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Myocardial infarction (MI) is associated with renal alterations resulting in poor outcomes in patients with MI. Renal fibrosis is a potent predictor of progression in patients and is often accompanied by inflammation and oxidative stress; however, the mechanisms involved in these alterations are not well established. Endoplasmic reticulum (ER) plays a central role in protein processing and folding. An accumulation of unfolded proteins leads to ER dysfunction, termed ER stress. Since the kidney is the organ with highest protein synthesis fractional rate, we herein investigated the effects of MI on ER stress at renal level, as well as the possible role of ER stress on renal alterations after MI. Patients and MI male Wistar rats showed an increase in the kidney injury marker neutrophil gelatinase-associated lipocalin (NGAL) at circulating level or renal level respectively. Four weeks post-MI rats presented renal fibrosis, oxidative stress and inflammation accompanied by ER stress activation characterized by enhanced immunoglobin binding protein (BiP), protein disulfide-isomerase A6 (PDIA6) and activating transcription factor 6-alpha (ATF6α) protein levels. In renal fibroblasts, palmitic acid (PA; 50-200 µM) and angiotensin II (Ang II; 10−8 to 10−6M) promoted extracellular matrix, superoxide anion production and inflammatory markers up-regulation. The presence of the ER stress inhibitor, 4-phenylbutyric acid (4-PBA; 4 µM), was able to prevent all of these modifications in renal cells. Therefore, the data show that ER stress mediates the deleterious effects of PA and Ang II in renal cells and support the potential role of ER stress on renal alterations associated with MI.

Resumen: Introducción: Los objetivos son analizar las alteraciones neuropsicológicas a medio plazo de los niños intervenidos del arco aórtico mediante perfusión cerebral selectiva (PCS) y detectar posibles factores modificables en la técnica quirúrgica que pueden ayudar a minimizar la afectación neurológica posterior. Material y métodos: Se establecieron como criterios de inclusión: patología del arco aórtico intervenida mediante PCS durante el primer año de vida, entre el 10 de agosto del 2004 y el 24 de mayo del 2016, fisiología biventricular y edad gestacional mayor de 31 semanas. En ausencia de cromosomopatía, se clasificaron desde el punto de vista neurológico siguiendo el modified Rankin score. En mayores de 4 años se realizaron estudios de inteligencia, nivel de atención, maduración y aptitudes psicolingüísticas. Resultados: Se incluyeron ochenta y dos pacientes, cuya edad media en el momento de la cirugía fue de 1,8 meses. El flujo medio en PCS fue de 32 ml/kg/min. El tiempo medio de PCS fue de 31 min. La mortalidad global de la serie fue del 14,8%. Con disfunción neurológica se observaron un 35,9% y se detectaron como factores de riesgo: cirugía en menores de 10 días de edad, duración de PCS mayor de 40 min y la duración del enfriamiento o calentamiento. Un 35,2% de los pacientes mayor de 5 años fueron diagnosticados de déficit de atención. Conclusiones: Los pacientes intervenidos en el primer año de vida con PCS precisan un seguimiento neuropsicológico y hay factores modificables quirúrgicos que pueden influir en el desarrollo neurológico. Abstract: Introduction: The aims of this article are to analyse the neuropsychological changes in the medium–term in children subjected to aortic arch surgery using selective cerebral perfusion (SCP), as well as to detect any modifiable factors in the surgical technique that may contribute to minimising the subsequent neurological involvement. Material and methods: Inclusion criteria were established as: aortic arch disease operated on using SCP during the first year of life, between 10 August 2004 and 24 May 2016, biventricular physiology, and gestational age greater than 31 weeks.In the absence of a chromosomal disease, they were classified, from a neurological point of view, using the Rankin score. Children over 4-years of age were subjected to intelligence studies, including attention level, development, and psycho-lingual skills. Results: The study included a total of 82 patients with a mean age of 1.8 months. The mean SCP flow was 32 ml/kg/min. The mean time of SCP was 31 minutes. The overall mortality of the series was 14.8%. Neurological dysfunction was observed in 35.9% of patients, and the following were detected as risk factors: surgery in patients less than 10-days-old, duration of SCP greater than 40 minutes, and the time required for the cooling down and/or warming-up. Attention deficit was diagnosed in 35.2% of patients greater than 5-years-old. Conclusions: Patients operated on using SCP in in the first year of life required a neuropsychological follow-up, and there are modifiable surgical factors that may have an influence on neurological development.

Introduction: The aims of this article are to analyse the neuropsychological changes in the medium–term in children subjected to aortic arch surgery using selective cerebral perfusion (SCP), as well as to detect any modifiable factors in the surgical technique that may contribute to minimising the subsequent neurological involvement. Material and methods: Inclusion criteria were established as: aortic arch disease operated on using SCP during the first year of life, between 10 August 2004 and 24 May 2016, biventricular physiology, and gestational age greater than 31 weeks. In the absence of a chromosomal disease, they were classified, from a neurological point of view, using the Rankin score. Children over 4-years of age were subjected to intelligence studies, including attention level, development, and psycho-lingual skills. Results: The study included a total of 82 patients with a mean age of 1.8 months. The mean SCP flow was 32 ml/kg/min. The mean time of SCP was 31 min. The overall mortality of the series was 14.8%. Neurological dysfunction was observed in 35.9% of patients, and the following were detected as risk factors: surgery in patients less than 10-days-old, duration of SCP greater than 40 min, and the time required for the cooling down and/or warming-up. Attention deficit was diagnosed in 35.2% of patients greater than 5-years-old. Conclusions: Patients operated on using SCP in in the first year of life required a neuropsychological follow-up, and there are modifiable surgical factors that may have an influence on neurological development. Resumen: Introducción: Los objetivos son analizar las alteraciones neuropsicológicas a medio plazo de los niños intervenidos del arco aórtico mediante perfusión cerebral selectiva (PCS) y detectar posibles factores modificables en la técnica quirúrgica que pueden ayudar a minimizar la afectación neurológica posterior. Material y métodos: Se establecieron como criterios de inclusión: patología del arco aórtico intervenida mediante PCS durante el primer año de vida, entre el 10 de Agosto de 2004 y el 24 de Mayo de 2016, fisiología biventricular y edad gestacional mayor de 31 semanas. En ausencia de cromosomopatía se clasificaron desde el punto de vista neurológico siguiendo el modified Rankin score. En mayores de 4 años se realizaron estudios de inteligencia, nivel de atención, maduración y aptitudes piscolingüisticas. Resultados: 82 pacientes se incluyeron, cuya edad media en el momento de la cirugía fue de 1,8 meses. El Flujo medio en PCS fue de 32 ml/kg/min. El tiempo medio de PCS fue de 31 minutos. La mortalidad global de la serie fue de 14,8 %. Con disfunción neurológica se observaron un 35,9 % y se detectaron como factores de riesgo: cirugía en menores de 10 días de edad, duración de PCS mayor de 40 minutos y la duración del enfriamiento y/o calentamiento. Un 35,2 % de los pacientes mayor de 5 años fueron diagnosticados de déficit de atención. Conclusiones: Los pacientes intervenidos en el primer año de vida con PCS precisan un seguimiento neuropsicológico y hay factores modificables quirúrgicos que pueden influir en el desarrollo neurológico.

Pulmonary valve replacement (PVR) is the most common operation in adults with congenital heart disease (CHD). There is controversy regarding the best bioprosthesis. We compare the performance of stented bioprosthetic valves (the Mosaic [Medtronic™] porcine pericardial against Carpentier Perimount Magna Ease [Edwards™] bovine) in pulmonary position in patients with CHD.Between January 1999 and December 2019, all the PVRs were identified from hospital databases in 2 congenital heart centres in Spain. Valve performance was evaluated using clinical and echocardiographic criteria. Propensity score matching was used to balance the 2 treatment groups.Three hundred nineteen patients were retrospectively identified. After statistical adjustment, 79 propensity-matched pairs were available for comparison Freedom from reintervention for the porcine cohort was 98.3%, 96.1%, and 91.9% at 3, 5, and 10 years and 100%, 98%, and 90.8% for the bovine cohort (p=0.88). Freedom from structural valve degeneration (SVD) for the porcine cohort was 96.9%, 92.8% and 88.7% at 3, 5, and 10 years and 100%, 98%, and 79.1% for the bovine cohort (p=0.38). Bovine prosthesis was associated with a reintervention hazard ratio (HR), 1.12; 95% confidence intervals (CIs), 0.24-5.26; p=0.89 and SVD HR, 1.69 (0.52-5.58); p=0.38. In the first 5 years, there was no difference in outcomes. After 5 years, the recipients of the bovine bioprosthesis were at higher risk for SVD (reintervention HR, 2.08 [0.27-16.0]; p=0.49; SVD HR, 6.99 [1.23-39.8]; p=0.03).Both bioprosthesis have similar outcomes up to 5 years, afterwards, porcine bioprosthesis seem to have less SVD.

Resumen: Introducción y objetivos: La pericarditis constrictiva es una enfermedad poco frecuente, con una elevada morbimortalidad, cuyo tratamiento es la pericardiectomía quirúrgica. El objetivo es presentar nuestra experiencia y analizar los resultados a corto y largo plazo. Métodos: Se incluyeron todos los pacientes intervenidos de pericardiectomía por pericarditis constrictiva desde enero de 2003 hasta febrero de 2018. Se describe la serie y se analizan los resultados a corto y largo plazo y los factores de riesgo de mortalidad. Resultados: Cincuenta y tres pacientes, con edad media de 60,5 años (±10,3). El 71,7% eran varones. La etiología más frecuente fue la idiopática (52,8%), seguida de la infecciosa/inflamatoria (28,3%) y la poscardiotomía (11,3%). El 62,3% presentaba una NYHA III-IV en el preoperatorio. La mortalidad hospitalaria fue del 11,3% (n = 6). Sin recidivas en el seguimiento. Mediana de seguimiento 64,9 meses (IQR 3,1-131,2). Supervivencia al año, a los 5 y a los 8 años del 86,4%, 81,6% y 75,1%. La NYHA IV fue el único factor independiente de mortalidad a largo plazo en el análisis multivariante. Conclusiones: La pericardiectomía es el tratamiento de elección en la pericarditis constricitiva. Aunque se trata de un procedimiento con elevada morbimortalidad, puede disminuirse significativamente si la indicación de la cirugía es precoz, antes de la aparición de síntomas refractarios. Además, una técnica quirúrgica agresiva previene la recidiva en el seguimiento a largo plazo. Abstract: Introduction and objectives: Constrictive pericarditis is a rare disease with a high morbidity and mortality. His treatment is the surgical pericardiectomy. The aim of this study is to present our experience and analyze the short and long-term outcomes. Methods: All patients who were underwent to a subtotal pericardiectomy for constrictive pericarditis from january 2003 to february 2018 were included. A description of the serie was made, short and long-term outcomes and mortality risk factors were analyzed. Results: A total of 53 patients were underwent to a subtotal pericardiectomy. The mean age was 60.5 years (±10.3). The 71.7% were males. The most frequent etiology was idiopathic (52.8%), followed by infectious/inflammatory (28.3%) and postcardiotomy (11.3%). A 62.3% of the patients had NYHA functional class III-IV preoperatively. In-hospital mortality rate was 11.3% (n = 6). There were no recurrences in follow-up. Median postoperative follow-up was 64.9 months (IQR 3.1 – 131.2). One, 5 and 10 years survival rates were 86.4%, 81.6% and 75.1%, respectively. NHYA functional class IV was the only independent factor of risk of long-term mortality. Conclusions: Pericardiectomy is the surgical technique of choice for the treatment of constrictive pericarditis. Although it is a procedure with high morbidity and mortality, it can be significantly reduced if the indication for surgery is early, before the appearance of refractory symptoms. In addition, an aggressive surgical technique prevents recurrence in long-term follow-up. Palabras clave: Pericardiectomía, Constricción pericárdica, Efusión pericárdica, Pericarditis, Pericardio, Keywords: Pericardiectomy, Pericardial constriction, Pericardial effusion, Pericarditis, Pericardium

Resumen: Introducción: La ateromatosis coronaria difusa actualmente es un reto para el cirujano cardiaco. La endarterectomía coronaria es un procedimiento útil para el tratamiento de esta enfermedad en conjunto con la cirugía de revascularización. Actualmente existe poca evidencia del impacto de la endarterectomía coronaria en la supervivencia a largo plazo de la cirugía de revascularización miocárdica. Objetivos: Analizar y comparar supervivencia y eventos adversos cardiovasculares mayores de la endarterectomía en la cirugía coronaria a corto y largo plazo. Material y métodos: Revisión retrospectiva de los pacientes sometidos a cirugía coronaria aislada, comparando endarterecomías vs revascularización aislada. Comparación de supervivencia a largo plazo en la cohorte total y análisis de riesgos proporcionados de Cox para la supervivencia. Comparación de eventos adversos cardiovasculares en una muestra ajustada mediante propensity score. Resultados: Media de seguimiento: 5,9 años (±3,9). Ciento siete pacientes sometidos a endarterectomía y 1.936 a revascularización aislada, a 10 años. La supervivencia fue del 62% y del 70% (p = 0,044) para el grupo de endarterectomía y revascularización aislada, respectivamente. La endarterectomía fue un factor de riesgo independiente para mortalidad (HR: 1,6; IC 95%: 1,1-2,3). En la muestra ajustada observamos una mayor incidencia de eventos adversos cardiovasculares perioperatorios (23,8% vs 10,4%; p

We have evaluated cardiac function and fibrosis in infarcted male Wistar rats treated with MitoQ (50 mg/kg/day) or vehicle for 4 weeks. A cohort of patients admitted with a first episode of acute MI were also analyzed with cardiac magnetic resonance and T1 mapping during admission and at a 12-month follow-up. Infarcted animals presented cardiac hypertrophy and a reduction in the left ventricular ejection fraction (LVEF) and E- and A-waves (E/A) ratio when compared to controls. Myocardial infarction (MI) rats also showed cardiac fibrosis and endoplasmic reticulum (ER) stress activation. Binding immunoglobulin protein (BiP) levels, a marker of ER stress, were correlated with collagen I levels. MitoQ reduced oxidative stress and prevented all these changes without affecting the infarct size. The LVEF and E/A ratio in patients with MI were 57.6 ± 7.9% and 0.96 ± 0.34, respectively. No major changes in cardiac function, extracellular volume fraction (ECV), or LV mass were observed at follow-up. Interestingly, the myeloperoxidase (MPO) levels were associated with the ECV in basal conditions. BiP staining and collagen content were also higher in cardiac samples from autopsies of patients who had suffered an MI than in those who had died from other causes. These results show the interactions between mitochondrial oxidative stress and ER stress, which can result in the development of diffuse fibrosis in the context of MI.

Resumen: Introducción: Actualmente existe una gran controversia sobre el uso de prótesis biológicas o mecánicas en posición aórtica para pacientes de mediana edad. Objetivos: Analizar la supervivencia a largo plazo de los pacientes entre 50 y 69 años según el tipo de prótesis implantada. Métodos y materiales: Revisión retrospectiva de pacientes con sustitución valvular aórtica convencional, con o sin revascularización miocárdica con edad entre 50 y 69 años. Análisis y comparación de supervivencia. Predictores del evento primario mediante análisis de riesgos proporcionales de Cox. Análisis con muestra ajustada mediante propensity score. Resultados: Media de seguimiento 5,3 años (±3,7). Doscientos noventa (52,5%) recibieron prótesis biológica y 262 (44,4%) una mecánica. Supervivencia a 7 años de 85 vs. 88% (p = 0,26) respectivamente. No identificamos el tipo de prótesis como factor predictor o de riesgo para el evento primario (HR1,5; 95% CI: 0,91-2,6). Supervivencia en la muestra ajustada: 86 vs. 90%(= 0,89) respectivamente. Conclusiones: Tanto en la cohorte total como en la ajustada, no existen diferencias significativas en la supervivencia a largo plazo según el tipo de prótesis utilizada. Abstract: Introduction: There continues to be controversy on the use of biological or mechanical prosthesis for aortic valve replacement in the middle aged population. Objectives: To analyse and compare long-term survival in patients aged from 50-69 years, according to the type of valve replacement. Methods and materials: A retrospective review was conducted on of patients aged 50-69 years with aortic valve replacement, with or without adjunct coronary artery surgery. The long-term survival was analysed and compared. A proportional hazard risks model was also performed for the primary outcome. This primary outcome was then analysed in a propensity score-matched cohort. Results: The mean follow-up was 5.3 years (±3.7). A total of 290 (52.5%) patients received a bioprosthesis, and 262 (44%) a mechanical one. The 7- year survival was 85 vs. 88% (P = .26), respectively. Valve replacement type was not associated with the primary outcome (HR1,5; 95%CI: 0.91-2.6). Survival on the adjusted cohort was 86% vs. 90% (P = .89), respectively. Conclusions: In the total cohort studied, as well as in the adjusted cohort, there was no difference in long-term survival between middle aged patients with a biological or mechanical aortic valve. Palabras clave: Sustitución valvular aórtica, Prótesis biológica, Prótesis mecánica, Edad media, Keywords: Aortic valve replacement, Surgical aortic valve replacement, Mechanical prosthesis, Biologic prosthesis, Middle aged

Resumen: Introducción y objetivos: Las prótesis híbridas combinan una prótesis vascular convencional con un stent graft de nitinol, facilitando el abordaje simultáneo de la aorta ascendente, cayado y descendente proximal. Presentamos nuestra experiencia en el tratamiento de la patología compleja de la aorta torácica. Métodos: Un total de 27 pacientes intervenidos con prótesis híbridas E-vita (n = 27) o Thoraflex (n = 1) desde octubre de 2013. Se realiza descripción de la serie y análisis de los resultados. Resultados: Edad media: 64,1 años (DE: 14,5). Varones: n = 21 (75%); 17 aneurismas (60,7%), 5 disecciones agudas (17,9%), 5 crónicas, una aortitis. EuroSCORE logístico medio: 20,2 (DE: 11,5). Cirugía previa: n = 5 (17,9%). Tiempos de circulación extracorpórea, isquemia, parada circulatoria y perfusión cerebral anterógrada: 184,7 min (DE: 52,6), 109,4 min (DE: 46,3), 50,6 min (DE: 19,6), y 75,7 min (DE: 32). Perfusión cerebral bilateral: n = 19 (67,9%). Temperatura media: 22,6 °C (DE: 3,5). Zona anastomosis distal: Z1 (n = 3; 10,7%), Z2 (n = 18; 64,3%) y Z3 (n = 7; 25%). Implante troncos supraaórticos: pastilla (n = 8; 28,6%), pastilla + bypass (n = 13; 46,3%) e injerto trifurcado (n = 7; 25%). Segundo tiempo programado en aorta distal: n = 12 (10 endovascular, una cirugía abierta y una combinada). Mortalidad hospitalaria: n = 3 (10,7%). Ictus permanente: n = 2 (7,1%). Reoperación por hemorragia: n = 2 (7,1%). Seguimiento medio: 16,6 meses (DE: 18). Supervivencia al año: 89,3%. Mortalidad en el seguimiento: n = 3 (2 de causa cardiovascular). Conclusiones: Las prótesis híbridas simplifican el tratamiento de la patología compleja de la aorta torácica, permitiendo con frecuencia resolverla en un solo tiempo o bien facilitando el segundo, sea quirúrgico o endovascular. Abstract: Introduction and objectives: The hybrid prostheses combine a conventional vascular prosthesis with a nitinol stented portion to facilitate the simultaneous approach of the ascending aorta, aortic arch, and proximal descending aorta. Experience in the treatment of this complex thoracic aorta pathology is presented. Methods: A total of 28 patients underwent surgery using the E-vita prosthesis (n = 27) or Thoraflex prosthesis (n = 1) from October 2013. The experience and the medium-term results are presented. Results: The patient variables included: mean age: 64.1 years (SD: 14.5). Men: n = 21 (75%). 17 aneurysms (60.7%), 5 acute aortic dissections (17.9%), 5 chronic dissections, 1 aortitis. Mean EuroSCORE logistic 20.2 (SD: 11.5). Prior cardiac surgery: n = 5 (17.9%). Mean cardiopulmonary bypass time, aortic cross clamp time, circulatory arrest time and selective antegrade cerebral perfusion: 184.7 min (SD: 52.6), 109.4 min (SD: 46.3), 50.6 min (SD: 19.6), and 75.7 min (SD: 32). Bilateral antegrade selective cerebral perfusion: n = 19 (67.9%). Temperature: 22.6 °C (SD: 3.5). Distal anastomosis zone: Z1 (n = 3, 10.7%), Z2 (n = 18, 64.3%), and Z3 (n = 7, 25%). Supra-aortic vessels re-implantation: En bloc (n = 8, 28.6%), En bloc + bypass (n = 13, 46.3%), and trifurcated graft (n = 7, 25%). Second-stage distal aortic intervention: n = 12 (10 endovascular, 1 open surgery, 1 combined). In-hospital mortality: n = 3 (10.7%). Permanent stroke: n = 2 (7.1%). Re-exploration due to bleeding: n = 2 (7.1%). Mean follow-up: 16.6 months (SD: 18). 1-year survival: 89.3%. Mortality during follow-up: n = 3 (2 cardiovascular). Conclusions: Hybrid prostheses simplify the treatment of complex pathology of the thoracic aorta, often being able to resolve it in a single stage, or facilitating an open or endovascular second stage. Palabras clave: Patología compleja aorta torácica, Prótesis híbridas, Trompa de elefante congelada, Keywords: Complex thoracic aortic disease, Hybrid prosthesis, Frozen elephant trunk

Resumen: La endocarditis protésica tras el implante de una prótesis aórtica transcatéter es una complicación poco frecuente que se asocia a una elevada mortalidad. Presentamos el caso de un varón de 63 años con antecedentes de implante de una prótesis aórtica transcatéter por vía transfemoral (29 mm Edwards SapienTM) quien, 4 meses tras el procedimiento, ingresa en nuestro centro por endocarditis protésica por Staphylococcus epidermidis. El ecocardiograma preoperatorio mostraba una vegetación gigante que ocupaba parte del tracto de salida del ventrículo izquierdo y la raíz aórtica, provocando una estenosis aórtica severa. Además, presentaba una insuficiencia mitral severa que no se trató en un primer procedimiento. Se explantó la prótesis infectada y se implantaron una prótesis aórtica y mitral. Abstract: Infective prosthetic valve endocarditis after a transcatheter aortic valve implantation (TAVI) is a rare complication with a high mortality rate. We report the case of a 63-years-old man with a previous history of a transfemoral transcatheter aortic valve implantation (29 mm Edwards SapienTM). Four months after the procedure, the patient was admitted to our Institution with aortic prosthetic valve endocarditis by Staphylococcus Epidermidis. The preoperative echocardiography demostrated a massive vegetation that occupied most of the left ventricle outflow tract and the aortic root resulting in a severe aortic stenosis. Besides, the echocardiogram showed a severe mitral regurgitation that was left undertreated when her transcatheter procedure was originally performed. The infected prosthesis was explanted and mitral and aortic tissue valves were implanted. Palabras clave: Endocarditis, Endocarditis protésica precoz, Prótesis valvular aórtica transcatéter, Keywords: Endocarditis, Early prostethic valve endocarditis, Transcatheter aortic valve implantation

Cardiac lipotoxicity is involved in the cardiac functional consequences associated with obesity. Therefore, the aim of this study was to explore whether changes in the mitochondrial lipid cardiac profile could reflect differences in cardiac function and structure in obese and non-obese rats with myocardial infarction (MI). Whether these changes can also be reflected in a specific plasma miRNA signature as markers of cardiac damage was also evaluated. Rats were fed with either standard (3.5% fat) or high fat diet (35% fat) for 6 weeks before the induction of MI and sacrificed 4 weeks later. MI showed cardiac lipotoxicity independently of the presence of obesity, although obese and non-obese rats did not present the same cardiac lipid profile at mitochondrial level. Several cardiac lipid species in mitochondria, including cardiolipins and triglycerides, were associated with myocardial fibrosis, with mitochondrial triglyceride levels being independently associated with it; this supports that lipotoxicity can affect cardiac function. MI down-regulated plasma levels of miRNA 15b-5p and 194-5p in obese and non-obese animals, which were associated with cardiac function, mitochondrial lipids and myocardial fibrosis, with miRNA 15b-5p levels being independently associated with cardiac fibrosis. This could support that lipotoxicity could affect heart function by modulating plasma miRNAs., This work was supported by Instituto de Salud Carlos III-FondoEuropeo de Desarrollo Regional (FEDER) (PI15/01060; CIBERCV) a way to build Europe, Ministerio de Economia y Competitividad (SAF2016-81063) and from the Sociedad Española de Cardiología (Basic Research in Cardiology 2016). EMM was supported by a contract from CAM (Atracción de talento).

Several surgical techniques have been described to channel the right pulmonary venous return to the left atrium in the Scimitar syndrome which includes direct reimplantation, graft interposition, or repair. Because these techniques can result in pathway obstruction, Lugones has devised a technique which uses in situ pericardium to construct a wide tunnel connecting the pulmonary venous return to the left atrium. We report the use of Lugones technique in an adult with Scimitar syndrome.

Membranous glomerulopathy is a common complication of renal allograft. However, its incidence and prognosis are not well defined, because an undetermined number of them pass undiagnosed under the generic epigraph of chronic allograft nephropathy.To assess the diagnostic refinement supplied by electron microscopy to conventional light and immunofluorescence procedures the authors reviewed 17 cases of electron microscopy-confirmed membranous glomerulonephritis in kidney allograft. In addition, they searched for other features of graft injury, particularly lesions associated with alloimmune reaction, in order to evaluate the contribution of each lesion to the long-term outcome of the allograft.In 4 of the 17 cases of their series the diagnosis of membranous glomerulopathy was made by electron microscopy. In addition, in 5 samples, lesions of chronic alloimmune rejection were present (in 4 cases the diagnosis was based on electron microscopy findings). At the end point of the study, 3 of the 5 patients with chronic alloimmune injury were in dialysis, 1 had died with functioning allograft, and the fifth suffered severe renal failure but was not in dialysis. On the other hand, 3 of the 12 patients without evidence of alloimmune injury had returned to the dialysis program.Electron microscopy is a useful tool in the assessment of renal allograft pathology and can provide additional morphological features of prognostic relevance.