F. Barili

G. Polvani

L. Dainese

P. Biglioli

Dainese, Luca

Barili, Fabio

Polvani, Gianluca

Biglioli, Paolo

AIR Universita degli studi di Milano

Downloadedby Universon 30 JulyLetters to the Editorwww.elsevier.com/locate/ejctsEuropean Journal of Cardio-thoracic Surgery 30 (2006) 411—417 fit 2Letter to the EditorAre the aortic anatomical normal leaflets, normal leaflets?§Luca Dainese*, Fabio Barili, Gianluca Polvani, Paolo BiglioliCentro Cardiologico Monzino,IRCCS, Department of Cardiac Surgery, University of Milan,Via Parea 4, 20138 Milan, ItalyReceived 14 March 2006; accepted 19 April 2006Keywords: Aortic root; Cardiac surgery; Innervation; Cardiac valvesI read with interest a recent article by Thubrikar et al.[1] where they suggest that in dilated aortic roots theanatomically normal leaflets, however, were not geome-trically normal. Thus they conclude that during valve-sparing surgery, it may be necessary in some cases tocorrect not only the dilatation of the aortic root but alsothe leaflet free-edge length in order to achieve a competentvalve.We studied the nervous fibers distributions with glycosa-minolglycans’ (GAG’s) leaflet distribution in 15 aortic valveleaflets in aortic root dilated and judged anatomically normaland 15 leaflets in normal aortic valve (homograft). We founda significant decrease in the fibers innervation — acetylcho-linesterase positive fibers — and also in GAG’s total quantityand distribution [2,3].The simple, anatomical, analysis of aortic leaflet beforethe surgery cannot be sufficient. As a matter of fact, thisquestion is particularly relevant in case of plastic of aorticvalve leaflets or valve-sparing procedures.References[1] Thubrikar MJ, Labrosse MR, Zehr KJ, Robicsek F, Gong GG, Fowler BL.Aortic root dilatation may alter the dimensions of the valve leaflets. Eur JCardiothorac Surg 2005;28:850—6.[2] Dainese L, Polvani GL, Barili F, Biglioli P. Aortic valve: do its nervousand contractile elements have any role? Ital Heart J 2003;4(11):810—2.[3] Dainese L, Barili F, Topkara VK, Cheema FH, Formato M, Guarino A, MicheliB, Biglioli P, Polvani GL. Effect of cryopreservation techniques on aorticvalve glycosaminoglycans. Artif Organs 2006;30:259—64.§The authors of the original paper [1] were invited to comment on thisLetter to the Editor but declined the offer.* Corresponding author. Tel.: +39 02 580021/355 563; fax: +39 02 580011194.E-mail address: luca.dainese@ccfm.it (L. Dainese).doi:10.1016/j.ejcts.2006.04.0231010-7940/$ — see front matter # 2006 Elsevier B.V. All rights reserved.rom https://academic.oup.com/ejcts/article-abstract/30/2/411/361611à degli Studi di Milano - Dip. Storia arti, musica e spettacolo user018Letter to the EditorCan we consider thymectomy before pregnancy in femalepatients with myasthenia gravis?Jose´ F. Te´llez Zenteno*Department of Neurology,National Institute of Medical Sciences andNutrition ‘‘Salvador Zubira´n’’, Mexico City, MexicoReceived 9 February 2006; accepted 19 April 2006Keywords: Myasthenia gravis; Pregnancy; Prognosis; Transient neonatalmyasthenia gravis; ThymectomyI have read with interest the article by Roth et al. [1]reporting the course of a group of patients with myastheniagravis (MG) during pregnancy. Roth et al. [1] analyzedretrospectively the outcome in eight patients with MG with aprevious thymectomy and seven patients without thymect-omy, reporting a better outcome during the pregnancy inthymectomized mothers and also in the babies. Recently ourgroup reported the prognosis of 18 pregnant women with MGduring the pregnancy [2]. The majority of the patients in ourstudy had a thymectomy before the pregnancy (17 of 18patients) and the prognosis was similar to the classical seriesof myasthenia gravis [3,4], 11% improved, 39% had worseningand 50% remained clinically unchanged. Our study containspatients with a previous thymectomy [2], and the trenddemonstrated in the study by Roth et al. [1] at least in thisgroup was not observed. This study was not considered in theanalysis of this article [1].Djelmis et al. [4] reviewed 69 pregnancies among 65women. Twenty-five percent showed improvement, 45% didnot change and 30% suffered exacerbations. Twenty-fivepatients (38.5%) had a previous thymectomy before thepregnancy. This study suggested that thymectomy before thepregnancy can minimize the likelihood of neonatal myasthe-nia. Batocchi et al. [3] evaluated the course of 47 femaleswith MG who became pregnant. During pregnancy 41% had nochange, 39% improved and 19% got worse. They concludedthat the course during pregnancy is highly variable andunpredictable. Forty-two patients had thymectomy beforethe pregnancy. Both studies did not analyze the prognosisaccording to the thymectomy status.The suggestion of Roth et al. [1] that thymectomy canimprove the prognosis during the pregnancy is good but theevidence to support this idea is not solid. In our institution,we empirically recommend the thymectomy in the majorityof the patients before the pregnancy. We do not have strongbasis to support this recommendation but we have the sameLetters to the Editor / European Journal of Cardio-thoracic Surgery 30 (2006) 411—417412Downloadedby Universon 30 Julyidea as Roth et al. [1] that thymectomy before the pregnancycan improve the evolution of MG during the pregnancy. Themost important limitation of the study of Roth et al. [1] isthe sample size and due to the unpredictable course ofmyasthenia gravis during pregnancy the observation about abetter prognosis in thymectomizedmothers could be obtainedonly by chance. The second observation in this study about abetter prognosis in babies of mothers with myasthenia gravisshould be taken carefully. The prevalence of transientneonatal myasthenia gravis is highly variable in reports, goingfrom 5 to 30% and mainly explained by the different methodsto perform the diagnosis but potentially a genetic variationhas been suggested [5]. In the study by Roth et al. [1], twonewborns had symptoms after the delivery and both belongedto the nonthymectomized group of mothers. Again thisobservation could be derived only due to the small samplesize of the study and not related directly with thymectomystatus of the mother. Overall, this study has an interestingobservation but more investigation is required.References[1] Roth TC, Raths J, Carboni G, Rosler K, Schmid RA. Effect of pregnancy andbirth on the course of myasthenia gravis before or after transsternalradical thymectomy. Eur J Cardiothorac Surg 2006;29(2):231—5.[2] Tellez-Zenteno JF, Hernandez-Ronquillo L, Salinas V, Estanol B, da Silva O.Myasthenia gravis and pregnancy: clinical implications and neonatal out-come. BMC Musculoskelet Disord 2004;5(1):42.[3] Batocchi AP, Majolini L, Evoli A, Lino MM, Minisci C, Tonali P. Course andtreatment of myasthenia gravis during pregnancy. Neurology 1999;52(3):447—52.[4] Djelmis J, Sostarko M, Mayer D, Ivanisevic M. Myasthenia gravis in preg-nancy: report on 69 cases. Eur J Obstet Gynecol Reprod Biol 2002;104(1):21—5.[5] Papazian O. Transient neonatal myasthenia gravis. J Child Neurol1992;7(2):135—41.* Corresponding author. Tel.: +52 55 56430741; fax: +52 55 56430741.E-mail address: jftellez@yahoo.com.doi:10.1016/j.ejcts.2006.04.026Reply to the Letter to the EditorReply to Tellez-ZentenoThierry Christophe Roth, Ralph Alexander Schmid*Division of General Thoracic Surgery,University Hospital,CH-3010 Berne, SwitzerlandReceived 18 April 2006; accepted 19 April 2006Keywords: Myasthenia gravis; Thymectomy; Pregnancy; Transient neonatalmyasthenia gravis; PrognosisWe thank Dr Tellez-Zenteno for his interesting remarks.We appreciate his valuable study on 18 patients, which weunfortunately did not cite [1]. Of course, we know thelimitations of our own study, but it seems that the Mexicangroup comes to the same conclusion, that thymectomyshould be recommended before pregnancy and that radicalthymectomy during pregnancy or in the early post-partumperiod should be avoided [2]. from https://academic.oup.com/ejcts/article-abstract/30/2/411/361611ità degli Studi di Milano - Dip. Storia arti, musica e spettacolo user 2018Despite the unpredictable course of myasthenia gravis(MG), most of the studies in the literature seem todemonstrate that themajority of patients have an unchanged(or improved) stage of MG during pregnancy [3] and that theradical thymectomy results independently in a more stablecourse of MG and long-term benefit (Table 3: literatureoverview, from our previous study) [4].The fact that we did not observe a single case of amyasthenic newborn in the group of thymectomized mothersis not an isolated observation. Although other studies did notdescribe a statistically relevant difference in the rate ofneonatal myasthenia between nonthymectomized or thy-mectomized mothers, Papatestas et al. [5] reported that theincidence of myasthenic newborns of women who had notundergone thymectomy was twice that of the thymectomygroup. In addition, we cannot confirm the contraindication ofbreast-feeding bymothers with MG, which is often advocatedempirically.We hope that our paper has stimulated further research inthis field.References[1] Tellez-Zenteno JF, Hernandez-Ronqillo L, Salinas V, Estanol B, da Silva O.Myasthenia gravis and pregnancy: clinical implications and neonatal out-come. BMC Musculoskelet Disord 2004;5(1):42.[2] Burke ME. Myasthenia gravis and pregnancy. J Perinat Neonatal Nurs1993;7(1):11—21.[3] Ossermann KE. Pregnancy in myasthenia gravis and neonatal myastheniagravis. Am J Med 1955;19:718—21.[4] Roth T, Ackermann R, Stein R, Inderbitzi R, Rosler K, Schmid RA. Thirteenyears follow-up after radical transsternal thymectomy for myastheniagravis. Do short-term results predict long-term outcome? Eur J Cardi-othorac Surg 2002;21(4):664—70.[5] Papatestas AE, Alpert LI, Ossermann KE, Ossermann RS, Kark AE. Studies inmyasthenia gravis: effects of thymectomy. Results on 185 patients withnonthymomatous and thymomatous myasthenia gravis, 1941—1969. Am JMed 1971;50:465.* Corresponding author. Tel.: +41 31 632 23 30; fax: +41 31 632 23 27.E-mail address: ralph.schmid@insel.ch (R.A. Schmid)doi:10.1016/j.ejcts.2006.04.025Letter to the EditorOxidative stress and one-lung ventilationThomas J. Birdas*Division of Thoracic Surgery,Department of Surgery,The Western Pennsylvania Hospital,4815 Liberty Ave, Ste 158,Pittsburgh, PA 15224,United StatesReceived 28 March 2006; accepted 1 May 2006Keywords: Lung—basic science; AnesthesiaI read with great interest the paper by Misthos et al. [1]. Inthis prospective, nonrandomized report, the authors exam-ine the effects of the duration of one-lung ventilation (OLV)

Are the aortic anatomical normal leaflets, normal leaflets?

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Are the aortic anatomical normal leaflets, normal leaflets?

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