Global psychological assessment with the evaluation of life and sleep quality and sexual and cognitive function in a large number of patients with acromegaly: a cross-sectional study

OBJECTIVE

Acromegaly is associated with somatic disfigurements which impair self-perception of well-being and quality of life. Nowadays, limited data are available on the interplay between hormonal excess and psychological discomfort. The study aimed at investigating the psychological profile, sleep quality, sexual function, cognitive functions, and quality of life in patients with acromegaly.

METHODS

In 223 acromegaly patients from 5 referral centres, global psychological profile, sleep quality, sexual function, cognitive function, and quality of life were investigated.

RESULTS

Depression was found in ~30% of patients, and anxiety in two-thirds, together with severe discomfort in body image mainly in women. Obstructive sleep apnoea syndrome risk and sleep disorders were found in >50% of patients and daily sleepiness in ~20%. Sexual dysfunction was reported in most of the patients, with the most severe impairment in women. Cognitive functions were compromised in ~10% of cases. Disease duration and patient's age and gender were the main determinants of these psychopathological conditions. Depression (P = 0.047), somatic-affective mood lowering (P = 0.021), state (P < 0.001) and trait (P = 0.013) anxiety, and body image distortion in body uneasiness test A (P < 0.001) and B (P = 0.006) were significantly worsened in patients <45 years and slightly worsened in those with disease duration less than 2 years. Male (P < 0.001) and female (P < 0.001) sexual function scores were significantly worsened in patients aged >64 years and slightly worsened in those with disease duration for more than 10 years, particularly in presence of cardiometabolic and respiratory complications. Cognitive symptoms were slightly worsened in older patients and in those with long disease duration.

CONCLUSIONS

Acromegaly is associated with a relevant impairment of psychological profile persisting despite remission and long-term medical treatment.

Multimodal measurement of glycocalyx degradation during coronary artery bypass grafting

Background

Glycocalyx shedding and subsequent endothelial dysfunction occur in many conditions, such as in sepsis, in critical illness, and during major surgery such as in coronary artery bypass grafting (CABG) where it has been shown to associate with organ dysfunction. Hitherto, there is no consensus about the golden standard in measuring glycocalyx properties in humans. The objective of this study was to compare different indices of glycocalyx shedding and dysfunction. To this end, we studied patients undergoing elective CABG surgery, which is a known cause of glycocalyx shedding.

Materials and methods

Sublingual glycocalyx thickness was measured in 23 patients by: 1) determining the perfused boundary region (PBR)-an inverse measure of glycocalyx thickness-by means of sidestream dark field imaging technique. This is stated double, 2) measuring plasma levels of the glycocalyx shedding products syndecan-1, hyaluronan, and heparan sulfate and 3) measuring plasma markers of impaired glycocalyx function and endothelial activation (Ang-2, Tie-2, E-selectin, and thrombomodulin). Measurements were performed directly after induction, directly after onset of cardiopulmonary bypass (CPB), and directly after cessation of CPB. We assessed changes over time as well as correlations between the various markers.

Results

The PBR increased from 1.81 ± 0.21 μm after induction of anesthesia to 2.27 ± 0.25 μm (p < 0.0001) directly after CPB was initiated and did not change further during CPB. A similar pattern was seen for syndecan-1, hyaluronan, heparan sulfate, Ang-2, Tie-2, and thrombomodulin. E-selectin levels also increased between induction and the start of CPB and increased further during CPB. The PBR correlated moderately with heparan sulfate, E-selectin, and thrombomodulin and weakly with Syndecan-1, hyaluronan, and Tie-2. Shedding markers syndecan-1 and hyaluronan correlated with all functional markers. Shedding marker heparan sulfate only correlated with Tie-2, thrombomodulin, and E-selectin. Thrombomodulin correlated with all shedding markers.

Conclusion

Our results show that glycocalyx thinning, illustrated by increased sublingual PBR and increased levels of shedding markers, is paralleled with impaired glycocalyx function and increased endothelial activation in CABG surgery with CPB. As correlations between different markers were limited, no single marker could be identified to represent the glycocalyx in its full complexity.

Safety of endomyocardial biopsy in new-onset acute heart failure requiring veno-arterial extracorporeal membrane oxygenation

Background

Refractory cardiogenic shock (CS) complicating new onset acute heart failure (new-AHF) is a medical emergency, requiring immediate mechanical circulatory support (MCS) to prevent hemodynamic deterioration. When non-invasive testing is impossible, endomyocardial biopsy (EMB) has an important role in determining the etiology of new-AHF.

Purpose

The aim of this study was to determine the procedural safety of EMB in patients with new-AHF requiring VA-ECMO. Additionally, we describe the detection rate of an underlying etiology of new-AHF on histopathological examination.

Methods

A retrospective, multicenter cohort of patients undergoing EMB while requiring VA-ECMO for new-AHF between 1990 and 2020 was compared with a cohort of non-transplant related biopsies not requiring VA-ECMO. Primary endpoint of the study was the safety of EMB with a secondary endpoint being the detection rate of an underlying etiology causing new-AHF on histopathologic examination.

Results

A total of 23 patients underwent EMB while requiring VA-ECMO (10.0%), 125 (54.3%) during an unplanned admission and 82 (35.7%) in elective setting. Major complications occurred in 8.3% of all procedures with a significantly higher rate in patients requiring VA-ECMO (26.1% vs. 8.0% vs. 3.7%,p=0.003), predominately due to occurrence of sustained ventricular tachycardia or need of resuscitation (13.0% vs. 3.2% vs. 1.2%,p=0.02). EMB led to a histopathological diagnosis in 78.3% of the patients requiring VA-ECMO which consisted primarily of patients with myocarditis (73.9%).

Conclusions

EMB in patients requiring VA-ECMO can be performed albeit with a substantial risk of major complications. This risk of the procedure was offset by a high detection rate of an underlying etiology on histopathological examination. The important therapeutic and prognostic implications of EMB in this population warrant further refinement to improve procedural safety.

Funding Acknowledgement

Type of funding sources: None. Major safety endpoints according to EMB

Quality of life following adult veno-venous extracorporeal membrane oxygenation for acute respiratory distress syndrome: a systematic review

BACKGROUND

Veno-venous extracorporeal membrane oxygenation (VV-ECMO) has been used successfully for the past decade in adult patients with acute respiratory distress syndrome (ARDS) refractory to conventional ventilatory support. However, knowledge of the health-related quality of life (HRQoL) in VV-ECMO patients is still limited. Thus, this study aimed to provide a comprehensive overview of the HRQoL following VV-ECMO support in ARDS patients.

METHODS

A systematic search was performed on PubMed and Web of Science databases from January 1st, 2009 to October 19th, 2020. Studies reporting on HRQoL following VV-ECMO for ARDS in adults were included. Two authors independently selected studies, extracted data, and assessed methodological quality.

RESULTS

Eight studies were eligible for inclusion, consisting of seven observational studies and one randomized controlled trial (total N = 441). All eight studies had a quantitative design and reported 265 VV-ECMO survivors to have a reduced HRQoL compared to a generally healthy population. Follow-up time varied between six months to three years. Additionally, only four studies (total N = 335) compared the HRQoL of VV-ECMO (N = 159) to conventionally treated survivors (N = 176), with one study showing a significantly better HRQoL in VV-ECMO survivors, while three studies were stating comparable HRQoL across groups. Notably, most survivors in these studies appeared to experience varying degrees of anxiety, depression, and post-traumatic stress disorder (PTSD).

CONCLUSIONS

ARDS survivors supported by VV-ECMO have a decline in HRQoL and suffered from physical and psychological impairments. This HRQoL reduction is comparable or even better to the HRQoL in conventionally treated ARDS survivors.

ECPella: Concept, Physiology and Clinical Applications

Addition of Impella on top of venoarterial extracorporeal membrane oxygenation (VA-ECMO) has gained wide interest as it might portend improved outcomes in patients with cardiogenic shock. This has been consistently reported in retrospective propensity-matched studies, case series, and meta-analyses. The pathophysiologic background is based on the mitigation of ECMO-related side effects and the additive benefit of myocardial unloading. In this perspective, thorough knowledge of these mechanisms is required to optimize the management of mechanical circulatory support with this approach and introduce best practices, as the interplay between the two devices and the implantation-explantation strategies are key for success.

Neurocognitive assessment and DNA sequencing expand the phenotype and genotype spectrum of Alström syndrome

Alström syndrome (OMIM#203800) is an ultra-rare autosomal recessive monogenic disease presenting pathogenic variants in ALMS1 (chromosome 2p13). It is characterized by early onset of blindness, hearing loss and systemic comorbidities, with delayed development without cognitive impairment. We aimed to investigate the cognitive functions and describe new pathogenic variants in Alström syndrome patients. Nineteen patients (13 adults, 6 children) underwent a thorough clinical, genetic, laboratory, instrumental, and neurocognitive assessment. Six new pathogenic variants in ALMS1 including the first described in exon 6 were identified. Four patients displayed a "mild phenotype" characterized by slow disease onset or absence of complications, including childhood obesity and association with at least one pathogenic variant in exon 5 or 6. At neurocognitive testing, a significant proportion of patients had deficits in three neurocognitive domains: similarities, phonological memory, and apraxia. In particular, 53% of patients showed difficulties in the auditory working memory test. We found ideomotor and buccofacial apraxia in 74% of patients. "Mild phenotype" patients performed better on auditory working memory and ideomotor apraxia test than "typical phenotype" ones (91.9 + 16.3% vs. 41.7 + 34.5% of correct answers, Z = 64.5, p < .01 and 92.5 + 9.6 vs. 61.7 + 26.3, Z = 61, p < .05, respectively). Deficits in auditory working memory, ideomotor, and buccofacial apraxia were found in these patients and fewer neuropsychological deficits were found in the "mild" phenotype group. Furthermore, in the "mild" phenotype group, it was found that all pathogenic variants are localized before exon 8.

Extracorporeal membrane oxygenation in peripartum cardiomyopathy: A review of the ELSO Registry

AIMS

Data on the use of extracorporeal membrane oxygenation (ECMO) for cardiogenic shock in peripartum cardiomyopathy (PPCM) is limited. We queried the Extracorporeal Life Support Organization (ELSO) Registry for PPCM patients treated with ECMO in order to characterize demographic and clinical features, complications, survival, and variables associated with mortality.

METHODS AND RESULTS

This was a retrospective review of patients voluntarily entered into the ELSO Registry. De-identified data was collected on patients with a diagnosis of PPCM based on ICD-9/ICD-10 coding who received ECMO between 2007 and 2019. Collected data included demographics, ECMO mode, cannulation strategies, pre-ECMO ventilator, biochemical, and hemodynamic parameters, run duration, complications, and survival to wean off ECMO and hospital discharge. Our primary outcome measure was survival to discharge. In the final analysis, 88 veno-arterial (VA) ECMO patients were included. Overall, 72% of patients were weaned off ECMO, including 10% who were weaned to ventricular assist device or heart transplantation, and 64% survived to hospital discharge. Extracorporeal cardiopulmonary resuscitation (ECPR) was performed in 11% of patients with 60% survival. Factors associated with decreased survival included neurologic complications (p = 0.03), specifically central nervous system hemorrhage (p = 0.01).

CONCLUSION

Our review is the largest to date of PPCM patients supported with VA ECMO for cardiogenic shock. ECMO and ECPR are valuable forms of short-term mechanical circulatory support with acceptable mortality profiles for PPCM patients who remain refractory to aggressive medical management. Complications should be meticulously avoided, especially neurologic complications.

Sleep disorders and cognitive dysfunction in acromegaly

PURPOSE

In the general population, sleep disorders are associated with an increased risk of cognitive impairment. The prevalence of sleep disorders, such as sleep apnea, in acromegalic patients is higher than in the general population, and they may have additional risk of cognitive impairment due to acromegaly treatment and comorbidities. We aim to study the relationship between sleep disturbances and cognitive dysfunction in a group of acromegalic patients.

METHODS

We studied 67 consecutive acromegalic patients. We performed a neurocognitive assessment and patients completed the Acromegaly Quality of Life Questionnaire (AcroQoL), Epworth Sleepiness Scale, and Pittsburgh Sleep Quality Index.

RESULTS

Of the 67 acromegaly patients in the study, 38.8% were male and median age at the neurological examination was 56 (IQR 48, 65). Approximately 6-10% of patients had impaired cognitive assessment, depending on the test. In linear regression models adjusted for age, sex, BMI, disease duration, and disease activity, poorer sleep quality was associated with lower global cognitive z-score (B = -0.03, 95% CI -0.06, -0.002). Daytime somnolence was associated with poorer physical AcroQoL sub-score (B = -0.04, 95% CI -0.08, -0.002). Sleep quality was associated with poorer overall AcroQoL (B = -0.03, 95% CI -0.05, -0.006), physical AcroQoL (B = -0.04, 95% CI -0.07, -0.005), psychological AcroQoL (B = -0.02, 95% CI -0.04, -0.001), and social AcroQoL (B = -0.02, 95% CI -0.04, -0.0009).

CONCLUSIONS

In acromegaly patients, we found robust evidence that poor sleep quality is associated with poorer quality of life, and some evidence that it is associated with poorer cognitive function.

Transnasal endoscopic microfractured fat injection in glottic insufficiency

OBJECTIVE

We evaluated a novel treatment for glottic insufficiency involving the injection of autologous material with direct glottic visualisation in an outpatient setting.

METHODS

Three patients with vocal cord palsy underwent laryngoplasty under local anaesthesia using only a flexible endoscope with a working canal for Microfractured Fat Fibre-endoscopic Injection (MFFI). Adipose tissue was processed using the Lipogems device, which allows optimal purity, fluidity, and mesenchymal stem cell content in the resultant emulsion.

RESULTS

According to the preliminary data, MFFI was well tolerated and no complications were observed. During the 12-month follow-up period, voice improvement was constant in all three patients, hinting at the stem cell-related regenerative potential of the procedure.

CONCLUSIONS

MFFI was proven to be a useful and straightforward tool, combining all of the relevant advantages of other known treatments for glottic insufficiency, and is an efficacious and innovative treatment that can be performed on an outpatient basis using only autologous material.

Effects of transcatheter aortic valve implantation on left ventricular mass and global longitudinal strain: tissue Doppler and strain evaluation

INTRODUCTION

Transcatheter aortic valve implantation is the option of choice for high surgical risk patients suffering from symptomatic aortic stenosis. We aimed to evaluate the influence of baseline global longitudinal strain on left ventricular mass regression after the procedure.

METHODS

We enrolled 23 patients with pure symptomatic severe aortic stenosis who underwent CoreValve prosthesis (Medtronic, Minneapolis, MN) implantation. Everyone had echocardiography registration before the procedure and after six months in order to analyze two-, three-, and four-chamber peak longitudinal strain and global longitudinal strain.

RESULTS

After the procedure New York Heart Association class, peak and mean aortic valve gradients (p<0.001 for all) improved. Interventricular septum and posterior wall thicknesses decreased (p<0.001 for both). Moreover, left ventricular mass index for body surface area changed from 190±44 to 143±30 g/m(2), (p<0.001). Finally, global longitudinal strain significantly increased (from 9.4±0.9 to 11.5±0.8%; p<0.001), as well as its components. Baseline global longitudinal strain correlated with left ventricular mass regression (r=0.560; p=0.005; 2-sided) and predicted it at linear regression analysis (B=23.707; p=0.005; adjusted R(2)=0.281).

CONCLUSIONS

Global longitudinal strain and its components improved six months after the procedure. Moreover, baseline global longitudinal strain seemed to predict left ventricular mass regression in patients with pure aortic stenosis undergoing transcatheter aortic valve implantation. This finding could be related to the extent of myocardial fibrosis which is also responsible for lack of left ventricular mass regression and poorer prognosis.

Elastic aortic properties in hypertrophic cardiomyopathy: a single center echocardiographic evaluation

OBJECTIVE

Previous studies revealed that hypertrophic cardiomyopathy (HCM) patients have impaired aortic elastic properties with contrasting data about aortic dimensions. We aimed to extend our knowledge about this topic, considering tissue Doppler imaging (TDI) and tissue strain.

PATIENTS AND METHODS

25 HCM patients and 25 healthy volunteers matched for age and sex were enrolled. They underwent transthoracic echocardiography to measure aortic dimensions at four levels (Valsalva sinuses, sinotubular junction, tubular tract, aortic arch), elastic properties (i.e., distensibility, stiffness, M-mode strain, tissue strain), and TDI aortic wall velocities (S', E', A' waves).

RESULTS

Aortic dimensions differed between the two groups only at sinotubular junction (18 ± 6 vs. 15 ± 3 mm/m2; p = 0.039) and aortic arch levels (19 ± 5 vs. 11 ± 8 mm/m2; p < 0.001). Aortic stiffness was significantly higher among patients (16.4 ± 23.2 vs. 5.9 ± 3.4; p = 0.034), and TDI waves greater (S': 5.2 ± 1.9 vs. 8.0 ± 2.7 cm/s, p < 0.001; E': -5.3 ± 2.4 vs. -7.2 ± 2.7 cm/s, p = 0.012; A': -5.3 ± 1.6 vs. -8.6 ± 4.5 cm/s, p = 0.002). M-mode and tissue strains, and aortic distensibility did not reach statistical significance, although showing a tendency to altered values in the HCM group.

CONCLUSIONS

Patients affected by HCM show a larger aorta and altered aortic elastic properties compared with healthy volunteers. These findings could help to investigate treatment response and prognosis of these alterations.

Aortic valve stenosis and lipid-lowering therapy: the state of the art

Aortic valve stenosis is the most common native valve disease and its most common cause in the United States and Europe is the calcification of a normal trileaflet. Recently, there is increasing evidence indicating that valve calcification has common underlying mechanisms with atherosclerosis. This connection raises interest in the potential efficacy of antiatherosclerosis medications in calcific valve stenosis (AS) therapy. Among them statins, are one of the most promising candidates, because of their pleiotropic effects. The aim of this review is to summarize and analyze the findings of contemporary studies and to discuss the rationale for statin usage in AS populations.

Stem cells and repair of the heart: cell-releasing epicardial scaffolds

Cell transplantation represents the last frontier within the treatment of cardiac diseases. From the first paper published in 1992 that has documented the potentials of the transplantation of autologous skeletal muscle cells to treat the damage induced by acute myocardial infarction, innumerable techniques of implantation and types of cells used has been reported, greatly expanding this innovative and appealing field of search in cardiovascular medicine. Despite original promises and expectations, current evidences of stem cell transplantation are still weak and controversial. Therefore, alternative line of research are being explored, particularly in the field of techniques of cell implantation and engraftment. Besides direct implantation or myocardial colonization by bone marrow stimulation, epicardial application of cell-delivering systems (scaffold and patches) have gained popularity due to the possibility to apply selectively a cell-containing device which may gradually release the chosen cell type, alone or in combination with trophic substances. The scaffolds have proven to be successful in this respect and may represent a valid alternative to coronary, intra-myocardial, or venous injection of stem cells, or to stem cell stimulating factors. Finally these systems may be applied through minimally invasive procedures and act as external constraint to enhance ventricular reverse remodelling or limit further cardiac dilatation.

Malignant insulinoma presenting as metastatic liver tumor. Case report and review of the literature

Insulin-secreting tumors are the commonest hormone-producing neoplasm of the gastrointestinal tract. They occur with an incidence of 4 cases per million per year. About 10% of them are metastatic and malignant insulinomas very rarely observed in children and in elderly. We report a rare case of very large malignant insulinoma in a 71-year-old woman admitted in our Oncological Institute on October 2005. She presented with fasting hypoglicemia (blood glucose 35 mg/dl) and high serum insulin levels (insulin 115.9 microU/ml). A computerized tomographic scan showed a pancreatic tail lesion of about 6 cm in max diameter and multiple liver metastases. A whole body scintiscan using 111In-DTPA-D-Phe1-octreotide was made and an increased uptake in the tail of the pancreas has been found. The patient was submitted to liver biopsy and the diagnosis of a metastatic insulin-secreting tumor was immunoistochemically confirmed. Due to the presence of some hypoglicemic episodes uncontrolled by medical treatment, on December 2005 the patient was admitted to surgical intervention with a body and tail pancreatic resection. Post-operatively the patient experienced again syncope with hypoglycemia and hyperinsulinemia. It was then decided to start a schedule of treatment with somatostatin analog (octreotide subcutaneously 500 microg three times a day) with a good control of blood glucose levels (101 mg/dl). A trans-arterial chemioembolization was planned but the patient died for pancreatic and cardiovascular complications before this treatment started.

Modified liver hanging maneuver during orthotopic liver transplantation with inferior vena cava preservation: results after 120 consecutive applications

The outflow venovenous anastomosis represent a crucial aspect during orthotopic liver transplantation (OLT) with inferior vena cava (IVC) preservation. The modified Belghiti liver hanging maneuver applied to the last phase of hepatectomy, lifting the liver, provides a better exposure of the suprahepatic region and allows easier orthogonal clamping of the three suprahepatic veins with a minimal portion of IVC occlusion. The outflow anastomosis constructed with a common cloacae of the three native suprahepatic veins is associated with a lower incidence of graft related venous outflow complications. The procedure planned in 120 consecutive OLT was achieved in 118 (99%). The outflow anastomosis was constructed on the common cloaca of the three hepatic veins in 111/120 cases (92.5%). No major complications were observed (bleeding during tunnel creation, graft outflow dysfunction, etc) except in one patient with acute Budd-Chiari, who successfully underwent retransplantation.

Cystic pancreatic neoplasms: 12-year surgical experience

Cystic pancreatic neoplasms have been increasingly diagnosed in the last years. Resection is recommended in most cases, but their management has not been standardized since an accurate nonoperative differentiation is often difficult. A retrospective review of 30 patients undergoing surgical resection for cystic pancreatic neoplasms between 1993 and 2005 was performed. Median age of the patients was 63 years and 63.5% were female. Twelve patients (40%) were asymptomatic. Twenty-nine had curative resections. Pathologic analysis revealed 13 serous cystadenomas, 9 mucinous cystadenomas, 3 mucinous cystadenocarcinomas, 4 intraductal papillary mucinous neoplasms and 1 solid pseudopapillary neoplasm. Overall mortality was 6.5% (2 patients). Postoperative complications occurred in 12 patients (41%). Pancreatic fistula occurred in 7 cases (24%). Reoperation was required in 2 patients (6.5%). Two patients operated for mucinous cystadenocarcinoma and invasive intraductal papillary mucinous neoplasms died of recurrence at 24 and 7 months postoperatively. Excluding another patient died from other cause, all others are currently alive with no evidence of disease. Diagnostic accuracy for cystic pancreatic neoplasms is still limited. Considering the good prognosis and acceptable morbidity and minimal mortality after surgical treatment in specialized centers, resection seems still justified in most cases.

The surgical treatment of ilio-femoral venous obstruction

METHODS

A series of 9 patients of a mean age of 48 years, operated on for compression of the ilio-femoral venous axis is reported. The cause of obstruction was external compression in 3 cases, a retroperitoneal sarcoma in 1 case, and an infrarenal aortic aneurysm in 2. Two patients presented with a Cockett's syndrome, 3 with a chronic ilio-femoral thrombosis, and one with a post-traumatic segmentary stenosis. Treatment consisted in a resection/Dacron grafting of 2 infrarenal aortic aneurysms, one femoro-caval bypass graft, 2 transpositions of the right common iliac artery in the left hypogastric artery for Cockett's syndrome, 3 Palma's operations for chronic thrombosis, and one internal jugular vein interposition for segmentary stenosis.

RESULTS

There were no postoperative deaths and no early thromboses of venous reconstructions performed. All the patients were relieved of symptoms during the follow-up period, whose mean length was 38 months.

CONCLUSION

The cause of venous obstruction and the presence of symptoms which are resistant to medical treatment are the main indications to ilio-femoral venous revascularization. The choice of the optimal treatment in each single case yields satisfactory results.

Pancreaticoduodenectomy for pancreatic metastatic melanoma

Isolated pancreatic metastatic melanoma is a rare occurrence. Even more rare is the surgical treatment of this lesion. However, considering the lack of effective systemic treatment and the decreasing morbidity and mortality rates of pancreatic resections in specialized centers, selected patients, especially if symptomatic, may be considered for surgical resection to achieve good palliation or improve survival. We performed a pancreaticoduodenectomy in a patient with a bleeding pancreatic metastasis from cutaneous melanoma excised 10 years before and reviewed the recent literature.

[Small bowel stromal tumors in a "meckelian" location. About a clinical observation]

The Meckels divetriculum has a prevalence of the 0.3-3%. It is surgically removed only when arise a complication or a neoplasia. The Meckels diverticulum tumors are unfrequent and observed in only the 0.5-3.2% of the Meckels diverticula. The 12% of these tumors are a GIST. We report a case of a gastrointestinal stromal tumor with neural immunophenotype, observed in a patient presenting a deep venous thrombosis perhaps with a paraneoplastic origin. We also report some observations about the state of the art about the GIST management and particularly of all of them arising in a Meckels diverticulum.

[Surgical treatment of lung metastasis: experience with 108 cases]

In this study the Author's analyze their experience (between September 1973 and December 2002) with 108 pulmonary resections for metastatic tumors to the lungs to evaluate prognostic factors and the impact on survival of extended metastasectomy. Overall mortality and major morbidity were 1.85% and 2.78%. The actuarial survivals at 5 and 10 years were respectively 46.6% and 39.9%. The best mean survivals are observed in patients with metastases from breast, colorectal, thyroid and urinary tract carcinomas, in cases with disease free interval > 12 months and in the patients who underwent sequentially surgery and chemotherapy. Patients with pulmonary metastases also potentially benefit from iterative pulmonary resection.

[Growth hormone secretion in heart failure]

Growth hormone is a pituitary polypeptide hormone regulating growth in paediatric age as well as inducing anabolic actions directly or IGF-I mediated in adult age. Particularly, in many animals GH and IGF-I receptors were observed in cardiac myocyte membrane. GH modifies left ventricle structure and function. As concerns spontaneous GH secretion, some data suggest that pituitary gland can have a compensatory role on endocrine response to heart failure. Heart failure stage was directly correlated to nocturnal GH levels. All GH spontaneous night secretion parameters as well as IGF-I levels showed a range between normal people and very high spontaneous secretion. Therefore in these patients there are either a GH peripheric resistance or a reduction of the activity of GH/IGF-I axis. Anyhow in our patients, GH 24 hour infusion was inducing a 5 fold increase in GH concentration and a 50% increase in basal IGF-I levels. Anker et al. suggested to evaluate nutritional state in heart failure patients, observing no differences in non-cachectic patients vs controls, while cachectic patients presented a typical GH resistance syndrome. Interestingly, cardiovascular effects of GH administration seem to be only marginally correlated to hemodynamic basal state. On the other hand basal hormonal setting of the patient seems to correlate to the GH-induced cardiovascular response. In fact, low basal IGF-I but high basal GH patients presented the worst endocrine and cardiovascular response to GH infusion. In literature there are controversial data about GH treatment in patients with chronic heart failure. The heterogeneity of the population could be the reason for this discrepancy. Besides very different IGF-I responses to GH have been reported. Therefore, as there is good clinical evidence that GH acute infusion can improve heart failure, it seems to be necessary firstly to evaluate the basal endocrine status of the patients. Particularly attention should be given to those patients that present a peripheric GH resistance. On the other hand, those patients with a reduced pituitary GH reserve are supposed to have very beneficial effects from GH treatment.

Preliminary observations on the effects of acute infusion of growth hormone on coronary vasculature and on myocardial function and energetics of an isolated and blood-perfused heart

Recent studies have shown that growth hormone (GH) deficiency may deteriorate post-ischemic myocardial reperfusion damage. Furthermore, GH has been reported to be a promising therapeutic option in the treatment of chronic myocardial dysfunction. However, the exact mechanisms of action of GH on the cardiovascular system, particularly in the acute setting, are still unclear. The aim of our study consisted of monitoring the acute effects of GH infusion on isolated blood-perfused rabbit heart according to dose-response pattern and during ischemic conditions to test its anti-ischemic property. Seven blood-donors perfused isolated hearts were used as experimental model. The mechanical and metabolic data of the isolated organs were continuously monitored. Under aerobic conditions, dose-response curves were initially tested after intracoronary infusion of GH at increasing dosages (1, 2, 3 mg/l). After a stabilization period, the effects of GH infusion (5 mg/kg) administered 30 minutes prior to acute global myocardial ischemia (30 minutes) were also investigated. At the doses tested, GH did not induce any changes either in the developed or in the diastolic pressures of the isolated organ. However, transient reduction of the coronary perfusion pressure was observed at the dosage of 3 mg/l. During the ischemia/reperfusion study, at the dosages used in this study, GH did not modify either the degree of stunning in the early reperfusion or the recovery of the developed pressure at the end of reperfusion. In addition, GH did not prevent either the increase of diastolic pressure during ischemia or the release of lactate and CPK during reperfusion. Tissue content of high-energy phosphates was also not changed by GH infusion. In our experimental model, acute GH infusion did not reduce the ischemic/reperfusion damage of the myocardium. However, GH transiently induced coronary vasodilation without modifying the myocardial contractility. Acute effects of GH appear, therefore, to predominantly relate to vascular dilation suggesting that the effects on myocardial contractility may require long-lasting intake being likely linked to enhancement of specific protein synthesis or gene expression of cardiac myocytes.

Transperitoneal approach for pericardial drainage

A variety of surgical approaches for pericardial drainage have been proposed. The choice of the best approach can be, therefore, oriented depending on the cause of the pericardial effusion. Recently a different approach, for neoplastic or post-traumatic pericardial effusion, has been proposed, in order to create a peritoneal-pericardial window avoiding the insertion of a tube. We report a case of late postoperative cardiac tamponade in a patient with a previous coronary surgery in which, due to extensive adhesion of the anterior wall a modified transperitoneal approach to the pericardium, was used.

Combined surgical approach for carotid and coronary stenosis. Sixty-four patients and review of literature

BACKGROUND

The proper role of combined carotid endarterectomy (CEA) and coronary bypass (CABG) is still controversial. We contribute to the discussion through the critical evaluation of 64 consecutive patients, whose data have been collected in a prospective way.

METHODS

Between 1990 and 1999, 64 patients presenting a critical coronary disease (unemendable by PTA) associated with severe carotid stenosis (= or >70% if symptomatic, = or >80% if asymptomatic), underwent combined CEA-CABG. Cardiological symptoms were evident in 90.6% of cases. Thirty-five patients (54.7%) had a three-vessel coronaropathy, 18 (28.1%) a two-vessel disease and 11 (17.2%) severe stenosis of the common trunk; furthermore 7 patients (10.9%) had a low ejection fraction (<50%). A positive neurologic history was present in 22 (44%) patients. Thirty-four patients (55%) had a carotid stenosis >90%; a significant disease of the contralateral carotid axis was observed in 53% of cases: stenosis >50% in 30 patients and thrombosis in 4. CEA was performed with somato-sensorial evoked potential monitoring.

RESULTS

The hospital mortality rate was 6.2% (4 patients). The cause of death was cardiac in 2 cases (1 early bypass thrombosis and 1 irreversible coronary spasm) and related to a multiorgan failure in 2. The neurologic morbidity rate was 0%.

CONCLUSIONS

Our data highlight that in these high-risk patients the combined approach dramatically reduces the stroke risk although the mortality rate is still higher than that observed after CEA or CABG.

[Neurinoma of the brachial plexus: 2 case reports]

Neurinomas, also referred to as neurilemmomas and schwannomas, are rare benign tumours of the peripheral nerves. A small percentage of these lesions arise from the brachial plexus. The Authors report two cases of schwannoma arising from the brachial plexus. Such lesions, usually asymptomatic, may cause sensitivity alterations or, less frequently, motor deficits in the involved arm. Tumour enucleation, avoiding damage to any of the nervous fascicles, is the treatment of choice.

A new method to assess the fluidodynamic behaviour of an angiographic contrast agent

PURPOSE

To propose a new method for the assessment of the fluidodynamic behaviour of angiographic contrast agents. The method enables measurement of the spatial distribution and time dependence of the contrast agent along a pseudo-vessel on images obtained with an X-ray image intensifier.

MATERIAL AND METHODS

A particular phantom was devised consisting of a plexiglas box with an insert into which a latex tube with a 0.4 cm in diameter was placed in order to simulate the tortuous flow of a blood vessel. The box, which is filled with water to simulate the thickness of a normal patient, is connected to an injection and pumping system which serve to keep the contrast agent flowing in the pseudo-vessel tube. The pseudo-vessel tube was filled with plain water in one case and with saline solution in another case to assess their different dilution capabilities. The phantom and the flow of contrast agent were imaged with a conventional X-ray image intensifier system and the images were stored in digital format during 35 second acquisitions at a speed of 4 frames per second; for any frame it is possible to measure the mathematical contrast in any position in the image. Further, a diagram showing the time dependence of the spatial distribution of the mathematical contrast is proposed. The X axis shows the spatial distribution of the mathematical contrast, whereas the Y axis shows its temporal variation with a gray level proportional to the mathematical contrast value. By building an horizontal profile of this diagram one can obtain the spatial distribution at a fixed time, while by building a vertical profile one can obtain the temporal variation at a fixed point. Several different contrast agents were so tested.

RESULTS

The proposed method allows different fluido-dynamic behaviour patterns of contrast agents and flowing media to be shown. Owing to the different chemical characteristics of water and saline solution these media have different dilution capabilities (higher for water) and this is well demonstrated by the diagram profiles obtained for each. The system has also allowed the detection of a particular behaviour of some contrast agents, whose spatial distribution was non uniform even in the last frames, thus showing a tendency to maintain their bolus-nature over time. An interesting feature which can be noticed in all the temporal profiles is the presence of a "pre-bolus", i.e. the contrast is higher at the very beginning of the flow, then decreases and after some time starts to increase again. Though the initial contrast value obviously depends on the iodine concentration employed, the method shows the contrast variation as a function of time is different for different contrast agents.

CONCLUSIONS

The method and the equipment proposed provide a good description of the fluidodynamic behaviour of different contrast agents, but do not constitute a reference method for testing haemodynamic behaviour which, "in vivo", is obviously affected by several other chemical and metabolic factors. However, the method allows evaluation of the contrast agents from a physical and fluidodynamic point of view, showing that the iodine content is not the only feature affecting their behaviour. The method can be used in quality control to test the constancy of the physical behaviour of different contrast agents.

[Use of abdominal wall retractor Laparo Tenser in gasless laparoscopic cholecystectomy]

High pressure CO2-peritoneum for laparoscopic surgery is not indicated in patients with impairment of cardiorespiratory and renal function and in high risk patients and in obesity. On the other site the uncontrolled abdominal insufflation and the blind insertion of the first trocar in patients with extended intraperitoneal adhesions, often cause bleeding and the intestinal loops dislocation, and can determine visceral lesions. In these patients gasless technique with an abdominal laparolifter can be employed. We report an experience of 36 patients undergoing laparoscopic cholecystectomy by a subcutaneous planar retractor. It was observed a good operative exposure in 83.3%; the surgery was safely performed in 88.8%. Two suprafascial hematoma related to the insertion of the needles of the Laparo Tenser occurred. A regular post-operative discharge was observed in 84.4%. These good results supports the extension of the laparoscopic approach for the cholecystectomy to complicated or to high risk patients.

Long-term results of coronary artery bypass grafting procedure in the presence of left ventricular dysfunction and hibernating myocardium

OBJECTIVE

Long-term left ventricular (LV) performance and patient outcome after coronary artery bypass grafting (CABG) procedure in the presence of depressed LV function and hibernating myocardium (HM) have been poorly determined. Therefore, we prospectively evaluated patients undergoing CABG with severe LV dysfunction and HM to elucidate postoperative prognosis.

METHODS

We enrolled 120 consecutive patients undergoing CABG with severe LV dysfunction and HM as assessed by dobutamine echocardiography and by rest-redistribution radionuclide (Thallium-201) study. Mean patient age was 60+/-9 years (range 31-77 years). Mean preoperative LVEF was 28%+/-9 (range 10-40%). All patients underwent echocardiographic study to assess LV recovery of function intraoperatively, prior to hospital discharge, at 3 months, at 1 year, and yearly during the follow-up. Univariate and multivariate analysis were performed to to evaluate predictors of postoperative survival.

RESULTS

There were 2 hospital (1.6%) and 15 late (12.5%) deaths, mainly for heart failure, leading to an actuarial survival of 80+/-6% and 60+/-9% at 5 and 8 years, respectively. LVEF significantly improved perioperatively (from 28+/-9% to 40+/-2%, P<0.01). Increase in LVEF, however, was gradually offset over the time (EF of 33+/-9%, 32+/-8%, and 30+/-9% at 3 months, and 12 months, and 8 years after surgery, respectively). Furthermore, patients who experienced limited LV functional recovery perioperatively had a more remarkable decline of LVEF thereafter, and suffered from recurrence of heart failure symptoms (freedom from heart failure 82+/-5% and 60+/-8% at 4 and 8 years respectively). Advanced preoperative NYHA Class, and age were independent risks factors for reduced postoperative survival. Preoperative angina and use of arterial conduits apparently did not influence patient morbidity and mortality at long term.

CONCLUSION

CABG procedure in the presence of HM enhances LV recovery of function and has a favourable prognosis. Functional benefit of the left ventricle, however, appears to be time-limited, despite remarkable improvement in patient functional capacity. Advanced preoperative heart failure, minimal perioperative improvement of LVEF, and age account for a poor long-term prognosis.