Acute ascending aortic dissection complicating open heart surgery: cerebral perfusion defines the outcome

Objective: This retrospective study was designed to assess the risks of acute ascending aorta dissection (AAD) as a rare but potentially fatal complication of open heart surgery. Method: Among 8624 cardiac surgical procedures under cardiopulmonary bypass (CPB) and cardioplegic myocardial protection from 1978 to 1997, 10 patients (0.12%) presented with a secondary or so called ‘iatrogenic' AAD. There were seven men and three women, mean age 64±9 years, ranging from 47 to 79. The original procedures involved five coronary artery bypass grafts (CABG), one repeat CABG, one aortic valve replacement (AVR), one AVR and CABG, one mitral valvuloplasty (MVP) and CABG and one ascending aorta replacement. We retrospectively analyzed their hospital records. Results: Group I consisted of seven patients with AAD intraoperatively and group II consisted of three patients who developed acute AAD 8-32 days after cardiac surgery. In group I, treatment consisted of the original procedure, plus grafting of the ascending aorta in six patients and closed plication and aortic wrapping in one. In group II, two patients received a dacron graft and one patient developed lethal tamponnade due to aortic rupture before surgery. Postoperatively, six patients responded well and three died (33%), two patients from group I on the 2nd postoperative day with severe post-anoxic encephalopathy, and one from group II with severe peroperative cardiogenic shock. Conclusion: Preventing AAD with the appropriate means remains standard practice in cardiac surgery. If AAD occurs, it requires prompt diagnosis and interposition graft to allow a better prognosis. Intraoperative AAD happens at the beginning of CPB jeopardizing perfusion of the supra-aortic arterie

Primary isolated aortic valve surgery in octogenarians

Objectives: We reviewed our surgery registry, to identify predictive risk factors for operative results, and to analyse the long-term survival outcome in octogenarians operated for primary isolated aortic valve replacement (AVR). Methods: A total of 124 consecutive octogenarians underwent open AVR from January 1990 to December 2005. Combined procedures and redo surgery were excluded. Selected variables were studied as risk factors for hospital mortality and early neurological events. A follow-up (FU; mean FU time: 77 months) was obtained (90% complete), and Kaplan-Meier plots were used to determine survival rates. Results: The mean age was 82±2.2 (range: 80-90 years; 63% females). Of the group, four patients (3%) required urgent procedures, 10 (8%) had a previous myocardial infarction, six (5%) had a previous coronary angioplasty and stenting, 13 patients (10%) suffered from angina and 59 (48%) were in the New York Heart Association (NYHA) class III-IV. We identified 114 (92%) degenerative stenosis, six (5%) post-rheumatic stenosis and four (3%) active endocarditis. The predicted mortality calculated by logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) was 12.6±5.7%, and the observed hospital mortality was 5.6%. Causes of death included severe cardiac failure (four patients), multi-organ failure (two) and sepsis (one). Complications were transitory neurological events in three patients (2%), short-term haemodialysis in three (2%), atrial fibrillation in 60 (48%) and six patients were re-operated for bleeding. Atrio-ventricular block, myocardial infarction or permanent stroke was not detected. The age at surgery and the postoperative renal failure were predictors for hospital mortality (p value ≪0.05), whereas we did not find predictors for neurological events. The mean FU time was 77 months (6.5 years) and the mean age of surviving patients was 87±4 years (81-95 years). The actuarial survival estimates at 5 and 10 years were 88% and 50%, respectively. Conclusions: Our experience shows good short-term results after primary isolated standard AVR in patients more than 80 years of age. The FU suggests that aortic valve surgery in octogenarians guarantees satisfactory long-term survival rates and a good quality of life, free from cardiac re-operations. In the era of catheter-based aortic valve implantation, open-heart surgery for AVR remains the standard of care for healthy octogenarian

Assessment of successful incorporation of cages after cervical or lumbar intercorporal fusion with [(18)F]fluoride positron-emission tomography/computed tomography

The purpose of this study is to assess the successful incorporation of cages in patients after cervical or lumbar intercorporal fusion with positron-emission tomography/computed tomography (PET/CT). Twenty patients (14 female and 6 male; mean age 58years, age range 38-73years) with 30 cervical (n=13) or lumbar (n=17) intercorporal fusions were prospectively enrolled in this study. Time interval between last intercorporal intervention and PET/CT ranged from 2 to 116months (mean 63; median 77months). IRB approval was obtained for all patients, and written informed consent was obtained from all patients. About 30min prior to PET/CT scanning, 97-217MBq (mean 161MBq) 18F-fluoride were administered intravenously. Patients were imaged in supine position on a combined PET/CT system (Discovery RX/STE, 16/64 slice CT, GE Healthcare). 3D-PET emission data were acquired for 1.5 and 2min/bed position, respectively, and reconstructed by a fully 3D iterative algorithm (VUE Point HD) using low-dose CT data for attenuation correction. A dedicated diagnostic thin-slice CT was optionally acquired covering the fused region. Areas of increased 18F-fluoride uptake around cages were determined by one double-board certified radiologist/nuclear physician and one board certified radiologist in consensus. In 12/20 (60%) patients, increased 18F-fluoride uptake around cages was observed. Of the 30 intercorporal fusions, 15 (50%) showed increased 18F-fluoride uptake. Median time between intervention and PET/CT examination in cages with increased uptake was 37months (2-116months), median time between intervention and PET/CT examination in those cages without increased uptake was 91months (19-112months), p (Wilcoxon)=0.01 (one-sided). 14/29 (48%) cages with a time interval>1year between intervention and PET/CT scan showed an increased uptake. In conclusion, PET/CT frequently shows increased 18F-fluoride uptake in cervical and lumbar cages older than 1year (up to almost 8years in cervical cages and 10years in lumbar cages) possibly indicating unsuccessful fusion due to increased stress/microinstabilit

The additional value of CT images interpretation in the differential diagnosis of benign vs. malignant primary bone lesions with 18F-FDG-PET/CT

Objective: To evaluate the value of a dedicated interpretation of the CT images in the differential diagnosis of benign vs. malignant primary bone lesions with 18fluorodeoxyglucose-positron emission tomography/computed tomography (18F-FDG-PET/CT). Materials and methods: In 50 consecutive patients (21 women, 29 men, mean age 36.9, age range 11-72) with suspected primary bone neoplasm conventional radiographs and 18F-FDG-PET/CT were performed. Differentiation of benign and malignant lesions was separately performed on conventional radiographs, PET alone (PET), and PET/CT with specific evaluation of the CT part. Histology served as the standard of reference in 46 cases, clinical, and imaging follow-up in four cases. Results: According to the standard of reference, conventional 17 lesions were benign and 33 malignant. Sensitivity, specificity, and accuracy in assessment of malignancy was 85%, 65% and 78% for conventional radiographs, 85%, 35% and 68% for PET alone and 91%, 77% and 86% for combined PET/CT. Median SUVmax was 3.5 for benign lesions (range 1.6-8.0) and 5.7 (range 0.8-41.7) for malignant lesions. In eight patients with bone lesions with high FDG-uptake (SUVmax ≥ 2.5) dedicated CT interpretation led to the correct diagnosis of a benign lesion (three fibrous dysplasias, two osteomyelitis, one aneurysmatic bone cyst, one fibrous cortical defect, 1 phosphaturic mesenchymal tumor). In four patients with lesions with low FDG-uptake (SUVmax < 2.5) dedicated CT interpretation led to the correct diagnosis of a malignant lesion (three chondrosarcomas and one leiomyosarcoma). Combined PET/CT was significantly more accurate in the differentiation of benign and malignant lesions than PET alone (p = .039). There was no significant difference between PET/CT and conventional radiographs (p = .625). Conclusion: Dedicated interpretation of the CT part significantly improved the performance of FDG-PET/CT in differentiation of benign and malignant primary bone lesions compared to PET alone. PET/CT more commonly differentiated benign from malignant primary bone lesions compared with conventional radiographs, but this difference was not significan

Impact of duration of chest tube drainage on pain after cardiac surgery

Objective: This study was designed to analyze the duration of chest tube drainage on pain intensity and distribution after cardiac surgery. Methods: Two groups of 80 cardiac surgery adult patients, operated on in two different hospitals, by the same group of cardiac surgeons, and with similar postoperative strategies, were compared. However, in one hospital (long drainage group), a conservative policy was adopted with the removal the chest tubes by postoperative day (POD) 2 or 3, while in the second hospital (short drainage group), all the drains were usually removed on POD 1. Results: There was a trend toward less pain in the short drainage group, with a statistically significant difference on POD 2 (P=0.047). There were less patients without pain on POD 3 in the long drainage group (P=0.01). The areas corresponding to the tract of the pleural tube, namely the epigastric area, the left basis of the thorax, and the left shoulder were more often involved in the long drainage group. There were three pneumonias in each group and no patient required repeated drainage. Conclusions: A policy of early chest drain ablation limits pain sensation and simplifies nursing care, without increasing the need for repeated pleural puncture. Therefore, a policy of short drainage after cardiac surgery should be recommende

Long-term outcome after mitral valve repair: a risk factor analysis

Objective: Mitral valve repair is the gold standard to restore mitral valve function and is now known to have good long-term outcome. In order to help perioperative decision making, we analyzed our collective to find independent risk factors affecting their outcome. Methods: We retrospectively studied our first 175 consecutive adult patients (mean age: 64±10.4 years; 113 males) who underwent primary mitral valve repair associated with any other cardiac procedures between January 1986 and December 1998. Risk factors influencing reoperations and late survival were plotted in a uni- and multivariate analyses. Results: Operative mortality was 3.4% (6 deaths, 0-22nd postoperative day (POD)). Late mortality was 9.1% (16 deaths, 3rd-125th POM). Reoperation was required in five patients. Kaplan-Meier actuarial analysis demonstrated a 96±1% 1-year survival, 88±3% 5-year survival and a 69±8% 10-year survival. Freedom from reoperations was 99% at 1 year after repair, 97±2% after 5 years and 88±6% after 10 years. Multivariate analysis demonstrated that residual NYHA class III and IV (p=0.001, RR 4.55, 95% CI: 1.85-14.29), poor preoperative ejection fraction (p=0.013, RR 1.09, 95% CI: 1.02-1.18), functional MR (p=0.018, RR 4.17, 95% CI: 1.32-16.67), and ischemic MR (p=0.049, RR 3.13, 95% CI: 1.01-10.0) were all independent predictors of late death. Persistent mitral regurgitation at seventh POD (p=0.005, RR 4.55, 95% CI: 1.56-20.0), age below 60 (p=0.012, RR 8.7, 95% CI: 2.44-37.8), and absence of prosthetic ring (p=0.034, RR 4.76, 95% CI: 1.79-33.3) were all independent risk factors for reoperation. Conclusions: Mitral valve repair provides excellent survival. However, long-term outcome can be negatively influenced by perioperative risk factors. Risk of reoperation is higher in younger patients with a residual mitral regurgitation and without ring annuloplast

Ist der Kohlenstoffabbau in Unterböden limitiert auf Hotspots? - Räumliche Erfassung des Substratabbaus und der Enzymaktivitäten mittels Radiographie und Zymographie

Durch die größere Relevanz von präferentiellen Fließwegen und Wurzeln für den Kohlenstoffinput in den Unterboden (&lt; 30 cm) ergibt sich eine höhere räumliche Heterogenität der Kohlenstoffverteilung und -flüsse als im Oberboden. Eine mögliche räumliche Segregation zwischen Konsumenten und Kohlenstoff im Unterboden ist eine Theorie, weshalb der dortige Kohlenstoff nur langsam abgebaut wird. Dies lässt vermuten, dass im Unterboden der Kohlenstoffumsatz hauptsächlich in mikrobiellen „Hot Spots“ stattfindet. Bisherige methodische Ansätze können diese Theorie nicht untersuchen, da z.B. bei Substratmineralisierungsstudien nur gestörte Proben verwendet werden können. Die Kombination aus Radiographie und Zymographie kann ein neuer Ansatz sein, um die räumliche Aktivität von Enzymen und den Abbau von C14-markierten Substraten an ungestörten (Unter)Bodenproben zu untersuchen. An der Probe (11 x 7 cm) wird zunächst die räumliche Aktivität von Enzymen aus verschieden Nährstoffkreisläufen mittels Zymographie (1) erfasst. Anschließend wird die Bodenoberfläche mit einem C14-markierten Substrat (z.B. Glukose) besprüht (100 Bq cm-2). Hierfür wird ein hochpräziser Sprühroboter (iMatrix Spray) verwendet, der ein sehr kleines Volumen von 1 µl cm-2 auf die Probe bringt. Die Probe wird für 2 Wochen inkubiert und das mineralisierte C14 in einer KOH-Lösung gefangen und nach ausgesuchten Zeiträumen mittels b-Counter analysiert. Der räumliche Abbau des Substrats wird zu denselben Zeitpunkten mit Hilfe der Radiographie (Bestimmung der Verteilung der Radioaktivität) erfasst. Die Kombination der zwei verschiedenen Methoden wird zeigen, ob das Substrat hauptsächlich in den mikrobiellen „Hot Spots“ abgebaut wird. Nach Beendigung der Inkubation wird die Zymographie wiederholt, um zu untersuchen, ob durch die C-Zugabe neue „Hotspots“ im Laufe der Inkubation entstanden sind. Dieser Beitrag wird die ersten Ergebnisse für Oberboden vs. Unterboden behandeln

Erfassung der mikrobiellen Dynamik im Boden unter Verwendung von aktiver und passiver Infrarot-Thermographie sowie Radiographie

Die mikrobielle Aktivität in Böden ist bei der Bewertung der Fruchtbarkeit, des Kohlenstoffverlusts und der Kontamination von Böden von großen Interesse. Bisher war eine hochauflösende räumliche und zeitliche Analyse der mikrobiellen Aktivität aufgrund methodischer, instrumenteller und analytischer Herausforderungen nicht möglich. Daher werden neue Techniken wie aktive und passive Infrarot-Thermographie (IRT) in Kombination mit Radiographie eingesetzt, um ein Verfahren zur Überwachung der räumlichen mikrobiellen Dynamik ungestörter Bodenproben zu entwickeln. In dieser Studie wurden Bodenproben dreier Äcker und eines Waldes verwendet, deren bodenbiologischen Eigenschaften sich signifikant unterscheiden. Diese wurden auf 50% der maximalen Wasserhaltekapazität befeuchtet und in einer luftdichten Handschuhbox mit kontrollierter relativer Luftfeuchtigkeit von 92% in Mikroplatten vorinkubiert. Anschließend wurde 14C-Glukose tröpfchenweise pipettiert oder flächenhaft mit einem Robotersprühsystem aufgetragen. Dadurch wird die mikrobielle Aktivität, die durch die Wärmeerzeugung der Bodenatmung messbar ist, auf eine für die IRT nachweisbare Grenze erhöht. Nach Glukoseapplikation wurde die mikrobielle Aktivität mit einer IRT-Kamera durch minütliche Aufnahmen der Oberflächentemperatur (passive IRT) überwacht. Darüber hinaus wurden die Raten der 14C-Glukose-Mineralisierung mittels Radiographie analysiert. Da Unterschiede der Bodenfeuchtigkeit und der Oberflächenstruktur die gemessenen Temperaturen potenziell beeinflussen können, wird die Veränderung des flächigen Bodenwassergehaltes und -struktur mittels aktiver IRT überwacht. Zusammenfassend konnte gezeigt werden, dass sowohl die IRT als auch die Radiographie die mikrobielle Dynamik nach Glukoseapplikation abbilden können. Alle Bodenproben verzeichnen eine Erhöhung der Oberflächentemperatur und eine erhöhte 14C-Mineralisierung zwei Tage nach Glukoseapplikation, die charakteristisch für mikrobielle Mineralisierungsprozesse der substratinduzierten Respiration sind

Biosynthesis of allene oxides in Physcomitrella patens

Background: The moss Physcomitrella patens contains C-18- as well as C-20-polyunsaturated fatty acids that can be metabolized by different enzymes to form oxylipins such as the cyclopentenone cis(+)-12-oxo phytodienoic acid. Mutants defective in the biosynthesis of cyclopentenones showed reduced fertility, aberrant sporophyte morphology and interrupted sporogenesis. The initial step in this biosynthetic route is the conversion of a fatty acid hydroperoxide to an allene oxide. This reaction is catalyzed by allene oxide synthase (AOS) belonging as hydroperoxide lyase (HPL) to the cytochrome P450 family Cyp74. In this study we characterized two AOS from P. patens, PpAOS1 and PpAOS2. Results: Our results show that PpAOS1 is highly active with both C-18 and C-20-hydroperoxy-fatty acid substrates, whereas PpAOS2 is fully active only with C-20-substrates, exhibiting trace activity (similar to 1000-fold lower k(cat)/K-M) with C-18 substrates. Analysis of products of PpAOS1 and PpHPL further demonstrated that both enzymes have an inherent side activity mirroring the close inter-connection of AOS and HPL catalysis. By employing site directed mutagenesis we provide evidence that single amino acid residues in the active site are also determining the catalytic activity of a 9-/13-AOS - a finding that previously has only been reported for substrate specific 13-AOS. However, PpHPL cannot be converted into an AOS by exchanging the same determinant. Localization studies using YFP-labeled AOS showed that PpAOS2 is localized in the plastid while PpAOS1 may be found in the cytosol. Analysis of the wound-induced cis(+)-12-oxo phytodienoic acid accumulation in PpAOS1 and PpAOS2 single knock-out mutants showed that disruption of PpAOS1, in contrast to PpAOS2, results in a significantly decreased cis(+)-12-oxo phytodienoic acid formation. However, the knock-out mutants of neither PpAOS1 nor PpAOS2 showed reduced fertility, aberrant sporophyte morphology or interrupted sporogenesis. Conclusions: Our study highlights five findings regarding the oxylipin metabolism in P. patens: (i) Both AOS isoforms are capable of metabolizing C-18- and C-20-derived substrates with different specificities suggesting that both enzymes might have different functions. (ii) Site directed mutagenesis demonstrated that the catalytic trajectories of 9-/13-PpAOS1 and PpHPL are closely inter-connected and PpAOS1 can be inter-converted by a single amino acid exchange into a HPL. (iii) In contrast to PpAOS1, PpAOS2 is localized in the plastid where oxylipin metabolism takes place. (iv) PpAOS1 is essential for wound-induced accumulation of cis(+)-12-oxo phytodienoic acid while PpAOS2 appears not to be involved in the process. (v) Knock-out mutants of neither AOS showed a deviating morphological phenotype suggesting that there are overlapping functions with other Cyp74 enzymes