George J. Koullias

State-of-the-Art of Hybrid Procedures for the Aortic Arch: A Meta-Analysis

Questions have risen regarding procedural indications, techniques, and outcomes for hybrid arch procedures. We performed a meta-analysis to benchmark this innovative approach. Studies and case reports involving hybrid aortic arch procedures listed through May 2008 were reviewed (n = 718). End points were 30-day mortality, stroke, paraplegia, and endoleak rates. A total of 15 studies with 463 patients were included in the meta-analysis. Overall 30-day mortality was 8.3%. Endoleak rate was 9.2%, stroke was 4.4%, and paraplegia was 3.9%. Treated on-pump or off-pump did not affect any of the endpoints. Results compare favorably with standard operative repair. Long-term follow-up is needed.

Low preoperative HSP70 atrial myocardial levels correlate significantly with high incidence of postoperative atrial fibrillation after cardiac surgery.

PURPOSE OF THE STUDY Atrial fibrillation after cardiac surgery is still a frequent encountered complication and has been associated with increased hospital length of stay and numerous postoperative complications. The pathogenesis of atrial fibrillation involves an overall sequence of perioperative events, collectively termed as ischemia-reperfusion injury. Heat-shock proteins have been found to provide increased protection during ischemia-reperfusion as well as increased postischemic cardiac functional recovery. We sought to determine whether preoperative atrial heat shock levels were correlated with the appearance of postoperative atrial fibrillation. BASIC METHODS Preoperative atrial myocardial samples obtained just before cannulation from 101 patients were used to detect immunohistochemically the expression of heat-shock proteins. The derived results were compared statistically with the incidence of postoperative atrial fibrillation, its time of appearance, duration and resistance to administered antiarrhythmics. PRINCIPAL FINDINGS The overall incidence of postoperative atrial fibrillation was 22.3%. Of these patients, 58.3% had no detectable heat shock proteins in their cytoplasm, in sharp contrast with 100% of the patients with no atrial fibrillation who were positive for heat shock proteins (p<0.01). Four percent of our patient group had prolonged atrial fibrillation (defined as duration >48 h). These patients had significantly less (p<0.01) nuclear heat shock protein expression compared with the non-atrial fibrillation group. However, the difference of the heat shock protein expression between the prolonged atrial fibrillation and the rest of the atrial fibrillation patients was not significant (p=0.891). CONCLUSIONS Our results indicate that patients with low preoperative atrial heat shock protein expression have a significantly greater incidence of postoperative atrial fibrillation. Heat shock protein expression did not, however, correlate with the onset of atrial fibrillation and the resistance to administered medications. Heat shock protein preoperative induction as a measure of myocardial preconditioning may potentially decrease the incidence of postoperative atrial fibrillation.

Is endovascular repair the new gold standard for primary adult coarctation

OBJECTIVE Primary adult aortic coarctation (PAAC) is an unusual cause of hypertension. The standard of care includes surgical repair, which can be associated with considerable morbidity and operative risk. Although balloon angioplasty has been successfully used in paediatric and adolescent patients with coarctation, little information exists regarding the endovascular repair of PAAC. This study examines the procedural safety and efficacy of endovascular repair of PAAC along with midterm outcomes. METHODS Between January 2000 and July 2008, 16 patients underwent endovascular repair of PAAC. All patients were hypertensive with 13 patients (81.3%) receiving medical therapy. Symptoms included chest pain (n=11, 69%), progressive fatigue (n=5, 31%), exercise intolerance (n=4, 25%) and shortness of breath (n=3, 19%). Associated cardiac concerns included depressed ejection fraction (n=6, 38%), pulmonary hypertension (n=5, 31%), ascending aortic dilatation (n=5, 31%) and bicuspid aortic valve (n=4, 25%). Endovascular repair was achieved using a percutaneous femoral approach. Balloon angioplasty of the coarctation was performed prior to treatment using a balloon-expandable uncovered stent. Aortic diameters were assessed using intravascular ultrasound. Pre- and post-procedure pressure gradients were measured and success was determined as a residual pressure gradient across the treated aorta of less than 20 mmHg. RESULTS The male:female (M:F) ratio was 9:7 with a mean age of 39.7 years. Procedural success was 100%. Mean pre-procedural aortic diameter was 8.4mm (3-14 mm) and mean post-procedural aortic diameter was 16.3mm (10-20mm) (p=0.04). The mean pre-procedural pressure gradient was 48.3 mmHg (25-100 mmHg) and the mean post-procedural pressure gradient was 0.5 mmHg (0-15 mmHg) (p=0.05). Twelve patients received one stent, two patients received two stents, one patient received three stents and one other patient received a thoracic stent graft. The rate of paraplegia was 0% with no blood transfusions, strokes or deaths. Follow-up ranged from 12 to 72 months (mean=22.8 months). One patient required re-intervention with an additional stent 14 months following the initial procedure and all the patients remain symptom-free. CONCLUSION Endovascular repair of PAAC is safe and effective and compares favourably with open surgical repair. Midterm follow-up suggests that the treatment is durable and may be an alternative to surgical repair. Although this is the largest endovascular treatment series for PAAC reported to date, additional study and follow-up are needed.

Increased estrogen receptor and epidermal growth factor receptor gene product co-expression in surgically resected gastric adenocarcinomas

Evidence exists that estrogens influence the action of epidermal growth factor (EGF) and its receptor (EGF‐R) at multiple levels. Estrogen and antiestrogen action on gastric and other gastrointestinal malignancies has been evaluated by several groups with conflicting results, and EGF‐R has been implicated in the current growth factor‐mediated models for gastric cancer progression.

Massive Paradoxical Embolism Caught in the Act

A 33-year-old scientist with recent exertional shortness-of-breath presented with new onset right flank and groin pain. For weeks, he had spent over 16 hours a day at his desk writing a grant. History and physical examination revealed resting tachypnea, sinus tachycardia, tender right flank with (+) Giordano sign, and resting oxygen saturation of 91% on room air. Computed tomography showed recent right renal infarct and ventilation/perfusion scan revealed multiple areas of mismatch. Transthoracic and transesophageal echocardiography revealed a large “snake-like” mass waving in …A 33-year-old scientist with recent exertional shortness-of-breath presented with new onset right flank and groin pain. For weeks, he had spent over 16 hours a day at his desk writing a grant. History and physical examination revealed resting tachypnea, sinus tachycardia, tender right flank with (+) Giordano sign, and resting oxygen saturation of 91% on room air. Computed tomography showed recent right renal infarct and ventilation/perfusion scan revealed multiple areas of mismatch. Transthoracic and transesophageal echocardiography revealed a large “snake-like” mass waving in …

Oncogenes in cancer of the pancreas

A three-step immunoperoxidase staining technique was used in order to estimate the immunohistochemical expression of K-ras, c-fos, c-myc and c-erbB-2 oncoproteins, in paraffin sections of 20 patients, with histologically proven adenocarcinoma of the pancreas. The two oncogenes that were found to be associated with pancreatic adenocarcinoma were K-ras and c-erbB-2. in 15 patients (75%) and four patients (20%), respectively. Positive immunostaining was intense, cytoplasmic and was noted in a great percentage of cancer cells. The same model of expression was observed in the examined cases of metastatic tissue from liver and lymph node metastases. The expression of myc and fos oncogenes was nuclear, weak and was observed in a small number of patients.

Correlation between immunohistochemical expression of proliferating cell nuclear antigen and flow cytometry parameters in colorectal neoplasia

PURPOSE: Proliferating cell nuclear antigen immunohistochemical expression and flow cytometry techniques were used in this study to estimate the proliferation tendency and biologic aggressiveness in benign and malignant epithelial tumors of the colon and rectum. METHODS: Thirty-five adenomas and 60 adenocarcinomas were studied immunohistochemically concerning proliferating cell nuclear antigen positivity in tumor cell nuclei. In addition, flow cytometry techniques were used to estimate the DNA content and percentage of tumor cells in the S-phase. RESULTS: The mean proliferating cell nuclear antigen score for adenomas was 38 percent compared with a mean score of 50.4 percent for adenocarcinomas that were studied (P<0.05). In dysplastic areas of malignantly transformed adenomas (n=5), the highest proliferating cell nuclear antigen score (80 percent) was focally observed. Taking flow cytometry parameters into account, we found out that proliferating cell nuclear antigen can be used as an indirect indicator of the number of cells in the S-phase (SPF) but not as an independent prognostic factor. Statistical significance was found between Type III (aneuploid carcinomas) and increased proliferating cell nuclear antigen expression (proliferating cell nuclear antigen score ⩾ 60 percent). Furthermore, aneuploidy was especially found on cancer located on the left colon (44 percentvs.14 percent of right colon neoplasms). Considering DNA ploidy of the above neoplasms, the aneuploid adenocarcinomas had a tendency for poorer prognosis especially if they were related to Dukes Stage C female patients. CONCLUSIONS: The comparative assessment of the above parameters might be of considerable importance in the study of the proliferation activity of any form of colorectal neoplasia.

Early bioprosthetic mitral valve “pseudostenosis” after complete preservation of the native mitral apparatus

An advantage of bioprosthetic mitral valve replacement in patients with normal sinus rhythm is avoidance of the need for long-term anticoagulation. Bioprosthetic valve thrombosis is a rare complication, supporting this approach. This case report represents an example of porcine mitral valve stenosis, likely secondary to thrombosis, in which all of the native mitral valve apparatus was left intact. This was successfully treated with standard anticoagulation therapy. This complication should be considered in patients in whom retention of the mitral valve apparatus has been performed. Such patients may benefit from long-term anticoagulation treatment to obviate this event.

Images in cardiovascular medicine. Massive paradoxical embolism: caught in the act.

A 33-year-old scientist with recent exertional shortness-of-breath presented with new onset right flank and groin pain. For weeks, he had spent over 16 hours a day at his desk writing a grant. History and physical examination revealed resting tachypnea, sinus tachycardia, tender right flank with (+) Giordano sign, and resting oxygen saturation of 91% on room air. Computed tomography showed recent right renal infarct and ventilation/perfusion scan revealed multiple areas of mismatch. Transthoracic and transesophageal echocardiography revealed a large “snake-like” mass waving in …A 33-year-old scientist with recent exertional shortness-of-breath presented with new onset right flank and groin pain. For weeks, he had spent over 16 hours a day at his desk writing a grant. History and physical examination revealed resting tachypnea, sinus tachycardia, tender right flank with (+) Giordano sign, and resting oxygen saturation of 91% on room air. Computed tomography showed recent right renal infarct and ventilation/perfusion scan revealed multiple areas of mismatch. Transthoracic and transesophageal echocardiography revealed a large “snake-like” mass waving in …

Inferior Mesenteric Artery Stenting: A Solution for Chronic Mesenteric Ischemia

Chronic mesenteric ischemia (CMI) is a rare entity with potentially tragic consequences. Meanwhile, there is still no consensus regarding the most adequate treatment approach. The authors herein report a case of a 65-year-old woman with severe CMI as a result of an occlusion of both the celiac artery (CA) and superior mesenteric artery (SMA) and a significant stenosis of the inferior mesenteric artery (IMA) ostium. The patient was successfully treated by angioplasty and stenting of the IMA. Even though the usual approach for CMI is revascularization of the CA and the SMA, the present case demonstrates that IMA can have a central role in visceral circulation, and its endovascular revascularization can be the first treatment option in selected cases.