The role of anti-infectives in the treatment of refractory asthma.

Refractory asthma not only has a significant effect on quality of life, but also imposes an economic burden on society. Increasing evidence suggests that there is a pathophysiologic interaction between infection and allergic disease in patients with severe or refractory asthma. Therapeutic trials of macrolides and azoles are being utilized in some patients with refractory asthma who fail to respond to standard therapy.

Strategies in the prevention of ventilator-associated pneumonia.

Ventilator-associated pneumonia (VAP) remains a significant problem in the hospital setting, with very high morbidity, mortality, and cost. We performed an evidence-based review of the literature focusing on clinically relevant pharmacological and nonpharmacological interventions to prevent VAP. Owing to the importance of this condition the implementation of preventive measures is paramount in the care of mechanically ventilated patients.

Use of the Valsalva graft and long-term follow-up.

Objective: The Valsalva graft is a specifically designed Dacron graft that, on implantation and pressurization, generates pseudosinuses of Valsalva. We reviewed a multicenter experience of the reimplantation procedure with the Valsalva graft in patients with aneurysms involving the aortic root.

Methods: A total of 278 patients underwent valve-sparing aortic root replacement using the Valsalva graft at 4 different Italian cardiac surgery centers and were studied by clinical assessment and echocardiography.

A method to avoid knot-tying in artificial chordae implantation for mitral valve repair.

Background And Aim Of The Study: Expanded polytetrafluoroethylene (ePTFE) neo-chordae implantation requires knot-tying inside the heart, which can be especially difficult if a minimally invasive approach is used. A system has been developed that allows the implantation of neo-chordae, without a need for knot-tying, in addition to a simultaneous and reversible length adjustment after the evaluation of valve continence using hydrostatic tests.

Methods: The system consists of a suture with a needle at one end and a 20 mm pledgeted loop at the opposite end.

Preoperative very short-term, high-dose erythropoietin administration diminishes blood transfusion rate in off-pump coronary artery bypass: a randomized blind controlled study.

Objective: Human recombinant erythropoietin has been used to obtain a rapid increase in red blood cells before surgery. Previously, the shortest preparatory interval has been 4 days, but at the European Hospital only 2.4 days on average separate hospitalization and surgery.

Double-arterial cannulation for aortic valve replacement with porcelain aorta.

We describe a new technique of aortic valve replacement (AVR) in patients with porcelain aorta. Three patients (mean age 75 years) were treated. The cardiopulmonary bypass (CPB) was established after side-graft right axillary artery and direct femoral artery cannulation.

Re-creation of a sinuslike graft expansion in Bentall procedure reduces stress at the coronary button anastomoses: A finite element study.

Objective: The Bentall procedure is routinely performed using a straight Dacron graft coupled with a mechanical or a biologic valve. Creation of coronary ostia buttons significantly reduces tension on the coronary anastomoses and consequently the incidence of pseudoaneurysm formation. We sought to evaluate if the use of a specifically designed graft with a sinuslike root portion that bulges out upon pressurization can reduce stress on coronary anastomoses.

Valsalva graft in the Bentall procedure: from mechanical valve to the BioValsalva, world's first biological aortic conduit.

Aortic root replacement is the procedure of choice for patients with ascending aortic aneurysms and diseased aortic valve leaflets. The increasing age of patients who undergo aortic root surgery, and data that support the use of a biological aortic valve in the younger population, have significantly increased the need for a composite biological valved conduit. The third-generation Triplextrade (Terumo Vascutek, Renfrewshire, Scotland, UK) Dacron conduit with its three-layer technology, can be stored in glutaraldehyde along with biological prostheses while maintaining a complete blood impermeability.

Sorin Solo stentless valve: extended adaptability for sinotubular junction mismatch.

Stentless valve continence is affected by the implantation technique, annular symmetry and dilatation of the sinotubular junction. We tested in vitro how the Sorin Solo stentless pericardial valve adapts to a slightly dilated sinotubular junction. Stentless Sorin Solo aortic valves (25 mm) were sutured into a 32-mm Valsalva graft suspending the commissures into the expandable region of the graft.

Initial experience of an arterial shunt for bilateral antegrade cerebral perfusion during hypothermic circulatory arrest.

Purpose: The purpose of this study is to describe an intravessel cerebral shunt that allows perfusion of both cerebral hemispheres through the axillary artery.

Description: The cerebral shunt is a 10-cm to 12-cm long cannula with a lumen for blood perfusion and two balloons, one at each distal end. The proximal balloon is adapted for retaining the proximal end of the catheter in the innominate artery; the second inflatable balloon is adapted for retaining the distal end of the catheter into the left common carotid artery.

A third generation of ascending aorta Dacron graft: preliminary experience.

Purpose: To develop a preassembled biological valved conduit, a Dacron conduit was modified to be stored in glutaraldehyde without loss of blood impermeability. This study reports the preliminary experience with this "third generation" aortic Dacron graft.

Description: Eight patients underwent ascending aorta or root replacement using the new Triplex prosthetic conduit (Vascutek Terumo, Renfrewshire, Scotland) consisting of three layers.

Sinotubular junction size affects aortic root geometry and aortic valve function in the aortic valve reimplantation procedure: an in vitro study using the Valsalva graft.

Background: Sinotubular junction (STJ) size in aortic valve reimplantation procedures is usually predetermined on the basis of experience or intraoperative mathematical calculations. Given the small coaptation reserve of aortic valve leaflets, small errors can produce an incompetent aortic valve. We tested in vitro the effect of geometrically changing the relationship between aortic annulus size and STJ size on aortic root geometry and aortic valve function.

Endovascular balloon versus transthoracic aortic clamping for minimally invasive mitral valve surgery: impact on cerebral microemboli.

To evaluate micro embolic events occurrence during minimally invasive mitral valve procedures, comparing balloon endovascular aortic occlusion (Group I) and transthoracic aortic clamping technique (Group II), 36 patients (20 in Group I and 16 in Group II) undergoing minimally invasive mitral valve surgery were selected by CT scan and Doppler studies for absence of atherosclerotic disease at aortic, coronary or peripheral level. Assignment to one of the two groups was made on the basis of surgeon's preference. Continuous automated intra-operative transcranial Doppler was used to monitor micro embolic events during five operative steps: cardiopulmonary bypass (CPB) setup, time interval from CPB start until aortic clamp positioning, first minute after clamp-on, first minute after clamp-off, first ten minutes after CPB weaning start.

Multifrequency transcranial Doppler for intraoperative automatic detection and characterisation of cerebral microemboli during port-access mitral valve surgery.

In 20 patients (6 male; age 56.5+/-6.4 years; BSA 1.

A new method for artificial chordae length "tuning" in mitral valve repair: preliminary experience.

Objectives: Implanting expanded polytetrafluoroethylene neochordae is an established technique in treating complex mitral regurgitation. Difficulty in obtaining reliable preoperative and intraoperative measurements of an ideal neochordae length, as well as the unfeasibility of adjusting lengths once set in place with traditional techniques, led us to develop a system that allows rapid change of length after the evaluation of valve continence with hydrostatic tests.

Methods: The system consists of two components: a papillary component with arrest knots at constant intervals and a leaflet component with a reversible noose-lace to fix the loop to 1 of the knots on the papillary component.

Emergency coronary artery bypass grafting in patients with acute myocardial infarction treated with glycoprotein IIb/IIIa receptor inhibitors.

Glycoprotein (GP) IIb/IIIa receptor inhibitors before primary angioplasty in patients with ST-elevation acute myocardial infarction (STEMI) are recommended by current guidelines. Thus, an increasing number of patients receive these drugs before coronary angiography, particularly if a between-hospital transfer is needed. However, when coronary anatomy is unsuitable for angioplasty, emergency coronary artery bypass grafting (CABG) under GP IIb/IIIa inhibitor treatment may be needed, with a potential increase in bleeding risk.

Rest and Dobutamine stress echocardiography in the evaluation of mid-term results of mitral valve repair in Barlow's disease.

Background: Surgical "anatomical" repair is the most frequent technique used to correct mitral regurgitation due to severe myxomatous valve disease. Debate, however, persists on the efficacy of this technique, as well as on the durability of the repaired valve, and on its functioning and hemodynamics under stress conditions. Thus, a basal and Dobutamine echocardiographic (DSE) study was carried out to evaluate these parameters at mid-term follow-up.

Adjustable sinotubular junction for aortic valve reimplantation procedures.

Sinotubular junction size in aortic valve reimplantation procedures is usually predetermined on the basis of mathematical calculations and intraoperative measurements. We propose a new method for aortic valve reimplantation by which intraoperative measurements can be eliminated and sinotubular junction size adjusted after cross clamp removal to fit the patient's need. Aortic valve commissures are reimplanted in the expandable skirt of a Valsalva (Vascutek, Renfrewshire, Scotland) graft to realize an oversized sinotubular junction that is subsequently reduced to the proper size by wrapping, with Dacron rings of decreasing size, the neo-sinotubular ridge under transesophageal echocardiographic guidance.

Cardiac protection by volatile anaesthetics: a multicentre randomized controlled study in patients undergoing coronary artery bypass grafting with cardiopulmonary bypass.

Background And Objectives: To evaluate the effects of total intravenous anaesthesia vs. volatile anaesthesia on cardiac troponin release in coronary artery bypass grafting with cardiopulmonary bypass, we performed a multicentre randomized controlled study to compare postoperative cardiac troponin release in patients receiving two different anaesthesia plans.

Methods: We randomly assigned 75 patients to propofol (intravenous anaesthetic) and 75 patients to desflurane (volatile anaesthetic) in addition to an opiate-based anaesthesia for coronary artery bypass grafting.

Evaluation of 17-mm St. Jude Medical Regent prosthetic aortic heart valves by rest and dobutamine stress echocardiography.

Background: The prosthesis used for aortic valve replacement in patients with small aortic root can be too small in relation to body size, thus showing high transvalvular gradients at rest and/or under stress conditions. This study was carried out to evaluate rest and Dobutamine stress echocardiography (DSE) hemodynamic response of 17-mm St. Jude Medical Regent (SJMR-17 mm) in relatively aged patients at mean 24 months follow-up.

Myocardial damage prevented by volatile anesthetics: a multicenter randomized controlled study.

Objective: The purpose of this study was to evaluate the effects of volatile anesthesia versus total intravenous anesthesia on cardiac troponin release in off-pump coronary artery bypass grafting (OPCAB).

Design: The authors performed a multicenter randomized controlled study to compare cardiac troponin release in patients receiving either volatile anesthetics or total intravenous anesthesia for cardiac surgery on the beating heart, which is an excellent model of human myocardial ischemia.

Setting: Three university hospitals.

Percutaneous mitral annuloplasty: an anatomic study of human coronary sinus and its relation with mitral valve annulus and coronary arteries.

Background: To allow performance of "stand-alone" mitral annuloplasty with minimal invasiveness, percutaneous techniques consisting of delivery into the coronary sinus (CS) of devices intended to shrink the mitral valve annulus have recently been tested in animal models. These techniques exploit the anatomic proximity of the CS and mitral valve annulus in ovine or dogs. Knowledge of a detailed anatomic relationship between the CS, coronary arteries, and mitral valve annulus in humans is essential to define the safety and efficacy of percutaneous techniques in clinical practice.