A. Gallino

Alloimmunity and nonimmunologic risk factors in cardiac allograft vasculopathy

Graft vasculopathy is an accelerated form of coronary artery disease that occurs in transplanted hearts. Despite major advances in immunosuppression, the prevalence of the disease has remained substantially unchanged during the last two decades. According to the response to injury paradigm, graft vasculopathy is the result of a continuous inflammatory response to tissue injury initiated by both alloantigen-dependent and independent stress responses. Experimental evidence suggests that these responses may become self-sustaining, as allograft re-transplantation into the donor strain at a later stage fails to prevent disease progression. Histological evidence of endothelitis and arteritis, in association with intima fibrosis and atherosclerosis, reflects the central role of alloimmunity and inflammation in the development of arterial lesions. Experimental results in gene-targeted mouse models indicate that cellular and humoral immune responses are both involved in the pathogenesis of graft vasculopathy. Circulating antibodies against donor endothelium are found in a significant number of patients, but their pathogenic role is still controversial. Alloantigen-independent factors include donor-transmitted coronary artery disease, surgical trauma, ischaemia-reperfusion injury, viral infections, hyperlipidaemia, hypertension, and glucose intolerance. Recent therapeutic advances include the use of novel immunosuppressive agents such as sirolimus (rapamycin), HMG-CoA reductase inhibitors, calcium channel blockers, and angiotensin converting enzyme inhibitors. Optimal treatment of cardiovascular risk factors remains of paramount importance.

Dealing with dilated ascending aorta during aortic valve replacement: advantages of conservative surgical approach.

Five to fifteen percent of patients undergoing aortic valve replacement (AVR) will have an ascending aortic aneurysm requiring a concomitant surgical procedure. On the other hand, a dilated ascending aorta is known to be a potential source of complications after AVR. From 1972 to 1988, 2278 AVR, either isolated or combined with a second cardiac procedure, were performed in our institution. In the same time interval, a dilated ascending aorta was treated in additional 291 consecutive patients during AVR. Three different surgical options were employed: aortic remodelling and external wall support in 164 patients (56.4%), composite graft replacement in 81 patients (27.8%) and a supracoronary graft in 46 patients (15.8%). Early mortality was 4.8%. Aortic remodelling plus external wall support had the lowest early mortality (1.8%) and the best 8-year survival (89.6%). Supracoronary grafting had a higher early mortality (6.4%) and lower 8-year survival (73.2%). The results of the composite graft were least favourable: early mortality was 9.8% and 8-year survival 76.5%. The results point out the necessity for instituting the appropriate surgical procedure for a dilated ascending aorta during AVR. They show that conservative aortic surgery with preservation of endothelial lining gives excellent early and late results.

Superior hemodynamics in left heart bypass without systemic heparinization

Open-chest left heart bypass was performed in 10 canine experiments (30 +/- 9 kg) by a servo controlled roller pump for 6 h at a pump flow of 50 ml/min per kg bodyweight. The surfaces of the tubing sets were either standard (with systemic heparinization) or with end-point attached heparin (no systemic heparin). Besides continuous monitoring of hemodynamics, a standard battery of blood samples was taken before bypass, after 10 min and every hour thereafter. There is no evidence of increased fibrin production in the group with end-point attached heparin surfaces perfused without systemic heparinization. Superior hemodynamics in left heart bypass performed without systemic heparinization appear to be due to improved hemostasis, reduced blood loss and therefore reduced transfusion requirements. Left heart bypass with heparin-coated equipment has been successfully used for resection of a thoracoabdominal aneurysm in six patients.

Effect of Percutaneous Transluminal Angioplasty on Severely Stenotic Femoral Lesions In Vivo Demonstration by Noninvasive Magnetic Resonance Imaging

The angiogram of a 68-year-old woman with severe claudication (Rutherford clinical class 3) of the right leg revealed a chronic high-grade preocclusive stenosis of the distal superficial femoral artery, with multiple collateral vessels (Figure 1A). Post-percutaneous transluminal angioplasty (PTA) angiography demonstrated restoration of both lumen and antegrade flow (Figure 1B). Cross-sectional magnetic resonance (MR) imaging performed 24 hours after PTA at the level of the arterial occlusion (Figure 2) revealed severe disruption …

Telemedicine for cardiac surgery candidates.

BACKGROUNDnCardiac surgery is generally well or over-represented in many Western countries. Since the southern part of Switzerland relies on 300 km distance centers for cardiac surgery, we started a project of telemedicine for the distant evaluation of cardiac surgery candidates. We report our experience of the results of the diagnosis made by telemedicine and by direct scrutiny of coronary angiograms.nnnMETHODSnCoronary angiography was performed at the distant hospital by an invasive cardiology team. Teletransmission of images was performed using three Integrated Service Digital Network (ISDN) lines by direct transmission of recent recording. A total of 98 cases were reviewed (87 aorto-coronary bypass candidates, seven valvular and four congenital heart disease). We further performed a prospective blinded comparison of 47 consecutive cases with severe coronary artery disease (CAD) with respect to localization and number of significant coronary lesions, obtained by direct scrutiny of the original angiograms and the evaluation obtained with the teletransmitted images.nnnRESULTSnIn 89 cases of the 98 analyzed (91%) correct diagnosis and surgical approach could be established by distant transmission. In nine cases (9%, all aortocoronary bypass candidates) definitive diagnosis and treatment was feasible only by direct scrutiny of the original angiograms. Five critically ill patients were urgently referred to the surgical care center based on the correct distant diagnosis. The blinded comparison of distant diagnosis and direct scrutiny of angiograms in defining 1-2-3 vessel CAD was good: r=0.87, P<0.01.nnnCONCLUSIONnInitial experience using non-sophisticated telemedical transmission of angiograms of cardiac surgery candidates seems to be a promising facility for distantly located centers.

Images in cardiovascular medicine. Posttraumatic cardiac contrecoup: in vivo evidence by cardiac magnetic resonance imaging.

A 33-year-old previously healthy man, victim of a motorcycle accident, had been violently ejected from the vehicle falling to the ground on his right-hand side. At admission he was conscious, hemodynamically stable, and without skin wounds. Chest x-ray examination performed immediately after the accident at a district hospital revealed a fracture of the sixth right rib; ECG showed repolarisation abnormalities with T-wave inversion in inferior and lateral leads (Figure 1). Cardiac enzymes were negative at admission, but an increase in Troponin I was noted in the following 4 hours (peak 3.19 ng/mL at 12 hours). nnnnFigure 1. ECG repolarization abnormalities with T-wave inversion in inferior …A 33-year-old previously healthy man, victim of a motorcycle accident, had been violently ejected from the vehicle falling to the ground on his right-hand side. At admission he was conscious, hemodynamically stable, and without skin wounds. Chest x-ray examination performed immediately after the accident at a district hospital revealed a fracture of the sixth right rib; ECG showed repolarisation abnormalities with T-wave inversion in inferior and lateral leads (Figure 1). Cardiac enzymes were negative at admission, but an increase in Troponin I was noted in the following 4 hours (peak 3.19 ng/mL at 12 hours). nnnnFigure 1. ECG repolarization abnormalities with T-wave inversion in inferior …

Type A Aortic Dissection in a Patient With Congential Coarctation of the Aorta Emergency Surgical Repair With an Extra-Anatomic Bypass

Congenital coarctation of the aorta was diagnosed in a 3-year-old boy with a systolic murmur, a brachial pressure of 130/95 mm Hg, and an ankle pressure of 75 mm Hg. Diagnosis was confirmed by echocardiography, which also showed a bicuspid aortic valve.nnThe parents, despite the advice of several pediatric cardiologists and cardiac surgeons, had always refused surgical correction or percutaneous angioplasty. In 1994, at the age of 13, the boy suddenly suffered an acute type A aortic dissection originating 2 cm distal from the aortic annulus and ending at …

The characteristics of infero-lateral early repolarisation are different between young males and females athletes

Purpose: Early Repolarisation in inf-lat leads (ER), a common ECG pattern in athletes, has been recently linked with an increased risk of cardiac death, particularly for some phenotypes (malignant ER): J wave amplitude > 2 mm in inferior leads with horizontal/descending ST segment. The aim of this study was to assess the different ECG phenotypes of ER in males and females young athletes.nnMethods: ECG was analysed in young (14-35 years) competitive athletes. ER was defined as J point elevation ≥ 1 mm in 2 or more contiguous leads (except V1-V3). Localisation of ER (inf, lat or inf-lat), for each localisation amplitude and morphology of J wave (notch, slurred or indeterminate) and ST segment pattern (ascending, horizontal/descending) were noted.nnResults: ECG of 1070 athletes (75% males, age 19.7±6.3 years) was analysed and result reported in Table 1.nnView this table:nnTable 1nnnnnnConclusions: The ER are different by sex: in males ER is more prevalent, more frequent in infero-lateral leads with notched or indeterminate J waves and ascending ST segment. In females, ER is more frequent in inferior leads with slurred J wave of lower amplitude and horizontal/descending ST segment. There is a trend towards more malignant ER in males. The clinical significance of these findings are currently undetermined.

Herz- und Gefässchirurgie: Die endovaskuläre Sanierung von Aortenaneurysmen setzt sich durch!

Seit Anfang der neunziger Jahre des letzten JahrhundertswirdanderendovaskulärenAneurysmasanierung mit Hilfe von kathetergängigen Endoprothesen (EVAR) [1] gearbeitet. Diese Prothesen sind blutdicht, sogenannte «covered stents». In der Regel werden dafür selbstexpandierende Stents aus Nitinol oder nichtrostendem Stahl eingesetzt, die mit einer Hülle aus Dacron® oder Polytetrafluorethylen versehen sind. Die Verankerung dieser Implantate in der Aorta und in ihren Ästen, diesund jenseits des zu sanierendenAneurysmas,geschiehtdurchgeeigneteÜberdimensionierung des Implantats (Reibungsfixation). Mit der Zeit haben sich die für diese Therapieform relevanten Fragestellungen von der Machbarkeit (Verbesserung der Einführungsbestecke), zur Verlässlichkeit (Verbesserung der Implantate, Nachkontrollen) und schliesslich zur potentiellen Gefährdung der Patienten wegen Nachoperationen einerseits und der Erweiterung der Indikationen andererseits verlagert. In unseren Händen hat sich die endovaskuläre Aneurysmasanierung zur Evaluation erster Wahl für die Routinebehandlung entwickelt. Dies gilt sowohl für elektive als auch für notfallmässige Eingriffe und wurde durch die Bereitstellung folgender Elemente ermöglicht: durch die gängigen geraden bzw. konischen Endoprothesen und Bifurkations-Endoprothesen im Operationstrakt; durch einen EVAR-Katheterwagen, ergänzt mit den nötigen Schleusen, Führungsdrähten, Ballonen usw. für die Einrichtung der spezifischen vaskulären Zugänge, sowie durch ein mobiles intravaskuläres Ultraschallgerät (IVUS) für die intraoperative Ausmessung der Aneurysmakonfiguration [2] und einen mobilen C-Bogen für die Durchleuchtung. Dadurch sind wir in der Lage, in jedem Operationssaal unseres Hauses, und in Kombination mit einem Lieferwagen auch ausser Haus, endovaskuläre Eingriffe mit Ausmessung in Echtzeit durchzuführen.

Gefäßchirurgische Ausbildung in endovaskulärer Technik in Lausanne

ZusammenfassungZwischen 1995 und 2005 wuchs die Anzahl der jährlich von uns mit endovaskulären Techniken versorgten Aortenaneurysmen (EVAR) von 0 auf 50, und dies auf allen Stufen der Aorta. Zu unserer Organisation gehören ein breites Team von Chirurgen, ein Lager mit 3xa0kompletten Familien von Endoprothesen (gerade Endoprothesen, konische Endoprothesen, und Bifurkationen), ein mobiler Wagen mit Zubehör (Einführungsbestecke, Führungsdrähte, Katheter, Ballone etc.) und ein Apparat auf Rädern für die intravaskuläre Ultraschalluntersuchung (IVUS). Letzterer erlaubt es zusammen mit einer mobilen Durchleuchtungsanlage (C-Bogen), in jedem Operationssaal unserer Institution endovaskulär Aneurysmen zu analysieren, und dies in der Regel ohne Angiographie bzw. Kontrastmittel. Deshalb sind wir nicht mehr auf eine ausgiebige bildgebende präoperative Abklärung potenzieller Kandidaten für eine endovaskuläre Sanierung von Aneurysmen angewiesen und können rupturierte Aneurysmen der Bauchaorta oder der thorakalen Aorta ohne Verzug behandeln. Bei der endovaskulären Sanierung von Aortenaneurysmen unterscheiden wir zwischen Prozessschritten (Indikationsstellung, Darstellung der Zugangsgefäße, Ausmessen mittels IVUS und Roadmapping mittels Durchleuchtung, Implantatwahl, Implantatinsertion, Positionierung, Implantatabwurf, Erfolgsbeurteilung, Rekonstruktion der Zugangsgefäße und Nachkontrolle) und Kompetenzstufen (Assistent, Oberarzt, Leitender Arzt). Unsere ultraschallgestützte Technik zur endovaskulären Sanierung von Aneurysmen wurde mittels IVUS-Transporter und Telementoring erfolgreich auch anderen Institutionen zur Verfügung gestellt.AbstractBetween 1995 and 2005, the number of aortic aneurysms treated annually using endovascular techniques (EVAR) increased from 0 to 50, including all aortic stages. Our organization includes a large team of surgeons, a stock of three complete families of endoprostheses (straight, conical and bifurcated), a mobile trolley with accessories (arterial introducer/introducer sheath, guide wire, catheters, balloons, etc.) and an appliance on wheels for intravascular ultrasound examination (IVUS). This appliance, together with a mobile fluoroscopy device (c-arm), allows endovascular aneurysms analysis of every operating room in our institution, usually without angiography or the use of contrast medium. In general, we are therefore not depending on substantial preoperative imaging in order to identify candidates for endovascular aneurysms repair and can treat abdominal and thoracic aortic ruptures without delay. For endovascular aortic aneurysms repair we distinguish between process steps on the one hand (determining indications, imaging of the access vessels, measurement using IVUS and road mapping via fluoroscopy, selection of implant, implant insertion, positioning, setting the implant, determining success, reconstruction of the access vessel and follow-up) and the level of competence on the other (assistant, senior and directing physicians). Our ultrasound supported technique for endovascular aneurysms repair has been successfully brought to other hospitals using an IVUS transporter and telementoring.