La minitoracotomia come approccio per il trattamento concomitante della fibrillazione atriale

RIASUNTO Introduzione La fibrillazione atriale (FA) è un tachiaritmia sopraventricolare caratterizzata dalla presenza di un'attivazione atriale caotica ed incoordinata con conseguente inefficacia nell'attività meccanica. La fibrillazione atriale costituisce la più comune aritmia nella pratica clinica ed un importante problema sanitario con alto peso economico e sociale. La sua prevalenza nella popolazione generale si aggira tra 0,4% e 1% e sale all'8% negli ultra ottantenni. Cardiopatie organiche, malattia della valvola mitrale in particolare, costituisce importane ruolo nell'eziologia della FA. Il gold standard della terapia chirurgica della FA ovvero la procedura di Cox-Maze IV. La chirurgia mini-invasiva cardiaca sta diventando sempre più popolare nel mondo. Implementazione della chirurgia mini-invasiva nel trattamento della FA è un aspetto promettente. Materiali e metodi Sono stati raccolti i dati in modo retrospettivo riferiti al periodo Gennaio 2007 e Dicembre 2009. In questo periodo settantacinque (75) pazienti consecutivi sono stati sottoposti preso l'Ospedale del Cuore “G. Pasquinucci”, Fondazione CNR-Regione Toscana “G. Monasterio” di Massa, a trattamento chirurgico della FA in corso di interventi di chirurgia mini-invasiva valvolare per via minitoracotomica destra. La nostra popolazione è composta da 43 (57,3%) individui di sesso femminile e 32(42,7%) di sesso maschile. L'età media dei pazienti al ricovero era di 66,7 ± 9,8 anni. La durata media della FA nella casistica complessiva era di 25,1±22,7 mesi. Tutti i pazienti sono stati sottoposti ad ECG, ecocardiografia transtoracica bidimensionale, doppler e color doppler, e studio coronarografico. Tutti i pazienti sono stati sottoposti alla stessa procedura di anestesia generale. In tutti i pazienti l’allestimento della circolazione extracorporea è stato eseguito secondo la nostra tecnica standard per le procedure di chirurgia mininvasiva minitoracotomica. La mini-toracotomia destra di circa 5-6 cm è stata fatto al livello 2, 3, 4 spazio seconda intervento chirurgico eseguito. Tutti pazienti sono stati sottoposti RF ablazione compresi intervento chirurgico principali. I dati sono stati espressi come media ± deviazione standard nel caso di variabili continue e come percentuali nel caso di variabili categoriche. L'analisi Kaplan-Meier di sopravvivenza libera da tachiaritmie sopraventricolari e l'analisi di sopravvivenza libera da eventi è stata effettuata con programma statistico StatView®. Risultati Tutti i 75 pazienti della nostra casistica sono stati sottoposti ad ablazione a RF della FA con l'impiego di sistemi di erogazione monopolare, bipolare o di entrambi. Più dell'80% dei pazienti l'unico tipo di energia impiegata è stata la RF monopolare. Circa la modalità di erogazione nel 44% dei pazienti è avvenuta per via epicardica, nel 21,3% per via endocardica e nel 34,7% con entrambe le modalità. Nello specifico, tutti i 75 pazienti sono stati sottoposti a isolamento delle vene polmonari (PVI); 6 (8%) mediante encircling separato delle vene polmonari di destra e di sinistra in posizione antrale, 9 (12%) mediante il confezionamento di una box lesion con RF monopolare endocardica, 47 (62,7%) mediante box lesion con RF monopolare epicardica, 13 (17,3%) mediante box lesion con RF bipolare. In 22 pazienti (29,3%) all'isolamento delle vene polmonari è stata aggiunta una linea di lesione verso l'anulus mitralico posteriore. L'esclusione chirurgica dell'auricola sinistra e una linea di connessione tra l'auricola stessa e la vena polmonare superiore sinistra (LSPV) è stata effettuata in 12 (16%) pazienti. Solo in un paziente (1,3%) si è proceduto ad una Cox-Maze IV sinistra completa ed in un altro paziente ad una Cox Maze IV biatriale. Solo 1 (1,3%) decesso perioperatorio per sanguinamento incoercibile per rottura di cuore. Nell'unica conversione intraoperatoria in sternotomia per sanguinamento si è evidenziata una lesione dell'apice dell'auricola sinistra. Alla dimissione 43 (57,3%) pazienti erano in RS e 30 (40%) in FA. Al termine di un follow-up medio di 21,6±10,1 mesi con range 5-45 mesi, completo al 98,6%, ad un'analisi di prevalenza, 46 pazienti (63%) risultano in RS stabile e 27 (37%) in FA. Da un'analisi statistica effettuata con valutazione della curva di sopravvivenza libera da fibrillazione atriale o oltre tachiaritmie sopraventricolari secondo Kaplan-Meier si evincono risultati sovrapponibili all'analisi di prevalenza. Tra gli eventi avversi postoperatori tardivi si segnalano: 3 nuovi impianti di Pace- maker; 2 TIA; 1 ictus cerebri senza reliquati. Al follow-up, 26 (56,5%) pazienti sono liberi da terapia antiaritmica mentre 19 (42,2%) sono tuttora trattati con almeno un farmaco. Conlusione Al base del nostro studio, possiamo concludere che il trattamento concomitante della fibrillazione atriale con approccio mini-invasivo minitoracotomico destro con energia a radiofrequenza in pazienti candidati a chirurgia cardiaca per differenti valvulopatie è fattibile, sicuro e riproducibile

Evaluation of Distensibility and Stiffness of Ascending Aortic Aneurysm using Magnetic Resonance Imaging

Introduction: Magnetic resonance imaging emerging as a new tool for the diagnosis and evaluation of ascending aortic aneurysm. The aim of our study is to evaluate in vivo distensibility and pulse wave velocity of the aortic wall using functional magnetic resonance imaging technique.Methods: We enrolled 25 patients undergoing surgery for ascending aortic aneurysm and or aortic valve replacement for a period of 8 months. Preoperatively, all the patients underwent functional MRI study of the aorta. Aortic wall distensibility and pulse wave velocity of ascending aorta was evaluated. Results: Mean age of the patient was 66 years (66.68 ± 5.62 years) with 60% (15) male patients. More than fifty percentages of patients were smoker (52%), hypertensive (64%) and diabetic (56%). We have observed significant decrease of distensibilty in the patients with aortic diameter above 50 mm (p-0.0002). Furthermore, we have found a significant inverse correlation between aortic distensibility and pulse wave velocity (R= -0.650, R2= 0.42, p-0.0004). Similarly, we have found a significant inverse correlation between ascending aortic diameter and distensibility of the aorta (R= -0.785, R2= 0.61, p-0.00001). Statistically significant positive correlation was observed between aortic diameter and pulse wave velocity (R= 0.865, R2= 0.74, p-0.00001).Conclusions: MRI measurement of aortic diameters, distensibility, and flow wave velocity is an easy, reliable and reproducible technique. Distensibility and pulse wave velocity define the elasticity of the aorta. We have observed that elasticity of aortic wall is decreased in ascending aorta aneurysm patients. Keywords: ascending aorta aneurysm; distensibility; pulse wave velocity; MRI. | PubMe

Comparative and temporal transcriptome analysis of peste des petits ruminants virus infected goat peripheral blood mononuclear cells

Peste des petits ruminanats virus (PPRV), a morbillivirus causes an acute, highly contagious disease – peste des petits ruminants (PPR), affecting goats and sheep. Sungri/96 vaccine strain is widely used for mass vaccination programs in India against PPR and is considered the most potent vaccine providing long-term immunity. However, occurrence of outbreaks due to emerging PPR viruses may be a challenge. In this study, the temporal dynamics of immune response in goat peripheral blood mononuclear cells (PBMCs) infected with Sungri/96 vaccine virus was investigated by transcriptome analysis. Infected goat PBMCs at 48 h and 120 h post infection revealed 2540 and 2000 differentially expressed genes (DEGs), respectively, on comparison with respective controls. Comparison of the infected samples revealed 1416 DEGs to be altered across time points. Functional analysis of DEGs reflected enrichment of TLR signaling pathways, innate immune response, inflammatory response, positive regulation of signal transduction and cytokine production. The upregulation of innate immune genes during early phase (between 2-5 days) viz. interferon regulatory factors (IRFs), tripartite motifs (TRIM) and several interferon stimulated genes (ISGs) in infected PBMCs and interactome analysis indicated induction of broad-spectrum anti-viral state. Several Transcription factors – IRF3, FOXO3 and SP1 that govern immune regulatory pathways were identified to co-regulate the DEGs. The results from this study, highlighted the involvement of both innate and adaptive immune systems with the enrichment of complement cascade observed at 120 h p.i., suggestive of a link between innate and adaptive immune response. Based on the transcriptome analysis and qRT-PCR validation, an in vitro mechanism for the induction of ISGs by IRFs in an interferon independent manner to trigger a robust immune response was predicted in PPRV infection

Cardiac surgery and small island states: a bridge too far?

Background Small island developing states (SIDS) make up nearly 1% of the world’s population, with 65 million people across 58 countries. Small island developing states have some of the highest rates of rheumatic heart disease in addition to a substantial burden of congenital heart defects and a growing burden of ischemic heart disease. Here, we present an overview of cardiac surgical services in SIDS, with a focus on Papua New Guinea, the Maldives, and Aruba. Methods We performed a literature review using the PubMed/MEDLINE and Google Scholar databases to identify articles describing cardiac surgery services in SIDS. Case studies of the history and current state of cardiac surgery in Papua New Guinea, the Maldives, and Aruba were developed and informed by local clinical experience. Results Nine SIDS have independent cardiac surgical centers and 5 SIDS have local centers supported by visiting teams. Papua New Guinea started cardiac surgery in 1993 and is served by a public center, performing nearly 100 cardiac surgeries per year. The Maldives introduced cardiac surgery services in 2018, with 1 local cardiac surgeon supported by Nepalese cardiac surgeons, performing 33 cardiac surgeries in 15 months. In Aruba, no local cardiac center exists and over 150 patients are sent abroad for cardiac surgery, representing 12% of total health spending. Conclusions Small island developing states have limited availability of cardiac surgery but pressing clinical needs. Independent cardiac centers exist with acceptable outcomes and lower costs than foreign treatment, which suggests the need to strengthen regionalization models to deliver cardiac surgical care in SIDS

Right-sided minithoracotomy as a surgical approach for the concomitant treatment of atrial fibrillation

Background: Atrial fibrillation (AF) is the most common arrhythmia diagnosed in humans and therefore causes a high socioeconomic burden. The Cox-Maze IV procedure is the gold standard treatment for atrial fibrillation. Minimally invasive surgery for the treatment of AF is also promising. Objectives: Our aim is to evaluate the feasibility, safety, and immediate plus medium-term results of concomitant AF ablation therapy in patients undergoing minimally invasive valve surgery through right-sided minithoracotomy. Patients and Methods: Retrospective data were collected from January 2012 to December 2013. Seventy-five consecutive patients underwent radiofrequency ablation during valve surgery through a right-sided minithoracotomy. Results: All 75 patients underwent radiofrequency ablation. The pulmonary vein was isolated in 6 (8%) by encircling the left and right pulmonary veins. In 9 (12%) patients, endocardial box lesions were created using a monopolar probe, while in 47 (62.7%), epicardial box lesions were produced with a monopolar probe. Thirteen (17.3%) patients received a box lesion created with a bipolar probe. Finally, in 22 (293%) patients, a line of lesions was produced leading up to the posterior mitral annulus. Only 1 (1.3%) perioperative death was observed. At discharge, 43 (57.3%) patients were in sinus rhythm and 30 (40%) were in AF. After a mean follow-up of 21.6 ± 10.1 months, 46 patients (63%) were in a stable sinus rhythm and 27 were in (37%) in AF; 26 (56.5%) patients were free from antiarrhythmic therapy, while 19 (42.2%) were still taking at least one drug. Conclusions: We can conclude that treatment of AF using a right-sided minithoracotomy approach and RF energy in patients undergoing cardiac surgery for various valve diseases is feasible, safe, and reproducible

Analysis of Consecutive Cases of Vascular Injury in Tertiary Level Hospital in Central Nepal

Background &amp; Objectives:Vascular injury diagnosis and management can be challenging and need expert clinical judgments. The current study aims to present diagnostic methods and management outcome in vascular injury patients attending our centre.Materials &amp; Methods: The study  is a prospective study conducted during the study period of one and half years (From January 2015 to June 2016). Diagnosis of vascular injury was done by clinical examination, hand Doppler or in conjugation with duplex scan/CT Angiography. Primary vascular repair with end to end anastomosis was carried out whenever technically feasible; however, if it was not possible interposition reversed saphenous graft (SVG) was used to complete the repair.Results:Out of hundred cases of vascular injury, 77% were male and 23% female with a mean age of 35.18± 16.93 years. The majority of the cases 53% were diagnosed by duplex study followed by additional imaging by CT angiography in 30% cases and 17% cases were diagnosed only on clinical judgment. The main type of vascular injury was a complete transaction in 62% of cases followed by complex wall defect in 22%. The most common type of vascular reconstruction was end-end anastomosis in 76% of cases followed by ligation and haemostasis in 13% and reverse SVG graft repair in six percent of cases.Conclusion:The study concluded with the observation that early presentation, diagnosis and management including initial resuscitation and definitive multi-specialist surgical approach are paramount for excellent outcome after vascular injury.</p

Evaluation of Distensibility and Stiffness of Ascending Aortic Aneurysm using Magnetic Resonance Imaging

Introduction: Magnetic resonance imaging emerging as a new tool for the diagnosis and evaluation of ascending aortic aneurysm. The aim of our study is to evaluate in vivo distensibility and pulse wave velocity of the aortic wall using functional magnetic resonance imaging technique. Methods: We enrolled 25 patients undergoing surgery for ascending aortic aneurysm and or aortic valve replacement for a period of 8 months. Preoperatively, all the patients underwent functional MRI study of the aorta. Aortic wall distensibility and pulse wave velocity of ascending aorta was evaluated. Results: Mean age of the patient was 66 years (66.68 ± 5.62 years) with 60% (15) male patients. More than fifty percentages of patients were smoker (52%), hypertensive (64%) and diabetic (56%). We have observed significant decrease of distensibilty in the patients with aortic diameter above 50 mm (p-0.0002). Furthermore, we have found a significant inverse correlation between aortic distensibility and pulse wave velocity (R= -0.650, R2= 0.42, p-0.0004). Similarly, we have found a significant inverse correlation between ascending aortic diameter and distensibility of the aorta (R= -0.785, R2= 0.61, p-0.00001). Statistically significant positive correlation was observed between aortic diameter and pulse wave velocity (R= 0.865, R2= 0.74, p-0.00001). Conclusions: MRI measurement of aortic diameters, distensibility, and flow wave velocity is an easy, reliable and reproducible technique. Distensibility and pulse wave velocity define the elasticity of the aorta. We have observed that elasticity of aortic wall is decreased in ascending aorta aneurysm patients. Keywords: ascending aorta aneurysm; distensibility; pulse wave velocity; MRI. | PubMe

Evaluation of Distensibility and Stiffness of Ascending Aortic Aneurysm using Magnetic Resonance Imaging

Introduction: Magnetic resonance imaging emerging as a new tool for the diagnosis and evaluation of ascending aortic aneurysm. The aim of our study is to evaluate in vivo distensibility and pulse wave velocity of the aortic wall using functional magnetic resonance imaging technique. Methods: We enrolled 25 patients undergoing surgery for ascending aortic aneurysm and or aortic valve replacement for a period of 8 months. Preoperatively, all the patients underwent functional MRI study of the aorta. Aortic wall distensibility and pulse wave velocity of ascending aorta was evaluated. Results: Mean age of the patient was 66 years (66.68 ± 5.62 years) with 60% (15) male patients. More than fifty percentages of patients were smoker (52%), hypertensive (64%) and diabetic (56%). We have observed significant decrease of distensibilty in the patients with aortic diameter above 50 mm (p-0.0002). Furthermore, we have found a significant inverse correlation between aortic distensibility and pulse wave velocity (R= -0.650, R2= 0.42, p-0.0004). Similarly, we have found a significant inverse correlation between ascending aortic diameter and distensibility of the aorta (R= -0.785, R2= 0.61, p-0.00001). Statistically significant positive correlation was observed between aortic diameter and pulse wave velocity (R= 0.865, R2= 0.74, p-0.00001). Conclusions: MRI measurement of aortic diameters, distensibility, and flow wave velocity is an easy, reliable and reproducible technique. Distensibility and pulse wave velocity define the elasticity of the aorta. We have observed that elasticity of aortic wall is decreased in ascending aorta aneurysm patients. Keywords: ascending aorta aneurysm; distensibility; pulse wave velocity; MRI. | PubMe

Evaluation of chemokine receptors (CCRs) expression on peripheral blood T-lymphocyte subsets in patients with thoracic aortic aneurysm

Background &amp; Objectives: Mortality and morbidity from the complication of aortic aneurysm remain very high. Aortic size index, which classify thoracic aortic aneurysm patients in three risk groups for aortic rupture prediction. Recent data support that aortic wall remodeling is a dynamic process with active involvement of the chronic inflammation and immunological system. Aim of our study is to evaluate expression level of chemokine receptors known to be involved in the T-cells migration and to correlate them with aortic size index. Materials &amp; Methods: Total 20 patients undergoing surgery for ascending aortic aneurysm and/or aortic valve surgery were enrolled. Aortic size index was calculated. Preoperatively blood samples collected. By flowcytometry and dual parameter dot plot technology percentage of positivity of CCR5 on these T-cell subsets were quantified. Results: Mean age of the patients was 67±5.93 years. Majority of patients had hypertension. Mean ascending aortic diameter was 42.1±8.14 mm. Mean Aortic size Index was 22.21±3.38 mm/m2. A statistical significance has observed between aortic size index and the expression of CCR5 on total CD4 positive T-cells (p-0.0949), and between aortic size index and CCR5 expression on the total CD3 positive T-cells (p-0.0293). Significant correlation observed between ASI and CCR5 expression on the CD8+/CD3+ T-cell subset (p-0.0183). Similarly, strong positive relationship between ASI and the expression of CCR5 on the cytotoxic CD28-/CD4+ T-cell subset (p-0.0055). Activated state of cytotoxic CD28-/CD4+ cell also correlated with aortic size index (p-0.0668).Conclusion: We conclude that T-cell mediated cytotoxic mechanism driven by CCR5 play an important role in the pathophysiology of the thoracic aortic aneurysm.JCMS Nepal. 2016;12(1):23-27.</p

Preoperative evaluation of basal free triiodothyronine in patients undergoing coronary artery bypass grafting surgery. Does it help?

noBackground &amp; Objectives: The postoperative Low T3 syndrome has been considered as a possible source of reduced myocardial contractility, resulting in increased mortality after CABG. Effect of preoperative Low T3 has not been well studied in patients undergoing CABG surgery. Aim of our study is to evaluate effect of preoperative Low T3 syndrome in patients undergoing CABG surgery.Materials &amp; Methods: Six hundred and six patients undergoing CABG were included in this prospective study. The impact of the base-line FT3 concentration and of preoperative low T3 syndrome on the risk of postoperative low cardiac output and hospital death was analyzed.Results: Fifteen patients (2.3%) postoperatively and 159 (26.2%) developed major complications. At univariate analysis a reduced EF, the presence of peripheral vascular disease, the NYHA class, the surgical urgency, the aortic cross-clamp time, the CPB time and the FT3 concentration at admission were significantly associated with low CO and higher mortality. At multivariate analysis, the CPB time, an emergency procedure, a reduced LVEF, and the fT3 concentration were independently related to the development of low CO. However, in multivariate analysis low EF, and the fT3 concentration were the only predictors of hospital death.Conclusion: We conclude that preoperative low EF and low T3 syndrome independently causes low cardiac output and higher mortality in patients undergoing CABG. Therefore, all patients undergoing CABG should be evaluated for low T3 syndrome and patients with low T3 syndrome should be considered at increased risk. Appropriate preoperative T3 replacement therapy could decrease the postoperative complications in patients undergoing CABG.JCMS Nepal. 2015; 11(2):1-7</p