Rapid deployment bioprostesis for aortic valve stenosis: single center short and long-term outcomes

Background

Despite recent advances, surgical aortic valve replacement (SAVR) remains the gold standard for most of the patients with aortic valve stenosis. The ageing population, with increased comorbidities and the rising of minimally invasive techniques, led to the development of new prosthetic devices of easier and faster implantation.

Purpose

This study aimed to analyse short and long-term outcomes of SAVR with rapid-deployment (RD) aortic bioprosthesis for isolated aortic valve stenosis

Method

Singe center, retrospective longitudinal cohort study of patients with isolated aortic valve stenosis who underwent elective aortic valve replacement using RD devices between 2014 and December 2021.

Continuous variables are presented with median (IQR) and were analyzed using Mann-Whitney test. Categorical variables are presented in percentage or frequency and were analyzed using chi-square test. Kaplan-Meyer survival curve was constructed base on collected data from national registry.

Results

A RD device was implanted in 358 patients with a median age of 75,8 years and Euroscore II of 2,3. Median cross clamp and extracorporeal circulation time were 27,4 and 36,7 min, respectively. No significant paravalvular leaks.

Intensive care unit (ICU) length of stay was 3 days with acute renal lesion (any stage-53,2%; Dialysis-2,5%), need for hemodynamic support (63,1%) and new onset atrial fibrillation (33,6%) being the most frequent post-operative complications. Stroke occurred in 0,6% of cases and mortality was 1,1%. Pacemaker implementation rate of 11%.

The mean follow-up time was 6,7 years with 90% 5-years survival rate. Mean gradients of 11,2±4,8 mmHg at 6 months

Conclusion

Surgical treatment of aortic valve stenosis using RD devices is safe, with a low mortality rate. ICU length of stay and hospital length of stay are reduced. Follow-up shows an excellent long-term survival and hemodynamic performance.

Funding Acknowledgement

Type of funding sources: None.

Early results of rapid-deployment aortic prosthesis in multivalvular surgery – a propensity score matching

Background

Multivalvular surgery (MV) requires prolonged extracorporeal circulation (ECC) and aortic cross-clamp times (X-Ao). Rapid-deployment aortic prosthesis (RD-AV) allow lower ECC and X-Ao times in isolated aortic valve surgery (AVR), but have not been studied in MV surgery.

Purpose

To determine if RD-AV use influences early outcomes when compared to biological stented or mechanical aortic valves in MV surgery.

Methods

Retrospectively collected pre, intra and immediate post-operatory data on all MV adult patients with AVR operated on our Department from January 2016 to February 2022. Bentall surgery and aortic dissection patients were excluded. A propensity score matching (PSM) of patients receiving RD-AV (Group A) compared to patients with non-RD-AV (Group B) was performed using sex, age, Euroscore II, type of surgery (involved valves, CABG, ascending aortic replacement), active endocarditis, ventricular function and redo surgery. After PSM, we compared outcomes until death or discharge. Normal distribution of samples was tested using the Kolmogorov-Smirnov test. Normal data was analysed with unpaired t-testing and non-normal data with non-parametric Mann Whitney U test. Categorical data were analysed with Fisher test. A significance level of p<0.05 was accepted.

Results

205 patients received non-RD-AV and 58 patients RD-AV. After PSM, 57 pairs of patients were obtained. Sex, BMI, Euroscore II, age, redo surgery, insulin dependent DM, baseline creatinine, left ventricle ejection fraction, right ventricle dysfunction, pulmonary artery systolic pressure, and active endocarditis were similar in both groups. Intra-operatory, RD-AV valves (Group A) were associated with shorter surgery duration (167.3±52 vs 206.6±91 min, p=0.005), shorter ECC duration (89.5±36.5 vs. 118.9±56.5 min, p=0.002), and aortic X-clamp time (71.6±28 vs. 98.9±38.2 min, p<0.001). No differences were found between both groups A vs. B in ventilation time (1270±1911 vs. 2428±5627 min, p=0.59), inotropic support (113±178 h vs. 85±101 h, p=0.38), transfusion of red cells units (1.1±1.6, vs. 1.2±1.7, p=0.73), Fresh frozen plasma units (0.86±1.9, vs. 0.77±1.8, p=0.77), platelet pools (0.79±1.0 vs. 0.7±0,9, p=0.67), fibrinogen (0.77±1.5 vs. 0.75±1.4 g, p=0.98), intra-aortic balloon pump use (5 vs. 12 patients, p=0.11), chest drain output (804±656 vs. 825±992 ml, p=0.69), new-onset dialysis (10 vs. 10 patients, p=1.0), new-onset atrial fibrillattion (10 vs 13 patients, p=0.6) and permanent pacemaker implantation (8 vs. 3 patients, p=0.20). Total ICU stay (9.25±21 vs. 4.5±4 days, p=0.3), hospital stay (14.4±26 vs. 10.1±13 days, p=0.52) and intra-hospital mortality (7 vs 9 patients, p=0.79) were also similar.

Conclusion

Despite shorter surgery duration, ECC duration and aortic X-clamp duration, RD-AV have similar early outcomes when compared with non-RD-AV in multivalvular surgery.

Funding Acknowledgement

Type of funding sources: None.

P371 1 YEAR OUTCOME OF BICARBON AORTIC MECHANICAL VALVE IN LOW–INR REGIMEN: RESULTS FROM SURE–AVR REGISTRY

Background

The drawback of using mechanical valve is lifelong anticoagulation use, and close monitoring is required to prevent postoperative complications, including thromboembolism and anticoagulation–related bleeding. Moderate anticoagulation after mechanical heart valve replacement has been proposed to reduce these risks. The present study aimed to evaluate the safety and feasibility of reduced oral anticoagulation after Bicarbon aortic mechanical valve replacement.

Methods

SURE–AVR is a propsective, multinational registry of patients undergoing aortic valve replacement. Between July 2018 and October 2020, among subjects undergoing AVR with Bicarbon valve in the SURE–AVR registry, 108 were assigned at discharge to low–INr regimen (international normalized ratio 1.5–2.5). Mean INr at discharge was 1.8+/–0.5 and 2.2+/–0.4 at 1 year. in–hospital and post–discharge outcomes up to 1 years were collected. The mean age was 55.5 +/–10.6 years old (range 25–82). Concomitant procedures included coronary artery bypass grafting (14.6%), mitral valve procedure (3.7%) and myectomy (1.9%). The follow–up duration averaged 1 year (361.8 +/– 258 days).

Results

No bleeding events were reported in the late follow up. The low–INR regimen did not affect the thromboembolism rates, since no stroke or transient ischemic attack were reported post–operatively at each time point. No in–hospital or late deaths were reported among the 108 subjects analyzed. In the early period (<30 days), three reinterventions occurred: two because of postoperative bleeding requiring thoracotomy and one due to pericardial effusion. In the late postoperative period two reinterventions with device explant occurred (one for non–structural valve dysfunction and one for endocarditis (1.2%).

Conclusion

The results of the SURE–AVr Registry demonstrated that the proposed Lower–INR Target is safe and feasible after Bicarbon aortic mechanical valve replacement. The low–intensity anticoagulation strategy is associated with a low risk of hemorrhagic events without any increase of thromboembolic complications.

Sutureless bioprosthesis as an alternative to conventional aortic valve replacement surgery

Background

Aortic valve stenosis is the most common adult valve disease in industrialized countries. The ageing population and the rising in comorbidities have urged the development of safer alternatives to the current gold standard surgical treatment. Sutureless bioprosthesis have shown promising results, especially in technically difficult procedures and as more and more patients need concomitant surgeries.

Purpose

Assess clinical and haemodynamic performance, safety and durability of the sutureless bioprosthesis implanted in patients with aortic valve disease, over a period of 5 years, both in isolated aortic valve replacement surgeries as well as in concomitant procedures.

Methods

Single centre retrospective longitudinal cohort study collected data of all adult patients with aortic valve disease who underwent valve replacement with a sutureless bioprosthesis between February 2015 and October 2020. Of the 196 patients analysed (mean age 77.20±5.08 years; 45.40% were female; mean logistic EuroSCORE 2.91±2.20%), the majority had aortic stenosis. To assess the comparative risk of adding concomitant procedures, patients were divided into two groups and compared: one comprised patients who underwent isolated valve implantation (n=132) and the other patients who had concomitant coronary artery bypass graftings (n=49). 15 patients had other heterogeneous concomitant procedures and were therefore not considered in this comparison.

Results

Overall mean cross-clamp and cardiopulmonary bypass times were 45.50±19.04 and 36.50±11.40 minutes, respectively. 4 valves were reimplanted due to misplacement. Mean transvalvular gradients were 7.82±3.62 mmHg. Mean ICU and total hospital stay were 3.32±3.20 and 7.70±5.82 days, respectively. Procedural success was 99%, as two explantations occurred. Pacemaker implantation occurred in 12.8% of patients, atrial fibrillation de novo in 21.9% and renal replacement support was necessary in 3.1%. Early mortality was 0.51%. We report no structural valve deterioration, strokes or endocarditis and one successfully treated valve thrombosis. By comparison, patients with concomitant procedures had worse left ventricular function (40.8 vs 79.5%; p=0.030), longer aortic clamping (43.33±11.60 vs 27.30±8.10 minutes; p<0.001) and cardiopulmonary bypass times (59.98±17.60 vs 37.45±11.30 minutes; p<0.001), as expected. ICU stay after surgery was also longer (3.96±3.20 vs 2.80±2.70 days; p=0.016). Apart from this, there were no other significant differences in postoperative complications and survival, even up to 5 years.

Conclusion

Our study confirms the excellent clinical and haemodynamic performance and safety of a truly sutureless aortic valve, even up to the 5-year follow-up. These results were consistent both in isolated and concomitant interventions, solidifying this device as a viable treatment of isolated aortic valve disease, and now also in patients needing concomitant procedures.

Funding Acknowledgement

Type of funding sources: None.

Persistant genital arousal disorder and venlafaxine: A case report

Introduction

In this presentation we describe the case of a woman referred to the Sexology Department after having developed symptoms of Persistent Genital Arousal (PGAD) for the last 5 years, during treatment for Depression with Venlafaxine. PGAD is a clinical entity first described in 2001 by Leiblum and Nathan. Despite having received more attention in the last few years, its etiology remains unclear, with numerous causal factors of different natures being suggested.

Objectives

We aim to describe this clinical case of PGAD and to discuss the possible etiological factors involved as well as to make a brief revision of the literature on this topic.

Methods

We conducted a detailed interview, focused on the nature of the complaints, psychological history, medications, diet and neurologic disorders and performed a thorough clinical examination. We also searched for relevant articles in medical databases such as PubMed and Google Scholar.

Results

A 52 year-old woman previously treated for Depression with Venlafaxine complains of involuntary sensations of genital arousal, with perceived vasocongestion, tingling and pulsatlity during her journey to work in public transportations. The symptoms subsided only after getting home 8-10 hours later and reaching orgasm by masturbating. She stopped Venlafaxine in 2015, but these symptoms persisted. Some authors suggest a link between SSRIs/SNRIs and PGAD.

Conclusions

PGAD is a relatively recent addition to our diagnostic catalog with increasingly more cases being reported in the last few years. It is likely that the condition, however, has no discrete etiology and that a customized approach will be necessary to successfully treat most patients.

Effects of the COVID-19 pandemic on mental health - what do we know so far?

Introduction

The devastating effects of the current pandemic are profoundly affecting peoples’s physical and psychological health. Numerous studies on the effects of previous infectious outbreaks have been published. Similarly, an increasingly growing body of research on COVID-19 has been developed and released, reporting a substancial psychological impact of both the outbreak and the response, suggesting that the population may express high levels of psychological symptoms.

Objectives

This presentation aims to synthesize existent literature that reports on the effects of COVID-19 on psychological outcomes of the general population, groups with higher vulnerability and its associated risk factors.

Methods

Bibliographic research was made through scientific databases such as PubMed and EMBASE. No time limit was used. Pertinent articles were carefully reviewed for additional relevant citations.

Results

Generally, there is a higher prevalence of symptoms of adverse psychiatric outcomes among the public when compared to the prevalence before the pandemic. Psychological reactions to pandemics include maladaptive behaviours, emotional distress and symptoms of stress, anxiety, depression, and avoidance behaviors. The groups known to be at higher risk for mental health problems during the pandemic are: women, healthcare workers, people under 40 years old and with chronic diseases. Other risk factors are: frequent exposure to social media/news relating to COVID-19, poor economic status, lower education level, and unemployment.

Conclusions

The COVID-19 pandemic represents an unprecedented threat to mental health. In addition to flattening the curve of viral transmission, special attention needs to be paid to the challenges it poses to the mental health of the population at a global scale.

No man is an island: spatial clustering and access to primary care as possible targets for the development of new community mental health approaches

BACKGROUND

to understand if patients seen at Centro Hospitalar Psiquiátrico de Lisboa (CHPL) live in geographical clusters or randomly throughout the city, as well as determine their access to the psychiatric hospital and primary care facilities (PCF).

METHODS

spatial autocorrelation statistics were performed (queen criterion of contiguity), regarding all patients observed at CHPL in 2017 (at the census subsection level), and considering not only their overall number but also main diagnosis, and admission to the psychiatric ward - voluntary or compulsory. Distance to the hospital and to the closest PCF was measured (for each patient and the variables cited above), and the mean values were compared. Finally, the total number of patients around each PCF was counted, considering specified radius sizes of 656 and 1000 m.

RESULTS

All 5161 patients (509 psychiatric admissions) were geolocated, and statistical significance regarding patient clustering was found for the total number (p-0.0001) and specific group of disorders, namely Schizophrenia and related disorders (p-0.007) and depressive disorders (p-0.0002). Patients who were admitted in a psychiatric ward live farther away from the hospital (p-0.002), with the compulsory admissions (versus voluntary ones) living even farther (p-0.004). Furthermore, defining a radius of 1000 m for each PCF allowed the identification of two PCF with more than 1000 patients, and two others with more than 800.

CONCLUSIONS

as patients seem to live in geographical clusters (and considering PCFs with the highest number of them), possible locations for the development of programs regarding mental health treatment and prevention can now be identified.

P871 Giant left ventricular (pseudo?)aneurysm complicating anterior myocardial infarction

Introduction

Clinical approach of cardiac aneurysms and pseudoaneurysms is significantly distinct. Therefore, it is crucial to accurately differentiate these two entities, which could be a real challenge.

Case report

We describe a case of a 55-year-old woman, with hypertension and previous smoking habits. She was admitted in our Cardiology Department with the diagnosis of anterior acute myocardial infarction, and was submitted to emergent coronariography, unveiling an occlusion of the middle segment of the anterior descending artery. She underwent successful primary percutaneous coronary intervention (PCI) 1h45 after the chest pain onset. Transthoracic echocardiogram (TTE) revealed depressed left ventricle ejection fraction (LVEF 30%), with akinesia of anterior and septal walls and all apical segments. She evolved in Killip-Kimbal class 2 and was discharged clinically stable. One week later, the patient performed a control TTE that showed an apical thrombus, with a small pericardial effusion, and she initiated warfarin. Three weeks later, a reevaluation TTE demonstrated a severe increase of the left ventricle dimensions, with LVEF 32%, and a small pericardial effusion. In apical 4-chambers incidence, it was visualized a linear structure (42 mm x 5 mm) attached to the endocardial border of the anterolateral apical segment and to the apical segment of the interventricular septum, of undefined nature. The apical segments were dyskinetic and had a very thin wall, which could correspond to aneurysm versus pseudoaneurysm. To clarify these findings, the patient performed a cardiac magnetic resonance revealing a large anterior myocardial infarction complicated with extensive myocardial necrosis, severe depression of LV systolic function (LVEF 25%) and septum rupture distal to the right ventricle apex (without connecting with it), compatible with a large apical pseudoaneurysm. The clinical case was discussed in the Heart Team and it was decided to perform cardiac surgery. However, surgical findings showed integrity of septal and free walls, and she underwent an aneurysmectomy, without further complications. Histological examination confirmed the presence of a thin myocardial wall with marked fibrosis and, consequently, the diagnosis of ventricular aneurysm. She was discharged clinically stable and maintains follow-up in Cardiology consultation of our Hospital.

Conclusion

In this patient, initially admitted with an anterior myocardial infarction submitted to primary PCI, follow-up with advanced imaging modalities pointed to the diagnosis of pseudoaneurysm. Despite the preoperative diagnosis, surgical findings were compatible with a giant left ventricular aneurysm. Even with high spatial resolution exams, postoperative evaluation of tissue layers remains the gold standard for this differential diagnosis.

Abstract P871 Figure. Apical pseudoaneurysm vs aneurysm

501 A common finding with an atypical (rare) presentation

Introduction

Hypereosinophilic syndrome (HES) is characterized by persistent eosinophilia and eosinophil-mediated organ damage. Cardiac thrombosis and thromboembolic complications are common causes of morbidity and mortality in these patients. The echocardiogram is the first method of image in the assessment of cardiac involvement by HES.

Clinical Case

An 81 year-old male, with previous history of hypereosinophilia under investigation without specific treatment, presented to the emergency department after several episodes of syncope and exertional dyspnea. The patient denied fever. He was hemodynamically stable and had a holosystolic murmur (III/VI) audible in the entire precordium.

The ECG was normal. The blood tests showed leukocytosis (26.69 x10^9/L) mainly related to hypereosinophilia (17.5 x10^9/L), thrombocytopenia (134.000/uL), elevation of troponin (hsTnT= 276 ng/L, normal range <14) and reactive C-protein (3.27mg/dL, normal range <0.5).

The transthoracic echocardiogram (limited for the acoustic window) showed a mass in the aortic valve with obstruction of the left ventricle outflow tract (LVOT) during systole (maximum velocity= 3.85m/s, maximum gradient = 59mmHg, mean gradient = 31mmHg), moderate mitral regurgitation, left ventricle hypertrophy with normal ejection fraction and mild pericardial effusion.

A transesophageal echo (TEE) was performed confirming the presence of a hyperechogenic sessile mass, with irregular contours, measuring 23x30 mm, attached to the aortic valve causing obstruction of the LVOT (Figure 1 A and B – TEE midesophageal long axis in diastole and systole, respectively; C and D - TEE midesophageal short axis in diastole and systole, respectively).

The patient was submitted to emergent cardiac surgery for excision of the mass and aortic valve replacement (Figure 1E and F- intraoperative and macroscopic views of the mass, respectively). The anatomopathological diagnosis confirmed an aortic valve thrombus.

Discussion/Conclusion: Native aortic valve thrombosis is a rare situation with severe complications like acute myocardial infarction, peripheral ischemia, stroke, cardiogenic shock and sudden death.

In HES, cardiac involvement is present in up to 40-50% of patients, mainly with endomyocardial fibrosis and mural thrombus formation. Native and prosthetic mitral valve thrombosis has also been described, but aortic valve involvement is very unusual.

Thrombi are one of the most common intracardiac masses, but here we present a rare case of native aortic valve thrombosis with high risk of sudden cardiac death, possibly related to HES. The echocardiogram, particularly the transesophageal echo was essential for the identification of the mass and surgical planning, but as usual in intracardiac masses, the final diagnosis was histological.

Abstract 501 Figure.

Affective disorders, psychosis and lipid levels: Is there a connection? Linking psychopathology, clinical exams and neurobiology

Introduction

Published research regarding the relationship between lipid levels in affective disorders has been contradictory. Additionally, most studies correlating psychosis to lipid serum concentrations only concern schizophrenic patients.

Objective

To access the relationship between serum lipid levels with the diagnosis and pathophysiology of affective disorders.

Methods

Diagnostic data (ICD–10: F31–32), including mood and psychotic features, were prospectively collected for all patients admitted at the affective disorder ward at Centro Hospitalar Psiquiátrico de Lisboa (Portugal), during the third trimester of 2016. Serum concentrations of triglycerides and total/HDL/LDL cholesterol were evaluated using standard laboratory tests. Statistical analysis was performed for possible correlations between serum lipid levels and:

– different stages of bipolar disorder (BD);

– elevated versus depressive mood (unipolar and bipolar);

– depressive mood (BD versus non-BD);

– psychotic features.

Results

Sixty-three patients admitted were enrolled in this study: 47 presented with BD (32 manic, 10 depressives and 5 mixed episodes) and 16 presented depressive disorders. Statistical analysis (R software) revealed that depressed bipolar patients had significantly higher triglyceride (P = 0.026), total and LDL cholesterol (P = 0.525) levels than other states; mixed episodes presented higher HDL levels (P = 0.542). Although not significant, manic patients’ HDL levels were consistently elevated compared to depressive ones, whom presented with lower values overall. Finally, when adjusted for age, psychotic patients showed lower levels of total (P = 0.031) and LDL cholesterol (P = 0.052) compared to non-psychotic patients.

Conclusions

There is a potential link between serum lipid levels and diagnosis/psychopathology of affective disorders. Further research is needed to characterize its pathophysiologic relevance.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Insomnia and aggressiveness in affective disorders: Self-assessment versus clinical examination

Introduction

Although, disturbances of sleep, as well as aggressiveness, have been described in patients with mood disorders, these patients may not be aware of them.

Objectives/aims

To access the personal perception of sleep, disturbances and aggressiveness in patients with mood disorders, admitted to an acute psychiatric ward.

Methods

Diagnostic data (ICD-10: F31–33), including mood evaluation, were prospectively collected for all patients admitted at the affective disorder ward at Centro Hospitalar Psiquiátrico de Lisboa (Portugal), during the third trimester of 2016. Then, 2 auto-questionnaires – Athens insomnia scale (AIS) and Buss and Perry aggression scale (both validated to the Portuguese population) – were applied to these patients. Statistical analysis was performed for possible correlations between patients’ mood and the questionnaires’ scores, using R software.

Results

Thirty-eight patients admitted were enrolled in this study: 28 with bipolar disorder (19 manic, 4 depressive and 5 mixed episodes), and 10 with depressive disorder. Depressed patients presented statistically higher values in the AIS (average = 20), compared to manic (14) and mixed ones (17.2) (P = 0.031). However, there were no statistical differences found between depressed patients (bipolar versus non-bipolar). Even though manic patients presented an increased average score in the Buss and Perry questionnaire (both total–65; but also sub-scores), these values were not significantly different than depressed (60) or mixed patients’ scores (57.4).

Conclusions

Even though some symptoms (like sleep or aggressiveness) seem to be relevant to the clinics, patients with affective disorders do not seem to be aware these disturbances, and therefore are not able to acknowledge their relevance.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Operational decision support system for large combined sewage systems: Lisbon/Tagus estuary case study

Managing combined sewage systems in large cities discharging to coastal waters, often bearing recreational activities, remains a challenge. Studying the impacts of such discharges requires the development of specific models. Hydrodynamic and water quality modelling of coastal waters employs numerical methods and algorithms, leading to the design of complex models which require expert use. The use of such models as decision support tools to simulate discharge impacts and define adequate corrective measures could represent a key part in meeting this challenge. In this paper, the authors describe the work undertaken to develop an operational decision support system (ODSS) methodology aiming to enable wastewater utilities' non-expert staff to carry out user-friendly scenario analysis based on computational fluid dynamics simulations. This article depicts the application and validation of the ODSS to the combined sewage system and the Tagus estuary of the city of Lisbon in Portugal. The ODSS was used for simulating the effects in the receiving coastal waters of a discharge caused by a scheduled maintenance operation in the sewage infrastructure. Results show that the use of such ODSS by non-expert staff increases their decision capabilities and knowledge of the wastewater utility's contribution to reducing negative impacts of sewage discharges on the receiving water bodies.

Biomethanation potential of macroalgae Ulva spp. and Gracilaria spp. and in co-digestion with waste activated sludge

Biochemical methane potential of four species of Ulva and Gracilaria genus was assessed in batch assays at mesophilic temperature. The results indicate a higher specific methane production (per volatile solids) for one of the Ulva sp. compared with other macroalgae and for tests running with 2.5% of total solids (196±9 L CH(4) kg(-1)VS). Considering that macroalgae can potentially be a post treatment of municipal wastewater for nutrients removal, co-digestion of macroalgae with waste activated sludge (WAS) was assessed. The co-digestion of macroalgae (15%) with WAS (85%) is feasible at a rate of methane production 26% higher than WAS alone without decreasing the overall biodegradability of the substrate (42-45% methane yield). The use of anoxic marine sediment as inoculum had no positive effect on the methane production in batch assays. The limiting step of the overall anaerobic digestion process was the hydrolysis.

Analysis of postural oscillation in children with cerebral palsy

It is believed that static balance undergoes changes in children with cerebral palsy (CP). Thus, we analyzed postural oscillation in 19 children with the aim of comparing balance between healthy children and those with CP. The sample was divided into two groups--one with 10 children diagnosed with diparetic CP (CPG) and a control group (CG) with nine healthy children, all capable of remaining in an orthostatic position without support and obeying spoken commands. The assessment of postural oscillation was performed with the children barefoot, arms alongside the body and looking toward a fixed point while standing on an unrestricted base for the feet. Data collection was performed using a TEKScan force platform with 30-second duration for each condition. The children had an average age of 7.9 years (+/- 2.07) in the CPG and 7.5 years (+/- 1.58) for the CG. Postural oscillation data in the anterior-posterior and medial-lateral directions were analyzed using the Data Analysis and Technical Graphics Origin 6.0 program. Statistical analysis of the mean oscillation value in the conditions of eyes open and eyes closed did not differ significantly between groups. However, there was a significant difference in mean anterior-posterior oscillation between groups (p = 0.00). The groups behaved similarly with regard to the visual deprivation. We conclude that children with CP exhibit less postural oscillation in comparison to healthy children under the same conditions.

[Cardiological medical treatment after coronary bypass surgery]

When a decision has been reached to proceed with coronary bypass surgery, this represents a therapeutical option for a partnership between surgical revascularization and an optimized multifaceted medical treatment. We report the guidelines implemented in our department concerning the secondary prevention therapy after coronary bypass surgery. The antiplatelet therapy (and its association with coumadin), the bradycardizing treatments (with a special reference to the approach of unappropriate sinus tachycardia), the specific anti-ischemic therapy, the treatment of dyslipidemia, and the antihypertensive therapy are reviewed as well as the use of additional anti-atheromatous measures, the approach of hyperuricemia and hyperhomocysteinemia, and the oral antidiabetic treatment.

[Kommerell diverticula associated with dysphagia: a clinical case and review of the literature]

We report the case of a young female with disphagia and weigth loss caused by a vascular ring associated with right aortic arch, Kommerell diverticula, and left retroesophageal ligamentum arteriosum (ductus arteriosus). The patient underwent surgical treatment. A left thoracotomy was performed. Surgical technique included diverticulum ressection and an aortopexia. There were no major complications. We also discuss the incidence, pathology, diagnosis, clinical features and treatment of this rare disease.

Osteoinduction in human fat-derived stem cells by recombinant human bone morphogenetic protein-2 produced in Escherichia coli

Bioactive recombinant human bone morphogenetic protein-2 (rhBMP-2) was obtained using Escherichia coli pET-25b expression system: 55 mg purified rhBMP-2 were achieved per g cell dry wt, with up to 95% purity. In murine C2C12 cell line, rhBMP-2 induced an increase in the transcription of Smads and of osteogenic markers Runx2/Cbfa1 and Osterix, measured by semi-quantitative RT-PCR. Bioassays performed in human fat-derived stem cells showed an increased activity of the early osteogenic marker, alkaline phosphatase, and the absence of cytotoxicity.

[Surgical diagnosis of mediastinal pathology: eleven-years experience]

Between January 1993 and December 2004, 68 patients with mediastinal pathology were submitted to diagnosis surgery. All the pathological process were located in the anterior mediastinum, and most of them were malignant (64.1%). The most common pathology was limphoma (26.5%), sarcoidosis (23.5%) and thymomas (23.5%). Seven cases consisted in ganglionar tuberculosis (10.3%), six cases were ganglionar metastases of lung adenocarcinoma (8.8%), and three cases were thymic carcinoma (4.4%). One patient had no definite diagnosis (1.5%). In this experience high diagnosis accuracy (98.5%), and low morbidity were demonstrated. Although the present video assisted thoracic surgery progress and development, mediastinoscopy still remains as a reliable, safe and efficient surgical approach for the diagnosis of mediastinal pathology.

[Surgery of mediastinal tumors: 11-years experience]

Between 1993 and 2004, 70 operations on patients with the diagnosis of mediastinal tumors were performed in the Cardiothoracic Surgery Department of Santa Maria Hospital. In this study we did not include diagnostic surgery of mediastinal tumors. In 70 patients treated, 63 p (90%) had the tumor located in the anterior mediastinum, 21 p with thymoma, 6 p with lymphoma, 4 p with carcinoid tumors, 1 p with sarcoma and 1 p with adenocarcinoma. 3 patients had tumors located in the medium and 4 patients in the posterior mediastinum. We analysed the results of the mediastinal tumors surgery during the 11-years period. Also, we evaluated the clinical effects of the thymectomy in myasthenia gravis.

["Off pump" coronary surgery and simultaneous carotid endarterectomy]

The occurrence of significant carotid artery disease in patients requiring coronary artery bypass grafting (CABG), results in a dilemma regarding the best surgical management. Our philosophy has been to perform simultaneous carotid endarterectomy and CABG off-pump. We reviewed the efficacy of this therapy in six patients treated in our hospital between January 2001 and December 2002. The result was satisfactory and there was no hospital mortality.

[Pulmonary arterio-venous fistula: a clinical report]

A 44 years old female was admitted with previous history of several cerebral vascular accident (CVA). A transthoracic echocardiogram showed a patent foramen ovale (PFO) that was closed, under extracorporeal circulation. The patient remained free of symptoms for ten years. In the year 2003 she was admitted to our hospital with paresthesias of the left arm. The clinical evaluation led to the diagnosis of arteriovenous fistula (AVF) of the lung. In November 2003, the patient underwent right inferior lobectomy. This is a rare association of PFO with AVF fistula of the lung with a delayed diagnosis. The differential diagnosis, the surgical treatment and the most frequent complications of this pathology are reported and discussed.

[Reoperation in mitral valve reconstructive surgery]

In the past few years reconstructive surgery of the mitral valve has experienced a growing popularity. It is now clearly established that restoration of a normal function valve is preferable to valve replacement. The authors report the results of the mitral valve reconstructive surgery in a population of 701 patients with high incidence of restrictive lesions of rheumatic fever. This represents an experience of 14 years. 5.1% of patients who underwent mitral valvuloplasty required late reoperation for recurrent mitral valve dysfunction. Repeat mitral valve repair resulted in successful treatment for 40% of these patients.

CONCLUSION

The mitral valve repair failure are: 1--Procedure related: (58.1%); a--surgical technical related--35.8%; b--no ring implantation (in restrictive lesions)--15%; c-rupture of previously chordae shortened--7.4%. 2--Valve related: (41.9%); a--progressive primary valve disease--(25.4%); b--wrong surgical indication--(15%); c--endocarditis--(1.5%).

A physiological and enzymatic study of Debaryomyces hansenii growth on xylose- and oxygen-limited chemostats

The effect of changing growth rate and oxygen transfer rate (OTR) on Debaryomyces hansenii physiology was studied using xylose-limited and oxygen-limited chemostat cultures, respectively, and complemented with enzymatic assays. Under xylose-limited chemostat (oxygen-excess), neither ethanol nor xylitol was produced over the entire range of dilution rate ( D). The maximal volumetric biomass productivity was 2.5 g x l(-1) x h(-1) at D =0.25 h(-1) and cell yield was constant at all values of D. The respiratory rates and xylose consumption rate increased linearly with growth rate but, above 0.17 h(-1), oxygen consumption rate had a steeper increase compared to carbon dioxide production rate. Enzymatic analysis of xylose metabolism suggests that internal fluxes are redirected as a function of growth rate. For values of D up to 0.17 h(-1), the xylose reductase (XR) titre is lower than the xylitol dehydrogenase (XDH) titre, whereas above 0.17 h(-1) XR activity is about twice that of XDH and the NADPH-producing enzymes sharply increase their titres indicating an internal metabolic flux shift to meet higher NADPH metabolic requirements. Moreover, the enzymes around the pyruvate node also exhibited different patterns if D was above or below 0.17 h(-1). Under oxygen-limited chemostat (xylose-excess) the metabolism changed drastically and, due to oxidative phosphorylation limitation, cell yield decreased to 0.16 g g(-1) for an OTR of 1.4 mmol l(-1) h(-1) and xylitol became the major extracellular product along with minor amounts of glycerol. The enzymatic analysis revealed that isocitrate dehydrogenase is not regulated by oxygen, whereas XR, XDH and the NADPH-producing enzymes changed their levels according to oxygen availability.

Transport and utilization of hexoses and pentoses in the halotolerant yeast Debaryomyces hansenii

Debaryomyces hansenii is a yeast species that is known for its halotolerance. This organism has seldom been mentioned as a pentose consumer. In the present work, a strain of this species was investigated with respect to the utilization of pentoses and hexoses in mixtures and as single carbon sources. Growth parameters were calculated for batch aerobic cultures containing pentoses, hexoses, and mixtures of both types of sugars. Growth on pentoses was slower than growth on hexoses, but the values obtained for biomass yields were very similar with the two types of sugars. Furthermore, when mixtures of two sugars were used, a preference for one carbon source did not inhibit consumption of the other. Glucose and xylose were transported by cells grown on glucose via a specific low-affinity facilitated diffusion system. Cells derepressed by growth on xylose had two distinct high-affinity transport systems for glucose and xylose. The sensitivity of labeled glucose and xylose transport to dissipation of the transmembrane proton gradient by the protonophore carbonyl cyanide m-chlorophenylhydrazone allowed us to consider these transport systems as proton symports, although the cells displayed sugar-associated proton uptake exclusively in the presence of NaCl or KCl. When the V(max) values of transport systems for glucose and xylose were compared with glucose- and xylose-specific consumption rates during growth on either sugar, it appeared that transport did not limit the growth rate.

Human extrastriate visual cortex and the perception of faces, words, numbers, and colors

Electrophysiological correlates of the processing of visual information were studied in epileptic patients with electrodes chronically implanted on the surface of striate and extrastriate cortex. In separate experiments patients viewed faces, letter strings (words and non-words), numbers, and control stimuli. A negative potential, N200, was evoked by faces, letter strings, and numbers, but not by the control stimuli. N200 was recorded bilaterally from discrete regions of the fusiform and inferior temporal gyri. These category-specific face, letter-string, and number "modules" vary in location. In most cases there was no overlap in the location of face and letter-string modules, suggesting a mosaic of functionally discrete regions. In some cases letter-string and number N200s were recorded from the same location, suggesting that these modules may be less spatially and functionally discrete. Face N200-like potentials can be recorded from temporal scalp, allowing the possibility of studying early face processing in normal subjects. Longer-latency face-specific potentials were recorded from the inferior surface of the anterior temporal lobe. Potentials evoked by colored checkerboards were recorded from a region of the fusiform gyrus posterior to the fusiform region from which category-specific N200s were recorded. These results suggest that there are several processing streams in inferior extrastriate cortex. In addition to object recognition systems previously proposed for faces and words, our preliminary results suggest a separate system dealing with numbers. Postulated systems dealing with larger manipulable objects and animals have not been detected.

Absent left-sided atrioventricular connexion, with right atrium connected to left ventricle: prospective diagnosis in infancy, and outcome

Prospective echocardiographic diagnosis of absence of the left atrioventricular connexion, with the right atrium connected to a morphologic left ventricle through a bileaflet morphologically mitral valve, was made in six infants. The rudimentary right ventricle was left-sided in all patients, and separated from the left atrium by sulcus tissue. The ventriculoarterial connexions were discordant. Associated defects included subpulmonary stenosis (2 patients), pulmonary atresia (1 patient), and a patent duct (4 patients). All patients developed early left atrial hypertension due to a restrictive interatrial septum, and required transcatheter septostomy (5 patients), or surgical septectomy (3 patients). One patient who had a severely restrictive ventricular septal defect died following cardiac catheterization. In three others the ventricular septal defect has become progressively restrictive on serial catheterization. Successful intermediate term palliation has been performed in two patients using a bidirectional Glenn anastomosis, together with enlargement of the ventricular septal defect and a Damus-Kay-Stansel procedure in one. It is possible to distinguish this malformation from "mitral atresia" using cross-sectional echocardiography. The long-term outlook is influenced by early relief of left atrial hypertension. Balloon atrial septostomy alone is usually inadequate, and either blade septostomy or surgical septectomy are required. Serial cardiac catheterization is mandatory for planning definitive palliation.

Traumatic ventricular septal defect: serial follow-up with Doppler ultrasound

A three-year-old girl presented with a gunshot wound of the chest. Cross-sectional and Doppler echocardiography enabled precise location of the bullet, and assessment of the haemodynamic effects of the traumatic ventricular septal defect. Serial ultrasound examination in the acute stage confirmed that the bullet was well embedded in the left ventricular myocardium, and the ventricular septal defect was restrictive, enabling conservative management.