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A 52-year-old male. Admitted for acute coronary syndrome because of three-vessel disease with a FMJ–LAD

Reinke edema (RE) is an uncommon lesion of the vocal folds and a potential cause of complications during airway management. We report the case of a woman with previously unknown RE admitted to the intensive care unit who experienced postextubation inspiratory stridor immediately after separation from mechanical ventilation. RE should be considered among causes of postextubation stridor.

Background: The aim of our study is to test procalcitonin (PCT) as surrogate marker of identification of Candida spp. by blood culture (BC) and real-time-polymerase chain reaction (PCR), whether alone or in association with bacteria, in septic patients.Methods: We performed a single-centre retrospective study. We reviewed the clinical charts of patients with a diagnosis of severe sepsis or septic shock treated at our general intensive care unit from March 2009 to March 2013. We analysed all diagnostic episodes consisting of BC, real-time PCR assay and dosage of PCT. We registered age, sex, white blood count, sequential organ failure assessment score and type of admission between medical or surgical. When inclusion criteria were met more than once, we registered the new diagnostic episode as subsequent diagnostic episode. The diagnostic performance of PCT to predict Candida spp. identification alone or in mixed infections by either BC or PCR was tested using the receiver-operative characteristic curve. Logistic regression was constructed using presence of Candida spp. as the dependent variable.Results: A total of 260 diagnostic episodes met the inclusion criteria. According to BC results classification, a significantly lower value of PCT was observed in Candida spp. BSI (0.99 ng/ml, 0.86 - 1.34) than in BSI caused by bacteria (16.7 ng/ml, 7.65 - 50.2) or in mixed infections (4.76 ng/ml, 2.98 - 6.08). Similar findings were observed considering PCR results. A cut-off of ≤ 6.08 ng/ml for PCT yielded a sensitivity of 86.8%, a specificity of 87.4%, a positive predictive value of 63.9%, a negative predictive value (NPV) of 96.3% and an area under the curve of 0.93 for Candida spp. identification by BC. A similar high NPV for a cut-off ≤ 6.78 ng/ml was observed considering the classification of diagnostic episodes according to PCR results, with an AUC of 0.85. A subsequent diagnostic episode was independently associated with Candida spp. detection either by BC or PCR.Conclusion: PCT could represent a useful diagnostic tool to exclude the detection of Candida spp. by BC and PCR in septic patients. © 2014 Cortegiani et al.; licensee BioMed Central Ltd.

OBJECTIVE: Association between aortic aneurysm wall and risk of rupture or dissection. METHODS: Aortic specimens were obtained from 73 patients (51 men and 22 women, whose median age 61.7± 10.7 years) undergoing surgical repair of thoracic ascending aneurysm (TAA). Histopathological and immunohistochemical analyses were performed using adequate tissue specimens, appropriate techniques and criteria. Furthermore, genetic risk factors were also investigated. RESULTS: We identified three phenotypes of TAAs with different quality of aortic wall at the time of operation: phenotype I (normal wall); phenotype II (moderate wall thickness); phenotype III (thin and weak wall). No significant differences were detected in term of demographic and clinical data, co-morbidity conditions and pharmacological treatments. In contrast, significant statistical differences were observed by comparing abnormalities of extracellular matrix components among three phenotypes (fibrosis p

Objectve: Metalloproteinases (MMPs) are endopeptidases involved in extracellular matrix remodelling, associated with both physiopatological processes of several human tissues and systems, such as vascular system. It is well known their involvement in mediating both beneficial and pathological aorta effects, such as abdominal orta aneurysms and its complcations. On the contrary, unclear data exist about their role in the pathophysiology of sporadic thoracic aneurysm (TAA) and its complications. Thus, the aim of this study was to nalyse the role of MMPs in TAA complications, i.e. rupture and dissection.Methods: Aortic specimens obtained from 73 patients (51 men and 22 women, age 61.7 years) affected by TAAs, 18 patients with type A aortic dissection (TAD) and 30 controls were utilised for histopathological and immne-histochemical analyses. In addition, a second group of 128 subjects (61men and 67 womem, age 61.7 years) was enrolled to examine the role of single nucleotide polymorphirms (SNPs) of MMP-9 and MMP-2 genes in disease risk. Results: Three different patterns of MMPs(extracellular, intracellular, and mixed) with different concentration (low, moderate, elevated) have been observed in case aorta samples. The pattern with elevated MMP amount in aorta samples from TAD cases was also characterised by increased cystic medial degeneration, whitout substitutive fibrosis, and plurifocal apoptosis. In the context of TAA aorta samples, we identified three phenotypes. In particular, the phenotype III mainly observed in case samples showed the same histological features of TAD with elevated MMP concentration with a mixed pattern. in addition, significant associations were obserbved between the -1562C/T MMP9, -735C/T MMP2 SNPs and the risk of both TAA and TAD. Conclusions: OUR data suggest a crucial role of both MMP-2 and -9 in both TAA and its complications. such as TAD. in future they might be considered as new criteria in TAA surgical indications.

AGE8. Is the Serum N Terminal Pro-Brain Natriuretic Peptide the Best Candidate Biomarker for Long-term Prognosis in Patients with Prosthesis-patient Mismatch after Mitral Valve Replacement? C. R. Balistreri1, C. Pisano1, R. Franchino1, S.R. Vacirca1, F. Crapanzano1, O. F. Triolo1, C. Palmeri1, G. Ruvolo1 1University Of Palermo, Palermo, Italy Background: Natriuretic peptides (NPs) are released from the heart in response to pressure and volume overload. Among these, B-NP and Nterminal- proBNP (NT-proBNP) have become important diagnostic tools for the management of heart failure. However, B-NP and NT-proBNP levels reflect complications of systolic and diastolic function as well as alteration of right ventricular and valvular function. In addition, their serum levels have a prognostic value in multiple clinical settings. Based on these observations, we sought to evaluate the relationship between prosthesis patient mismatch (PPM) and serum NT-pro-BNP levels after mitral valve replacement (MVR). PPM following MVR has been less investigated and it seems to mediate deleterious effects on long-term survival, even if contrasting opinions and data exist in the literature. Methods: A total of 100 patients that have undergone this surgical treatment will be enrolled, and opportune clinical data and peripheral blood samples will be collected. Blood samples are utilized to analyze clinical conditions and serum NT-proBNP levels. Evaluation of hemodynamic performances before or under dobutamine infusion is also being assessed. Results: The preliminary data on the serum NT-proBNP levels obtained seem to be interesting and promising, as well as their correlations with hemodynamic performances. Conclusions: The demonstration of negative effects on tricuspid valve and pulmonary hypertension and consequently on survival induced by PPM after MVR through the serum quantification of NT-proBNP levels might lead to consider it as an optimal biomarker to evaluate patients’ long-term prognosis and optimize surgical recommendations (i.e. tricuspid valve repair during mitral valve surgery in patients with moderate-severe mismatch).

Thoracic aorta shows with advancing age various changes and a progressive deterioration in structure and function. As a result, vascular remodeling (VR) and medial degeneration (MD) occur as pathological entities responsible principally for the sporadic TAA onset. Little is known about their genetic, molecular, and cellular mechanisms. Recent evidence is proposing the strong role of a chronic immune/inflammatory process in their evocation and progression. Thus, we evaluated the potential role of Toll like receptor- (TLR-) 4-mediated signaling pathway and its polymorphisms in sporadic TAA. Genetic, immunohistochemical, and biochemical analyses were assessed. Interestingly, the rs4986790 TLR4 polymorphism confers a higher susceptibility for sporadic TAA (OR=14.4,P=0.0008) and it represents, together with rs1799752 ACE, rs3918242 MMP-9, and rs2285053 MMP-2 SNPs, an independent sporadic TAA risk factor. In consistency with these data, a significant association was observed between their combined risk genotype and sporadic TAA. Cases bearing this risk genotype showed higher systemic inflammatory mediator levels, significant inflammatory/immune infiltrate, a typical MD phenotype, lower telomere length, and positive correlations with histopatological abnormalities, hypertension, smoking, and ageing. Thus, TLR4 pathway should seem to have a key role in sporadic TAA. It might represent a potential useful tool for preventing and monitoring sporadic TAA and developing personalized treatments.

Obiettivo. La chirurgia bariatrica è caratterizzata da un incre- mento di morbidità e mortalità post operatoria tre volte maggiore dei pazienti normopeso, in assenza di altri fattori di rischio. La decurarizzazione efficace, riduce il rischio di cura- rizzazione residua post operatoria, e le complicanze ad essa associate 1. Obiettivo del nostro studio è di valutare l’efficacia in termini di recupero dell’attività neuromuscolare all’accele- romiografia e in termini di ripresa clinicamente obiettivabile della Neostigmina vs Sugammadex. Materiali e metodi. Abbiamo arruolato 40 pazienti sottoposti a chirurgia bariatrica per bypass, suddivisi in due gruppi di età >18 anni, BMI >30 kg/m2, classe ASA 2-3. I pazienti sono stati sottoposti a monitoraggio, intraoperatorio standard e della funzione neuromuscolare, con Tof Watch. È stata con- dotta un’anestesia bilanciata con Desfluorane e Remifentani- le, miorisoluzione ottenuta con Rocuronio Bromuro 0.8 mg/kg IBW (Ideal Body Weight) +40%TBW (Tidal Body Weight) all’induzione, e mantenuta con richiami di Rocuronio Bromuro 0,1 mg/kg IBW+40%TBW per garantire un blocco neuromuscolare profondo (TOF 0.9 (Tof Ratio). Abbiamo, inoltre, valutato la capacità di alzare la testa per 5’’e passare autonomamente in barella (score:0 passaggio senza aiuto-5 assenza di collaborazione del paziente). Per l’analisi statistica sono stati utilizzati il test esatto di Fisher, il Mann- Whitney Test e il test t Student. È stato ritenuto significativo un valore di p0.9), con tempi medi di 2.52 min. (DS 35,43 sec. ) per il gruppo S e di 14.10 min. (DS 223.48 sec.) per il gruppo N, che per la capacità di sollevamento del capo per 5’’ (gruppo N 30% gruppo S 80%), che per la capacità di passare in barella auto- nomamente (valore mediana score: gruppo N:2 gruppo S:4). Non è stato registrato alcun evento avverso. Conclusioni. Il tempo medio di raggiungimento del TR >0.9 è minore nei pazienti sottoposti a reversal con Sugammadex, ottimizzando i tempi di risveglio. Il paziente bariatrico, sotto- posto a reversal con Sugammadex, nell’immediato postopera- torio è facilmente mobilizzabile, necessita di minore supporto durante il passaggio in barella con maggiore autonomia moto- ria tale da ridurre l’impegno del personale di sala durante tale manovra. Un campione maggiore è necessario per confermare i nostri dati.

OBJECTIVES: The purpose is to evaluate in vivo at rest and under stress conditions hemodynamic performance of the small size St. Jude Medical Regent (SJMR) prosthetic valve in patients with a body surface area (BSA) of 1.8 ± 0.11 m(2) and to define the role of valve prosthesis- patient mismatch on left ventricular mass regression following aortic valve replacement. METHODS: We evaluated 25 cases (12 males and 13 females, mean age 65.2 ± 8 years) of aortic valve replacement (17 mm SJMR in three cases and 19 mm SJMR in 22 cases). All the patients underwent at rest Doppler echocardiography before and after surgery and both basal and dobutamine stress echocardiography (DSE) at follow-up. The mean duration of follow-up was 41.3 ± 24 months. RESULTS: A significant reduction in mean and peak transaortic gradients and peak transaortic velocity over time following valve replacement has been identified. After surgery, there was a significant increase of ejection fraction. DSE significantly increased heart rate, ejection fraction, peak transaortic gradient and peak transaortic velocity. All patients passed DSE without complication. Even if a significant mismatch was present in 76% of cases, the left ventricular mass decreased significantly from preoperative value of 278.7 ± 51.1 g to 181.5 ± 52.73 g, respectively. CONCLUSION: Aortic valve replacement with 17 mm SJMR or 19 mm SJMR prostheses appear to provide satisfactory clinical and hemodynamic results at rest and under DSE, even in those patients with BSA of 1.8 ± 0.11 m(2) where it was not possible to enlarge the aortic annulus. Prosthesis-patient mismatch is not associated with lesser regression of left ventricular mass. Dobutamine stress echocardiography should be a useful and effective means for evaluating prosthesis hemodynamic aspects.

article is on the screeening of acute coronary disease in cardiac surgery from the preoperatory evaluation to the perioperative and postoperative treatment