Vascular Complications following Isolated Limb Perfusion for Local Recurrence of Extremity Melanoma: A Case Report and Literature Review

Introduction. To evaluate the role of hyperthermic isolated limb perfusion (HILP) in arterial thrombosis following melanoma-soft tissue sarcoma chemotherapy. Report. Here is presented one case of iliac-common femoral artery subacute thrombosis and a review of the appropriate literature performed using a MEDLINE search. Acute/subacute arterial occlusion is one of the most feared vascular complications of HILP, located nearly always in the external iliac-femoral artery axis, being those vessels cannulated for perfusion. Conclusions. The small number of reported cases indicates either the rarity of this complication or unawareness of its existence. The true incidence of this complication is probably underreported

Postoperative Echocardiographic Reduction of Right Ventricular Function: Is Pericardial Opening Modality the Main Culprit?

Echocardiographic reduction of RV function, measured using TAPSE, is a well described phenomenon after cardiac surgery. The aim of the present study was to investigate the relation between the modality of pericardial opening (lateral versus anterior) and the postoperative right ventricular systolic function by comparing echocardiographic parameters in patients undergoing minimally invasive or traditional mitral valve repair. 34 patients with severe mitral regurgitation due to mitral valve prolapse underwent traditional (sternotomy) operation (Group A) or minimally invasive surgery with right anterolateral thoracotomy (Group B). A postoperative TAPSE fall was found in both groups. Group A experienced a significant postoperative TAPSE fall versus Group B with p<0.0001

The impact of pericardial approach and myocardial protection onto postoperative right ventricle function reduction

Background The reduction of RV function after cardiac surgery is a well-known phenomenon. It could persist up-to one year after the operation and often leads to an incomplete recovery at follow-up echocardiographic control. The aim of the present study is to analyze the impact of different modalities of pericardial incision (lateral versus anterior) and of myocardial protection protocols (Buckberg versus Custodiol) onto postoperative RV dynamic by relating two- and three-dimensional echocardiographic parameters in patients undergoing mitral valve repair through minimally invasive or traditional surgery approach. Methods We have analyzed 44 consecutive patients with severe degenerative mitral regurgitation who underwent mitral reparation with different surgical approach and cardioplegia type: Group 1 (17 pts): sternotomy with Buckberg cardioplegia protocol; Group 2 (10 pts): sternotomy with Custodiol cardioplegia; Group 3 (17 pts): mini-invasive surgery with Custodiol cardioplegia. Two-dimensional transthoracic echocardiography was performed pre- and 6 months post-surgery to evaluate RV function by tricuspid annular plane systolic excursion (TAPSE). Results All patients underwent successful and uneventful. A postoperative TAPSE reduction was found in all groups. However, mini-invasive patients experienced a significant reduced variation versus traditional surgery. Conclusions Mini-invasive mitral repair, with lateral incision of pericardium, reduces postoperative TAPSE fall, while cardioplegia protocol fails to have an impact onto longitudinal RV function. In our study, the RV seems to experience a clinically irrelevant geometrical modification too, whose entity appears to be less evident in case of lateral pericardial approach. These results could strengthen the use of minimally invasive approach also to preserve RV function

Modified maze procedure for atrial fibrillation as an adjunct to elective cardiac surgery : predictors of mid-term recurrence and echocardiographic follow-up

The radiofrequency maze procedure achieves sinus rhythm in 45%\u201395% of patients treated for atrial fibrillation. This retrospective study evaluates mid-term results of the radiofrequency maze\u2014performed concomitant to elective cardiac surgery\u2014to determine sinus-rhythm predictive factors, and describes the evolution of patients\u2019 echocardiographic variables. From 2003 through 2011, 247 patients (mean age, 64 \ub1 9.5 yr) with structural heart disease (79.3% mitral disease) and atrial fibrillation underwent a concomitant radiofrequency modified maze procedure. Patients were monitored by 24-hour Holter at 3, 6, 12, and 24 months, then annually. Eighty-four mitral-valve patients underwent regular echocardiographic follow-up. Univariate and multivariate analysis for risk factors of maze failure were identified. The in-hospital mortality rate was 1.2%. During a median follow-up of 39.4 months, the late mortality rate was 3.6%, and pacemaker insertion was necessary in 26 patients (9.4%). Sinus rhythm was present in 63% of patients at the latest follow-up. Predictive factors for atrial fibrillation recurrence were arrhythmia duration (hazard ratio [HR]=1.296, P=0.045) and atrial fibrillation at hospital discharge (HR=2.03, P=0.019). The monopolar device favored maze success (HR=0.191, P <0.0001). Left atrial area and indexed left ventricular end-diastolic volume showed significant decrease both in sinus rhythm and atrial fibrillation patients. Early sinus rhythm conversion was associated with improved left ventricular ejection fraction. Concomitant radiofrequency maze procedure provided remarkable outcomes. Shorter preoperative atrial fibrillation duration, monopolar device use, and prompt treatment of arrhythmia recurrences increase the midterm success rate. Early sinus rhythm restoration seems to result in better left ventricular ejection fraction recovery

Proteomic analysis of plasma from patients undergoing coronary artery bypass grafting reveals a protease/anti-protease imbalance in favor of the serpin alpha1-antichymotrypsin

We used proteomics to identify systematic changes in the plasma proteins of patients undergoing coronary artery bypass grafting (CABG) by means of cardiopulmonary bypass surgery. It is known that, after CABG, a complex systemic inflammatory responses ensues that favours the occurrence of adverse postoperative complications frequently recognizing inflammation itself and/or thrombosis as the underlying mechanism. We found a marked and persistent postoperative increase in the levels of the serin-protease inhibitor alpha 1-antichymotrypsin (alpha1-ACT) that fully maintains the inhibitory activity blunting its protease substrate cathepsin G. An intraoperative increase followed by a rapid decline in proteases activation was documented, accompanied by a substantial induction of leucine-rich-alpha-2-glycoprotein, a protein involved in neutrophilic granulocyte differentiation. Finally, a time-dependent alteration in the expression of haptoglobin, transthyretin, clusterin and apoE was observed. In conclusion, we showed that after CABG, a protease/antiprotease imbalance occurs with early cathepsin G activation and a more delayed increase in alpha1-ACT. As cathepsin G is a serpin involved both in inflammation and coagulation activation, this confirms and expands the concept of a marked dysregulation of both inflammatory and hemostatic balances occurring after CABG. And the pharmacologic modulation of this imbalance may be a new therapeutic target to reduce postoperative complications. Funding: EC, FP6, LIFESCIHEALTH-contract n\ub0 LSHM-CT-2007-037273-PROCARDI

Maternal functional hemodynamics in uncomplicated twin pregnancies: a longitudinal study using impedance cardiography

Longitudinal studies of maternal hemodynamics in twin pregnancy are scarce and preload reserve in twin pregnancies has not been studied. Thus, we aimed to investigate serial changes in maternal systemic hemodynamics from first to third trimester, and cardiovascular response to passive leg raising to evaluate preload reserve using impedance cardiography in a cohort of uncomplicated twin pregnancies

Maternal functional hemodynamics in uncomplicated twin pregnancies: A longitudinal study using impedance cardiography

Introduction: Longitudinal studies of maternal hemodynamics in twin pregnancy are scarce and preload reserve in twin pregnancies has not been studied. Thus, we aimed to investigate serial changes in maternal systemic hemodynamics from the first to third trimester, and cardiovascular response to passive leg raising to evaluate preload reserve using impedance cardiography in a cohort of uncomplicated twin pregnancies. Material and methods: This was a prospective longitudinal study of 50 twin pregnancies. Maternal hemodynamics was assessed at baseline and 120&nbsp;seconds after passive leg raising using impedance cardiography, at five time points during gestation. Women were excluded from the analysis if there were pregnancy complications or fewer than three of five planned assessments were available. Results: Data from 37 uncomplicated twin pregnancies were available for analysis. Mean arterial pressure slightly decreased until 17&nbsp;weeks’ gestation, then increased. Systemic vascular resistance was constant in the first half of pregnancy before rising steadily thereafter, whereas the cardiac output increased from the first trimester, peaked by the end of the second trimester and then decreased in the third trimester. The change in stroke volume and cardiac output following passive leg raising during pregnancy ranged from −2.2% to 1.6% and from −3.7% to 3.2%, respectively. Although passive leg raising caused no significant changes in systemic vascular resistance, cardiac output or heart rate, mean arterial pressure decreased in the first and second trimesters. Conclusions: In uncomplicated twin pregnancies, maternal cardiovascular adaptation is evident from the first trimester. Twin pregnancies show a reduced preload reserve in the second half of gestation

Uterine artery Doppler in the management of dichorionic twin pregnancies discordant for intrauterine growth restriction

Objectives To evaluate the role of uterine artery Doppler in the expectant management of dichorionic twin pregnancies discordant for intrauterine growth restriction (IUGR). Methods Retrospective study. We retrieved from our database (2002–2012) data on dichorionic twin pregnancies complicated by IUGR of one twin, defined as abdominal circumference 95th percentile, with no structural or chromosomal abnormalities. Perinatal and pediatric records were examined. In all cases gestational age and chorionicity were determined by ultrasound in the first trimester. Chorionicity was confirmed by placental pathology. Results We identified 31 dichorionic twin pregnancies discordant for IUGR. The median gestation at presentation was 26+3 weeks (interquartile range (IQR) 24+0-30+4 weeks). Pre-eclampsia (PE) complicated 8/31 cases. Uterine artery Doppler was evaluated in 28/31 cases, and mean PI was > 95th percentile in 10/28, of which half (5/10) subsequently developed PE, requiring delivery before 32 weeks in 3/5 of cases All pregnancies were offered expectant managed for fetal conditions until 32 weeks. In 5/31 (16%) cases delivery was carried out before 32 weeks because of severe PE (n = 4) or placental abruption (n = 1). There were 7 perinatal deaths. The IUGR twin died in 6/31 pregnancies (19%); in 5 cases intrauterine death occurred before 32 weeks. In one pregnancy both twins died in the neonatal period after a Caesarean section performed at 27+0 weeks because of severe PE. Among the 55 survivors there were 4 infants with disability. The relative risk of developing pre-eclampsia with abnormal uterine artery Doppler waveform in our cohort was 4.5 (1.05-19.11, 95% confidence interval; p = 0.04). Conclusions Uterine artery Doppler might be useful to identify cases at higher risk of pre-eclampsia that warrant increased maternal surveillance during expectant management