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Představujeme kazuisticke sděleni zkusenosti s lecbou mlade 35lete pacientky s vzacným tumorem CNS - pineoblastomem. Po parcialnim neurochirurgickem zakroku byla pacientka indikovana multidisciplinarnim týmem k protonove terapii tužkovým svazkem s profylaktickým ozařenim kraniospinalni osy davkou 36 Gy (Gray equivalent), do celkove davky na lůžko tumoru 59,4 Gy a konkomitantni aplikaci chemoterapie temozolomidem. Po ukonceni chemoradioterapie pacientka absolvovala 4 cykly vysokodavkovane chemoterapie s podporou perifernich kmenových buněk. 11 měsiců po ukonceni protonove chemoradioterapie s dobrou toleranci pacientka zůstava bez přiznaků rezidualniho onemocněni. Kazuistika poukazuje na přiznivou kratkodobou lecebnou odpověď a přiznivý neurologický výsledek terapie tohoto vzacneho tumoru pinealni krajiny. Jsou prodiskutovany různe literarně popisovane lecebne strategie.

Twenty (10 intensity-modulated proton therapy (IMPT) and 10 intensity-modulated x-ray therapy (IMXT) treatment plans for patients with advanced prostate carcinoma were compared in this study. All chosen patients were indicated for prostate and pelvic lymph nodes irradiation using simultaneous integrated boost technique. These patients represent typical specimen for this diagnose. IMPT irradiates just half of the tissue volume with a low dose (up to 10 cobalt gray equivalent) compared to IMXT without compromise in target volumes coverage and in this way reduces the risk of secondary cancer development or other possible complications.

Introduction Extreme hypofractionated radiotherapy for prostate cancer is a common modality in photon therapy. Pencil beam scanning (PBS) in similar fractionation allows better dose distribution and makes proton therapy more available for such patients. The purpose of this study is the feasibility of extreme proton hypofractionated radiotherapy and publication of early clinical results. Methods Two hundred patients with early-stage prostate cancer were treated with IMPT (intensity-modulated proton therapy), extreme hypofractionated schedule (36.25 GyE in five fractions) between February 2013 and December 2015. Mean age of the patients was 64.3 years, and the mean value of prostate-specific antigen (PSA) before treatment was 6.83 μg/L (0.6-17.3 μg/L). Ninety-three patients (46.5%) were in the low-risk group. One hundred and seven patients (53.5%) were in the intermediate-risk group. Twenty-nine patients (14.5%) had neoadjuvant hormonal therapy, and no patients had adjuvant hormonal therapy. Acute toxicity, late toxicity and short-term results were evaluated. Results All patients finished radiotherapy without interruptions. The median follow-up time was 36 months. The mean treatment time was 9.5 days (median 9 days). Acute toxicity according to Common Terminology Criteria for Adverse Events (CTCAE) v 4.0 was (gastrointestinal toxicity) GI (grade) G1-17%, G2-3.5%; (genitourinary toxicity) GU G1-40%, G2-19%; and no G3 toxicity was observed. Late toxicity was GI G1-19%, G2-5.5%; GU G1-17%, G2-4%; and no G3 toxicity was observed. PSA relapse was observed in one patient (1.08%) in the low-risk group (pelvic lymph node involvement was detected) and in seven patients (6.5%) in the intermediate-risk group (three lymph node metastases, two lymph node and bone metastases, two PSA relapses). No patient died of prostate cancer, and three patients died from other reasons. No local recurrence of cancer in the prostate was observed. Conclusions Proton beam radiotherapy for prostate cancer is feasible with a low rate of acute toxicity and promising late toxicity and effectivity.

Background and purpose: A collaborative network between proton therapy (PT) centres in Trento in Italy, Poland, Austria, Czech Republic and Sweden (IPACS) was founded to implement trials and harmon...

Purpose To analyze the 5-year biochemical disease-free survival (bDFS) and late toxicity profile in patients with prostate cancer treated with pencil beam scanning (PBS) proton radiation therapy. Methods and Materials Between January 2013 and March 2016, 284 patients with prostate cancer were treated using intensity modulated proton therapy (IMPT), with an ultrahypofractionated schedule (36.25 GyE in 5 fractions). Five patients were immediately lost from follow-up and thus were excluded from analysis. Data for 279 patients were prospectively collected and analyzed with a median follow-up time of 56.5 (range, 3.4-87.5) months. The mean age at time of treatment was 64.5 (40.1-85.7) years, and the median prostate-specific antigen (PSA) value was 6.35 μg/L (0.67-17.3 μg/L). A total of 121 (43.4%) patients had low-risk, 125 patients (44.8%) had favorable, and 33 (11.8%) unfavorable intermediate-risk cancer. In addition, 49 (17.6%) patients underwent neoadjuvant hormonal therapy, and no patients had adjuvant hormonal therapy. bDFS and late toxicity profiles were evaluated. Results The median treatment time was 9 days (range, 7-18 days). The 5-year bDFS was 96.9%, 91.7%, and 83.5% for the low-, favorable, and unfavorable intermediate-risk group, respectively. Late toxicity (Common Terminology Criteria for Adverse Events v.4) was as follows: gastrointestinal: grade 1, 62 patients (22%), grade 2, 20 patients (7.2%), and grade 3, 1 patient (0.36%); genitourinary: grade 1, 80 patients (28.7%), grade 2, 14 patients (5%), and grade 3, 0 patients. PSA relapse was observed in 17 patients (6.1%), and lymph node or bone recurrence was detected in 11 patients. Four (1.4%) local recurrences were detected. Nine patients (3.2%) died of causes unrelated to prostate cancer. No deaths related to prostate cancer were reported. Conclusion Ultrahypofractionated proton beam radiation therapy for prostate cancer is effective with long-term bDFS comparable with other fractionation schedules and with minimal serious long-term GI and GU toxicity.

Nowadays, the irradiation methodology in proton therapy is switching from the use of passively scattered beams to active pencil beams due to the possibility of more conformal dose distributions. The dose rates of active pencil beams are much higher than those of passive beams. The purpose of this study was to investigate whether there is any difference in the biological effectiveness of these passive and active irradiation modes. The beam qualities of double scattering and pencil beam scanning were measured dosimetrically and simulated using the Monte Carlo code. Using the medulloblastoma cell line DAOY, we performed an in vitro comparison of the two modes in two positions along the dose&ndash, deposition curve plateau and inside the Bragg peak. We followed the clonogenic cell survival, apoptosis, micronuclei, and &gamma, H2AX assays as biological endpoints. The Monte Carlo simulations did not reveal any difference between the beam qualities of the two modes. Furthermore, we did not observe any statistically significant difference between the two modes in the in vitro comparison of any of the examined biological endpoints. Our results do not show any biologically relevant differences related to the different dose rates of passive and active proton beams.

A well-known shortcoming of radiotherapy is the lack of information regarding the effect that metallic implants, located near the area of interest, have on the dose distribution in the target volume. In this work, a scanned proton pencil beam was applied to hip implant phantoms to evaluate Linear Energy Transfer (LET) and to study the secondary particles produced close to the implant. Using two different materials that are in standard use in hip implant production worldwide, phantoms with thicknesses of 2, 5, 10, 15, and 20 mm were manufactured. The first phantom type consists of a titanium (Ti) alloy, while the second is composed of a stainless steel (SS) alloy. Both phantoms were irradiated at various energies. Solid - state nuclear track etched detectors (TEDs) have been used to determine LET spectra of primary protons and secondary particles, both behind the implants and near their edges. The results indicate that LET spectra behind particular materials of different thicknesses do not differ from qualitative point of view. When we compared LET spectra of Ti and SS materials of the same thickness, more particles with LET, below 20 keV/μm, were detected behind the SS phantom. At the border of a phantom made from 20 mm metallic alloy, there was an accumulation of tracks, resulting from the scattering of the protons in the material. The dosimetric information, obtained in the experimental study, can be further applied either for benchmarking treatment planning systems or for biological dose calculations.

Představujeme kasuistiku perforace Valsalvova sinu do prave sině u 44leteho pacienta s osmiměsicni progredujici namahovou dusnosti, obcasnými palpitacemi a otoky dolnich koncetin. Při echokardiografickem vysetřeni bylo nalezeno masivni levoprave zkratove prouděni mezi výtokovým traktem leve komory a pravou sini. U pacienta byl indikovan chirurgický výkon, během ktereho byl nalezen defekt v oblasti nekoronarniho cipu, jdouci do prave sině, s kalcifikacemi v anulu vrozeně bikuspidalni aortalni chlopně, bez přitomných znamek endokarditidy, z prave sině byla excidovana abundantni tkaň, ktera byla původně aneurysmatem nekoronarniho cipu aortalniho kořene. Aneurysma Valsalvova sinu je velice vzacnou patologii, ktera je větsinou asymptomaticka. V tomto připadě se projevila perforaci do prave sině a symptomatologii pravostranneho srdecniho selhani. Jedinou možnosti lecby byl chirurgický zakrok.

Monte Carlo (MC) simulations using the MCNPX™ code supported by measurements were exploited for detailed characterization of secondary neutrons generated by high energy protons during pencil beam proton therapy. The study focused on the estimation of the distribution of secondary neutron points of origin, their average initial energy, and the distribution of absorbed dose and equivalent dose from neutrons and photons inside the NYLON 6 phantom (diameter of 25.5 cm, length of 31.0 cm) irradiated with a proton beam with the energies of 100, 150 and 200 MeV. Validation of the MC model and the used methods was done by comparison of calculated responses of the extended-range Bonner Sphere Spectrometer at several positions outside the phantom with the measured ones. The results show that high energy neutrons predominate in the direction of the proton beam and more neutrons are generated by higher energy protons. The MC simulations also demonstrated that the majority of high energy neutrons is generated at the beginning of the proton trajectory in the phantom and the neutron yield and neutron initial average energy decrease with increasing depth. Therefore, attention should be paid not only to the tissues behind the irradiated volume, but also to the preceding ones. However, the neutron spectral fluence in the vicinity of the treated tissue can only be determined by calculation, mainly due to the dimensions of the neutron spectroscopic instrumentation. The calculation of the spatial distribution of the radiation weighting factor for neutrons allowed us to estimate the distribution of the neutron equivalent dose inside the phantom. The maximal value of the neutron equivalent dose within the phantom reached 42, 24, and 15 pSv per one primary 100, 150, and 200 MeV proton, respectively, and occurred on the beam axis roughly at the half of the proton range. With respect to the proton dose, these maximal values of the neutron equivalent dose correspond to 2.1%, 1.3%, and 1.4% of the proton dose in the Bragg peak for these proton energies. Moreover, equivalent doses of secondary induced photons were more than 3 orders of magnitude lower that the neutron ones.

Simple Summary Eligible patients received PBS IMPT at a single institution. Treatment was administered in two volumes: 1—tumour with margins plus involved lymph nodes; 2—regional lymph node groups: perirectal (mesorectal), obturatory, inguinal, internal, external, and common iliac. The total doses of 57.5 GyE and 45 GyE, respectively, were administered in volumes 1 and 2 in 25 fractions, 5 fractions per week, respectively (a simultaneous integrated boost). Concomitant chemotherapy cisplatinum (CDDP) plus 5-FU or CDDP plus capecitabine was administered as per protocol. This single-institution study showed the high efficacy of PBS IMPT, achieving a high rate of complete regression. The 2-year overall survival, relapse-free survival and colostomy-free survival were 94.2, 93.8 and 91.0%, respectively. The haematological acute toxicity of grade 3–4 remained low. The acute toxicity completely resolved in all patients and had no lethal outcomes. Abstract Background: A favourable dose distribution has been described for proton beam therapy (PBT) of anal cancer in dosimetric studies. The relationship between dosimetric parameters in bone marrow and haematologic toxicity, treatment interruptions, and treatment efficacy has also been documented. There are only few references on clinical results of PBT for anal cancer. The primary objective of the retrospective study was to assess the efficacy of pencil beam scanning intensity-modulated proton therapy (PBS IMPT) in the definitive chemoradiotherapy of anal cancer. Secondary objectives were established to identify the risks of acute chronic toxicity risks and to assess colostomy rates. Materials and methods: Patients were treated for biopsy-proven squamous cell cancer (SCC) of the anus at initial or advanced stages. Eligible patients received PBS IMPT at a single institution. Treatment was administered in two volumes: 1—tumour with margins plus involved lymph nodes; 2—regional lymph node groups: perirectal (mesorectal), obturatory, inguinal, internal, external, and common iliac. The total doses of 57.5 GyE and 45 GyE, respectively, were administered in volumes 1 and 2 in 25 fractions, 5 fractions per week, respectively (a simultaneous integrated boost). Concomitant chemotherapy cisplatinum (CDDP) plus 5-FU or CDDP plus capecitabine was administered as per protocol. The treatment effect was assessed using DRE (digital rectal examination) and MRI (magnetic resonance imaging) within the follow-up period. Toxicity was scaled using CTCAE version 4.0 criteria. Results: 39 of 41 patients treated during the period of February 2014–August 2021 were eligible for analysis. All patients completed treatment, 76.9% without interruption. The median treatment time was 35 days (32–35). The median follow-up period was 30 months, 34 patients are alive to-date, 5 patients died prior to the date of analysis, and 2 deaths were unrelated to the primary disease. The 2-year overall survival, relapse-free survival, and colostomy-free survival were 94.2%, 93.8%, and 91.0%, respectively. Complete regression was achieved in 36 patients (92.3%), partial regression was achieved in 2 (5.1%), and immediate progression at end of treatment occurred in 1 patient (2.6%). Salvage resection was indicated for two patients in partial regression and due to severe chronic dermatologic toxicity. The grade 3 and 4 haematological toxicity rates were 7.7% and 5.1%, respectively. The most frequent non-haematological acute toxicities of grade 3–4 observed were dermatitis (23.1%), diarrhoea (7.7%), and dehydration (7.7%). Chronic toxicity emerged predominantly as skin atrophy/ulceration grade 2 (26.5%) and grade 3–4 (5.8%), and radiation proctitis grade 2 (38.2%) and grade 3 (2.9%). Discussion, conclusions: This single-institution study showed the high efficacy of PBS IMPT, achieving a high rate of complete regression. The haematological acute toxicity of grade 3–4 remained low; however, the impact of altered chemotherapy (CDDP instead of mitomycin C) remains unclear. The incidence of other acute toxicities shares similarity with photon therapy investigated in large studies. The acute toxicity completely resolved in all patients, had no lethal outcomes, and never resulted in the necessity for colostomy. By contrast, it was chronic toxicity, skin ulceration, perirectal fistulation, and fibrosis that resulted in salvage surgery and/or the need for a colostomy. A challenging question remains: to what extent can PBT prevent chronic toxicity? Longer follow-up remains necessary.

Extended Bonner Spheres spectrometer was used to measure the angular distribution of neutron spectral fluence around NYLON6 phantom irradiated with pencil beam of 100, 150 and 200 MeV protons at the Proton Therapy Center Praha. Measurements were supplemented by a calculation of neutron spectral fluences at different depths of the phantom. The calculation of neutron spectral fluence at different depth of the phantom demonstrated that the majority of high energy neutrons was generated at the beginning of the proton trajectory in the phantom and the neutron yield decreased with increasing depth, with a minimum at the depth corresponding to the Bragg peak. Therefore, attention should be paid not only to the tissue behind the irradiated volume, but also to the preceding tissue. However, the neutron spectral fluence in the vicinity of the treated tissue can only be determined by calculation, mainly due to the dimensions of the neutron spectroscopic instrumentation. This paper presents a suitable technique and experimental conditions to acquire reliable data necessary for the proper determination of neutron spectral fluence. From the measured spectral fluences, the neutron fluence in whole-range and partial energy intervals were determined together with the corresponding ambient dose equivalents at measurement positions. The obtained results indicate that high energy neutrons predominate at the direction of the proton beam and more neutrons are generated by higher energy protons.

Purpose: To investigate the clinical implications of a variable relative biological effectiveness (RBE) on proton dose fractionation. Using acute exposures, the current clinical adoption of a generic, constant cell killing RBE has been shown to underestimate the effect of the sharp increase in linear energy transfer (LET) in the distal regions of the spread-out Bragg peak (SOBP). However, experimental data for the impact of dose fractionation in such scenarios are still limited.Methods and Materials: Human fibroblasts (AG01522) at 4 key depth positions on a clinical SOBP of maximum energy 219.65 MeV were subjected to various fractionation regimens with an interfraction period of 24 hours at Proton Therapy Center in Prague, Czech Republic. Cell killing RBE variations were measured using standard clonogenic assays and were further validated using Monte Carlo simulations and parameterized using a linear quadratic formalism.Results: Significant variations in the cell killing RBE for fractionated exposures along the proton dose profile were observed. RBE increased sharply toward the distal position, corresponding to a reduction in cell sparing effectiveness of fractionated proton exposures at higher LET. The effect was more pronounced at smaller doses per fraction. Experimental survival fractions were adequately predicted using a linear quadratic formalism assuming full repair between fractions. Data were also used to validate a parameterized variable RBE model based on linear α parameter response with LET that showed considerable deviations from clinically predicted isoeffective fractionation regimens.Conclusions: The RBE-weighted absorbed dose calculated using the clinically adopted generic RBE of 1.1 significantly underestimates the biological effective dose from variable RBE, particularly in fractionation regimens with low doses per fraction. Coupled with an increase in effective range in fractionated exposures, our study provides an RBE dataset that can be used by the modeling community for the optimization of fractionated proton therapy.

Measurements described in this article were carried out with the aim of evaluating risks of the patient exposure to secondary neutrons during treatment at the Proton Therapy Centre Prague. The neutron spectral fluence was measured by means of the extended Bonner sphere spectrometer (EBS). The article presents secondary neutron spectral fluences obtained by the EBS with passive thermoluminescent detectors, i.e. pairs of 6LiF and 7LiF chips. Measurements were performed in two positions: the first one behind the Nylon 6 phantom, and the second one close to the range shifter to evaluate their contribution to the generation of neutrons. Both the Nylon 6 phantom and the range shifter were irradiated with a pencil beam of protons 4 mm in diameter and the energy of 200 MeV. The results are supplemented with the values of effective dose derived from neutron spectral fluences.

The aim of this study was to investigate the absorbed dose and the linear energy transfer (LET) of a scanning proton pencil beam at the Proton Therapy Center Czech, applied to phantoms containing metal implants. We investigated two different phantoms composed of commonly used metals with a known chemical composition. Two rectangular phantoms consisted of water-equivalent environment material with a 65 mm thickness surrounding the 2, 5, 10 and 15 mm inserts of grade-2 and grade-5 Titanium. Track-etched detectors (TEDs) were placed behind the phantoms to gather the data. The measured LET spectra behind the implants were compared with Monte Carlo simulations using the Geant4 toolkit, version 10.03.p01. The simulations were used to provide additional information regarding the contribution of each type of particles to the LET spectra (protons, alpha particles, deuteron, neutrons, photons, and electrons) and to estimate the LET spectra above the TED's detection threshold. We used two different beam energies to study the most pertinent irradiation scenarios, one in the Bragg curve plateau and one at the maximum. The measurement of the LET spectra behind phantoms irradiated with a proton beam in the plateau region of the Bragg curve led to the detection of numerous particles with a very high LET. Lateral dose enhancement at the border between implants and the plastic material was detected when the phantoms were exposed to a proton beam and the data were recorded in the Bragg peak maximum. In this area, the dose increased 13 times for grade-2 Ti and 12 times for grade-5 Ti. The performed experimental study highlights the effect of dental implants on the LET spectra and absorbed dose when a proton pencil beam is crossing high-density titanium.

Dose delivered outside the proton field during radiotherapy can potentially lead to secondary cancer development. Measurements with a 170-MeV proton beam were performed with passive detectors (track etched detectors and thermoluminescence dose-meters) in three different depths along the Bragg curve. The measurement showed an uneven decrease of the dose outside of the beam field with local enhancements. The major contribution to the delivered dose is due to high-energy protons with linear energy transfer (LET) up to 10 keV mu m(-1). However, both measurement and preliminary Monte Carlo calculation also confirmed the presence of particles with higher LET.

In recent years, there is an increased interest in using scanning modes in proton therapy, due to the more conformal dose distributions, thanks to the spot-weighted dose delivery. The dose rate in each spot is however much higher than the dose rate when using passive irradiation modes, which could affect the cell response. The purpose of this work was to investigate how the relative biological effectiveness changes along the spread-out Bragg peak created by protons delivered by the pencil beam scanning mode. Cell survival and micronuclei formation were investigated in four positions along the spread-out Bragg peak for various doses. Monte Carlo simulations were used to estimate the dose-averaged linear energy transfer values in the irradiation positions. The cell survival was found to decrease the deeper the sample was placed in the spread-out Bragg peak, which corresponds to the higher linear energy transfer values found using Monte Carlo simulations. The micronuclei frequencies indicate more complex cell injuries at that distal position compared to the proximal part of the spread-out Bragg peak. The relative biological effectiveness determined in this study varies significantly and systematically from 1.1, which is recommended value by the International Commission on Radiation Units, in all the studied positions. In the distal position of spread-out Bragg peak the relative biological effectiveness values were found to be 2.05 ± 0.44, 1.85 ± 0.42, 1.53 ± 0.38 for survival levels 90, 50 and 10%, respectively.

To present the feasibility and results of accelerated radiotherapy with concomitant boost technique (69.5 Gy/5 weeks) in the treatment of locally advanced head and neck cancer. A total of 65 patients were treated between June 2006 and August 2009. The distribution of clinical stages was as follows: II 11%, III 23%, IV 61%, and not defined 5%. The median follow-up was 30.5 months. The treatment plan was completed in 94% of patients. Patients were treated using the conformal or intensity-modulated radiotherapy (IMRT) technique. The median overall treatment time was 37 days (13–45 days). The mean radiotherapy dose was 68.4 Gy (16–74 Gy). Overall survival was 69% after 2 years. Disease-free survival was 62% after 2 years. Acute toxicity ≥ grade 3(RTOG scale) included mucositis (grade 3: 42.6%), pharynx (grade 3: 42.3%), skin (grade 3: 9.5%), larynx (grade 3: 4%), while late toxicity affected skin (grade 3: 6.25%) and salivary glands (grade 3: 3.7%). Accelerated radiotherapy with concomitant boost technique is feasible in patients with locally advanced head and neck cancer, has an acceptable toxicity profile, and yields promising treatment results.

Introduction Pencil beam scanning mode is becoming widely used in proton therapy. The biological consequences of the use of pencil beam scanning instead of double scattering mode have not been studied in detail yet. Most of the biological studies of relative biological effectiveness of protons were carried out using double scattering mode. The dose rates in pencil beam scanning are locally essentially higher than those in double scattering mode, which could affect the cell response. Purpose The main purpose of this study was to study the in vitro biological consequences of the use of pencil beam scanning in comparison to double scattering mode. Materials and methods Cell culture samples (normal human fibroblasts, medulloblastoma cell line DAOY) were irradiated by both modes using the same proton energies and doses. The initial energy of protons used for the irradiations was selected according to the clinical options in double scattering. The same energy was then adjusted for the pencil beam scanning mode. Several parameters (cell survival, apoptosis level, double strand break induction) of the cells were followed in various times post irradiation. Results The cell survival was found to be lower for the pencil beam scanning mode in both studied positions in the Bragg curve (plateau, peak). The apoptosis level and the induction of double strand breaks were found to be higher for pencil beam scanning mode. Conclusion We suggest that pencil beam scanning mode is slightly more efficient than double scattering mode. Disclosure No conflict.

Spectral fluences of neutrons generated in the heads of the radiotherapeutic linacs Varian Clinac 2100 C/D and Siemens ARTISTE were measured by means of the Bonner spheres spectrometer whose active detector of thermal neutrons was replaced by an activation detector, i.e. a tablet made of pure manganese. Measurements with different collimator settings reveal an interesting dependence of neutron fluence on the area defined by the collimator jaws. The determined neutron spectral fluences were used to derive ambient dose equivalent rate along the treatment coach. To clarify at which components of the linac neutrons are mainly created, the measurements were complemented with MCNPX calculations based on a realistic model of the Varian Clinac.

We present an alternative way to create a video-assisted port access proximal anastomosis in the ascending aorta with the Symmetry Bypass System Aortic Connector (St. Jude Medical ATG, St. Paul, MN). This technique was successfully used in a patient undergoing urgent minimally invasive direct coronary artery bypass grafting (MIDCABG), in whom the left internal mammary artery was not harvested owing to subtotal occlusion of the left subclavian artery. Port access use of mechanical anastomotic devices may increase the indications for minimally invasive coronary artery surgery.

Calcification of the mitral annulus is a degenerative process, which occurs mainly in older patients. Rarely, an extensive mitral annular calcification (MAC) with central liquefaction was reported. We report the case of extension of MAC into the adjacent left ventricular posterior wall along with central liquefaction and posterior mitral leaflet displacement in a 63-year-old woman. The abnormal size of the MAC and unusual echo density of pasty material inside made a correct diagnosis difficult and intracardiac tumor was suspected. Thus, similar uncommon clinical presentation of MAC should be considered in the differential diagnosis of intracardiac masses.

Objective: We sought to demonstrate the applicability of video-assisted multivessel revascularization through a left anterior small thoracotomy approach with the use of the Symmetry Aortic Connector System (St Jude Medical Anastomotic Technology Group, Inc, St Paul, Minn) as an alternative to the standard median sternotomy approach and to evaluate predischarge angiographically documented graft patency. Methods: From October 2001 through February 2002, a total of 15 patients with triple-vessel disease were operated on through a left anterior small thoracotomy approach with video-assisted port-access construction of proximal aorta-to-saphenous vein anastomoses with the Symmetry Aortic Connector System and cardiopulmonary bypass with femoral cannulation and without cardioplegic arrest. There were 9 male and 6 female subjects with a mean age of 68.3 ± 3.6 years and an average ejection fraction of 55.8% ± 19.6%. Subject inclusion criteria consisted of female sex (initially but not throughout the study), coronary artery reoperations, and sternal bone disease. Subject exclusion criteria consisted of an age younger than 65 years, extensive atheromatous plaques in the ascending aorta, and aortoiliac occlusive disease. All but 1 patient underwent angiographic patency evaluation before discharge. Results: Fifteen operations were performed successfully without any deaths. Twenty-nine sutureless proximal anastomoses were performed, with an average of 3.13 ± 0.62 distal anastomoses per patient. Eleven (73%) patients underwent a fast track protocol with extubation in the operating room. We did not observe any instances of low cardiac output syndrome, stroke, renal insufficiency, wound complication, or perioperative myocardial infarction. A single episode of atrial fibrillation occurred in this group. Angiographic assessment of 44 bypass grafts and target arteries was performed, and 86% of those examined were widely patent (FitzGibbon score A). Conclusions: We have demonstrated a potential advantage of the sutureless Symmetry Aortic Connector System as a suitable approach that affords minimal access. Video-assisted multivessel revascularization through a left anterior small thoracotomy approach with an automated mechanical anastomosis device is particularly useful in patients undergoing coronary artery bypass reoperations or those at risk of poor sternal healing or infection. This approach seems to be a safe alternative to standard median sternotomy. J Thorac Cardiovasc Surg 2003;125:129-34

Left ventricular (LV) hypertrophy is a strong predictive factor for cardiovascular morbidity and mortality. LV structure and function are influenced by many variables, including genetic background. The potential role of gene polymorphisms of different components of the renin angiotensin system remains controversial. The aim of this study was to determine the influence of deletion/insertion (D/I) polymorphism of the angiotensin-converting enzyme (ACE) gene and M235--T polymorphism of the angiotensinogen (AG) gene on left ventricular morphology and function in young normotensive men. The study included 110 normotensive healthy males (mean age 24 +/- 4 years, age range 18 to 34 years) who were assessed by echocardiography for LV structure and function. In all subjects ACE D/I polymorphism was evaluated using a polymerase chain reaction (PCR) method. M235--T polymorphism assessment was available in 98 individuals. Significant differences between groups according to ACE I/D or AG M235--T polymorphisms were not found for parameters of LV morphology or for parameters of systolic and diastolic function. When subjects with DD or ID genotypes were grouped, their LV mass index was higher than that in subjects with II genotypes (86 +/- 14 vs 79 +/- 15, r = 0.033, p = 0.05). There were no significant differences among other variables. In a population of young normotensive men where the influence of confounding variables such as age, gender and associated pathological conditions is minimized, the gene polymorphisms of ACE I/D and AG M235--T are not important determinants of LV structure and function.