Cristiano Spadaccio

Old Myths, New Concerns: the Long-Term Effects of Ascending Aorta Replacement with Dacron Grafts. Not All That Glitters Is Gold

Synthetic grafts are widely used in cardiac and vascular surgery since the mid-1970s. Despite their general good performance, inability of mimicking the elastomechanical characteristics of the native arterial tissue, and the consequent lack of adequate compliance, leads to a cascade of hemodynamic and biological alterations deeply affecting cardiovascular homeostasis. Those concerns have been reconsidered in more contemporaneous surgical and experimental reports which also triggered some research efforts in the tissue engineering field towards the realization of biomimetic arterial surrogates. The present review focuses on the significance of the “compliance mismatch” phenomenon occurring after aortic root or ascending aorta replacement with prosthetic grafts and discusses the clinical reflexes of this state of tissue incompatibility, as the loss of the native elastomechanical properties of the aorta can translate into detrimental effects on the normal efficiency of the aortic root complex with impact in the long-term results of patients undergoing aortic replacement.

Use of allogeneic tissue to treat infective valvular disease: Has everything been said?

From the Cardiac Surgery Center, Cardiologique du Nord de Saint-Denis; Department of Cardiothoracic Surgery, Golden Jubilee National Hospital; Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom; and Department of Cardiovascular Surgery, Hôpital de la Salp etri ere, Paris, France. Received for publication Aug 8, 2016; revisions received Sept 21, 2016; accepted for publication Sept 26, 2016. Address for reprints: Francesco Nappi, MD, Cardiologique du Nord de Saint-Denis, 36 Rue des Moulins G emeaux, 93200 Saint-Denis, France (E-mail: francesconappi2@gmail.com). J Thorac Cardiovasc Surg 2016;-:1-5 0022-5223/

Implantation of a Poly-L-Lactide GCSF-Functionalized Scaffold in a Model of Chronic Myocardial Infarction.

36.00 Copyright 2016 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2016.09.071

Apoptosis and autoimmunity induced by clodronate in systemic lupus erythematosus mononuclear circulating cells.

A previously developed poly-l-lactide scaffold releasing granulocyte colony-stimulating factor (PLLA/GCSF) was tested in a rabbit chronic model of myocardial infarction (MI) as a ventricular patch. Control groups were constituted by healthy, chronic MI and nonfunctionalized PLLA scaffold. PLLA-based electrospun scaffold efficiently integrated into a chronic infarcted myocardium. Functionalization of the biopolymer with GCSF led to increased fibroblast-like vimentin-positive cellular colonization and reduced inflammatory cell infiltration within the micrometric fiber mesh in comparison to nonfunctionalized scaffold; PLLA/GCSF polymer induced an angiogenetic process with a statistically significant increase in the number of neovessels compared to the nonfunctionalized scaffold; PLLA/GCSF implanted at the infarcted zone induced a reorganization of the ECM architecture leading to connective tissue deposition and scar remodeling. These findings were coupled with a reduction in end-systolic and end-diastolic volumes, indicating a preventive effect of the scaffold on ventricular dilation, and an improvement in cardiac performance.

Euler's elastica–based biomechanical assessment for neochordal insertion in the treatment of degenerative mitral valve repair

The aim of this study is to evaluate the effect of clodronate on apoptosis of human systemic lupus erythematosus circulating mononuclear cells and to analyze possible correlations with changes in autoantibody production in vitro. Lympho-monocytes from 20 SLE patients were isolated and incubated with or without addition of 1 μM clodronate for 72 hours. Apoptosis and release of genomic material was assessed by immunofluorescent detection of cleaved caspase-3 and by Cell-Death-Detection ELISAPLUS kit (Roche). Anti-Nucleosome IgG and anti-dsDNA IgM and IgG autoantibody levels were determined in supernatants by commercially available ELISA kits. Clodronate induced apoptosis in monocytes as confirmed by cleaved caspase-3 immunostaining and by quantification of cleaved nucleosome in the supernatants (treated 0.22±0.05 O.D. vs untreated 0.09±0.04 O.D.; P<0.001). This finding was coupled with a significant increasing in supernatants of IgG anti-Nucleosome (treated 6.5±1.1 vs untreated 5.5±0.6 IU/mL; p=0.001) and IgM (treated 3.0±1.3 vs 2.2±0.9 IU/mL; p=0.02) and IgG (treated 4.0±1.8 vs untreated 2.8±1.5 IU/mL; p=0.02) anti-dsDNA autoantibody levels. Our findings stressed the proapoptotic activity of clodronate, as well as its potential autoimmunity induction in SLE mononuclear circulating cells. Clinical studies could clarify the role of bisphosphonates on autoantibody production and worsening of disease activity.

Long Term Outcome of Cryopreserved Allograft for Aortic Valve Replacement

resection, or preservation of the prolapsing segment of the posterior mitral leaflet have been shown to be effective and should remain as useful tools in the surgeons’ surgical armamentarium, because each may have special applicability to different types of valve pathology. Namely, when there is ‘‘excessive’’ leaflet tissue, appropriate resection may be indicated. Their position is very well illustrated by the flowchart that constitutes their central picture. The letter of Tom si c and colleagues reinforces the idea that I had expressed in the Editorial Commentary that accompanied the original article of Mazine and colleagues, ‘‘Isolated Posterior Mitral Leaflet Prolapse: Resect, Respect, or Resect With Respect?’’ There are questions remaining: How excessive is excessive? And how extensive should the resection be? The whole or part of the prolapsed segment? This is precisely what I meant by ‘‘resect with respect.’’ Actually, Mazine and colleagues were already pointing in the same direction when they stated that ‘‘it is critical that mitral surgeons can utilize several different techniques individualized to the quality and quantity of mitral tissue, as well as each patient’s specific dysfunction and lesions.’’ In fact, though, the main message of the article byMazine and colleagues was that preservation of the leaflet might achieve better functional results, not only in terms of preserving an adequate valve orifice, thus potentially avoiding mitral stenosis, a ‘‘complication’’ previously described in the literature, but also in terms of preservation of left ventricular function, by avoiding distortion of the mitral valve apparatus. In the meta-analysis performed by Mazine and colleagues, reoperation was more frequent in the resection group, although no difference in recurrence of mitral regurgitation was detected. As Tom si c and colleagues underlined, however, ‘‘most reoperations were performed shortly after the initial operation, indicating technical failure. Indeed, ring dehiscence was the most common cause of reoperation.’’ Tom si c and colleagues also considered that ‘‘the type (and size) of annuloplasty device can potentially cause unwanted, clinically significant functional mitral valve stenosis.’’ These two problems will probably remain a matter of discussion in the foreseeable future. Personally, I have never come across a single case of significant postrepair mitral stenosis, and it is unlikely that it will occur except after excessive reduction of leaflet tissue or use of extremely small rings. On the other hand, I cannot understand how can one of these techniques achieves better preservation of left ventricular function, because neither alters the

Mitral endocarditis: a new management framework

Objective The most efficient surgical approach to severe aortic valve disease in the young adult is still debated: cryopreserved aortic allograft offers excellent hemodynamic and avoid anticoagulation, but long‐term durability is influenced by structural valve deterioration (SVD). This study aimed to describe long‐term results of aortic allografts and to identify factors influencing long‐term durability. Methods From January 1993 to August 2010, 210 patients underwent aortic allograft replacement via the free‐hand subcoronary implantation technique (N = 55) or root replacement with coronary reimplantation (N = 155). Clinic and echocardiographic follow‐up was updated to April 2016. Results Overall mortality and cardiac mortality occurred in 80 (38.1%) and 64 (30.5%) patients, respectively. Reoperation was required in 69 cases (32.8%), whereas SVD required reoperation in 57 cases (27.1%). No early endocarditis occurred, whereas late endocarditis occurred in 4 patients. The free‐hand technique seems to be associated with improved left ventricular remodeling compared with the root‐replacement technique, and smaller allograft size represents a predictor of reoperation independently on the surgical technique used. In the overall population, there were 44 women of childbearing age, and 37 patients remained pregnant during the follow‐up of the study. No differences were found in the clinical outcomes among women who had children and who did not. Conclusions Cryopreserved allograft is a valid option, especially in complex infective endocarditis and in women of childbearing age. A careful choice of allograft size and implantation technique can reduce the risk of SVD.

Delayed prosthesis malposition after transcatheter aortic valve implantation causing coronaries obstruction

Abstract The surgical management of mitral valve endocarditis is still argument of debate. We reviewed the current evidences regarding preoperative assessment, timing for surgery, operative strategy and antibiotic treatment and elaborated a systematic approach to endocarditis management based on clinical and anatomopathological variables known to affect postoperative outcomes. An algorithm to guide decision-making in mitral valve endocarditis, which includes etiology, clinical presentation, and anatomic extension of the infection at preoperative imaging, has been designed. Hemodynamic instability, extensive valvular lesions, elevated risk of embolization and inability to control the infection notwithstanding appropriate antibiotic treatment, are considered indications for urgency or emergency surgery. Type of operation to be performed should be dependent on the etiology (i.e., non-invasive or invasive organism), extent of the infective lesion, involvement of a native or a prosthetic valve, and patient age and comorbidities, including the presence of cardiac and/or extra-cardiac organ dysfunction. In case of single infected scallop, a reparative strategy should be preferred and coupled with vegetectomy or reconstruction of the perforated mitral segment with a pericardial patch. In cases that involve two or three scallops, left ventricular dysfunction, or renal or other extra-cardiac organ failure, valve repair is not recommended and valve replacement with either prosthetic or allogeneic tissues should be performed. Evidence of complex endocarditis with involvement of the mitral annulus or abscess of the mitro-aortic junction, requires extensive demolitive surgery and the use of homografts and synthetic material.

Daytime variations in perioperative myocardial injury

A case of delayed malposition of a CoreValve device causing obstruction of coronary ostia is described. Nine months after the original implant, the patient developed an acute coronary syndrome and was readmitted to hospital. Angiogram demonstrated an ostial stenosis of both the left main stem and the right coronary ostia, which were filled by a paravalvular leakage of the bioprosthesis. Gated computed tomography scan with 3D reconstruction showed valve malposition with cusps situated 14 mm above the ostium of the right coronary and the presence of fibrous and calcific agglomerations associated to one of the cusp causing a tight stenosis of the left ostium. Computed tomography scan is a crucial imaging technique in the transcatheter aortic valve replacement field and in this case enabled us to identify an interesting phenomenon of fibrosis/calcification originating at the level of the misplaced valve, which was actually the triggering cause of the coronary obstruction. Considering the reported need for more accurate investigations regarding the predictors of negative outcomes and the selection of transcatheter aortic valve replacement candidates, the use of cardiac-gated computed tomography should be stimulated and promoted as a valuable aid for the diagnosis and further clinical decision making in those patients.

Simulating the ideal geometrical and biomechanical parameters of the pulmonary autograft to prevent failure in the Ross operation

www.thelancet.com Vol 391 May 26, 2018 2105 in univariable and multivariable regression models to avoid introduction of modelling bias. Finally, data from the human transcriptomic study need clarification. In a subgroup of patients from the randomised study, the authors did a microarray analysis in atrial tissue (collected from 18 patients operated on in the morning and 11 patients operated on in the afternoon) to identify the signalling pathways involved. The complete results of the analysis are not presented. Whether any other genes or pathways, or both, also exhibit significant morning-toafternoon changes is also important. Additionally, the authors state that in the randomised study patients with diabetes or renal insufficiency were excluded to maximise perioperative risk homogeneity; however, the published microarray dataset (GSE62871) included 16 samples from diabetic patients.