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BACKGROUND AND AIM OF THE STUDY: Enlarged (> 50 mm) atria, longstanding (> 5 years) persistent atrial fibrillation (AF) and age > 70 years are considered predictive of recurrent AF following surgical ablation. The electrophysiological and clinical outcome after AF-ablation was evaluated in high-risk patients undergoing concomitant procedures. METHODS: Between January 2005 and January 2009, a total of 45 patients who complied with the three major predictors of failure, but who had undergone AF ablation ('left + right bipolar radiofrequency Maze') during concomitant mitral surgery were followed up. Freedom from AF, atrial flutter (AFL) and atrial tachycardia (AT), without anti-arrhythmic therapy (discontinued at the sixth month) was the primary endpoint. Survival, freedom from AF/AFL/AT with anti-arrhythmic therapy, early events during post-ablation blanking period, freedom from congestive heart failure (CHF) and from re-hospitalization, and changes in NYHA functional class were registered. RESULTS: Postoperatively, 18 patients (40%) showed sinus rhythm (SR) at admission to the intensive care unit, while 16 (26%) showed junctional rhythm and five (11%) required definitive pacemaker. Eleven of the 40 patients (28%) were discharged without a pacemaker, and experienced early events during the post-ablation blanking period. After a mean of 21 +/- 14 months' follow up, the actuarial survival was 88 +/- 7%. The prevalence of SR at six, 12, and 18 months was 74%, 64%, and 64% respectively. Freedom from AF/AFL/AT was 54 +/- 10% without anti-arrhythmic medications, and 51 +/- 9% with such drugs. Freedom from CHF was 85 +/- 6%, and significantly better in SR patients (94 +/- 6%) than in AF patients (69 +/- 13%; p = 0.018). Freedom from rehospitalization was 75 +/- 8%, and better in SR patients (94 +/- 6%) than in AF patients (37 +/- 14%; p = 0.0001). Accordingly, when compared to AF patients, the NYHA class was significantly ameliorated in SR patients at both six months (1.4 +/- 0.6 versus 2.7 +/- 0.9) and at the final follow up control (1.2 +/- 0.5 versus 1.9 +/- 0.7; p < 0.0001). The E/A wave recovered in 22 (85%) of the SR patients. CONCLUSION: AF ablation during mitral valve surgery achieves good electrophysiological results, even in patients traditionally considered as poor candidates. SR recovery allows a higher freedom from CHF and rehospitalization, with a better functional recovery when compared to AF.

L’elevato valore naturalistico e socioeconomico di un Sito Natura 2000 richiede che tutte le attività antropiche che si svolgono al suo interno (es. pesca, turismo, trasporti, attività industriali, etc.) siano gestite in maniera tale da non pregiudicare le specie e gli habitat per i quali l’area è stata designata. Molti di questi Siti sono ambienti di transizione, ovvero zone che costituiscono il passaggio naturale tra terra e mare. La loro posizione di interfaccia tra questi due ambienti li rende ecosistemi unici e biologicamente molto produttivi, sede di meccanismi di regolazione dei processi interattivi della biosfera nelle due fasi, terrestre e marina. In alcuni Siti la presenza di attività antropiche diffuse e prolungate nel tempo ha portato al riscontro di stati di contaminazione elevata, fino all’inclusione di queste zone, o parti di esse, tra i Siti di bonifica di Interesse Nazionale (SIN). Il presente lavoro descrive le linee di indirizzo e le attività di monitoraggio da attuare per la salvaguardia della salute pubblica e dell’ambiente nel corso degli interventi di messa in sicurezza di emergenza predisposti nell’area lagunare antistante l’area industriale Ex Sitoco, all’interno della perimetrazione del SIN di Orbetello, incluso in un Sito di Importanza Comunitaria. Le matrici ambientali potenzialmente a rischio a causa dell’esecuzione di tali interventi sono: acqua, sedimento, biocenosi acquatiche, avifauna, uomo. È altresì importante valutare gli effetti che le ipotetiche modifiche su microscala, apportate a livello di ogni matrice, potrebbero causare nel lungo periodo su macroscala. The high naturalistic and socio-economic value of Natura 2000 sites requires that all human activities performed within their borders (e.g. fishing, tourism, transports, industrial activities) are regulated. Indeed, the site management should assure the effective safeguard of all species and habitats of European interest included in the protected area. A lot of such sites are located in transitional environments, that are areas characterised by a natural progression from the terrestrial to the water environments. Such environments include unique and very productive habitats, and they represent the regulation mechanisms of the interactive processes of the terrestrial and marine biosphere. In some sites, the presence of human activities that are distributed both in space and time has led to high levels of contamination, that in some cases even required their inclusion in Reclamation Sites of National Interest (SIN). The present study describes the planning and monitoring activities to be performed in order to safeguard human and environment health during the actions of MISE in the lagoonal area in front of the industrial area Ex Sitoco, within the borders of the Orbetello SIN, included in a SCI. The environmental parameters that are potentially at risk due to such activities are: water, sediment, water biocenosis, birds, humans. Furthermore, it is important to evaluate the effects that potential variations at the microscale level may cause at the macroscale level.

AIM: Recent reports have shown anti-inflammatory effects with conventional hemofiltration (CUF) in patients undergoing cardiopulmonary bypass (CPB). The aim of this study was to evaluate the immunological and the hemodynamic response to CUF or metilprednisolone in patients undergoing coronary artery bypass grafting. METHODS: Twenty-four consecutive patients were prospectively randomized to receive CUF (12 patients, Group A) or metilprednisolone (12 patients, Group B). Hemodynamic response was evaluated by Swan-Ganz catheter, immunological response was analyzed by IL-2, IL-4, IL-6, TNF-alpha, IFN-gamma, IL-10 before anesthetic induction (T0), at aortic-declamping (T1), at the end of surgery (T2), ITU admission (T3) and 24 hours (T4). Troponin I was measured at the same time-points. Hematological and coagulative controls were performed. RESULTS: Morbidity and mortality were comparable between the two groups. Group A demonstrated lower cardiac index at T1 (2.1 +/- 0.69 L/min m2 vs. 3.917 +/- 1.28, P = 0.034) without significantly higher indexed-systemic-vascular-resistances at the end of surgery (1 101 +/- 434.3 dyne s cm(-5) m(-2) vs. 797.7 +/- 316.67, P = 0.233). When proinflammatory and anti-inflammatory cytokines were considered, all improved during the postoperative time course, without differences between the 2 Groups (P = NS). Hematological and coagulative data were similar in the two groups, in terms of white blood cells, platelets, prothrombin time, and activated partial thromboplastin time (P = NS). CONCLUSIONS: Anti-inflammatory action of CUF was comparable to steroids, thus determining a similar proinflammatory response to CPB. However, hemodynamics was slightly impaired by CUF. Therefore, there is no reason to prefer CUF to steroids in patients undergoing elective CABG.

AIM: Atrio-ventricular anatomo-functional response to successful surgical atrial fibrillation (AF) ablation has been poorly investigated. Determinants of AF recurrence following surgical ablation are still debated. METHODS: Sixty-nine patients underwent AF ablation during major cardiac surgery. Main outcomes were clinical and echocardiographic results after monopolar and/or bipolar ablation were recorded. Secondary outcomes were freedom from AF, rehospitalization and congestive heart failure (CHF) at follow-up. Predictors of AF-recurrence were evaluated. RESULTS: Fifty-three patients (76.8%) were in sinus rhythm (SR) at 31.4±10.6 months of mean follow-up. Overall freedom from AF-recurrence was 61.4±6.6%, from hospital readmission 89.9±3.6%, from CHF 91.9±5.05%. Compared to AF-patients, SR-patients demonstrated better freedom from re-hospitalization (98.1±1.9% vs. 62.5±12.1%; P=0.0001) and CHF (94.7±5.1% vs. 77.8±13.9%; P=0.006). At follow-up SR-patients demonstrated atrial (preoperative 5.9±1.2 cm vs. follow-up 5.2±1.0; P=0.01) and ventricular reverse remodelling (preoperative LVDd 5.8±1.6cm vs. follow-up 5.0±1.3 cm; P=0.002 - preoperative LVDs 4.2±1.8 cm vs. follow-up 3.8±1.2 cm; P=0.045). E/A ratio was normal in 90.6% of SR-patients (69.6% of the total population of the study). TDI at the level of the left lateral annulus showed an improved left ventricular systole (Sm), and diastole (Em, E/Em) for SR-patients compared to AF-patients (Sm 9.30±1.66 vs. 7.81±1.41, P=0.001; Em: 10.55±1.87 vs. 7.44±0.40, P=0.001; E/Em: 0.06±0.02 vs. 0.11±0.05, P=0.0001). Preoperative atrial diameter (OR=23.9; P=0.002) and tricuspid insufficiency at follow-up (OR=3.5; P=0.008) were independent predictors of AF-recurrence. Neither etiology, nor duration of AF, nor even ablation technique influenced SR recovery (P=NS for all measurement). CONCLUSION: Radiofrequency AF ablation achieves 76.8% of SR recovery at follow-up. Maintenance of SR improves clinical, haemodynamic and echocardiographic results.