Emanuele Bovio

Cardiac surgery with extracorporeal circulation and concomitant malignancy: early and long-term results.

Aims We retrospectively evaluated early and long-term results of cardiac surgery using extracorporeal circulation (ECC) in patients affected by malignancies and the potential influence of ECC on malignancy progression during follow-up. Methods Out of 7078 patients referred for cardiac surgery from January 2001 to December 2012, 241 consecutive patients (3.4%) (mean age 72 ± 8 years; men 170) had malignancy either known before or detected during hospital stay. Organ malignancies were present in 201 patients (83%) and hematological malignancies in 40 (17%). Early stages of cancer (I–II, in remission) were present in 180 (75%) patients, and advanced stages (III–IV for organ malignancies , multiple organ involvement for hematological malignancies) in 61 (25%). EuroSCORE I and II were 8.6 ± 5.4 and 3.8 ± 2.1%, respectively. Cardiac surgery with ECC consisted in isolated (n = 176) or multiple procedures (n = 65). Follow-up (mean 57 ± 40 months) was 99% complete. Results In-hospital mortality was 5.8% (n = 14); 1.67% (n = 4) died from cancer-related causes. Ten-year survival was 65 ± 5%, and freedom from cardiac death was 92 ± 3.5%. Freedom from cancer-related death was 90 ± 3% for patients operated on in early stages of cancer compared with 60 ± 8.4% for those who operated on in advanced stages (P < 0.0001), and 89 ± 2.6% for organ malignancies compared with 48 ± 13% for hematological malignancies (P = 0.0002); hematological malignancies different from Hodgkin/non-Hodgkin lymphoma affected long-term survival (P < 0.05). Progression of malignancy was observed in 29 patients (12.8%) at 18 ± 10 months. Conclusion Cardiac surgery in cancer patients is not associated with increased in-hospital mortality and provides satisfactory freedom from cardiac death. Long-term survival in early stages of cancer appears satisfactory. Time interval between ECC and progression of malignancy during follow-up should apparently exclude a close relationship of ECC on cancer progression. Hematological malignancies seem to have a negative impact on the overall outcome.

Single versus double antiplatelet therapy in patients undergoing coronary artery bypass grafting with coronary endarterectomy: mid-term results and clinical implications

Objectives Coronary endarterectomy (CE) represents a useful adjunctive technique to coronary artery bypass grafting (CABG) in the presence of diffuse coronary artery disease. Nevertheless, the long-term patency of the graft remains unclear, and no standard anticoagulation and antiplatelet protocols exist for use after CE. The aim of this retrospective study was to evaluate and possibly to clarify the role of single (SAT) versus dual antiplatelet therapy (DAT) at mid-term follow-up. Methods Between January 2006 and December 2013, CE was performed in 90 patients (mean age 67 ± 8.2 years) who also underwent isolated CABG. After surgery, 20 patients received aspirin 100 mg daily (SAT group), and 52 patients received aspirin plus clopidogrel 75 mg daily (DAT group). Clopidogrel was discontinued in the DAT group 12 months after the operation. Results The overall in-hospital mortality rate was 2.7% (SAT 0% vs DAT 3.8%; P = ns). Perioperative myocardial infarction was 12.3% (SAT 15.0% vs DAT 11.5%; P = ns), and major bleeding requiring surgical re-exploration was 4.1% (SAT 10.0% vs DAT 1.9%; P = ns). Mean follow-up duration was 71.3 ± 32.7 months (median 79 months), and was 100% complete (5208/5208 pt-months). At 7 years of follow-up, freedom from cardiac death was 84 ± 9% in group SAT versus 85 ± 5% in group DAT (P = ns); freedom from new percutaneous coronary intervention was 93 ± 6% versus 100% (P = ns), and freedom from major adverse cardiac and cerebrovascular events was 73 ± 10% versus 75 ± 6% (P = ns). Conclusions In patients with diffuse coronary disease, CE is a safe and feasible technique with acceptable mid-term results. No differences were observed in terms of major clinical outcomes between patients treated with single versus dual antiplatelet therapy at least in a mid-term period of follow-up.

Total Arch versus Hemiarch Replacement for Type A Acute Aortic Dissection: A Single-Center Experience

We retrospectively evaluated early and intermediate outcomes of aortic arch surgery in patients with type A acute aortic dissection (AAD), investigating the effect of arch surgery extension on postoperative results. From January 2006 through July 2013, 201 patients with type A AAD underwent urgent corrective surgery at our institution. Of the 92 patients chosen for this study, 59 underwent hemiarch replacement (hemiarch group), and 33 underwent total arch replacement (total arch group) in conjunction with ascending aorta replacement. The operative mortality rate was 22%. Total arch replacement was associated with a 33% risk of operative death, versus 15% for hemiarch (P=0.044). Multivariable analysis found these independent predictors of operative death: age (odds ratio [OR]=1.13/yr; 95% confidence interval [CI], 1.04-1.23; P=0.002), body mass index >30 kg/m2 (OR=9.9; 95% CI, 1.28-19; P=0.028), postoperative low cardiac output (OR=10.6; 95% CI, 1.18-25; P=0.035), and total arch replacement (OR=8.8; 95% CI, 1.39-15; P=0.021) The mean overall 5-year survival rate was 59.3% ± 5.5%, and mean 5-year freedom from distal reintervention was 95.4% ± 3.2% (P=NS). In type A AAD, aortic arch surgery is still associated with high operative mortality rates; hemiarch replacement can be performed more safely than total arch replacement. Rates of distal aortic reoperation were not different between the 2 surgical strategies.

Devices for a Clampless Approach to Coronary Artery Operations: Effect on Stroke Rate

1. Pezzella AT, Holmes SD, Pritchard G, Speir AM, Ad N. Impact of perioperative glycemic control strategy on patient survival after coronary bypass surgery. Ann Thorac Surg 2014;98: 1281–5. 2. Desai SP, Henry LL, Holmes SD, et al. Strict versus liberal target range for perioperative glucose in patients undergoing coronary artery bypass grafting: a prospective randomized controlled trial. J Thorac Cardiovasc Surg 2012;143:318–25. 3. Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med 2001;345: 125–39. 4. Furnary AP, Gao G, Grukenmeier GL, et al. Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg 2003;125:1007–21. 5. Furnary AP, Wu TX. Clinical effects of hyperglycemia in the cardiac surgery population: the Portland Diabetic Project. Endocr Pract 2006;12:22–6.

MID-TERM RESULTS OF THE ON-PUMP VS OFF-PUMP CORONARY ARTERY BYPASS GRAFTING SURGERY

After the European Concert of 1815, “Old” Europe, characterized from ongoing wars for power, experienced the longest pediod of peace it ever had. In 40 years there were no war between the Great Powers. After the war at Crime in 1854, there was no general war for another 60 years. This was due to a strong equilibrium, wich proposed the existence of France, Germany, Austro-Hungary and Russia as main elements, having the support of England wich had the naval fleet superiority. The Balkan Wars of the 1912-1913 are the most important event in the history of the Balkan people and beyond. They are composed of a series sharp and bloody conflicts that swept Eastern Europe in the recent years. If we talk about the origins of the war, we must emphasize that the situation of the Balkan wars at the time and especially the situation that followed, was very alike to the conditions that existed before the Turks came to Europe. At that time, both during and after the Balkan Wars, the Christian states constantly fought against each other for hegemony in the peninsula. For the more serious and real judgment we should also see the impact and performance of the situations and events in the Balkans, with the new changes in the geopolitics of the European continent, at least since the early nineteenth century and the credit for this goes to the European Concert (1815).The Krena river based on its length has bigger flow than Llukaci river, and both of them spillat Ereniku river. The purpose of this study is to provide details on the quality of the waterof Krena river and its flow to the Ereniku river. The study and monitoring performed in of this paper annual period january-december 2011gives its physical-chemical results as:Iron,Manganese,nitrites,nitrates,Aluminium,phosphate,consumption of Potassium permanganate,dissolved Oxygen,water temperature,air temperature,pH value etc.Water samples were taken in polyethylene bottles of 500 ml, which initially are well cleaned.Some of parameters were measured at the location of the taken sample, since other analyzes were sent immediately to the laboratory and analyzes were made,based on pH value, conductometric,turbidymetric, spectro photometric etc. The given results show the quality of the pollution of Krena river as result of discharge of pollutants , municipal and industrial.Reading & understanding a text means being able to spot the ideas in it; to understand the given knowledge in order to compare them with the previous ones; to imply; to notice what is important, to split the known from the unknown in order to make use of ones knowledge. Readability is on the same rank with usability. Lexical knowledge and background make up two of the most essential elements that define the readability of a text. Precise reading, different techniques to ease its understanding has continuously changed especially in these years when its understanding is measured through testing. Reading comprehension development phases from analyses to synthesis enable you to deepen its study. In the long run, this study passed from a simple reading without defining objective to the one with measurable objective. Deepening the study for reading, increase its importance in a general communication in foreign language. Its complexity in many areas, affects not only the actors that play inside a class but also even the ones outside it.Inclusive education is priority in many educational systems. It seems that educational process could not be effective and successful if it is not inclusive one. Educational policy demands creating inclusive practice which means that every one would find his place and could be treated according to different needs that pupils have. It is not easy to develop educational philosophy and to implement it. On that way there are any obstacles, challenges, but the way is the only one. Those decades are dedicated to efforts to make educational process and system inclusive one. Every country has his story. We share our story so that we can collect suggestions and offer experience for all who must follow this way.Urbanization brings a sustainable development as it closely relates to demography, the movement of population. After 1990, in contrast to the communist regime era a shift from the planned population movements, to congestion mainly toward Tirana and other coastal areas has been noticed. The aim of this paper is to analyze the impact that the population movement has had into our country’s urban development. Urbanization is considered to be a major component for the economic growth of a country, especially in coastal areas, in which it is more incentive for sustainable development. The urbanization has passed through several stages: pre-industrial, industrial and postindustrial one. It is seen as a means to improve civilization, while bringing more progress and development. So we may ask: Was it worth a movement of population without a plan in Albania and should we put nowadays a planning strategy for the urbanization and demography?The environmental politics has assumed in the last times a wide and transversal dimension, focused on problems and relations of a complex system such as the environment, in the whose inner different elements act and put equity and disequity problems. With the new strategy, the European Community means to pursue the integration of environmental sustainability goals (Goteborg Agenda) with those of the economic and social development (Lisbon Agenda), the environmental politics integrate therefore substantially to the problems of social-economic development. The adoption of systems of eco-management from a relevant number of companies even in the touristic sector and their certification in conformity with international and European standards represent an important innovation element, following to this strategy inclined to conjugate the development with the protection of the environment. The systems of environmental management have by now become a distinctive element of the companies which aim to cover a relevant role in the competitive national and international scenery, even because their nature itself makes them verifiable from third independent subjects and suitable to stimulate the continuous improvement of environmental and productive performances. Object of the present work is the analysis of the project management for the improvement of the quality of services in the tourism sector which allows to obtain the Emas/Ecolabel certification in a touristic structure in South Italy.In this article are given on alternative energy considerations, including these forms of production: • Solar Energy (Photovoltaic) • Wind Energy • Biomass Energy • Biogas • Biodiesel Where are given technological considerations for the application of each case in the Albanian territory.The economic crime as a system of groupings of types of criminal acts with similar characteristics in modern conditions is characterized by a rich and diverse criminal phenomenology, adaptable to all stadiums of the development of society. The financial crime is part of the economic crime which is rapidly evolving and expanding causing huge material damage, as that undermines the foundations of the functioning of any country, especially some that ten years ago transited from contract in a trading economy, what is case of the Republic of Macedonia. The article presents observations of the current situation with financial crime in the Republic of Macedonia, which highlight the specifics regarding the actions of all subjects included in the fight against this difficult and complex phenomenon. It’s rightfully to point out the need for specialized treatment of financial crime in managing financial investigations as well as criminal operating items. For this purpose are applied modern criminality tools and methods derived primarily from the bosom of conspiratorial police and judicial instruments and methods provided by the Law of the Financial Police. Resolved financial crime in the country is not a reflection of reality, given that this area is with extremely high “dark number”.Public services and their management have a great influence in the development of the local economy of a country. During the process of transformation of the community in an intense computing system of information, the offering of these services through information technology, in an effective, fast, transparent and safe mannerin accordance with citizens and businessneeds are very important. Referring to makers of online declaration, this is an important measurethat will influence in increasing the effectiveness of tax administration, to minimize the tax evasion in labour market, and to facilitate the exchange between two important institutions: Tax Office and Social Insurance directory. However, this online information exchange between these two institutions, aims in facilitating the data exchange between these two directories, with the purpose of establishing a clear evidence of the data of social insurance payments from that of businesses and citizens. This exchange will help the history creation, for each social insurance payer, thereby helping them in having the necessary profits from these paid contributions.Christianity as a consummate and the most individualized religion, allows one to best harmonize the relationships between an individual, society, and the state. Christianity roots in the fundamental sentiment of personal responsibility for own thoughts and deeds. That the Christian doctrine has an immense variety of tools to resolve the whole gamut of socio-political issues has been brilliantly evidenced in hosts of victories on a civilization scale. Being a pro-active religion, Christianity has been the driving force behind the groundbreaking, epoch-making processes both at political and scientific level. Christianity has brought about a new model of state economy basing on equity and liberalism. However, having swerved from good intentions, the modern Christian nations are caught in the economic crisis, facing the urgency to regain their economic strength lavished on the rest of civilizations. The only way to reach this is to reconsider Christian values.

Mechanical Heart Valve Replacement in a Low-Middle Income Region in the Modern Era: Midterm Results from a Sub-Saharan Center

BACKGROUND  The management of patients with mechanical heart valves remains a major concern in populations with limited resources and medical facilities. This study reports the clinical outcomes of patients who underwent mechanical valve implantation in a sub-Saharan center over an 8-year period. METHODS  A total of 291 mechanical valves were implanted in 233 patients in our institution between February 2008 and June 2016. A total of 117 patients underwent mitral valve replacement (MVR, 50.2%), 57 had aortic valve replacement (AVR, 24.4%), and 59 underwent both AVR and MVR (double valve replacement [DVR], 25.7%). The mean age at surgery was 27.6 ± 13.4 years (range, 7-62 years). Rheumatic etiology was found in 80.6% of the patients. Hospital mortality, late deaths, and valve-related events were reviewed at follow-up (839 patient-years, range: 1-9.4 years, complete in 93%). RESULTS  The 30-day mortality was 4.7% (11/233). The overall survival at 1 and 6 years for the whole cohort was 88.8 ± 2.1% and 78.7 ± 3.3%, respectively. The 6-year survival for AVR, MVR, and DVR was 89.3 ± 4.8%, 73.2 ± 5.4%, and 79.3 ± 5.8%, respectively (p = 0.15). The freedom from neurologic events and anticoagulation-related bleeding at 6 years was 93.1 ± 2.1% and 78.9 ± 3.7%, respectively. No patient had reoperation at follow-up. No case of prosthetic valve thrombosis was identified. Eight full-term pregnancies were reported. CONCLUSION  This preliminary experience reports acceptable midterm results after mechanical heart valve implantation in our region. Both accurate surgical evaluation and strategies, either financial or social, facilitating patients education and medical assistance are crucial to ensure good results. Long-term follow-up and further studies comparing current nonthrombogenic options are warranted to draw reliable conclusions.

Neurologic Dysfunction after Aortic Dissection Surgery: Different Cerebral Hypothermic Antegrade Perfusion Techniques

Introduction: Neurologic dysfunction remains one of the most disabling complications of emergency aortic arch surgery. Many cerebral protection techniques are described, but their comparison has always been hampered by the wide spectrum of preoperative conditions, pathologic anatomies, complications, and surgical procedures. The aim of our study was to evaluate the incidence of early permanent neurologic injury and in-hospital mortality after emergency aortic arch surgery splitted by different antegrade cerebral perfusion techniques combined with hypothermic circulatory arrest (HCA). Methods: Between January 2005 and December 2015, 249 patients underwent emergent surgery for acute, type A aortic dissection. Of these, 112 (45%) (Mean age 63.8 ± 12.8 years, 82 males) received cerebral protection through antegrade perfusion of the supra-aortic vessels. Unilateral perfusion (UACP) was performed in 55 (49.1%) patients, while bilateral perfusion (BACP) was achieved via right axillary artery cannulation alone in 25 (22.3%) cases or with the Kazui technique in 32 (28.6%). Permanent neurologic injury was defined as the post-operative onset of focal stroke or lethal coma. Results: In-hospital mortality was 17.9% (UACP 20% vs. BACP 15.8%; p=0.56). The global rate of the early permanent neurologic injury was 12.3% (UACP 10.9% vs. BACP 15.8%; p=0.45). Conclusion: There is no evidence that BACP combined with HCA is superior to UACP combined with HCA for emergency aortic arch surgery in preventing early permanent neurologic injury and in-hospital mortality.

Warm blood cardioplegia versus cold crystalloid cardioplegia for myocardial protection during coronary artery bypass grafting surgery

We retrospectively analyzed early results of coronary artery bypass grafting (CABG) surgery using two different types of cardioplegia for myocardial protection: antegrade intermittent warm blood or cold crystalloid cardioplegia. From January 2015 to October 2016, 330 consecutive patients underwent isolated on-pump CABG. Cardiac arrest was obtained with use of warm blood cardioplegia (WBC group, n = 297) or cold crystalloid cardioplegia (CCC group, n = 33), according to the choice of the surgeon. Euroscore II and preoperative characteristics were similar in both groups, except for the creatinine clearance, slightly lower in WBC group (77.33 ± 27.86 mL/min versus 88.77 ± 51.02 mL/min) (P < 0.05). Complete revascularization was achieved in both groups. In-hospital mortality was 2.0% (n = 6) in WBC group, absent in CCC group. The required mean number of cardioplegia’s doses per patient was higher in WBC group (2.3 ± 0.8) versus CCC group (2.0 ± 0.7) (P = 0.045), despite a lower number of distal coronary artery anastomoses (2.7 ± 0.8 versus 3.2 ± 0.9) (P = 0.0001). Cardiopulmonary and aortic cross-clamp times were similar in both groups. The incidence of perioperative myocardial infarction (WBC group 3.4% versus CCC group 3.0%) and low cardiac output syndrome (4.4% versus 3.0%) were similar in both groups. As compared with WBC group, in CCC group CK-MB/CK ratio >10% was lower during each time points of evaluation, with a statistical significant difference at time 0 (4% ± 1.6% versus 5% ± 2.5%) (P = 0.021). In presence of complete revascularization, despite the value of CK-MB/CK ratio >10% was less in the CCC group, clinical results were not affected by both types of cardioplegia adopted to myocardial protection. As compared with cold crystalloid, warm blood cardioplegia requires a shorter interval of administration to achieve better myocardial protection.

The effect of postoperative malperfusion after surgical treatment of type A acute aortic dissection on early and mid-term survival.

Aim: To evaluate whether postoperative malperfusion (PM) affected in-hospital and longterm survival in acute type A aortic dissection (AAAD) surgical patients and to identify risk factors for PM. Methods: Patients who underwent AAAD surgery at a single institution between January 2005 and March 2015 were retrospectively analyzed. Results: Twohundred fourteen patients with complete data were identified. At presentation, 119 patients (55.6%) showed preoperative malperfusions: 68 (31.8%) were cerebral, 38 (17.7%) were renal, and 13 (6.1%) were mesenteric. PM was found in 55 patients (25.7%). In-hospital mortality was 47.3% (26/55) vs. 22.6% (36/159) in PM and non-PM patients, respectively (P < 0.0001). Independent predictors for in-hospital mortality included being 75 years or older [odds ratio (OR): 1.1, 95% confidence interval (CI): 1.03-1.13, P < 0.001] and having renal PM (OR: 53.5, 95% CI: 3.97-721.3, P < 0.01). Five-year survival was 78.6 ± 7.8% vs. 93.9 ± 3.4% in PM and non-PM patients, respectively (P < 0.001). Independent predictors for long-term survival were being at least 75 years old (OR: 3.7, 95% CI: 0.9-14.0, P = 0.05) and having renal PM (OR: 28.6, 95% CI: 1.8-462.0, P = 0.01). PM and intimal tears distal to the ascending aorta or the proximal aortic arch were also risk factors. Conclusion: PM, especially with renal involvement, is associated with in-hospital mortality and reduced long-term survival. AAAD surgeries reduced preoperative malperfusions. Sites of cannulation and interventions requiring circulatory arrest during cardiopulmonary bypass were not predictors of PM.

Focusing on Patient Subcategories: When Could We Expect a Suboptimal Late Result after Coronary Endarterectomy?

We read with very interest the paper from Bitan et al,1 in which they optimally described their experience in the treatment of complex coronary patients by means of coronary artery bypass grafting and adjunctive coronary endarterectomy (CE) on the left anterior descending (LAD) or patch angioplasty. With a detailed follow-up, they have reported a satisfactory 5-year survival and a good freedom from repeated revascularization. These data strongly confirmed our recent published clinical experience.2 Although we did not perform an angiographic follow-up of 72 patients undergoing CE (2006–2013), we focused on the results based on single versus double antiplatelet protocols. At 7 years, freedom from death of any cause, including operative mortality was respectively in the single and dual antiplatelet groups of patients 73 9% versus 81 5%, while freedom from cardiac death was 84 9% versus 85 5%. These results showed that different antiplatelet therapies does not make difference in the early and late outcomes. We were really interested in achieving a complete understanding of which risk factors could influence survival, and at the Cox regression analysis we identified as independent predictors of late survival the age older than 70 years (odds ratio [OR]: 1.29; p 1⁄4 0.003) and the presence of chronic obstructive pulmonary disease (COPD) (OR: 23.8; p 1⁄4 0.033). As far as we are concerned, patients with diffusive coronary artery disease represent a very complex category, in which both cardiac and noncardiac factors can play a crucial role. COPD was already been considered as a detrimental factor for coronary surgical patients.3 We believe that the presence of COPD and older age could be therefore considered as potential risk factors to guide revascularization strategy in a specific direction, that is, avoiding CE in older and COPD patients, and taking into account alternative strategies of revascularization, that is, hybrid or, when feasible, percutaneous. The study by Bitan et al gives us the opportunity to study not only clinical results of CE but also patch angioplasty. We would be really interested in knowing the authors’ opinion regarding the potential role of risk factors, both cardiac and extracardiac, that could influence in their experience the late results. What could we learn more from your excellent follow-up?