Silvia Mariani

Randomized study on removable PGE2 vaginal insert versus PGE2 cervical gel for cervical priming and labor induction in low-Bishop-score pregnancy

Background. Dinoprostone vaginal insert has been compared to Dinoprostone cervical gel in few studies, whose cases presented different Bishop scores and gestational ages at admission, and various treatment strategies in control arms. The present study compares the vaginal insert to the cervical gel in patients with low Bishop score at term. Methods. Prospective multicenter randomized trial, with parity‐based randomization. Admission criteria: single pregnancy with Bishop score of 0–4, gestational age of 37–41 weeks, intact membranes, no previous cesarean section, no bleeding or abnormal cardiotocography at admission. Results. Vaginal prostaglandins were required as a second‐line induction procedure in 25% of study patients versus 47.1% of controls (p<0.03, κ2). Study patients experienced shorter induction‐to‐delivery time (920±428 versus 1,266±740 min, p<0,01), with a mean difference of 5 h and 46 min between the groups. Even though patients that received vaginal insert showed a trend of increased incidence of abnormal cardiotocography during labor (12% versus 6.3%) and hyperkinetic labor (11.8% versus 2.1%), the incidence of cesarean sections (21.4% versus 21.6%), cesareans for fetal distress (12.5% versus 11.8%), and umbilical artery pH < 7.10 (4.9% versus 2.5%) was comparable between the two groups. Conclusions. Dinoprostone vaginal insert is more efficient than cervical gel in promoting cervical priming and labor induction in low‐Bishop‐score patients at term. The vaginal insert placement seems to be safe for the mother and the newborn, although larger studies are required to investigate uterine hyperstimulation incidence.

Endovascular Treatment of Degenerative Aneurysms Involving Only the Descending Thoracic Aorta Systematic Review and Meta-analysis

Purpose: To determine the efficacy of thoracic endovascular aortic repair (TEVAR) for degenerative aneurysm involving only the descending thoracic aorta (DTAA). Methods: An English-language literature review was performed through PubMed, Scopus, and Google Scholar to identify any study evaluating the outcomes of TEVAR for DTAA. The main endpoints of this analysis were all-cause 30-day and late postoperative mortality. Secondary outcome measures were procedure success, vascular access complications, paraplegia, stroke, early endoleaks during the index hospitalization, aneurysm-related death, reinterventions, and conversion to open repair. To control for the anticipated heterogeneity among small observational studies, absolute values and means were pooled using random effects models; the results are expressed as pooled proportions, means, or risk ratio (RR) with 95% confidence intervals (CIs). Results: Eleven studies reporting on 673 patients (mean age 72.6 years, mean aneurysm diameter 62.9 cm) with DTAA were selected for the analysis. Technical success was reported in 91.0% of patients, and vascular access complications requiring repair were encountered in 9.7% of cases. Pooled overall 30-day, 1-year, 2-year, and 3-year survival rates were 96.0%, 80.3%, 77.3%, and 74.0%, respectively. Five studies compared the results of TEVAR after elective (n=151) and urgent/emergent procedure (n=77); the latter was a predictor of 30-day mortality (17.1% vs 1.8%, RR 3.83, 95% CI 1.18 to 12.40, p=0.025). Paraplegia occurred in 3.2% of patients and was permanent in 1.4% of patients. The stroke rate was 2.7%. Early type I endoleak was observed in 7.3%, type II endoleak in 2.0%, and type III in 1.2% of patients. The mean follow-up of 9 studies was 22.3 months. At 3 years, freedom from reintervention was 90.3%. Death secondary to aneurysm rupture and/or fistula was reported in 3.2% of patients. Conclusion: Current results indicate that TEVAR for DTAA can be performed with rather high technical success, low postoperative morbidity, and good 3-year survival.

Unwarranted Variation in the Quality of Care for Patients With Diseases of the Thoracic Aorta

Background Thoracic aortic disease has a high mortality. We sought to establish the contribution of unwarranted variation in care to regional differences in outcomes observed in patients with thoracic aortic disease in England. Methods and Results Data from the Hospital Episode Statistics (HES) and the National Adult Cardiac Surgery Audit (NACSA) were extracted. A parallel systematic review/meta‐analysis through December 2015, and structure and process questionnaire of English cardiac surgery units were also accomplished. Treatment and mortality rates were investigated. A total of 24 548 adult patients in the HES study, 8058 in the NACSA study, and 103 543 from a total of 33 studies in the systematic review were obtained. Treatment rates for thoracic aortic disease within 6 months of index admission ranged from 7.6% to 31.5% between English counties. Risk‐adjusted 6‐month mortality in untreated patients ranged from 19.4% to 36.3%. Regional variation persisted after adjustment for disease or patient factors. Regional cardiac units with higher case volumes treated more‐complex patients and had significantly lower risk‐adjusted mortality relative to low‐volume units. The results of the systematic review indicated that the delivery of care by multidisciplinary teams in high‐volume units resulted in better outcomes. The observational analyses and the online survey indicated that this is not how services are configured in most units in England. Conclusions Changes in the organization of services that address unwarranted variation in the provision of care for patients with thoracic aortic disease in England may result in more‐equitable access to treatment and improved outcomes.

St. Jude Medical Trifecta aortic valve: results from a prospective regional multicentre registry

BackgroundThe Trifecta aortic bioprosthesis (St. Jude Medical, Inc., St. Paul, MN, USA) is a stented pericardial heart valve with excellent preliminary results. Aim of the study was to evaluate its early clinical and hemodynamic performances in a multicenter regional registry.MethodsBetween January 2011 and June 2012, 178 consecutive patients undergoing aortic valve replacement with the Trifecta bioprosthesis were prospectively enrolled at 9 Italian centers. Clinical and echocardiographic data were collectedat discharge, 6-months and at 1-year postoperatively.ResultsThe average age was 75.4u2009±u20097.7xa0years,and 95 (53xa0%) were men. Indication for valve replacement included stenosis in 123 patients (69xa0%), mixed lesions in 25 (14xa0%), and regurgitation in 30 (17xa0%). Ninety-three (52xa0%) patients were in NYHA functional class III/ IV. Hospital mortality accounted for 5 (2.8xa0%) patients. No valve-related perioperative complications were encountered. Median follow-up was 20.5xa0months (range: 1-34). Early (≤6xa0months) complications included one thromboembolic event, one major bleeding, and 3 endocarditis (2 explants). Two late (>6xa0months) thromboembolic events and two endocarditis (1 explant) were registered. No valve thrombosis or structural deterioration were observed after discharge. At 30-months, freedom from all-cause mortality was 87xa0%, freedom from valve-related mortality 99.4xa0%, freedom from endocarditis 97.5xa0%, and freedom from valve explants 98xa0%. At 1-year, mean gradients ranged from 8 to 16xa0mmHg, and effective orifice area indexes from 1.0 to 1.2xa0cm2/m2 for valve sizes from 19 to27 mm, respectively. No patients had severe prosthesis-patient mismatch.ConclusionsTrifecta bioprosthesis provided favourable clinical and hemodynamic results over time.

Effects of statins on delirium following cardiac surgery - evidence from literature.

Delirium is a common complication after cardiac surgery, being associated with significant mortality and morbidity. The pathogenesis of postoperative delirium (POD) is complex and multifactorial, involving an interaction of multiple predisposing and precipitating factors. There are several hypothesis regarding the underlying mechanisms of POD, and the most recent emerging one involves neuroinflammation, which is exacerbated by the cardiopulmonary bypass-induced systemic inflammatory response. Experimental and clinical studies have recently documented improved perioperative central neural protection exerted by statins because of their anti-inflammatory, immunomodulatory, and antithrombotic properties. The present review will focused on the possible protective effect exerted by preoperative statin administration on delirium following cardiac surgery.

An unusual case of a cardiocutaneous fistula presenting 30 years after a breast carcinoma

A 77-year old woman presented with bleeding and purulent drainage from a cutaneous fistula appearing 30 years after left mastectomy and cobaltotherapy due to breast cancer, in the left anterior thoracic wall. A computed tomography scan showed a left ventricle connection (Figs 1 and 2). Surgical treatment was recommended, but she refused. After 4 months, she died in spite of an emergency operation following an haemorrhage.

Fatal Huge Left Free Wall Ventricular Rupture after Acute Posterior Myocardial Infarction

A 77-year-old man, with a recent history of an acute inferior myocardial infarction, was referred to our hospital with echocardiographic and clinical signs of left ventricular free wall rupture (LVFWR). The intraoperative finding demonstrated a huge double LVFWR. The inferoposterior wall was dramatically destroyed without any possibility to repair.

Surgical Cannulation: Indication, Technique, and Complications

The establishment of ECMO support could be achieved through intrathoracic or extrathoracic cannulation strategies. Central cannulation requires a surgical approach, a sternotomy, and the cannulation of the right atrium and the ascending aorta. The features listed above make the central cannulation the best approach for patients with postcardiotomy complications. Such a cannulation strategy allows the best venous drainage and an anterograde blood flow in ascending aorta; it is though related to important complications such as bleeding and mediastinitis. In case of peripheral cannulation, it is necessary to choose among several sites: femoral vessels, axillary vessels, and cervical vessels are the most used ones. Peripheral vessel cannulation could be achieved either by percutaneous procedures or surgical incisions through an open approach with different techniques (direct cannulation or cannulation with side graft), a semi-Seldinger, or a full Seldinger method. The surgical approach allows the visualization of the vessels, the direct placement of the cannulas, and the control of possible complications. Therefore, it is recommended if immediate support is needed or if a peripheral vascular disease is suspected. Also a mixed central/peripheral cannulation approach is possible. The best cannulation technique should be chosen on the basis of patients and the clinical settings. Moreover, it is necessary to assess benefits and risks of the selected options to pick the best site and strategy of the cannulation.