Role of oral sildenafil in the treatment of right ventricular dysfunction after heart transplantation

OBJECTIVE

Right ventricular dysfunction (RVD) after heart transplantation is a major complication, especially in patients with pulmonary hypertension (PH). Herein we have presented our initial experience with oral sildenafil for RVD following heart transplantation.

MATERIALS AND METHODS

From February 2006 to February 2008, 10 patients (7 males and 3 females) of overall mean age of 56.7 +/- 9.5 years suffered from acute RVD immediately after heart transplantation. Preoperative hemodynamic data before and after a vasodilatation test (sodium nitroprusside; NTP) showed: systolic pulmonary arterial pressure (SPAP) 59.5 +/- 12.9 and 44.2 +/- 12.4 mm Hg; cardiac output (CO) 3.3 +/- 0.9 and 3.7 +/- 0.8 L/min; transpulmonary gradient (TPG) 11.7 +/- 3.9 and 8.7 +/- 3.6 mm Hg; and pulmonary vascular resistance (PVR) 3.9 +/- 2.1 and 2.4 +/- 1.3 wood units (WU), respectively. All patients required inotropes and inhaled nitric oxide (iNO) to be weaned from cardiopulmonary bypass (CPB).

RESULTS

Intravenous (IV) or inhaled vasodilators could be weaned using oral sildenafil in all patients. The hemodynamic data obtained during IV or inhaled drugs (between postoperative days 5 and 10) compared with those obtained on sildenafil therapy alone (about 1 month after transplantation) showed a significant decrease in SPAP (39.0 +/- 8.2 vs 32.0 +/- 6.5 mm Hg; P = .049).

CONCLUSION

These data suggested that oral sildenafil may have a role in the treatment of RVD after heart transplantation.

Additional applications of the Foley catheter in cardiac surgery

We describe an additional use of the Foley catheter for preoperative and postoperative evaluation of the regurgitant mitral valve.

Transcutaneous insertion of the Chitwood® clamp in case of minimally invasive cardiac surgery. Personal experience

We describe a simple trick consisting of an insertion of a trans-thoracic Chitwood® clamp (Scanlan International, Inc, St Paul, MN, USA) through a small skin incision (<1cm), via the second intercostal space along the anterior axillary line, in case of minimally invasive mitral surgery, through right thoracotomy. This trick has been used in more than 100 patients and no complication or discomfort have been reported so far.

Two cases of right atrial myxoma in redo patients. A mere coincidence?

We describe two cases of right atrial myxoma in redo patients who had previously undergone to coronary artery by-pass grafting (CABGs) and mitral valve replacement respectively. Both of patients experienced effort dyspnea and were assessed by trans-thoracic echocardiography, revealing the right atrial masses. They were operated on for myxoma resection and postoperative course was uneventful. Our report deals with the interesting topic of the location of benign masses that are usually more common in the left atrium. Should we hypothesize that the right atrial manipulation during the previous surgery induces the onset of the right atrial mass? It is an interesting matter to debate.

Aortic valve replacement through the upper ministernotomy: preliminary experience with modified technique

Minimally invasive approach for aortic valve surgery has been developed since 1995, reducing the complications related to the full sternotomy. We have introduced a new method for central cannulation that reduces the length of surgical incision for the aortic valve replacement through upper mini-sternotomy. To improve the surgical view without enlargement of the incision, two small additional incisions are performed for both arterial and atrial cannulation. We have used the modified technique in 60 patients without sternal infection or other surgical complications and with good cosmetic results.

The Actis-gouge: a simple cutting tool for proper muscular resection in hypertrophic cardiomyopathy

BACKGROUND

Surgical treatment of hypertrophic cardiomyopathy (HC) may be challenging for the risk of surgical complications or insufficient resection. We present our cutting tool to perform proper muscular resection in HC.

MATERIAL AND METHODS

Ten patients (5 males, mean age 43,1 +/- 19,6 years, range 9-70 years) were operated on for HC using this semicircular cutting device. Combined procedures were : mitral valve repair (n = 1), mitral valve replacement (n = 2), right ventricular myectomy (n = 1), aortic valve replacement (n = 1), mitral and aortic replacement (n = 1).

RESULTS

There was one early death. All the surviving patients are alive over a variable follow up from 2 to 8 years, with consistent reduction of symptoms: in fact, no patient had residual angina with significant reduction of the NYHA class from 3,2 +/- 0,6 to 1,3 +/- 0,5 postoperatively (p < 0,05). Muscular resection was effective with significant reduction of sub-valvular gradient from 84.5 + 33,4 mmHg to 14,1 +/- 17,6 mmHg (p < 0,05) without complications such as complete atrio-ventricular block or ventricular septal defects.

CONCLUSION

Our semicircular myotome is an effective tool to perform a safe myectomy and it avoids surgical complications such as atrio-ventricular blocks or sub-valvular injuries. Our experience suggests that this cutting tool offers a reproducible method for muscular resection and it shows appreciable effects in the reduction of sub-valvular gradient with promising results in terms of morbidity and mortality.

Transmyocardial laser revascularization. Personal experience

BACKGROUND

Indirect revascularization is a therapeutic approach in case of severe angina not suitable for percutaneous or surgical revascularization. Transmyocardial revascularization (TMR) is one of the techniques used for indirect revascularization and it allows to create transmyocardial channels by a laser energy bundle delivered on left ventricular epicardial surface. Benefits of the procedure are related mainly to the angiogenesis caused by inflammation and secondly to the destruction of the nervous fibers of the heart.

PATIENTS AND METHOD

From September 1996 up to July 1997, 14 patients (9 males - 66.7%, mean age 64.8±7.9 years) underwent TMR. All patients referred angina at rest; Canadian Angina Class was IV in 7 patients (58.3%), III in 5 (41.7%). Before the enrollment, coronarography was routinely performed to find out the feasibility of Coronary Artery Bypass Graft (CABG): 13 patients (91,6%) had coronary arteries lesions not suitable for direct revascularization; this condition was limited only to postero-lateral area in one patient submitted to combined TMR + CABG procedures.

RESULTS

Mean discharge time was 3,2±1,3 days after surgery. All patients were discharged in good clinical conditions. Perfusion thallium scintigraphy was performed in 7 patients at a mean follow-up of 4±2 months, showing in all but one an improvement of perfusion defects. Moreover an exercise treadmill improvement was observed in the same patients and all of them are in good clinical conditions, with significantly reduced use of active drugs. CONCLUSION; Our experience confirms that TMR is a safe and feasible procedure and it offers a therapeutic solution in case of untreatable angina. Moreover, it could be a hybrid approach for patients undergoing CABGs in case of absence of vessels suitable for surgical approach in limited areas of the heart.

Upper-rim CMPO-substituted calix[6]- and calix[8]arene extractants for the An3+/Ln3+separation from radioactive waste

Two new ligands (1and2) for actinide/lanthanide separation derived from calix[6]- and calix[8]arenes functionalised at the upper rim with six or eight CMPO binding units were synthesised. These ligands, having a methoxy group at the lower rim, are conformationally mobile in solution at room temperature. Extraction data from water to a NPHE/n-octanol (90/10) solution of ligands1and2, in the presence of bromo-cosan as synergist, show that these derivatives are less efficient and selective than the previously reported homologues derived from calix[4]arenes or from the lower rim CMPO calix[6]- and calix[8]arenes, especially at high nitric acid concentrations. However, although compound1and2do not appear promising for the actinide/lanthanide separation from high acidity radioactive waste, the results obtained in this work disclose some important structural results which can be useful for the design of new efficient and selective polytopic ligands.

Single versus double lung transplantation in pulmonary fibrosis: a debated topic

Idiopathic pulmonary fibrosis (IPF) represents the second most frequent indication for lung transplantation after chronic obstructive pulmonary disease. Survival rate after transplantation is poorer compared with other lung diseases for reasons that are not completely clear. Medical therapy with anti-inflammatory drugs may improve symptoms and quality of life, but it does not influence the survival rate. Lung transplantation is the best therapy for end-stage IPF. The debate regarding the superiority of double lung transplantation (DLT) compared with single lung transplantation (SLT) is still ongoing. Until some years ago, SLT was almost uniformly utilized for this indication. In the most recent years, a larger application of DLT has been observed worldwide, probably related to higher 1-year and 5-year survivals. The unanswered question is whether it is ethical to use two lungs for the same patient, considering the donor shortage, when a single lung would suffice. Many reports have demonstrated that SLT offers acceptable pulmonary function and satisfactory early and intermediate survival. Probably DLT should be reserved for younger recipients, for those with concomitant or possible chronic infection of the contralateral lung, or cases of marginal donors. Further studies will be needed to formulate recommendations regarding the preferred surgical approach in IPF.

A prospective study of prevalence of 60-days postoperative wound infections after cardiac surgery. An updated risk factor analysis

AIM

Postoperative wound infections generally cause considerable extra morbidity, mortality and costs. The prevalence of total wound infections after cardiac surgery, including both sternal wound and donor site infections, ranges from 1.3 to 12.8%. The present study was conducted to identify the incidence of wound infections following cardiac surgery, to identify the risk factors and evaluate the efficacy of present modes of management.

METHODS

From September 2004 to May 2005, 493 consecutive patients undergoing cardiac surgery were included in the study and were followed for the prevalence of surgical site infection (SSI) up to 60 days postoperatively. The wound infections were defined according to the Centers for Disease Control and Prevention (CDC) and U.S. National Nosocomial Infections Surveillance (NNIS) system criteria.

RESULTS

The total incidence of SSI was 3.9%. Sternal wound infection (SWI) occurred in 17 patients (3.4%). Superficial wound infection was diagnosed in 10 patients (2%) and deep wound infection in 7 patients (1.4%). Donor site infection (DSI) occurred in 2 patients (0.4%). Early reoperation for bleeding, postoperative dialysis and the use of one internal mammary artery were independently associated with an increased risk of SWI.

CONCLUSION

Preventing SSI in the operating room is the primary goal of the surgical team. Attention should be paid to antibiotic prophylaxis and Methicillin-resistant Staphylococcus aureus (MRSA) nasal carriage treatment. The identification of risk factors will help to further reduce the incidence of wound infection.

Calixarene-based multivalent ligands

Multivalency is a powerful concept which explains the strong binding observed in biological systems and guides the design and synthesis of ligands for self-assembly and molecular recognition in Chemistry. The phenol-formaldehyde cyclic oligomers, called calixarenes, have been used as scaffolds for the synthesis of multivalent ligands thanks to the fact that they have a variable number of reactive positions for attaching the ligating functions, well defined conformational properties and, in some cases, cavities of molecular dimensions eventually able to encapsulate guest species. This tutorial review illustrates the fundamental aspects of multivalency and the properties of calixarene-based multivalent ligands in lectin binding and inhibition, DNA condensation and cell transfection, protein surface recognition, self-assembly, crystal engineering, and nanofabrication.

[Check-list for inspection in banks]

We suggest a checklist for inspection in banks. The checklist is composed of 14 schedules where information on bank clerks and buildings is collected. Principle risk factors are analysed (workplaces, lighting and noise, air quality, emergency management). The critical points are observed and the times of intervention are established. Then follows data processing and the reports are transmitted to the employer. The checklist, tested on 250 workplaces, allows us to identify the interventions having priority to be realized through appropriate planning. A quantitative evaluation of the risk is matched with immediate and brief operative indications. The situations to improve are: cleanliness of workplaces, thermal comfort, electricity/telephone wires. The checklist seems to be a valid instrument for the evaluation of risk factors, their management and times of intervention. Such instrument simplifies, moreover, the employer choices of intervention.

The human tumor suppressor arf interacts with spinophilin/neurabin II, a type 1 protein-phosphatase-binding protein

The INK4a gene, one of the most often disrupted loci in human cancer, encodes two unrelated proteins, p16(INK4a) and p14(ARF) (ARF) both capable of inducing cell cycle arrest. Although it has been clearly demonstrated that ARF inhibits cell cycle via p53 stabilization, very little is known about the involvement of ARF in other cell cycle regulatory pathways, as well as on the mechanisms responsible for activating ARF following oncoproliferative stimuli. In search of factors that might associate with ARF to control its activity or its specificity, we performed a yeast two-hybrid screen. We report here that the human homologue of spinophilin/neurabin II, a regulatory subunit of protein phosphatase 1 catalytic subunit specifically interacts with ARF, both in yeast and in mammalian cells. We also show that ectopic expression of spinophilin/neurabin II inhibits the formation of G418-resistant colonies when transfected into human and mouse cell lines, regardless of p53 and ARF status. Moreover, spinophilin/ARF coexpression in Saos-2 cells, where ARF ectopic expression is ineffective, somehow results in a synergic effect. These data demonstrate a role for spinophilin in cell growth and suggest that ARF and spinophilin could act in partially overlapping pathways.

Reinitiation of protein synthesis in Escherichia coli can be induced by mRNA cis-elements unrelated to canonical translation initiation signals

In Eubacteria, de novo translation of some internal cistrons may be inefficient or impossible unless the 5' neighboring cistron is also translated (translational coupling). Translation reinitiation is an extreme case of translational coupling in which translation of a message depends entirely on the presence of a nearby terminating ribosome. In this work, the characteristics of mRNA cis-elements inducing the reinitiation process in Escherichia coli have been investigated using a combinatorial approach. A number of novel translational reinitiation sequences (TRSs) were thus identified, which show a wide range of reinitiation activities fully dependent on a translational coupling event and unrelated to the presence/absence of secondary structure or mRNA stability. Moreover, some of the isolated TRSs are similar to intercistronic sequences present in the E. coli genome.

Speech considerations in prosthodontic rehabilitation of the glossectomy patient

A knowledge of normal articulation is needed before the prosthodontist can assess the compensatory articulation used by glossectomy patients. The amount and portion of tongue resected is directly correlated with speech intelligibility. The loss of the tip of the tongue is more critical to intelligibility than a hemiglossectomy. Partial glossectomy speakers can often use the residual tongue stump to perform adaptive movements that approximate normal movements and should be treated as an articulation problem. The compensatory articulation used by the total glossectomy patient was reviewed. The prosthodontic management of patients with partial tongue resection often includes lowering the palatal vault, while the management of the total glossectomy patient usually requires a mandibular tongue prosthesis. These prostheses can be refined with the use of multiview videofluoroscopy, videotaping, and spectrographic analysis.

Morphologic and biochemical abnormalities of kidney lysosomes in mice with an inherited albinism

The light-ear mutation in the mouse may serve as a useful model for the human inherited oculocutaneous albinisms such as the Hermansky-Pudlak and Chédiak-Higashi syndromes. The authors have investigated the kidney lysosomes of le/le mutant mice by histochemical methods. A striking increase in the staining reaction for the lysosomal enzymes beta-galactosidase and acid-phosphatase was evident in kidney cortex of the mutant mice, in comparison with +/+ controls. The lysosomal protease, cathepsin C, is also found to be elevated in the mutant. By light microscopy, there appeared to be an increase in the number of lysosomes in mutant kidney. Electron microscopy revealed the presence of large, multilamellar granules in proximal tubule cells. Analysis of sedimentation through sucrose gradients demonstrated the presence of a low-density population of lysosomes in the mutant kidney. In addition, a striking accumulation of ceroidlike pigment was observed. The molecular lesions responsible for the melanolysosomal syndromes in mice and man are still unidentified.

[Echotomography in the diagnosis of abdominal masses]

The contribution of echotomography in the surgical approach to intra-abdominal masses is illustrated through description of several clinical observations. In order to effect frontal reconstruction of ultrasonic seriography, the authors used a manual-scanning B echotomograph probe working in the range of grays. This technic afforded detection of the intraperitoneal and extraperitoneal abdominal masses under investigation as well as precise definition of their location, size, and nature. Because of its rapidity and painlessness, echotomography should be adopted as firstchoice procedure for the diagnostic exploration of intraabdominal masses. Frontal reconstruction enables the surgeon to verify the topography of said masses with remarkable precision, and hence to plan surgery more intelligently.

Effect of glucagon infusion on plasma cyclic AMP in patients with cholestatic hepatitis and obstructive jaundice. New test of hepatic cholestasis

Plasma cyclic AMP concentration during glucagon infusion at various time intervals was determined in 8 normal subjects, 9 patients with extrahepatic obstructive jaundice and 10 patients with cholestatic hepatitis (hepatitis A and B). Plasma cyclic AMP concentrations (pmol/ml) during glucagon infusion in patients with both obstructive jaundice and cholestatic hepatitis were found to be greater than those in control subjects. In addition, a significant difference in plasma cyclic AMP concentrations was found between patients with cholestatic hepatitis and obstructive jaundice at the 10th minute of glucagon infusion. These results indicate that plasma cyclic AMP levels at the 10th minute of glucagon infusion represent a reliable diagnostic index of cholestatic jaundice.