Post-traumatic pseudoaneurysm of the mitral-aortic intervalvular fibrosa

The case of a patient with large pseudoaneurysm of the mitral-aortic intervalvular fibrosa following a blunt chest trauma is presented. A two dimensional echocardiographic study revealed a large aneurysmal sac situated between the posterior aortic root and the left atrium, which expanded in systole and partially collapsed in diastole. An echo-free space which represented the mouth of the aneurysm was seen just below the posterior aortic cusp in the junctional zone between the two valves, called mitral-aortic intervalvular fibrosa. Nuclear magnetic resonance imaging showed a better resolution of the echocardiographic feature. Cardiac catheterization and surgery confirmed the diagnosis.     

Metabolic syndrome and the decreased levels of uric acid by leflunomide favor redox imbalance in patients with rheumatoid arthritis

Oxidative stress plays a role in the pathophysiology of rheumatoid arthritis (RA). The aim of the present study was to verify the influence of metabolic syndrome (MetS) and disease-modifying antirheumatic drugs on nitrosative and oxidative biomarkers in patients with RA. A total of 177 patients with RA and 150 healthy volunteers participated in this study, which measured lipid hydroperoxides, advanced oxidation protein products (AOPP), nitric oxide metabolites (NOx), carbonyl protein, total radical-trapping antioxidant parameter (TRAP), uric acid (UA), and C-reactive protein (CRP). NOx and the NOx/TRAP ratio were significantly increased in RA, while no significant differences in lipid hydroperoxides, AOPP, UA, and TRAP levels were found between both groups. Treatment with leflunomide was associated with increased levels of carbonyl protein, and lowered levels in TRAP and UA, while the NOx/TRAP ratio further increased. NOx and the NOx/TRAP ratio were significantly higher in women than in men, while TRAP and UA were significantly lower in women. MetS was accompanied by increased AOPP and UA levels. RA was best predicted by increased NOx/TRAP ratio, CRP, and BMI. In conclusion, our data demonstrated that NOx and NOx/TRAP are strongly associated with RA physiopathology. Our findings suggest that inhibition of iNOS may become an interesting therapeutic approach for the treatment of RA. In addition, the presence of MetS and a decrease in levels of UA by leflunomide favor redox imbalance in RA patients. More studies are needed to evaluate the impact of antioxidant capacity reduction on RA progression.     

The role of the edge-to-edge repair in the surgical treatment of mitral regurgitation

The edge-to-edge (E-to-E) technique was introduced in the early 1990s and has provided a useful contribution to the surgical armamentarium of mitral valve repair. The free edges of the mitral leaflets have to be approximated in correspondence of the site of the regurgitant jet in such a way that mitral regurgitation is corrected without producing stenosis. A prosthetic ring is usually implanted to stabilize the repair. Middle- and long-term surgical results are now available. Appropriate indications and awareness of the important technical aspects of the procedure are prerequisites for a good outcome. In this review the present role of the E-to-E repair, the relevant technical aspects of the procedure, and some controversial issues will be outlined and discussed.     

Prophylactic Thoracic Duct Mass Ligation Prevents Chylothorax After Transthoracic Esophagectomy for Cancer

Background  Chylothorax after transthoracic esophagectomy for cancer is an uncommon but potentially life-threatening postoperative complication. It has been reported that preventive thoracic duct ligation can reduce the incidence of postoperative chylothorax after esophagectomy for cancer. In this prospective series, we evaluated the results of preventive intraoperative thoracic duct mass ligation in patients who underwent transthoracic esophagectomy for cancer. Methods  From 2001 to 2006, 323 patients underwent transthoracic esophagectomy for cancer and duct ligation during the operation was routinely performed. Results  No intraoperative or postoperative complications directly related to the procedure were recorded. No postoperative chylothorax was observed. Conclusions  In this series, the technique of intraoperative thoracic duct mass ligation proved to be safe and effectively prevented postoperative chylothorax in patients who underwent transthoracic esophagectomy for cancer.     

Concurrent prophylactic left atrial appendage exclusion: results from a randomized controlled trial pilot study

Objective: The left atrial appendage is a significant source of cardioembolic thrombi. Open mitral valve surgery presents an opportune time to exclude this appendage from cardiovascular circulation. However, sparse randomized trial support exists for this concomitant procedure. We therefore designed a randomized controlled trial to assess the short- and long-term outcomes of concomitant left atrial appendage exclusion. This report details early outcomes of the pilot trial. Methods: Forty-three patients were randomized to either undergo concomitant suture exclusion of their left atrial appendage under direct vision or not during their open mitral valve surgery. Clinical and biochemical postoperative outcomes, including hemodynamic and hemostatic parameters, were analyzed. Results: There were no deaths in either group. The incidence of cerebrovascular events, myocardial infarction, respiratory failure, and acute renal injury were similar between groups; a composite outcome of 10 major postoperative complications occurred in 32% of the left atrial appendage exclusion group versus 38% of the control group (p = 0.75). Intensive care (median stay 2 days vs 1 day in the control group, p = 0.55) and hospital lengths of stay (median stay 9 days in both groups, p = 0.98) were also similar between groups. Specifically, no additional hemodynamic alterations (need for intra-aortic balloon pump in 1 vs 2 patients in the control group, p = 0.61) or hemostatic complications (no re-operations for bleeding in either group, need for blood product transfusion in 2 vs 1 patient in the control group, p = 1.0) were noted in the left atrial appendage exclusion group. Conclusions: This pilot trial demonstrates the safety of and feasibility of a larger trial powered to detect clinically relevant short- and long-term outcomes of concomitant left atrial appendage exclusion with open mitral valve surgery.     

Surgical methods to reverse left ventricular remodeling

Heart transplantation remains the gold standard treatment for “end-stage” dilated cardiomyopathy. However, its epidemiologic impact on the heart failure problem continues to be small due to limited donor organ availability and contraindications. Therefore, several “conventional” surgical procedures have been developed to reverse the vicious cycle of ventricular remodeling that accompanies systolic heart failure and to improve symptoms and survival of the patients. This review discusses indications, results, and limitations of the most common surgical methods currently used to arrest or reverse cardiac remodeling.     

Identification of the infant-type R631C mutation in patients with the benign muscular form of CPT2 deficiency

Carnitine palmitoyltransferase 2 (CPT2) deficiency is the most common defect of mitochondrial fatty acid oxidation; three different clinical phenotypes have been described but the adult form, involving exclusively the skeletal muscle, is the most frequent. We describe herein 3 families where 4 individuals manifested with the adult form of CPT2 deficiency. CPT2 gene molecular analysis identified the homozygous R631C mutation, so far only reported in severe infantile cases. Our data evidenced that R631C mutation is not exclusively detected in the infantile form but it may be present in a wider spectrum of CPT2 phenotypes. These findings indirectly suggest that other modulators may influence clinical severity of CPT2 deficiency.     

Presentation, treatment and prognosis of intraductal papillary mucinous neoplasm

Intraductal papillary mucinous neoplasms (IPMNs) are rare tumours rising from the pancreatic duct epithelium. They are characterized by intraductal papillary growth and thick mucin secretion; mucin fills the Wirsung and/or branch pancreatic ducts and may cause ductal dilatation. IPMNs are classified into three types, according to the site of involvement: main duct type, branch duct type, and combined type. Most branch type IPMNs are benign, while the other two types are frequently malignant. Recent advances in diagnostic imaging have led to an increased frequency of diagnosis of IPMNs, but the clinical features of them can range broadly from benign, borderline, and malignant non-invasive to invasive lesions, and their management has not yet been clearly defined. The most of patients are asymptomatic. The possibility of malignancy is increased in cases which large mural nodules are presented. Presence of a large branch type IPMN and marked dilatation of the main duct indicate the existence of adenoma. Not infrequently, synchronous or metachronous malignancies may be developed in various organs. Endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasonography (EUS), intraductal ultrasonography, and magnetic resonance cholangiopancreatography (MRCP) are the most valuable imaging techniques for diagnosis of these lesions. Prognosis is excellent after complete resection of benign and non-invasive malignant IPMNs. Total pancreatectomy should be reserved for patients with resectable but extensive IPMN involving the whole pancreas; its benefits must be balanced against perioperative risks.