Influence of Body Mass Index on outcomes after minimal-access aortic valve replacement through a J-shaped partial upper sternotomy

BACKGROUND: Minimal-access aortic valve replacement (MAAVR) may reduce post-operative blood loss and transfusion requirements, decrease post-operative pain, shorten length stay and enhance cosmesis. This may be particularly advantageous in overweight/obese patients, who are at increased risk of post-operative complications. Obese patients are however often denied MAAVR due to the perceived technical procedural difficulty. This retrospective analysis sought to determine the effect of BMI on post-operative outcomes in patients undergoing MAAVR. METHODS: Ninety isolated elective MAAVR procedures performed between May 2006–October 2013 were included. Intra- and post-operative data were prospectively collected. Ordinary least squares univariate linear regression analysis was performed to determine the effect of BMI as a continuous variable on post-operative outcomes. One-way ANOVA and Chi-squared testing was used to assess differences in outcomes between patients with BMI <25 (n = 36) and BMI ≥25 (n = 54) as appropriate. RESULTS: There was no peri-operative mortality, myocardial infarction or stroke. Univariate regression demonstrated longer cross-clamp times (p = 0.0218) and a trend towards increased bypass times (p = 0.0615) in patients with higher BMI. BMI ≥25 was associated with an increased incidence of hospital-acquired pneumonia (p = 0.020) and new-onset atrial fibrillation (p = 0.036) compared to BMI <25. However, raised BMI did not extend ICU (p = 0.3310) or overall hospital stay (p = 0.2614). Similar rates of sternal wound complications, inotrope requirements and renal dysfunction were observed in both normal- and overweight/obese-BMI groups. Furthermore, increasing BMI correlated with reduced mechanical ventilation time (p = 0.039) and early post-operative blood loss (p = 0.004). CONCLUSIONS: Our results demonstrate that within the range of this study, MAAVR is a safe, reproducible and effective procedure, affording equivalent clinical outcomes in both overweight/obese and normal-weight patients considered for an isolated first-time AVR, with low post-operative morbidity and mortality. MAAVR should therefore be considered as an alternative surgical strategy to reduce obesity-related complications in patients requiring aortic valve replacement

The role of minimal access valve surgery in the elderly. A meta-analysis of observational studies

Background Minimal access valve surgery, both mitral and aortic, may be related to improvement in specific post-operative outcomes, therefore may be beneficial for the subgroup of the elderly referred for valve surgery. Methods A systematic literature review identified several different studies, of which 6 fulfilled criteria for meta-analysis. Outcomes for a total of 1347 patients (675 conventional standard sternotomy and 672 minimally invasive valve surgery) were assessed with a meta-analysis using random effects modeling. Heterogeneity, subgroup analysis with quality scoring were also assessed. The primary endpoint was early mortality. Secondary endpoints included intra and post-operative outcomes. Results In the context of elderly patients, minimal access valve surgery conferred comparable early mortality to standard sternotomy (odd ratio (OR) 0.79, CI [0.40,1.56], p\ua0=\ua00.50) with no heterogeneity (p\ua0=\ua00.13); it was also associated with reduced mechanical intubation time (OR 0.48, CI [0.30,0.78], p\ua0=\ua00.003) and reduced post-operative length of stay (weighted mean difference (WMD)\ua0 122.91, CI [ 123.09,\ua0 122.74] p\ua0<\ua00.00001), however both cardio-pulmonary bypass time and cross clamp time were longer (WMD 24.29, CI [22.97, 25.61] p\ua0<\ua00.00001 and WMD 8.61, CI [7.61, 9.61], p\ua0<\ua00.00001, respectively); subgroup analysis demonstrated statistically significant reduced post-operative length of stay for both minimally invasive aortic and mitral surgery (WMD\ua0 122.84, CI [ 123.07,\ua0 122.60] p\ua0<\ua00.00001 and WMD\ua0 122.98, CI [ 123.25,\ua0 122.71] p\ua0<\ua00.00001 respectively). Conclusions Despite a prolonged cardiopulmonary bypass and cross clamp time, minimally invasive valve surgery is a safe alternative to standard sternotomy in the elderly, with similar early mortality, and improvements in intubation time as well as length of stay

Transcatheter aortic valve implantation in 2015

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Heparan sulfates facilitate harmless amyloidogenic fibril formation interacting with elastin-like peptides

Heparan sulfates (HSs) modulate tissue elasticity in physiopathological conditions by interacting with various matrix constituents as tropoelastin and elastin-derived peptides. HSs bind also to protein moieties accelerating amyloid formation and influencing cytotoxic properties of insoluble fibrils. Interestingly, amyloidogenic polypeptides, despite their supposed pathogenic role, have been recently explored as promising bio-nanomaterials due to their unique and interesting properties. Therefore, we investigated the interactions of HSs, obtained from different sources and exhibiting various degree of sulfation, with synthetic amyloidogenic elastin-like peptides (ELPs), also looking at the effects of these interactions on cell viability and cell behavior using in vitro cultured fibroblasts, as a prototype of mesenchymal cells known to modulate the soft connective tissue environment. Results demonstrate, for the first time, that HSs, with differences depending on their sulfation pattern and chain length, interact with ELPs accelerating aggregation kinetics and amyloid-like fibril formation as well as self-association. Furthermore, these fibrils do not negatively affect fibroblasts' cell growth and parameters of redox balance, and influence cellular adhesion properties. Data provide information for a better understanding of the interactions altering the elastic component in aging and in pathologic conditions and may pave the way for the development of composite matrix-based biomaterials

Genome-Wide Association Study Identifies New Candidate Markers for Somatic Cells Score in a Local Dairy Sheep

In the Mediterranean basin countries, the dairy sheep production is usually based on local breeds, which are very well-adapted to their production systems and environments and can indeed guarantee income, employment, and economic viability in areas where production alternatives are scarce or non-existent. Mastitis is still one of the greatest problems affecting commercial milk production. However, genetic evaluation of mastitis is particularly difficult because of its low heritability and the categorical nature of the trait. The aim of this study was to identify genomic regions putatively associated with somatic cells count (SCC) in the local economically important Valle del Belice sheep breed using of deregressed breeding values (DEBV) as response variables. All the samples were genotyped using the Illumina OvineSNP50K BeadChip. Genome-wide association analysis was carried out based on regression of DEBV. A total of eight markers were found to be significantly associated with log-transformed SCC. Several candidate genes associated with SCC were identified related to immunity system and udder conformation. The results can help improving the competitiveness of the local Valle del Belìce breed. Further studies considering a higher sample size or independent population will be needed to confirm our results

Genomic structural diversity in local goats: Analysis of copy-number variations

Copy-number variations (CNVs) are one of the widely dispersed forms of structural variations in mammalian genomes, and are present as deletions, insertions, or duplications. Only few studies have been conducted in goats on CNVs derived from SNP array data, and many local breeds still remain uncharacterized, e.g., the Sicilian goat dairy breeds. In this study, CNV detection was performed, starting from the genotypic data of 120 individuals, belonging to four local breeds (Argentata dell’Etna, Derivata di Siria, Girgentana, and Messinese), genotyped with the Illumina GoatSNP50 BeadChip array. Overall, 702 CNVs were identified in 107 individuals using PennCNV software based on the hidden Markov model algorithm. These were merged in 75 CNV regions (CNVRs), i.e., regions containing CNVs overlapped by at least 1 base pair, while 85 CNVs remained unique. The part of the genome covered by CNV events was 35.21 Mb (1.2% of the goat genome length). Functional annotation of the CNVRs allowed the identification of 139 genes/loci within the most frequent CNVRs that are involved in local adaptations, such as coat colour (ADAMTS20 and EDNRA), mild behaviour (NR3C2), immune response (EXOC3L4 and TNFAIP2), reproduction (GBP1 and GBP6), and olfactory receptors (OR7E24). This study provides insights into the genomic variations for these Sicilian dairy goat breeds and should be of value for future studies to identify the relationships between this type of genetic variation and phenotypic traits

Non-sutureless minimally invasive aortic valve replacement: mini-sternotomy versus mini-thoracotomy: a series of 1130 patients

OBJECTIVES: Aortic valve replacement through conventional sternotomy still represents the gold-standard surgical approach for aortic valve disease. However, given the increasing number of patients with comorbidities, strategies that can improve operative results are always sought. Minimally invasive aortic valve surgery, although related to a steep learning curve, might be associated with improved post- operative outcomes. The main aim of this study was to assess whether significant differences exist in terms of operative and early results between a mini-sternotomy and a right mini-thoracotomy approach for isolated aortic valve replacement without sutureless technologies. METHODS: This is an observational retrospective multicentre study from nine Italian cardiac centres that analyses prospectively collected data of patients who underwent isolated minimally invasive aortic valve replacement between January 2010 and December 2014. Two approaches are considered (mini-sternotomy and mini-thoracotomy) and compared in terms of operative and early outcomes. RESULTS: After interrogation of the centralized database, a total of 1130 patients were retrieved (854 mini-sternotomy and 276 mini-thoracotomy). Patients in the mini-sternotomy group had a higher risk profile. There was no difference in terms of early mortality; cardiopulmonary bypass and cross-clamp time did not differ significantly between the groups; and a significantly higher number of reoperations for bleeding was observed in the right mini-thoracotomy group. CONCLUSIONS: Both mini-sternotomy and mini-thoracotomy could be performed safely, with low mortality and postoperative morbidity. The mini-thoracotomy approach was associated with a significantly higher rate of reoperation for bleeding. Uptake among cardiac centres was low. Sutureless technologies could potentially increase surgical volume by simplifying the mini-thoracotomy procedure

A First Investigation into the Use of Differential Somatic Cell Count as a Predictor of Udder Health in Sheep

Differential somatic cell count (DSCC), the percentage of somatic cell count (SCC) due to polymorphonuclear leukocytes (PMNs) and lymphocytes (LYMs), is a promising effective diagnostic marker for dairy animals with infected mammary glands. Well-explored in dairy cows, DSCC is also potentially valid in sheep, where clinical and subclinical mastitis outbreaks are among the principal causes of culling. We pioneered the application of DSCC in dairy ewes by applying receiver-operating characteristic (ROC) curve analysis to define the most accurate thresholds to facilitate early discrimination of sheep with potential intramammary infection (IMI) from healthy animals. We tested four predefined SCC cut-offs established in previous research. Specifically, we applied SCC cut-offs of 265 × 103 cells/mL, 500 × 103 cells/mL, 645 × 103 cells/mL, and 1000 × 103 cells/mL. The performance of DSCC as a diagnostic test was assessed by examining sensitivity (Se), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV), and area under curve (AUC) analyses. The designated threshold value for DSCC in the detection of subclinical mastitis is established at 79.8%. This threshold exhibits Se and Sp of 0.84 and 0.81, accompanied by an AUC of 0.88. This study represents the inaugural exploration of the potential use of DSCC in sheep’s milk as an early indicator of udder inflammation

Identification of Copy Number Variations and Genetic Diversity in Italian Insular Sheep Breeds

Copy number variants (CNVs) are one of the major contributors to genetic diversity and phenotypic variation in livestock. The aim of this work is to identify CNVs and perform, for the first time, a CNV-based population genetics analysis with five Italian sheep breeds (Barbaresca, Comisana, Pinzirita, Sarda, and Valle del Belìce). We identified 10,207 CNVs with an average length of 1.81 Mb. The breeds showed similar mean numbers of CNVs, ranging from 20 (Sarda) to 27 (Comisana). A total of 365 CNV regions (CNVRs) were determined. The length of the CNVRs varied among breeds from 2.4 Mb to 124.1 Mb. The highest number of shared CNVRs was between Comisana and Pinzirita, and only one CNVR was shared among all breeds. Our results indicated that segregating CNVs expresses a certain degree of diversity across all breeds. Despite the low/moderate genetic differentiation among breeds, the different approaches used to disclose the genetic relationship showed that the five breeds tend to cluster in distinct groups, similar to the previous studies based on single-nucleotide polymorphism markers. Gene enrichment was described for the 37 CNVRs selected, considering the top 10%. Out of 181 total genes, 67 were uncharacterized loci. Gene Ontology analysis showed that several of these genes are involved in lipid metabolism, immune response, and the olfactory pathway. Our results corroborated previous studies and showed that CNVs represent valuable molecular resources for providing useful information for separating the population and could be further used to explore the function and evolutionary aspect of sheep genome

Minimally invasive aortic valve surgery

Aortic valve disease is a prevalent disorder that affects approximately 2% of the general adult population. Surgical aortic valve replacement is the gold standard treatment for symptomatic patients. This treatment has demonstrably proven to be both safe and effective. Over the last few decades, in an attempt to reduce surgical trauma, different minimally invasive approaches for aortic valve replacement have been developed and are now being increasingly utilized. A narrative review of the literature was carried out to describe the surgical techniques for minimally invasive aortic valve surgery and report the results from different experienced centers. Minimally invasive aortic valve replacement is associated with low perioperative morbidity, mortality and a low conversion rate to full sternotomy. Long-term survival appears to be at least comparable to that reported for conventional full sternotomy. Minimally invasive aortic valve surgery, either with a partial upper sternotomy or a right anterior minithoracotomy provides early- and long-term benefits. Given these benefits, it may be considered the standard of care for isolated aortic valve disease