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Psoriasis is a chronic immune-mediated inflammatory disease characterized by erythematous plaques that can extend along the entire skin surface. In the latest years, it has been shown that serum calprotectin correlated strongly with several inflammatory biomarkers. Since high levels of calprotectin have been found in psoriatic lesions, it is of paramount importance to investigate the role of serum calprotectin as a possible novel diagnostic marker of psoriasis. Aim of our prospective pilot study was to assess the level of serum calprotectin in psoriatic patients.Between January 2018 and July 2019, 45 subjects were enrolled at the Dermatology Unit of Magna Graecia University of Catanzaro, Italy. Thirty-two of them were psoriatic patients and 13 healthy controls. Psoriasis severity was assessed by the Psoriasis Area Severity Index.A statistically significant difference between the two groups (P=0.01) was found in terms of body mass index, higher among patients than in controls. By performing the Student's t-test for unpaired data, serum calprotectin resulted significantly higher (P=0.033) among psoriatic patients than in controls. Furthermore, performing the receiver operator characteristic curve analysis, serum calprotectin showed a significant area under the curve, implying its possible role in finding psoriatic patients. Our study aimed to evaluate the serum levels of calprotectin in a group of psoriatic patients and in a control group. The results showed that serum calprotectin levels were significantly higher in the patient group than in the control group. This result confirms the observations present in the literature.In this pilot study psoriatic patients had a significant high level of serum calprotectin than healthy subjects, and this biomarker had high accuracy in identifying patients. Further studies, with larger sample size will need to confirm our data.

Minimal invasive extracorporeal circulation (MiECC) systems have initiated important efforts within science and technology to further improve the biocompatibility of cardiopulmonary bypass components to minimize the adverse effects and improve end-organ protection. The Minimal invasive Extra-Corporeal Technologies international Society was founded to create an international forum for the exchange of ideas on clinical application and research of minimal invasive extracorporeal circulation technology. The present work is a consensus document developed to standardize the terminology and the definition of minimal invasive extracorporeal circulation technology as well as to provide recommendations for the clinical practice. The goal of this manuscript is to promote the use of MiECC systems into clinical practice as a multidisciplinary strategy involving cardiac surgeons, anaesthesiologists and perfusionists.

Background and aim of the study The outcome of mitral valve (MV) repair for chronic ischemic mitral regurgitation (IMR) is suboptimal, due to the high recurrence rate of moderate or severe mitral regurgitation (MR) during follow-up. The MV adapts to new MR increasing its area to cover the enlarged annular area (mitral plasticity). As this process is often incomplete, we aimed to evaluate if augmenting the anterior leaflet (AL) and cutting the second-order chords (CC) together with restrictive mitral annuloplasty, a strategy we call "surgical mitral plasticity," could improve the midterm results of MV repair for IMR. Materials and methods From November 2017 to October 2019, 22 patients with chronic IMR underwent surgical mitral plasticity. Mean age was 73 ± 7 years and six were female. Mean ejection fraction was 32% ± 11%, IMR grade was moderate in 10 and severe in 12. Mean clinical and echocardiographic follow-up was 12 ± 6 months. Results There was no early death, and one patient died 6 months after surgery. Ejection fraction improved from 32% ± 15% to 40% ± 6% (P = .031). IMR was absent or mild in all patients, and none showed recurrent moderate or more IMR. Tenting area decreased significantly from 2.5 ± 0.5 to 0.5 ± 0.3 cm² and coaptation length increased from 1.9 ± 0.7 to 7.8 ± 1.6 mm. All patients were in New York Heart Association class I or II. Conclusions Mitral plasticity, if uncomplete, is ineffective in preventing IMR to become significant. Surgical mitral plasticity, by completing incomplete process of MV adaptation, has a strong rationale, which however needs to be validated with longer follow-up.

The most recent literature’s evidences on pathogenic mechanisms of psoriasis have been presented. They involve genetic factors, immune-response alteration, cytokines hyper-production and can be triggered by environmental stress. Thus, psoriasis may evolve in different and subsequent phases with different clinical behavior. The laboratory can support the early diagnosis and may address a personalized therapeutic treatment performing the evaluation of the immunoprofile of the patient. This consists in the measurement of the number and the activity of lymphocytes involved in this disease, for instance T-reg, and in the evaluation of circulating levels of cytokines, for instance IL-1, IL-17, TNF $\alpha $ , through accurate and reproducible methodologies in order to perform a correct diagnosis and evaluate the efficacy of the personalized therapy.

Acute Kidney Injury (AKI) after cardiac surgery is a complication influencing postoperative outcome. Preoperative hemoglobin is a predictor of postoperative AKI. We aimed to identify preoperative predictors of Renal Replacement Therapy (RRT) and to develop a new risk-scoring system including hemoglobin to better stratify the risk of events.We evaluated 3288 consecutive patients of the Regional Cardiac Surgery Registry of Puglia operated in 2011-2012. Chronic dialysis and renal transplantation patients were excluded. Primary outcome was post-operative RRT incidence.The study sample was divided in two cohorts: 1642 patients (70 RRT) operated during the year 2011 as derivation cohort and 1646 patients (69 RRT) of the year 2012 as validation. In a multivariable logistic regression model using a stepwise method, six preoperative risk factors were associated with RRT in the derivation cohort: creatinine clearance, preoperative hemoglobin, neurological dysfunction, left ventricular ejection fraction, urgency and combined procedures (discrimination c-index 0.844 and 0.818 in the validation cohort). Scoring system included risk factors obtained from derivation cohort adjusting their relative weight with updated rounded coefficients in the validation cohort: creatinine clearance50ml/min (1 point), hemoglobin≤12.5g/dl (1 point), left ventricular ejection fraction≤30% (1 point), urgent operation (1 point), emergency-salvage surgery (2 points), and combined procedures (1 point). In both cohorts, outcomes were strongly correlated with score points.Our simple bedside prognostic score demonstrates good performance in predicting RRT. Hemoglobin plays an important role and future studies will clarify if preoperative anemia correction will lead to decreased RRT risk.

OBJECTIVES: To evaluate performance of the European System for Cardiac Operation Risk Evaluation (EuroSCORE II), to assess the influence of model updating and to derive a hierarchical tree for modelling the relationship between EuroSCORE II risk factors and hospital mortality after cardiac surgery in a large prospective contemporary cohort of consecutive adult patients. METHODS: Data on consecutive patients, who underwent on-pump cardiac surgery or off-pump coronary artery bypass graft intervention, were retrieved from Puglia Adult Cardiac Surgery Registry. Discrimination, calibration, re-estimation of EuroSCORE II coefficients and hierarchical tree analysis of risk factors were assessed. RESULTS: Out 6293 procedures, 6191 (98.4%) had complete data for EuroSCORE II assessment with a hospital mortality rate of 4.85% and EuroSCORE II of 4.40 ± 7.04%. The area under the receiver operator characteristic curve (0.830) showed good discriminative ability of EuroSCORE II in distinguishing patients who died and those who survived. Calibration of EuroSCORE II was preserved with lower predicted than observed risk in the highest EuroSCORE II deciles. At logistic regression analysis, the complete revision of the model had most of reestimated regression coefficients not statistically different from those in the original EuroSCORE II model. When missing values were replaced with the mean EuroSCORE II value according to urgency and weight of intervention, the risk score confirmed discrimination and calibration obtained over the entire sample. A recursive tree-building algorithm of EuroSCORE II variables identified three large groups (55.1, 17.1 and 18.1% of procedures) with low-to-moderate risk (observed mortality of 1.5, 3.2 and 6.4%) and two groups (3.8 and 5.9% of procedures) at high risk (mortality of 14.6 and 32.2%). Patients with low-to-moderate risk had good agreement between observed events and predicted frequencies by EuroSCORE II, whereas those at greater risk showed an underestimation of expected mortality. CONCLUSIONS: This study demonstrates that EuroSCORE II is a good predictor of hospital mortality after cardiac surgery in an external validation cohort of contemporary patients from a multicentre prospective regional registry. The EuroSCORE II predicts hospital mortality with a slight underestimation in high-risk patients that should be further and better evaluated. The EuroSCORE II variables as a risk tree provides clinicians and surgeons a practical bedside tool for mortality risk stratification of patients at low, intermediate and high risk for hospital mortality after cardiac surgery.

Background— We aimed to evaluate the clinical results and biocompatibility of the minimal extracorporeal circulation system (MECC) compared with off-pump coronary revascularization (OPCABG). Methods and Results— In a prospective randomized study, 150 patients underwent coronary surgery with the use of MECC and 150 underwent OPCABG. End points were (1) circulating markers of inflammation and organ injury, (2) operative results, and (3) outcome at 1-year follow-up. Operative mortality and morbidity were comparable between the groups. Release of inflammatory markers was similar between groups at all time points (peak interleukin-6 167.2±13.5 versus 181±6.5 pg/mL, P =0.14, OPCABG versus MECC group, respectively). Peak creatine kinase was 419.3±103.5 versus 326±84.2 mg/dL ( P =0.28), and peak S-100 protein was 0.13±0.08 versus 0.29±0.1 pg/mL ( P =0.058, OPCABG versus MECC group, respectively). Length of hospital stay and use of blood products were similar between groups. Two cases of angina recurrence at 1 year in the MECC group were observed versus 5 cases observed in the OPCABG group ( P =0.44). A residual perfusion defect at myocardial nuclear scan was less frequent among patients in the MECC group (3 versus 9 cases, P =0.14; odds ratio 0.32, 95% confidence interval 0.07 to 1.32). Six (OPCABG group) versus 3 (MECC group) coronary grafts were occluded or severely stenotic at 1 year ( P =0.33, odds ratio 0.47, 95% confidence interval 0.09 to 2.14). Conclusions— Clinical results of coronary revascularization with MECC are optimal when this procedure is performed by experienced teams. Postoperative morbidity is comparable to that with OPCABG. MECC is associated with little pump-related systemic and organ injury. It may achieve the benefits of OPCABG (less morbidity in high-risk patients) while facilitating complete revascularization in the case of complex lesions unsuitable for OPCABG.

Background The concept of overreduction of the posterior annulus was applied in surgical treatment of degenerative mitral valve disease. Methods From April 1993 to November 2004, 141 patients underwent overreduction of the posterior annulus of the mitral valve in mitral valve repair for degenerative disease. Mean scallop involvement per patient was 2.3 and increased to 3.0 in the last period. Correction of the prolapse of the posterior leaflet included resection with focal sliding (n = 100), or application of artificial chordae (n = 28), with (n = 11) or without (n = 17) plication of one or more scallops. The anterior leaflet prolapse was corrected with edge-to-edge technique (n = 20) or chordal replacement (n = 28). An overreducting ring, 40 (n = 81) or 50 (n = 60) mm long (autologous pericardium in 64 cases and Sovering Miniband [Sorin, Saluggia, Italy] in 77) was used in all the patients. Results Three patients died in the early period (2.1%) and 3 (2.1%) were reoperated on from 3 to 24 months due to endocarditis (2 cases) and failure of repair (1 case). Ten-year freedom from death any cause was 91.6%, from reoperation 96.4%, from death any cause and reoperation 87.7%, from death any cause, reoperation, and New York Heart Association class III-IV 79.8%. Sixty-four patients out of 68 who survived more than 2 years (94.1%) at a mean follow up of 4.2 ± 2.5 years had no or 1+ residual mitral regurgitation. Conclusions Although the complexity of mitral valve repair for degenerative disease increased, results of surgery remained stable. Apposition of a posterior overreductive ring was useful to cover any mistake performed during the correction.

Background We evaluated our experience to investigate if the use of bilateral internal mammary artery (BIMA) grafting, with or without complementary saphenous vein grafts (SVG), increases the quality of the results of coronary bypass grafting in medically treated diabetic patients who undergo first myocardial revascularization, when compared with the use of a single left internal mammary artery (LIMA) and SVG. Methods From October 1991 to December 2001, 558 diabetic patients with multivessel coronary disease had first isolated myocardial revascularization using LIMA and SVG (group LIMA) in 217 cases and BIMA ± SVG (group BIMA) in 341. Propensity score analysis identified 400 patients, 200 for each group, with similar preoperative characteristics. Thirty-day outcome and 8-year freedom from death from any cause, cardiac death, acute myocardial infarction (AMI), AMI in a grafted area, redo/percutaneous transluminal coronary angioplasty (PTCA), redo/PTCA in a grafted area, target cardiac events, and any event were evaluated. Follow-up ranged from 2.0 to 12.2 years (mean 6.0 ± 2.0). Results There was no difference between groups except the cardiac deaths, which were significantly higher in the LIMA group (7 versus 0, p = 0.015). The BIMA group showed better 8-year freedom from death any cause (86.7 ± 3.2 versus 79.5 ± 4.1, p = 0.0274), cardiac death (96.3 ± 1.4 versus 88.4 ± 4.0, p = 0.0406), acute myocardial infarction (99.5 ± 0.5 versus 92.0 ± 3.9, p = 0.0092), and acute myocardial infarction in a grafted area (99.5 ± 0.5 versus 93.4 ± 3.7, p = 0.0204). Cox analysis confirmed that the use of LIMA and SVG was an independent predictor for lower freedom from death (hazard ratio [HR] = 1.8, p = 0.0310), cardiac death (HR = 1.9, p = 0.0426), AMI (HR = 9.7, p = 0.0033) and AMI in a grafted area (HR = 8.2, p = 0.0410). Conclusions In diabetic patients with multivessel disease who undergo first myocardial revascularization, BIMA ± SVG provides higher freedom from death, any cause, and cardiac-related death, if compared with LIMA + SVG. It plays a protective role in reducing the incidence of late AMI.

Early hematopoietic zinc finger/zinc finger protein 521 (EHZF/ZNF521) is a novel zinc finger protein expressed in hematopoietic stem and progenitor cells and is down-regulated during their differentiation. Its transcript is also abundant in some hematopoietic malignancies. Analysis of the changes in the antigenic profile of cells transfected with EHZF cDNA revealed up-regulation of HLA class I cell surface expression. This phenotypic change was associated with an increased level of HLA class I H chain, in absence of detectable changes in the expression of other Ag-processing machinery components. Enhanced resistance of target cells to NK cell-mediated cytotoxicity was induced by enforced expression of EHZF in the cervical carcinoma cell line HeLa and in the B lymphoblastoid cell line IM9. Preincubation of transfected cells with HLA class I Ag-specific mAb restored target cell susceptibility to NK cell-mediated lysis, indicating a specific role for HLA class I Ag up-regulation in the NK resistance induced by EHZF. A potential clinical significance of these findings is further suggested by the inverse correlation between EHZF and MHC class I expression levels, and autologous NK susceptibility of freshly explanted multiple myeloma cells. Copyright © 2009 by The American Association of Immunologists, Inc.

The study objective was to evaluate the effects on early outcome and midterm survival of performing coronary artery bypass grafting with the off-pump technique in comparison with cardiopulmonary bypass (on-pump) in patients with preoperative anemia.Consecutive adult anemic patients (preoperative hemoglobin13.0 g/dL in men and12.0 g/dL in women) resident in Puglia region who underwent isolated coronary artery bypass grafting between January 2011 and November 2013 were considered. Vital status was ascertained from the date of surgery to December 31, 2013. Odds ratio and hazard ratio (HR) were estimated. Propensity score methods were used to control for confounders.Of 939 anemic patients (234 female, aged 71 ± 9 years), 361 underwent operation with the off-pump technique and 578 underwent operation with the on-pump technique. Patients undergoing off-pump coronary artery bypass had a shorter intensive care unit length of stay, lower blood transfusion rate, and postoperative reduction in creatinine clearance. During a median follow-up of 18 months, 126 patients died: 46 in hospital (35 on-pump) and 80 after discharge (33 on-pump). In comparison with the off-pump technique, the on-pump technique had greater hospital mortality (odds ratio, 2.57; P = .028) and 30-day incidence of fatal events (HR, 2.67; P = .026). After a period without risk differences between groups (1-6 months; HR, 0.79; P = .618), a lower mortality in those undergoing the on-pump technique was detected (after 6 months HR, 0.35; P = .014). All results were confirmed in the 157 pairs of patients matched for propensity score, anemia grade, and surgery center.In patients with low levels of preoperative hemoglobin, off-pump coronary artery bypass was associated with lower early morbidity and mortality but a greater risk of mortality during follow-up compared with on-pump coronary artery bypass.

AIMS To evaluate the feasibility of a cardiac surgery registry and to describe patients' characteristics, type of procedures performed, incidence of postoperative complications with short and middle-term mortality. METHODS A database with clinical information and details on cardiac surgical operations was implemented by Puglia Health Regional Agency to collect data of each cardiac surgery procedure performed in the seven adult cardiac surgery centres of the region. Health regional agency personnel guaranteed data accuracy and quality control procedures. Mortality after the discharge was evaluated for residents in Puglia by linking clinical data to the Health Information System. RESULTS From January 2011 to December 2012, 6429 operations were performed. All operations were included in the registry with very high completeness of collected data (95.3% per patient). The majority of the operations performed were coronary artery bypass graft alone (41.1%), valve surgery alone (26.2%), coronary artery bypass graft and valve surgery (11.4%), or valve with other surgery (11.8%). During a median follow-up of 12 months (interquartile range 6-18 months), 211 deaths were detected after the discharge. Overall, cumulative mortality from the operation was 8.2% at 6 months and 9.5% at 12 months. CONCLUSION Implementation of a regional clinical registry of cardiac surgery is feasible with a great level of accuracy and the evaluation of mid-term mortality overcomes the limited value of hospital mortality. An accurate cardiac surgery registry elicits epidemiologic evaluations, comparisons between expected and observed mortality, incidence of postoperative complications and encourages a reliable public reporting.

Background: We sought to evaluate the long-term patency rate of composite lengthened conduits. Methods and Results: From December 1991 to April 2000, 43 patients had a composite lengthened arterial conduit. There was a mean of 2.83 ± 1.23 anastomoses per patient. No 30-day mortality occurred. Five patients died from 3 to 84 months after the operation (mean, 38.6 ± 34.6 months). After a mean follow-up of 57.0 ± 32.3 months (range, 3-99 months), all the survivors are asymptomatic. The only cardiac major events recorded were 2 (4.6%) late acute myocardial infarctions in the patients who died. Eight-year survival and event-free survival were both 80.4% ± 9.1% (range, 3%-93%). In the early period (13.5 ± 4.8 days) in 26 patients, 26 arterial composite lengthened conduits and 37 distal anastomoses had postoperative angiographic control; all the anastomoses were rates as grade A, according to Fitzgibbon classification. In the late period (29 ± 30 months) in 23 patients, 23 arterial composite lengthened conduits and 34 distal anastomoses were checked; the patency rate was 22 (95.6%) of 23 for the composite lengthened conduits and 33 (97%) of 34 for the distal anastomoses. Conclusions: In particular situations, when the length of an arterial conduit is not enough to allow a correct use of the graft, lengthening of an arterial conduit can be a safe and effective technique.

Anemia is a risk factor for adverse events after cardiac operations. We evaluated the incremental value of preoperative anemia over the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II to predict hospital death after cardiac operations.Data for 4,594 consecutive adults (1,548 women [33.7%]), aged 67 ± 11 years, who underwent cardiac operations from January 2011 to July 2013 were extracted from the Regional Cardiac Surgery Registry of Puglia. The last preoperative hemoglobin value was used, according to World Health Organization criteria, to classify anemia as mild (hemoglobin 11.0 to 12.9 g/dL in men and 11.0 to 11.9 g/dL in women) in 1,021 patients (22.2%) and as moderate to severe (hemoglobin11.0 g/dL) in 593 patients (12.9%). The EuroSCORE II was used to evaluate predicted hospital death after operations. Logistic regression analysis for in-hospital death was performed including EuroSCORE II risk factors and anemia, with model discrimination quantified by C statistic and risk classification by the use of net reclassification improvement (NRI).Overall expected and observed mortality rates were 4.4% and 5.9%. Anemia was significantly associated with a mortality rate of 3.4% in patients without anemia, 7.7% in mild anemia, and 15.7% in moderate to severe anemia (p0.001) and also at multivariate analysis correcting for EuroSCORE II (p0.001). When anemia was analyzed with EuroSCORE II, the model improved in discrimination (C statistic = 0.852 vs 0.860; p = 0.007) and reclassification (category free-NRI, 0.592; p0.001), preserving the calibration with good concordance between predicted probabilities and outcome.Preoperative anemia has strong association with operative death in cardiac surgical patients. Anemia provides significant incremental value over the EuroSCORE II and should be considered for assessment of cardiac surgical risk.

Background: We evaluated whether bilateral internal thoracic arteries provide the same long-term results when used as in situ grafts and as Y grafts. Methods and Results: From October 1991 to February 2000, 1818 patients had bilateral internal thoracic arteries used as in situ (n = 1378, group A) or as Y grafts (n = 440, group B). The number of anastomoses per patient and the number of bilateral internal thoracic artery anastomoses per patient were higher in group B (3.1 ± 0.9 and 2.7 ± 0.9) than in group A (2.9 ± 0.8 and 2.2 ± 0.6) (both P

Objective: We reviewed our experience with myocardial revascularization without cardiopulmonary by-pass (CPB) to evaluate early- and mid-term results compared with those obtained using CPB. Methods: From May 21 1997 to November 1998, 747 patients had isolated myocardial revascularization, 480 without CPB (Group A) and 267 with CPB (Group B). Exposure of the target vessels was obtained with four slings (two passed through the transverse sinus and two behind the inferior vena cava) and four deep pericardial sutures on the mobile pericardium around the left atrium (Lima stitches). The number of anastomoses/patient (when two or more conduits were used) was higher in Group B (3:1 ^ 1: 0v s 2:6 ^ 0:7, P , 0:001). More marginal branches were grafted in Group A (258 vs 239), but the percentage was higher in Group B (P , 0:001). Crude and risk adjusted mortality was similar in both groups, as well as cerebrovascular accident (CVA) and acute myocardial infarction incidences. Patients in Group A woke earlier, had less inotropes, lower creatinkinase myocardial band (CK‐MB) peak, lower bleeding and less transfusion, shorter Intensive Care Unit (ICU) and postoperative stay in hospital than patients in Group B. 266 anastomoses were checked; of these 98.5% were patent and 97.0% were patent and not restrictive. Conclusions: Myocardial revascularization without CPB can provide good early- and mid-term results in selected patients. Primary endpoints (death and acute myocardial infarction) were similarly independent from the technique used. Some of the secondary endpoints were favorable in Group A; however their importance is minor. Even if we feel that some high risk patients with severe comorbidities can benefit from CPB surgery; this aspect is difficult to demonstrate scientifically. q 1999 Elsevier Science B.V. All rights reserved.

To increase the number of anastomoses per patient, bilateral internal mammary arteries (BIMAs) were harvested with a skeletonized approach instead of a pedicled one.One thousand one hundred forty-six patients underwent isolated myocardial revascularization using BIMAs, 304 receiving pedicled grafts (group A, October 1991 through May 1994) and 842 receiving skeletonized conduits (group B, June 1994 through June 1998). Group B had a higher incidence of patients with diabetes (223 versus 40, p0.001).The number of BIMA anastomoses per patient was significantly higher in group B (2.4 +/- 0.3 versus 2.1 +/- 0.4, p0.001), as well as the number of sequential grafts (288 versus 42, p0.001). Twenty-three patients (2.0%) died in the first 30 days after surgery, 5 in group A (1.6%) and 18 in group B (2.1%) (not significant). Postoperative complications were similar in both groups; the incidence of sternal wound healing problems was higher as a whole and with regard to diabetic patients (4 of 40 [10%] versus 5 of 223 [2.2%], p0.05) in group A. Seventy-one patients in group A and 133 (15.8%) in group B underwent a postoperative angiography. Patency rate was similar, both early (100% in group A versus 98.6% in group B, not significant) and late (98.6% in group A versus 98.4% in group B, not significant).The use of skeletonized BIMA conduits allowed us to increase the number of BIMA anastomoses per patient with a lower rate of sternal wound complications and angiographic results similar to those obtained with pedicled BIMA conduits.

Lack of angiographic results and technical difficulty in grafting the vessels in the lateral and posterior walls have reduced interest in myocardial revascularization without cardiopulmonary bypass (CPB). We describe our experience to demonstrate the feasibility of coronary surgical intervention without CPB in multivessel disease.From May 21, 1997, through February 1998, 227 patients underwent revascularization with two or more arterial conduits as the first operation: 122 without CPB (group A) and 105 with CPB (group B). Group A included a greater number of high-risk patients.Mean +/- SD anastomoses per patient were 2.5 +/- 0.6 in group A and 2.8 +/- 0.8 in group B (p = NS). No patient died in group A, whereas 1 patient (0.9%) died in group B. The postoperative complication rate was low in both groups, but intensive care unit and in-hospital stays were shorter in group A than in group B (14.1 +/- 7.1 versus 27.3 +/- 36 hours, p0.001, and 4.1 +/- 1.6 versus 5.4 +/- 2.4 days, p0.001, respectively [group A versus group B]). Sixty-seven patients in Group A (54.9%) underwent postoperative angiography 33 +/- 35 days after operation. The patency rate was 98.9% (98.2% for the marginal branches).Arterial revascularization of the coronary arteries without CPB is feasible, with results similar to those obtained with CPB. The two techniques, in our opinion, are complementary, not antagonistic.

Background . Left internal mammary artery Doppler flow velocity assessment during the Azoulay maneuver (patient's legs are passively lifted up and actively maintained by the patient) can increase the information on the anastomosis quality after left internal mammary artery to left anterior descending coronary artery grafting after the left anterior, small thoracotomy operation. Methods . One hundred patients had an early postoperative angiography and a Doppler flow velocity assessment at rest and during the Azoulay maneuver. Peak and mean systolic velocities, peak and mean diastolic velocities, and peak and mean diastolic to systolic velocity ratios were recorded in all patients. Results . In 95 patients with no restrictive conduit or anastomosis, peak and mean diastolic to systolic velocity ratios increased during the Azoulay maneuver; all but 1 patient showed at least one ratio equal to or greater than 1. In 4 patients with restrictive conduit or anastomosis, peak and mean diastolic to systolic velocity ratios were always less than 1 during the Azoulay maneuver. In the patient with an occluded conduit these ratios were less than 0.6. Conclusions . Peak and mean diastolic to systolic velocity ratios less than 1 during the Azoulay maneuver are suggestive of conduit or anastomosis malfunction. If we limit the angiographic controls to these patients, it is very likely that a pathologic anastomosis or conduit will not be missed.

Background . Left anterior descending artery stabilization allows performance of left internal mammary artery grafting via a left anterior small thoracotomy on a beating heart. Our surgical experience was reviewed to assess if surgical results have improved as result of specialized instrumentation. Methods . Of 545 patients who had the left anterior small thoracotomy operation, 261 underwent this procedure for single left anterior descending artery disease. Two groups were considered, before and after the use of specialized instrumentation: group A (n = 93), operated on from November 21, 1994, to April 20, 1996; and group B (n = 168), operated on from April 21, 1996, to December 1997. Results . Early mortality was similar in the two groups. The further revascularization (operation or percutaneous transluminal coronary angioplasty) and the rate of occlusion of the conduit were higher in group A, whereas anastomotic or conduit malfunction was not. Cumulating angiography and Doppler flow evaluation, 92.5% of the anastomoses in group A and 98.8% in group B ( p = 0.026) were patent, and 90.3% in group A and 97.6% in group B ( p = 0.031) were patent and not restrictive. At 19 months, survival was similar, but the event-free survival was higher in group B. Conclusions . Both left anterior descending artery stabilization and safer left internal mammary artery harvesting contributed to improve angiographic and clinical results after the left anterior small thoracotomy operation.

Background:Left anterior descending artery grafting using the left internal mammary artery via a left anterior small thoracotomy (LAST) gained new popularity in 1994. We review our experience in 250 of 512 patients who underwent a LAST in single vessel left anterior descending artery disease from November 1994 to October 1997. Methods: Left anterior descending artery stabilization was obtained pharmacologically and mechanically. Two patients (0.8%) had percutaneous transluminal coronary angioplasty at a mean of 23 ± 5 days; 172 (68.8%) patients had early postoperative angiography. Results: Eight conduits were occluded (patency rate 95.30%). There was only one late death. Cumulative angiography and Doppler flow evaluation showed that 96.8% of the anastomoses were patent and 95.6% were both patent and nonrestrictive. At a mean follow-up of 16.3 ± 9.3 months, 9 (3.6%) patients had redo-surgery due to anastomotic/conduit failure and 249 (99.6%) patients were alive and asymptomatic. No patients had acute myocardial infarction. The 35-month actuarial survival rate was 99.6%± 0.4%, and the event-free survival rate for the entire experience was 93.7%± 1.3%. If only the last 157 patients are considered, at 18 months event-free survival was higher than in the entire group of patients (96.4%± 1.4% vs 93.7%± 1.390, p = 0.05). Conclusions: New instrumentation has made the operation easier and has contributed to its spread, along with increased experience and the end of the learning curve. At the moment we consider the LAST a more anatomical and physiological surgical approach to single vessel coronary disease. (J Card Surg 7998;73:306–309)

ObjectiveMyocardial damage occurs after valve surgery, but its prognostic implication has not been evaluated. The aim of the present study was to assess the influence of myocardial damage on mortality and morbidity in patients undergoing aortic surgery (AVS) and mitral valve surgery (MVS).MethodsIn a prospective multicenter study from the cardiac surgery registry of the Puglia region, cardiac troponin I (cTnI) was measured immediately after and the morning after the intervention in consecutive patients undergoing AVS or MVS. The percentile ranks of the cTnI peak values within each center were analyzed.ResultsOf 965 patients (age, 67 ± 12 years; 45.5% women), 579 had undergone AVS and 386 MVS. cTnI release was significantly greater in the MVS group than in the AVS group and in the nonsurvivors than in the survivors in both groups. The cTnI cutoff with the greatest sensitivity and specificity (60th percentile for AVS and 91st for MVS) in predicting hospital mortality (2.6%) was also associated with a greater rate of postoperative complications and mortality within 3 months postoperatively (multivariate hazard ratio, 3.38; P = .005). Compared with the reference model, which included the multivariate predictors of hospital mortality (active endocarditis, New York Heart Association class III-IV, left ventricular ejection fraction ≤ 30%, and cardiopulmonary bypass duration), the addition of cTnI greater than the cutoffs showed significant improvement in model performance (likelihood ratio test, P = .009; net reclassification improvement, 0.751; P

A 71-year-old female developed a painless neck mass three months following an aortic valve replacement, mitral commissurotomy, and coronary artery bypass. A cervical trunk angio revealed a pseudoaneurysm supplied from a branch of the thyrocervical trunk, which was successfully excised. (J Card Surg 2011;26:617-618)

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Background We evaluated the impact of ischemic mitral regurgitation (IMR) on long-term outcome of patients with an ejection fraction (EF) exceeding 0.30 undergoing isolated coronary artery bypass grafting (CABG). Methods From November 1994 to December 2002, 4226 patients (EF > 0.30) underwent a first isolated CABG. Preoperative IMR was present in 1421 (33.6%, group IMR), of which 1254 had mild (1/4) and 167 had moderate (2/4). The remaining 2805 patients (66.4%, group no-IMR) showed no IMR. A nonparsimonious regression model was built to determine the propensity score. Ten-year freedom from death from any cause, cardiac death, and cardiac events was evaluated by the Kaplan-Meier method. Results of Cox analysis were adjusted by entering the propensity score as an independent variable. Results All patients had similar early mortality (2.1% no-IMR vs 2.5% IMR, p = 0.502) and morbidity (6.5% no-IMR vs 6.6% IMR, p = 0.840). In patients with EF of 0.31 to 0.40, but not in those ones with EF exceeding 0.40, IMR grade was an independent variable for worse long-term freedom from cardiac death (82.8 ± 3.2 vs 91.4 ± 2.4; Cox hazard ratio [HR], 2.1 [95% confidence interval (CI), 1.1 to 4.1]; p = 0.0324) and cardiac events (78.6 ± 3.5 vs 88.5 ± 2.7; Cox HR, 2.0 [95% CI, 1.1 to 3.7]; p = 0.0174). Conclusions Mild or moderate IMR in patients with an EF exceeding 0.30 undergoing first isolated CABG influences long-term outcome when EF is 0.31 to 0.40, but not when it exceeds 0.40.

The case of a 52-year-old woman with subvalvular aortic stenosis and aortic regurgitation is presented. Mitral regurgitation was associated, due to insertion of two abnormal chordae tendineae at the apex of the anterior papillary muscle and at the free border of the subvalvular membranous annulus. This abnormality displaced the anterior papillary muscle, thus applying a traction at the mitral leaflet. The patient was operated on through a valve-sparing approach, in which the discrete subaortic stenosis was removed through aortotomy and the ectopic chordae were excised. Suture mitral annuloplasty completed the procedure. Aortic and mitral insufficiency almost disappeared at follow-up. From the examination of this case and from a review of pertinent literature it emerges that in event of similar complex congenital abnormalities without intrinsic valve disease, a conservative approach should be chosen so that valve replacement can be avoided.

Off-pump coronary artery bypass surgery is widely performed because of its proved safety, but its effectiveness remains controversial. The aim of this retrospective study was to compare early and late results in patients with multivessel disease, operated on off-pump and on-pump.From November 1994 to December 2001, 2957 patients with multivessel disease underwent isolated coronary revascularization, on-pump (n = 1924) and off-pump (n = 1033). Sixty-five patients (2.2%) who were converted from off-pump to on-pump were considered as part of the off-pump group.Stepwise logistic regression analysis showed that the use of cardiopulmonary bypass was an independent predictor for early death, early negative primary endpoints, and early major events. Conversion to on-pump was an independent risk factor for a higher incidence of death due to any cause and cardiac death, early negative primary endpoints, and early major events. Conversion, however, did not affect late clinical outcome. The 6-year freedom from death (any cause, cardiac cause), myocardial infarction, redo/coronary angioplasty and any events was similar in the two groups.These results suggest that off-pump surgery reduces early mortality and morbidity. These benefits are not at the expense of the long-term clinical outcome which seems to be similar in the two groups. Patients who require conversion from off-pump to on-pump have a much higher mortality and morbidity although this does not seem to influence their long-term clinical outcome.

Background: Mitral valve (MV) surgery for dilated cardiomyopathy (DCM) was proposed at the beginning of the 1990s, and its effectiveness has been confirmed by many studies. The aim of this study is to evaluate long-term survival and the functional results of our experience with MV surgery for DCM. Methods: From January 1990 to October 2002, MV surgery for DCM was performed in 91 patients (64 ischemic, 27 idiopathic). DCM was defined as in our previous reports. Patients with organic MV disease, severe right ventricle dilatation with impaired function, or severe renal or hepatic failure were excluded from the study. MV annuloplasty was performed in 64 patients, and 27 patients underwent a MV replacement. Results: The 30-day mortality rate was 4.4% (4 patients). The probability of being alive at 5 years was 78.4% +/- 4.3% and was higher in patients who underwent MV repair (81.4% +/- 4.5%) than in patients who underwent replacement operation (66.7% +/- 9.1%), even if the P value was not statistically significant. After a mean follow-up period of 27 +/- 30 months, the New York Heart Association (NYHA) class decreased from 3.5 +/- 0.7 to 2.1 +/- 0.6 in the 69 survivors ( P.001). The probability of being alive 5 years after surgery with an improvement of least 1 NYHA class was 65.9% +/- 5.0% and was higher in patients with MV repair (76.6% +/- 6.0%) than in patients who underwent valve replacement (51.9% +/- 9.6%), even if the P value was not statistically significant. Fifty patients were carefully followed with serial evaluations in our echocardiographic laboratory. Volumes did not change, nor did stroke volume or ejection fraction. Some degree of functional mitral regurgitation (FMR) was present in all but 8 of the patients who underwent repair. The analysis of these patients showed that all of the patients who had no residual MR had a mitral valve coaptation depth (MVCD) of 10 mm or less and had a better functional result. Conversely, the MVCD was shorter in patients who had no or mild (1/4) residual MR than in patients who had a residual MR1/4. NYHA class was lower in patients with no or up to 1/4 residual MR, showing that the purpose of the procedure is the reduction or elimination of FMR, which is the determinant of the clinical result. Conclusions: Long-term results in our patients are satisfying. FMR can be crucial for achieving a higher effectiveness of a combined strategy to improve the global outcome of these patients.

In a previous study, we demonstrated that patients with multivessel disease benefit during the first postoperative month from elimination of cardiopulmonary bypass (CPB). We evaluated the midterm results of the same patients excluding the first postoperative month from the analysis.From May 1997 to November 2000, 1,802 patients with multivessel disease survived the first postoperative month; 906 were operated on without (group A) and 896 with (group B) CPB. Follow-up ranged from 23 to 65 months (mean, 42 +/- 12 months). Four-year actuarial freedom from the following events was evaluated: death from any cause; cardiac death; acute myocardial infarction (AMI) in any territory; AMI in a grafted area; redo percutaneous transluminal coronary angioplasty (PTCA); redo PTCA in a target vessel; cardiac events (death from a cardiac cause, acute myocardial infarction on grafted vessel, redo PTCA on target vessel); and any event.No statistical difference was found between groups A and B with regard to freedom from any death (95.3 +/- 0.8 vs 95.7 +/- 0.7, p = 0.5160); from cardiac death (97.3 +/- 0.6 vs 97.5 +/- 0.6, p = 0.5345); from AMI (98.4 +/- 0.4 vs 98.7 +/- 0.4, p = 0.4655); from AMI in a grafted area (98.9 +/- 0.4 vs 98.7 +/- 0.4, p = 0.9374); from redo PTCA (97.9 +/- 0.5 vs 97.7 +/- 0.6, p = 0.8485); from redo PTCA in a grafted area (98.7 +/- 0.4 vs 98.5 +/- 0.5, p = 0.8774); from target cardiac events (95.8 +/- 0.7 vs 95.9 +/- 0.8, p = 0.6070); and from any event (92.9 +/- 0.9 vs 93.4 +/- 1.0, p = 0.3721).After exclusion of the first postoperative month, myocardial revascularization without CPB has midterm results similar to myocardial revascularization with CPB. In particular, failure of revascularization does not depend on intraoperative strategy.

Background . To evaluate the long-term clinical and angiographic results of the radial artery (RA) as a graft in coronary artery bypass surgery. Methods . One hundred sixty-four patients had a RA graft from July 1992 to July 1994. In 128 (group A) the RA was connected end to side (115) or end to end (13) to the left internal mammary artery. In 36 (group B) the proximal anastomosis was on the ascending aorta. Results . Early mortality was 1.8% (group A 1.6% and group B 2.8%). Eight-year survival was 83.2% ± 3.2% (group A 82.1% ± 3.8% and group B 86.7% ± 6.2%, p = not significant [NS]), and event free survival was 80.1% ± 3.5% (group A 79.9% ± 4.4% and group B 80.2% ± 7.3%, p = NS). Sixty-one patients (37.2%) had an early angiography within 90 days from the operation. Patency rate of RA distal anastomoses were 98.9% (88 of 89), 98.7% in group A (77 of 78), 100% in group B (11 of 11; p = NS). After a mean of 48 ± 27 months (6 to 96), 72 patients (51.1% of the survivors) had a new angiography. Patency rate of RA distal anastomoses was 95.6% (87 of 91), 93.8% in group A (61 of 65) and 100% in group B (26 of 26; p = NS). All the intermediate RA-LIMA anastomoses were patent at the early and late control. Patency rate for RA and IMAs was similar both early (88 of 89 versus 82 of 82; p = NS) and after 48 ± 27 months (87 of 91 versus 93 of 93; p = NS). Conclusions. Long-term clinical results after RA grafting are satisfying. Angiographic patency rate, both early and after 48 months, is higher than 90% and is similar to that obtained with internal mammary arteries. The site of the proximal anastomosis does not influence early and late patency.

Mitral valve (MV) procedure for dilated cardiomyopathy is becoming popular. We analyzed the indications to MV repair or replacement according to our 10-year experience.From January 1990 to May 2000, 49 patients with dilated cardiomyopathy (12 idiopathic and 37 ischemic) underwent MV operation, 29 repair and 20 replacement. Preoperative evaluation included measurement of MV coaptation depth (CD) as a mirror of the abnormalities of MV apparatus leading to functional mitral regurgitation.Thirty-day mortality was 4.2% (2 patients). One-, 3-, 5-, and 10-year actuarial survival was, respectively, 90%, 87%, 78%, and 73%. The possibility of survival with at least one New York Heart Association functional class improvement was 88%, 76%, 71%, and 65%. Return of functional mitral regurgitation after MV repair was nearly inevitable; however, using a scale from 0 to 4, mean postoperative functional mitral regurgitation was 1.2+/-0.8 when preoperative MVCD was 10 mm or less and 2.5+/-0.7 when preoperative MVCD was 11 mm or higher (p0.05). Globally, functional results were not influenced by the strategy of treatment (MV repair or replacement).Mitral valve operation can give satisfying survival and good palliation of dilated cardiomyopathy. The MVCD can be helpful in the choice of the surgical strategy on the MV.

Background. Mitral valve (MV) procedure for dilated cardiomyopathy is becoming popular. We analyzed the indications to MV repair or replacement according to our 10-year experience. Methods. From January 1990 to May 2000, 49 patients with dilated cardiomyopathy (12 idiopathic and 37 ischemic) underwent MV operation, 29 repair and 20 replacement. Preoperative evaluation included measurement of MV coaptation depth (CD) as a mirror of the abnormalities of MV apparatus leading to functional mitral regurgitation. Results. Thirty-day mortality was 4.2% (2 patients). One-, 3-, 5-, and 10-year actuarial survival was, respectively, 90%, 87%, 78%, and 73%. The possibility of survival with at least one New York Heart Association functional class improvement was 88%, 76%, 71%, and 65%. Return of functional mitral regurgitation after MV repair was nearly inevitable; however, using a scale from 0 to 4, mean postoperative functional mitral regurgitation was 1.2 ± 0.8 when preoperative MVCD was 10 mm or less and 2.5 ± 0.7 when preoperative MVCD was 11 mm or higher (p < 0.05). Globally, functional results were not influenced by the strategy of treatment (MV repair or replacement). Conclusions. Mitral valve operation can give satisfying survival and good palliation of dilated cardiomyopathy. The MVCD can be helpful in the choice of the surgical strategy on the MV.

EHZF/ZNF521 is a novel zinc finger protein expressed in hematopoietic stem and progenitor cells and is downregulated during their differentiation. Its transcript is also abundant in some hematopoietic malignancies. Analysis of the changes in the antigenic profile of cells transfected with EHZF cDNA revealed upregulation of HLA class I cell surface expression. This phenotypic change was associated with increased level of HLA class I heavy chain, in absence of detectable changes in the expression of other antigen processing machinery (APM) components. Enhanced resistance of target cells to NK cell-mediated cytotoxicity was induced by enforced expression of EHZF in the cervical carcinoma cell line HeLa and in the B-lymphoblastoid cell line IM9. Preincubation of transfected cells with HLA class I antigen-specific mAb restored target cell susceptibility to NK cell-mediated lysis, indicating a specific role for HLA class I antigen upregulation in the NK resistance induced by EHZF. A potential clinical significance of these findings is further suggested by the inverse correlation between EHZF and MHC class I expression levels, and autologous NK susceptibility of freshly explanted multiple myeloma cells.

A clinico-pathologic study was performed in 25 patients undergoing aortic valve replacement because of regurgitation, caused by myxoid degeneration of the valve leaflets. Associated cardiac anomalies were floppy mitral valve (2 cases), floppy mitral valve and idiopathic hypertrophic subaortic stenosis (1), left atrial myxoma (1), and aortic coarctation at the isthmus (1). Three patients died (2 immediately and 1 on the 30th postoperative day). Pathological studies of the explanted valves showed deformities characterized by redundant thin leaflets which appeared soft and gelatinous. On histologic examination the fibrous layer of the leaflets was seen to be infiltrated by myxomatous tissue. Echocardiography showed the aortic root to be dilated in 13 patients and normal in the others. In those with normal aortic root, the histological examination of aortic wall disclosed minimal cystic medial necrosis in two cases. In contrast, more severe forms of cystic medial necrosis were evident in all patients having a dilated aortic root. Aortic valve replacement was performed in all cases. It was accompanied by a Bentall procedure (1 case), repair of ascending aorta dissection (2), replacement of the ascending aorta (1), mitral valve replacement (2), mitral valve replacement and apico-ascending aorta conduit (1) and excision of a left atrial myxoma (1). Our experience suggests that prolapse of the aortic valve due to floppy leaflets is a common degenerative disease which is generally associated with noninflammatory aortic root degeneration. This, together with aortic root dilatation, contributes to valve insufficiency. Nevertheless, the disease, when isolated (with normal aortic root), is liable in itself to produce aortic regurgitation. The need for early diagnosis is stressed, so as to be able to perform valve replacement.

BACKGROUND Midterm clinical and morphologic results of the septal-reshaping exclusion of anteroseptal dyskinetic or akinetic areas were evaluated. METHODS From January to June 2003, 44 patients with myocardial infarction following left anterior descending coronary artery (LAD) occlusion underwent septal reshaping. The mean (+/- SD) New York Heart Association (NYHA) class of the patients at admission was 2.7 +/- 0.9. Angina was referred in 21 cases. The incision was started at the apex and directed parallel to the LAD toward the base of the heart. The septum was rebuilt with 1 or 2 U-stitches passed from the inside to join the anterior wall to the septum by starting as high as possible where the scar began and continuing in an oblique direction toward the new apex. An oval polyethylene terephthalate fiber (Dacron) patch was then sutured from the septum (at the end of the direct suture through the border with the inferior septum) to the anterior wall (between the healthy wall and the scarred wall) and up to the new apex. RESULTS The 30-day mortality rate was 2.2% (1 patient, due to the failure of a previously implanted defibrillator). Three patients experienced acute renal failure. No patient had restrictive syndrome. After a mean follow-up period of 8.5 +/- 4.9 months (range, 4-22 months), the mean NYHA class improved from 2.7 +/- 0.9 to 1.6 +/- 0.5 (P < .001). The 18- month survival rate and the probability of being alive in NYHA class I or II were 93.2% +/- 2.0% and 90.9% +/- 4.3%, respectively. Echocardiographic results showed reductions in the left ventricle volume with a normalization of the stroke volume. The diastolic longitudinal length remained unchanged, and the diastolic sphericity index was reduced but not significantly. CONCLUSIONS At 1 year after surgery, the good clinical and morphologic results demonstrate the safety and effectiveness of septal reshaping for anteroseptal scars.