gozzo è una delle patologie che più frequentemente colpiscono la tiroide. Mentre il termine gozzo è universalmente accettato, non altrettanto accade per il termine “immerso” in quanto non esiste univocità sul livello che la tiroide tumefatta deve raggiungere all’interno del torace per poter essere considerata “immersa”. La tendenza dei gozzi immersi di ingrandirsi e di comprimere strutture anatomiche adiacenti e la possibilità di trasformazione maligna, hanno imposto l’asportazione chirurgica come trattamento di scelta. Presentiamo in questo lavoro, partendo dalla nostra esperienza, una revisione della letteratura sul management chirurgico del gozzo tiroideo immerso

Management chirurgico di voluminoso paraganglioma dell’addome: case report e revisione della letteratura

A 58 years old woman was admitted to our Institution with acute endocrine impairment and simulatneous intestinal necrosis resulting from the mass effect of the tumor on the mesenteric vessels. Clinical and biochemical preoperative work up posed the suspect of paraganglioma. Previous intensive care tratment, the patient, underwent surgical resection of the tumor and left hemicolectoly, with immediate remission of both endocrine and abdominal syndromes. Histological examination con firm the preoperative clinical hypothesis. Paragangliomas are rare tumors of the extra-adrenal chromaffin tissue. A paraganglioma may be discovered in the absence of any sympton. When symptomatic, the clinical findings are related to the hypersecretion of catecholamines or to the compression of several anatomical structures from a growing mass. Combined acute syndromes of hormonal impairment and contemporaneous mass effect, as in our case, are exceptional. The diagnosis of the secreting forms may be obtained on the basis of biochemical dosage of serum and urinary catecholamines and metanephrines. The assessment of malignancy for paragangliomas is not always feasible. Several imaging, cytological and hystological parameters have been proposed as predictors of malignancy, but the only element widely accepted is the existence of distant metastais. Surgery represents the tratment of choice for paragangliomas. Benign forms, catecholamine secreting forms and tunors compressing neighbouring anatomical structures can be treated surgically with success. In general, an accurante follow-up after complete resection must be considered

Il Dosaggio del iPTH come indicatore prognostico di ipocalcemia postoperatoria nei pazienti sottoposti a tiroidectomia totale

L’ipocalcemia è la complicanza più frequente nei pazienti sottoposti a tiroidectomia totale e può presentarsi in forma transitoria, risolvendosi entro 6 mesi dall’intervento, o in forma permanente 1,2. L’incidenza dell’ipocalcemia transitoria varia in letteratura da 1,6% a 50%3, sebbene generalmente contenuta tra il 10- 30%, mentre quella permanente è più rara (1-2%) 4. In genere, l’ipocalcemia insorge nelle prime 24-72 ore dall’intervento.5 Considerando che il rischio di sanguinamento si esaurisce sostanzialmente nelle prime 24 ore postoperatorie 6, l’ipocalcemia costituisce la principale causa di allungamento dei tempi di degenza al fine di permettere un adeguato monitoraggio del paziente. L’utilizzo di parametri predittivi, clinici o biochimici, per l’individuazione dei soggetti a rischio di ipocalcemia e di quelli dimissibili precocemente ed in sicurezza dopo tiroidectomia è argomento di ampio dibattito in letteratura, in particolare riguardo all’utilizzo a tale scopo del dosaggio ematico del paratormone intatto (iPTH). Questo studio mira a valutare in maniera prospettica l’utilità del iPTH ematico dosato 1 ora dall’intervento di tiroidectomia totale, come indice di predittività di una eventuale ipocalcemia postoperatoria e quindi la sua possibile applicazione nella pratica clinica

Altemeier rectosigmoidectomy: a procedure worth considering

Several surgical techniques have been proposed for treatment of complete rectal prolapse. Mainly they can be distinguished in trans-abdominal and transperineal approaches. Former abdominal surgery can preclude a transabdominal approach. We report a case of complete rectal prolapse, treated by transperineal rectosigmoidectomy, in a patient with history of pelvic surgery

A planar fractal analysis of the arterial tree of the human thyroid gland: implications for additive manufacturing of 3D ramified scaffolds

It is currently known that a number of human vascular systems have a fractal geometry. Since we have recently developed a technique to prototype single arterial branches of human soft tissue organs by additive layer manufacturing (AM), we have explored the possibility that auto-similarity in vessel branching represents a key variable for accurate computational modeling of the organ three-dimensional (3D), macro / microscopic anatomy, and its reproduction by inverse engineering. To this purpose, ramification features of the intra-lobar arteries of the human thyroid were studied using injection-corrosion casts of a cadaveric gland. Vessel diameters, ramification angles and branch lengths were measured by light microscopic, computer-aided optical metrology. Distribution of morphological variables was considered on a cumulative basis, and special focus was given to the branching laws. To reduce the bias of vascular distortion due to the pressure of intra-vascular resin injection, measures were made dimensionless through the use of a scaling parameter set on the vascular caliber of major afferent arteries. In addition, using high resolution micro-tomography (mCT Skyscan 1172, Bruker micro-CT) equipped with CTAn software and the Otsu algorithm for segmentation, spaces occupied by vascular branches (referred to as Volume of Interests, VOI) were selected, and their planar fractal dimension calculated (Mandelbrot 1982). Finally, a computational simulation of the vascular tree was achieved using a mixed, stochastic / deterministic algorithm, based on diffusion limited aggregation (DLA; Witten and Sander, 1981), constrained by mean values of vascular variables. Ratios among decreasing cast calibers, ramification angles and branch lengths, respectively, were found strictly interrelated, mCT-VOI depicted fractal dimensions, and DLA simulation led to a fractal-like organization consistent with real data morphometrics. In summary, thyroid arterial geometry reliably exhibited a degree of auto-similarity, suggesting that fractality is a key feature for computational modeling and eventual AM of 3D vascular networks of the human thyroid

TOWARDS ADDITIVE MANUFACTURING OF RAMIFIED SCAFFOLDS OF THE THYROID VASCULAR SYSTEM: A PRELIMINARY FRACTAL ANALYSIS

Fractal properties have been demonstrated in literature for several human vascular systems. In the frame of the investigation of additive manufacturing (AM) as a viable solution to prototype single arterial branches of human soft tissue organs, the paper provides a fractal analysis of the arterial tree of the human thyroid gland. The possibility that the thyroid arterial structure may be described as auto-similar is investigated, by studying injection-corrosion casts of the cadaveric gland. Vessel branching is analyzed by measuring branch diameters, ramification angles, and vessel lengths with the use of an optical microscope. Metrological results are made dimensionless by applying, as a scaling parameter, the caliber of major arteries. Data are then studied on a cumulative basis and processed to infer general rules for vessel branching. High resolution microtomography (mCT) is used to determine the spaces occupied by vascular branches and calculate their planar fractal dimension. Finally, the vascular tree has been simulated by a mixed, stochastic / deterministic algorithm based on diffusion limited aggregation (DLA), in which mean values of vascular variables are set as constraints. The purpose of this research is to understand if fractality can be reliably assumed for computational modeling of the organ anatomy, in order to be able to produce, by AM, more representative physical prototypes and scaffolds. The finding allow to affirm that the human thyroid arterial structure exhibits a degree of auto similarity