Pasquale Santè

Intravascular hemolysis after mitral and aortic valve replacement with different types of mechanical prostheses

Heart valve replacement with mechanical prosthesis is associated with mild intravascular hemolysis. In this study we evaluated the incidence of hemolysis in patients with different combinations of two mechanical valves. Between 1974 and 1996, 680 patients underwent mitral and aortic valve replacement with mechanical prostheses; we selected 90 patients, divided into six groups according to the prosthetic model (Group A, ball and tilting disc; Group B, ball and bileaflet; Group C, tilting disc and tilting disc; Group D, tilting disc and bileaflet; Group E, bileaflet and tilting disc; Group F, bileaflet and bileaflet; respectively, in mitral and aortic position). Blood tests were performed to check blood hemoglobin, serum lactic dehydrogenase, percent-correlated reticulocyte fraction, serum haptoglobin, and schistocytes. Chi square test was performed for categorical data. ANOVA and Bonferroni tests were performed in order to evaluate significant statistical differences between media and variance of the hematological data. A mild degree of intravascular hemolysis was observed in 30% of patients with double mechanical prostheses. LDH values were above the normal values in all groups, although a significant difference was found only between Group B versus Groups C and D. Reticulocytes and schistocytes and serum haptoglobin values were within the normal range and no differences were found between the groups. Low levels of blood hemoglobin were found in Groups D and F. The difference was statistically significant when compared with Groups A and E. In conclusion, hemolysis is frequent but never severe in patients with mitral and aortic mechanical prostheses. A higher incidence of subclinical hemolysis was found in patients with bileaflet valves regardless of the position of the implant.

Ascending aorta dilatation in aortic valve disease: morphological analysis of medial changes

We investigated whether and how the severity of medial degeneration lesions varies along the circumference of the dilated intrapericardial aorta. Two groups of aortic wall specimens, respectively harvested in the convexity and concavity of ascending aorta in 72 patients undergoing surgery for dilatation of the intrapericardial aorta associated with aortic valve disease, were separately sent for pathology, morphometry, and ultrastructural examination. Cystic medial necrosis, fibrosis, and elastic fiber fragmentation were classified into three degrees of severity; their mean degree and morphometric findings in the convexity and in the concavity specimens were compared by paired t-test. Correlation between echocardiographic degree of aortic dilatation and severity of medial degeneration was assessed separately for each of the two groups of specimens. Morphologically, medial degeneration was found in all cases; a higher mean degree was found in the convexity group (2.39 ± 0.58 vs 1.44 ± 0.65 in the concavity group; P < 0.001). At morphometry normal smooth muscle cells in the convexity specimens were significantly reduced (P = 0.007); the length (P = 0.012) and number (P = 0.009) of elastic fibers reduced and increased, respectively. Moreover, in the convexity specimens a significantly smaller amount of smooth muscle cells and an increase of immunohistochemical labeling of apoptosis-associated proteins in the subintimal layer of the media was noticed. Correlation between aortic ratio and medial degeneration degree was significant in the convexity group (P < 0.001), but not in the concavity group (P = 0.249). Scanning electron microscopy analysis confirmed morphological results and allowed us to better distinguish the early pathological cavities from the microvessels, which were in the outer media in normal aorta and ubiquitous in aortitis or atherosclerosis. Electron transmission microscopy analysis showed changes in the extracellular matrix and smooth muscle cells, and these changes increased from the intima to the adventitial layer of the media. In dilated intrapericardial aorta, medial degeneration changes and expression of apoptosis-associated proteins are more marked in the ascending aorta convexity, likely due to hemodynamic stress asymmetry. Ultrastructural findings allow us to distinguish the early medial changes not yet evident on light microscopy.

c-Myc Antisense Oligonucleotides Preserve Smooth Muscle Differentiation and Reduce Negative Remodelling following Rat Carotid Arteriotomy

Objectives: The vascular biology of restenosis is complex and not fully understood, thus explaining the lack of effective therapy for its prevention in clinical settings. The role of c-Myc in arteriotomy-induced stenosis, smooth muscle cell (SMC) differentiation and apoptosis was investigated in rat carotids applying full phosphorothioate antisense (AS) oligonucleotides (ODNs). Methods: Carotid arteries from WKY rats were submitted to arteriotomy and to local application of ODNs through pluronic gel. Apoptosis (deoxynucleotidyl transferase-mediated dUTP nick end-labelling), SMC differentiation (SM22 immunofluorescence) and vessel morphology and morphometry (image analysis) were determined 2, 5 and 30 days after injury, respectively. Results: AS ODNs induced a 60% decrease of target c-Myc mRNA 4 h after surgery in comparison to control sense (S) and scrambled ODN-treated carotids (p < 0.05). A significant 37 and 50% decrease in SM22 protein in the media of S ODN-treated and untreated carotids was detected when compared to uninjured contralateral arteries (p < 0.05). This reduction in SM22 expression was prevented in AS ODN-treated carotids. Stenosis was mainly due to adventitial constrictive remodelling. Lumen area in AS ODN-treated carotids was 35% greater than in control arteries 30 days after surgery (p < 0.05). TUNEL assay revealed increased apoptosis in AS ODN-treated carotids (p < 0.05). Conclusions: c-Myc AS ODNs reduce arteriotomy-induced negative remodelling. This is accompanied by maintained SMC differentiation and greater apoptosis. The combination of reduced c-Myc-induced proliferation and increased apoptosis may thus underlie the less severe remodelling upon treatment with c-Myc mRNA AS ODN.

Italian multicentre study on type A acute aortic dissection: a 33-year follow-up

OBJECTIVES Despite substantial progress in surgical techniques and perioperative management, the treatment and long-term follow-up of type A acute aortic dissection (AAD) still remain a major challenge. The objective of this retrospective, multicentre study was to assess in a large series of patients the early and long-term results after surgery for type A AAD. METHODS We analysed the preoperative, intraoperative and postoperative conditions of 1.148 consecutive patients surgically treated in seven large referral centres from 1981 to 2013. We applied to each patient three different multi-parameter risk profiles (preadmission risk, admission risk and post-surgery risk) in order to compare risk factors and outcome. Long-term Kaplan-Meier survival was evaluated. RESULTS The median age was 64 years and the male population was predominant (66%). Identified diagnosis of collagen disease was present in 9%, and Marfan syndrome in 5%. Bicuspid aortic valve was present in 69 patients (6%). Previous cardiac surgery was identified in 10% of the patients. During surgery, the native aortic valve was preserved in 72% of the cases, including leaflet resuspension in 23% and David operation in 1.2%. Considering aortic valve replacement (AVR: 28%), bioprosthesis implantation was performed in 14.7% of the subjects. Neurological impairment at discharge was shown in 23% of the cases among which 21% of patients had new neurological impairment versus preoperative conditions. The overall 30-day mortality rate was 25.7%. All risk profiles remained independently associated with in-hospital mortality. During the available follow-up of hospital survivors (median: 70 months, interquartile range: 34-113, maximum: 396), cardiac-related death occurred in 7.9% of the subjects. The cumulative survival rate for cardiac death was 95.3% at 5 years, 92.8% at 10 years and 52.8% at 20 years. Severe aortic regurgitation (AR) (grade 3-4) at the time of surgery showed to be a significant risk factor for reintervention during the follow-up (P < 0.001). Among risk profiles, only the preadmission risk was independently associated with late mortality after multivariate analysis. Unexpectedly, there was no difference in freedom from cardiac death between patients with and without AVR. CONCLUSIONS Although surgery for type A has remained challenging over more than three decades, there is a positive trend in terms of hospital mortality and long-term follow-up. About 90% of patients were free from reoperation in the long term, although late AR remains a critical issue, suggesting that a thorough debate on surgical options, assessment and results of a conservative approach should be considered.

Evolution in the treatment of mediastinitis: single-center experience.

This study aimed to evaluate our 30-year experience in the treatment of deep sternal wound infection after cardiac surgery. Between 1979 and 2009, deep sternal wound infections occurred in 200 of 22,366 (0.89%) patients who underwent sternotomy. The study population was divided into 3 groups. In group A (62 patients; 1979–1994), an initial attempt at conservative antibiotic therapy was the rule, followed by surgery in case of failure. In group B (83 patients; 1995–2002), the treatment was in 3 steps: wound debridement and closed irrigation for 10 days; in case of failure, open dressing with sugar and hyperbaric treatment; delayed healing and negative wound cultures mandated plastic reconstruction. In group C (2002–2009), the treatment was based on early surgical debridement, vacuum application, and reconstruction using pectoralis muscle flap. Hospital mortality in group A was significantly higher than that in groups B and C. Hospital stay, time for normalization of white blood cell count and C reactive protein, and time for defervescence were significantly shorter in group C. In our experience, early surgical debridement and vacuum application followed by plastic reconstruction provided a satisfactory rate of healing and a good survival rate.

Expression profiles in surgically-induced carotid stenosis: a combined transcriptomic and proteomic investigation.

Vascular injury aimed at stenosis removal induces local reactions often leading to restenosis. The aim of this study was a concerted transcriptomic‐proteomics analysis of molecular variations in a model of rat carotid arteriotomy, to dissect the molecular pathways triggered by vascular surgical injury and to identify new potential anti‐restenosis targets. RNA and proteins extracted from inbred Wistar Kyoro (WKY) rat carotids harvested 4 hrs, 48 hrs and 7 days after arteriotomy were analysed by Affymetrix rat microarrays and by bidi‐mensional electrophoresis followed by liquid chromatography and tandem mass spectrometry, using as reference the RNA and the proteins extracted from uninjured rat carotids. Results were classified according to their biological function, and the most significant Kyoro Encyclopedia of Genes and Genomes (KEGG) pathways were identified. A total of 1163 mRNAs were differentially regulated in arteriotomy‐injured carotids 4 hrs, 48 hrs and 7 days after injury (P < 0.0001, fold‐change ≥2), while 48 spots exhibited significant changes after carotid arteriotomy (P < 0.05, fold‐change ≥2). Among them, 16 spots were successfully identified and resulted to correspond to a set of 19 proteins. mRNAs were mainly involved in signal transduction, oxidative stress/inflammation and remodelling, including many new potential targets for limitation of surgically induced (re)stenosis (e.g. Arginase I, Kruppel like factors). Proteome analysis confirmed and extended the microrarray data, revealing time‐dependent post‐translational modifications of Hsp27, haptoglobin and contrapsin‐like protease inhibitor 6, and the differential expression of proteins mainly involved in contractility. Transcriptomic and proteomic methods revealed functional categories with different preferences, related to the experimental sensitivity and to mechanisms of regulation. The comparative analysis revealed correlation between transcriptional and translational expression for 47% of identified proteins. Exceptions from this correlation confirm the complementarities of these approaches.

Local inhibition of ornithine decarboxylase reduces vascular stenosis in a murine model of carotid injury

OBJECTIVES Polyamines are organic polycations playing an essential role in cell proliferation and differentiation, as well as in cell contractility, migration and apoptosis. These processes are known to contribute to restenosis, a pathophysiological process often occurring in patients submitted to revascularization procedures. We aimed to test the effect of α-difluoromethylornithine (DFMO), an inhibitor of ornithine decarboxylase, on vascular cell pathophysiology in vitro and in a rat model of carotid arteriotomy-induced (re)stenosis. METHODS The effect of DFMO on primary rat smooth muscle cells (SMCs) and mouse microvascular bEnd.3 endothelial cells (ECs) was evaluated through the analysis of DNA synthesis, polyamine concentration, cell viability, cell cycle phase distribution and by RT-PCR targeting cyclins and genes belonging to the polyamine pathway. The effect of DFMO was then evaluated in arteriotomy-injured rat carotids through the analysis of cell proliferation and apoptosis, RT-PCR and immunohistochemical analysis of differential gene expression. RESULTS DFMO showed a differential effect on SMCs and on ECs, with a marked, sustained anti-proliferative effect of DFMO at 3 and 8 days of treatment on SMCs and a less pronounced, late effect on bEnd.3 ECs at 8 days of DFMO treatment. DFMO applied perivascularly in pluronic gel at arteriotomy site reduced subsequent cell proliferation and preserved smooth muscle differentiation without affecting the endothelial coverage. Lumen area in DFMO-treated carotids was 49% greater than in control arteries 4 weeks after injury. CONCLUSIONS Our data support the key role of polyamines in restenosis and suggest a novel therapeutic approach for this pathophysiological process.

Surgery for prosthetic valve endocarditis: a retrospective study of a national registry

OBJECTIVES We described clinical-epidemiological features of prosthetic valve endocarditis (PVE) and assessed the determinants of early surgical outcomes in multicentre design. METHODS Data regarding 2823 patients undergoing surgery for endocarditis at 19 Italian Centers between 1979 and 2015 were collected in a database. Of them, 582 had PVE: in this group, the determinants of early mortality and complications were assessed, also taking into account the different chronological eras encompassed by the study. RESULTS Overall hospital (30-day) mortality was 19.2% (112 patients). Postoperative complications of any type occurred in 256 patients (44%). Across 3 eras (1980-2000, 2001-08 and 2009-14), early mortality did not significantly change (20.4%, 17.1%, 20.5%, respectively, P  = 0.60), whereas complication rate increased (18.5%, 38.2%, 52.8%, P  < 0.001), consistent with increasing mean patient age (56 ± 14, 64 ± 15, 65 ± 14 years, respectively, P  < 0.001) and median logistic EuroSCORE (14%, 21%, 23%, P  = 0.025). Older age, female sex, preoperative serum creatinine >-2 mg/dl, chronic pulmonary disease, low ejection fraction, non-streptococcal aetiology, active endocarditis, preoperative intubation, preoperative shock and triple valve surgery were significantly associated with mortality. In multivariable analysis, age (OR = 1.02; P  = 0.03), renal insufficiency (OR = 2.1; P  = 0.05), triple valve surgery (OR = 6.9; P  = 0.004) and shock (OR = 4.5; P  < 0.001) were independently associated with mortality, while streptococcal aetiology, healed endocarditis and ejection fraction with survival. Adjusting for study era, preoperative shock (OR = 3; P  < 0.001), Enterococcus (OR = 2.3; P  = 0.01) and female sex (OR = 1.5; P  = 0.03) independently predicted complications, whereas ejection fraction was protective. CONCLUSIONS PVE surgery remains a high-risk one. The strongest predictors of early outcome of PVE surgery are related to patients haemodynamic status and microbiological factors.

Injury to rat carotid arteries causes time-dependent changes in gene expression in contralateral uninjured arteries

Vascular surgery aimed at stenosis removal induces local reactions often leading to restenosis. Although extensive analysis has been focused on pathways activated in injured arteries, little attention has been devoted to associated systemic vascular reactions. The aim of the present study was to analyse changes occurring in contralateral uninjured rat carotid arteries in the acute phase following unilateral injury. WKY (Wistar-Kyoto) rats were subjected to unilateral carotid arteriotomy. Contralateral uninjured carotid arteries were harvested from 4 h to 7 days after injury. Carotid arteries were also harvested from sham-operated rats and uninjured rats. Carotid morphology and morphometry were examined. Affymetrix microarrays were used for differential analysis of gene expression. A subset of data was validated by real-time RT-PCR (reverse transcription-PCR) and verified at the protein level by Western blotting. A total of 1011 genes were differentially regulated in contralateral uninjured carotid arteries from 4 h to 7 days after arteriotomy (P<0.0001; fold change, >or=2) and were classified into 19 gene ontology functional categories. To a lesser extent, mRNA variations also occurred in carotid arteries of sham-operated rats. Among the changes, up-regulation of members of the RAS (renin-angiotensin system) was detected, with possible implications for vasocompensative mechanisms induced by arteriotomy. In particular, a selective increase in the 69 kDa isoform of the N-domain of ACE (angiotensin-converting enzyme), and not the classical somatic 195 kDa isoform, was observed in contralateral uninjured carotid arteries, suggesting that this 69 kDa isoenzyme could influence local AngII (angiotensin II) production. In conclusion, systemic reactions to injury occur in the vasculature, with potential clinical relevance, and suggest that caution is needed in the choice of controls during experimental design in vivo.

Corrigendum to “A predictive model for early mortality after surgical treatment of heart valve or prosthesis infective endocarditis. The EndoSCORE”. [Int. J. Cardiol. Aug 15 2017;241:97-102.]

Michele Di Mauro ⁎, Guglielmo Mario Actis Dato , Fabio Barili , Sandro Gelsomino , Pasquale Santè , Alessandro Della Corte , Antonio Carrozza , Ester Della Ratta , Diego Cugola , Lorenzo Galletti , Roger Devotini , Riccardo Casabona , Francesco Santini , Antonio Salsano , Roberto Scrofani , Carlo Antona , Luca Botta , Claudio Russo , Samuel Mancuso , Mauro Rinaldi , Carlo De Vincentiis , Andrea Biondi , Cesare Beghi , Giangiuseppe Cappabianca , Vincenzo Tarzia , Gino Gerosa , Michele De Bonis , Alberto Pozzoli , Francesco Nicolini , Filippo Benassi , Francesco Rosato , Elena Grasso , Ugolino Livi , Sandro Sponga , Davide Pacini , Roberto Di Bartolomeo , Andrea DeMartino , Uberto Bortolotti , Francesco Onorati , Giuseppe Faggian , Roberto Lorusso , Enrico Vizzardi , Gabriele Di Giammarco , Daniele Marinelli , Emmanuel Villa , Giovanni Troise , Marco Picichè , Francesco Musumeci , Domenico Paparella , Vito Margari , Francesco Tritto , Girolamo Damiani , Giuseppe Scrascia , Salvatore Zaccaria , Attilio Renzulli , Giuseppe Serraino , Giovanni Mariscalco , Daniele Maselli , Massimiliano Foschi , Alessandro Parolari , Giannantonio Nappi ,