Biological niches within human calcified aortic valves. Towards understanding of the pathological biomineralization process

Despite recent advances, mineralization site, its microarchitecture, and composition in calcific heart valve remain poorly understood. A multiscale investigation, using scanning electron microscopy (SEM), transmission electron microscopy (TEM), and energy dispersive X-ray spectrometry (EDS), from micrometre up to nanometre, was conducted on human severely calcified aortic and mitral valves, to provide new insights into calcificationp rocess. Our aim was to evaluate the spatial relationship existing between bioapatite crystals, their local growing microenvironment, and the presence of a hierarchical architecture. Here we detected the presence of bioapatite crystals in two different mineralization sites that suggest the action of two different growth processes:a pathological crystallization process that occurs in biological niches and is ascribed to a purely physicochemical process and a matrix- mediated mineralized process in which the extracellular matrix acts as the template for a site-directed nanocrystals nucleation. Different shapes of bioapatite crystallization were observed at micrometer scale in each microenvironment but at the nanoscale level crystals appear to be made up by the same subunit

Clinical and Operative Determinants of Acute Kidney Injury after Cardiac Surgery.

Introduction: Cardiac surgery-associated acute kidney injury (CSA-AKI) is associated with increased morbidity and mortality. Objectives: We aimed to identify potentially modifiable risk factors for CSA-AKI. Methods: This was asingle-center retrospective cohort study of 495 adult patients undergoing cardiac surgery. AKI was diagnosed and staged using full KDIGO criteria incorporating baseline serum creatinine (SC) levels and correction of postoperative SC levels for fluid balance. We examined the association of routinely available clinical and laboratory data with AKI using multivariate logistic regression modeling. Results: A total of 103 (20.8%) patients developed AKI: 16 (15.5%) patients were diagnosed with AKI upon hospital admission, and 87 (84.5%) patients were diagnosed with CSA-AKI. Correction of SC levels for fluid balance increased the number of AKI cases to 104 (21.0%), with 6 patients categorized to different AKI stages. Univariate logistic regression analysis identified five preoperative (age, sex, diabetes mellitus, preoperative systolic pulmonary arterial pressure [PSPAP], acute decompensated heart failure) and five intraoperative predictors of AKI (age, sex, red blood cell [RBC] volume transfused, use of minimally invasive surgery, duration of cardiopulmonary bypass). When all preoperative and intraoperative variables were incorporated into one model, six predictors remained significant (age, sex, use of minimally invasive surgery, RBC volume transfused, PSPAP, duration of cardiopulmonary bypass). Model discrimination performance showed an area under the curve of 0.69 for the model including only preoperative variables, 0.76 for the model including only intraoperative variables, and 0.77 for the model including all preoperative and intraoperative variables. Conclusions: Use of minimally invasive surgery and therapies mitigating PSPAP and intraoperative blood loss may offer protection against CSA-AKI

A multi-scale investigation of biological niches within human calcified aortic valves helps to understand the pathological biomineralization process

Calcific aortic valve stenosis (CAVS) is the most common form of heart valve disease in the industrialized countries, being an important public health problem [1]. Ectopic calcifications within aortic valve leaflets are strictly associated with CAVS, interfering with cusps opening, they lead to ventricular outflow obstruction [2]. Up to date no proven medical therapy stops CAVS course progression, so valve replacement is the only possible treatment of severe CAVS. Unfortunately, the degenerative valve calcification process, affects also bioprosthetic implants [3]. Being the molecular mechanisms leading to valve calcification still not understood, our aim was to carry on a multi-scale investigation using Scanning Electron Microscopy, Transmission Electron Microscopy and Energy Dispersive X-ray Spectrometry, to provide new insights into calcification process. Severely calcified aortic (tricuspid type, n = 29; bicuspid type, n = 3) and mitral valves (n = 4) were obtained from patients of both sexes (males=25) and different ages (mean age 72±10, range 41-90 years old) undergoing valve replacement due to severe aortic and mitral valve stenosis. We detected bioapatite crystals in two different mineralization sites: niches and extracellular matrix. This suggests the action of two different growth processes: the first occurs in biological niches and it is ascribed to a purely physico-chemical process; the second has the extracellular matrix acting ass the template for a site-directed nanocrystals nucleation. Different shapes of bioapatite crystallization were observed at micrometer scale in each microenvironment but at the nanoscale level crystals appear made up by the same subunits. We suggest that bioapatite nanocrystals in heart valve may activate a strong inflammatory process leading to irreversible pathological condition that, once activated,may aggravate the inflammatory response against bioapatite nanocrystals leading to a severe calcification process

FE-SEM and VP-SEM imaging of human calcified aortic valves: conventional vs Ionic Liquid innovative techniques

Conventional FE-SEM protocol for calcified aortic valves (CAVs) consist of following steps: glutaraldehyde fixation, OsO4 post-fixation, dehydration in alcohol series, critical point drying and finally sputter coating. CAVs can be observed in their native state (fixed in glutaraldehyde with and without post-fixation in OsO4) by Variable Pressure-SEM (range 6- 650 Pa). Gas presence allows an inferior resolution (low signal to noise ratio), however there is the possibility to perform EDS elemental analysis without background noise due to sputter coating. Recently Ionic liquids (IL, salts in the liquid state at room temperature) were used as suppliers of electronic conductivity with insulating properties, so we have tested their ability to replace sputter coating on CAVs in high vacuum condition. Samples fixed in glutharaldehyde 2,5% in PBS with and without OsO4 post-fixation treated with ionic liquid (Hitachi HILEM® IL 1000) were compared with samples treated with conventional FE-SEM procedures. Several IL concentration (range from 5% to 20%) were tested, different operating voltages (range from 3 to 20Kv) were used. This novel technology requires a high degree of customization for each sample type. In our opinion fixation in glutaraldehyde with OsO4 post-fixation is recommended to preserve finest details, moreover residual liquid elimination is important to increase resolution and avoid beam interference as linear markings. Setting of a proper accelerating voltage allows to correctly visualize the surface topography. Processing CAVs with IL with respect to conventional FE-SEM is useful for several reasons. Mainly this method is time saving (and cost saving), secondary the same sample can be processed for transmission electron microscopy after SEM observations (allowing correlative microscopy), finally EDS can be performed without background noise due to sputter coating. Perhaps now this technique can not completely replaces the conventional SEM in terms of resolution but in our opinion rapid technical improvement can further reduce this gap

ECMO for COVID-19 patients in Europe and Israel

Since March 15th, 2020, 177 centres from Europe and Israel have joined the study, routinely reporting on the ECMO support they provide to COVID-19 patients. The mean annual number of cases treated with ECMO in the participating centres before the pandemic (2019) was 55. The number of COVID-19 patients has increased rapidly each week reaching 1531 treated patients as of September 14th. The greatest number of cases has been reported from France (n = 385), UK (n = 193), Germany (n = 176), Spain (n = 166), and Italy (n = 136) .The mean age of treated patients was 52.6 years (range 16–80), 79% were male. The ECMO configuration used was VV in 91% of cases, VA in 5% and other in 4%. The mean PaO2 before ECMO implantation was 65 mmHg. The mean duration of ECMO support thus far has been 18 days and the mean ICU length of stay of these patients was 33 days. As of the 14th September, overall 841 patients have been weaned from ECMO support, 601 died during ECMO support, 71 died after withdrawal of ECMO, 79 are still receiving ECMO support and for 10 patients status n.a. . Our preliminary data suggest that patients placed on ECMO with severe refractory respiratory or cardiac failure secondary to COVID-19 have a reasonable (55%) chance of survival. Further extensive data analysis is expected to provide invaluable information on the demographics, severity of illness, indications and different ECMO management strategies in these patients

Riociguat treatment in patients with chronic thromboembolic pulmonary hypertension: Final safety data from the EXPERT registry

Objective: The soluble guanylate cyclase stimulator riociguat is approved for the treatment of adult patients with pulmonary arterial hypertension (PAH) and inoperable or persistent/recurrent chronic thromboembolic pulmonary hypertension (CTEPH) following Phase

3D Printing and Its Future Directions in Aortic Diseases

3D printing has multiple useful applications in aortic surgery. It can be used in anatomical education for medical students who are pursuing their degrees. 3D printed models have helped patients have the best understanding of their anatomy, disease, surgical risk, and more satisfaction during the informed consent process. It is also possible to create 3D printed medical devices used directly in the treatment of patients. As a standard of care, in elective aortic surgery, a 3D printed model is made for preprocedural planning, training, and creation of personalized aortic grafts. In particular, this recent technology allows an accurate and real 3D replica, making possible the use of materials that resemble the properties of the heart and great vessel tissues. 3D printing can also provide a wide variety of normal and pathological anatomical examples for educational purposes. Moreover, it can provide better insight into the disease and recommended treatment options during patient and family counseling. Furthermore, 3D prototyping can provide to physicians a wider insight into the anatomy, favoring more accurate planning, especially in patients with complex anatomy.</p

Aortic arch repair in chronic dissection using 3D-printing planning

During imaging follow-up, the residual dissection after a type A repair dissection could progress and may require repair of the aortic arch and the distal aorta. Our approach for repairing the evolving dissection includes open aortic arch replacement involving all 3 supra-aortic branches in combination with the frozen elephant trunk (FET) technique (n = 14). Distal arch repair combines a vascular and endovascular treatment to treat aortic arch disease (n = 13). A 3D printed aorta model has been used preoperatively and intraoperatively to improve surgical results. Hereby we report our aortic arch surgical experience and results in the treatment for this challenging pathology