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L Caretti,1 A La Gloria Valerio,1 R Piermarocchi,1 G Badin,1 G Verzola,1 F Masarà,1 T Scalora,2 C Monterosso31Ophthalmology Unit, Santa Maria della Misericordia Hospital, Rovigo, Italy; 2Neurosciences Department, Ophthalmology Unit, University of Padua, Padua, Italy; 3Ophthalmology Unit, Dell’Angelo Hospital, Meste, ItalyPurpose: To evaluate the effects of carbomer sodium hyaluronate trehalose (CHT) and sodium hyaluronate eye drops on tear film stability and ocular discomfort after cataract surgery.Setting: Santa Maria della Misericordia Hospital, Rovigo, Italy.Design: Prospective randomized case-control study.Patients and methods: This study enrolled sixty patients scheduled for unilateral cataract surgery. After phacoemulsification, subjects received carbomer sodium hyaluronate trehalose (trehalose group) or sodium hyaluronate tears (HG group) substitute and were assessed through objective (break up time, corneal and conjunctival staining) and subjective (OSDI questionnaire) clinical evaluations after a two times a day topical administration. Outcome measures were collected preoperatively (baseline), one week (day 7) and 1 month (day 30) after surgery. Finally, each patient was asked to give his personal treatment satisfaction score.Results: Trehalose group showed a steeper break up time (BUT) increase compared to patient treated with hyaluronic acid (P

This article presents a case of heterotopic heart transplantation in a 47 year old man who had post-ischaemic dilated cardiomyopathy. The patient presented with an anterior myocardial infarction (MI) in 1989 and an inferior MI seven years later. In March 1997, the patient underwent double coronary bypass by means of internal mammary artery to left anterior descending coronary artery and saphenous vein to right coronary artery. Right heart catheterisation showed systolic pulmonary pressure of 94 mm Hg and 7.1 Wood units, and therefore he had to be considered for heterotopic heart transplantation. Finally in December 2003, he underwent heterotopic heart transplantation and during the operation, the two coronary grafts implanted before were found to be functioning.

Purpose: To compare the surgical and clinical outcomes of 27-gauge vitrectomy and 23-gauge vitrectomy., Methods: We conducted a single-center, prospective, randomized study. Fifty-three patients affected by vitreoretinal interface disorders (epiretinal membranes and macular holes) were randomly scheduled to undergo 27-gauge (28 patients) or 23-gauge (25 patients) pars plana vitrectomy. The presence of any potential factor of increased baseline inflammation or eye anatomy influencing the surgery was criteria for exclusion. The time of surgery, postoperative intraocular pressure (IOP), state of sclerotomy wounds, rate of complications, postoperative pain, and indicators of inflammation were studied. We also introduced a new parameter to compare intraocular inflammation after surgery, given by the change in the number of intraretinal hyperreflective foci (HRF)., Results: The 27-gauge vitrectomy was 1.28 min longer than 23-gauge vitrectomy ( P < 0.05). The day after surgery, the mean IOP value was significantly higher in the 27-gauge group (16.12 mmHg versus 13.04 mmHg in the 23-gauge group, P < 0.05), but this difference disappeared in successive follow-ups and the sclerotomy wounds closed after 2 weeks in the both groups. The rate of postoperative hypotony did not significantly differ in the two groups (10.71% in the 27-gauge group and 8% in the 23-gauge group the day after the surgery, P = 0.94). Less postoperative eye redness was seen in 27-gauge eyes (value 1 on the scale) compared to 23-gauge (value 2 on the scale) ( P < 0.05), but there was no significant difference in intraocular inflammation (cells, Tyndall, and number of HRF, P > 0.05 for all)., Conclusions: The 27-gauge vitrectomy may have better outcomes in terms of IOP maintenance and cause less redness after the surgery but with a slightly prolonged surgery time and no other differences under other parameters (inflammation, rate of complications, postoperative pain, visual gain, and closure of the sclerotomy wounds)., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Journal of Current Ophthalmology.)

Background: In patients with chronic thromboembolic pulmonary hypertension (CTEPH) undergoing pulmonary endarterectomy (PEA) it is important to minimize residual obstructions, in order to achieve low postoperative pulmonary vascular resistances and better clinical results. The aim of the study was to test the hypothesis that the greater the number of pulmonary artery branches treated at surgery, the better the hemodynamic and clinical outcome after PEA., Methods: In 564 consecutive CTEPH patients undergoing PEA the count of the number of treated branches was performed directly on the surgical specimens. Post-operative follow-up visits were scheduled at 3 months and 12 months after surgery including right heart catheterization and modified Bruce test., Results: The population was divided into tertiles based on the number of treated branches: Group 1 (from 4 to 30 treated branches, n = 194 patients); Group 2 (from 31 to 43 treated branches, n = 190 patients); Group 3 (from 44 to 100 treated branches, n = 180 patients). At 3 and at 12 months after PEA, after adjustment for confounders, patients in the highest tertile of treated branches had significantly lower values of pulmonary vascular resistance and higher values of pulmonary arterial compliance as compared to the other two groups (p < 0.002). Hospital mortality was 3% in Group 3, 6% in Group 2 and 10% in Group 1 (overall p = 0.035)., Conclusions: In CTEPH patients undergoing PEA, a higher number of treated pulmonary artery branches is associated with a better hemodynamic and a better clinical outcome at 3 months and 12 months after surgery., Competing Interests: Declaration of Competing Interest the authors have no conflict of interest to disclose., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Purpose: To evaluate outcomes of ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK) with donor corneas preserved at 31°C in Cornea Syn®, a medium formulated with recombinant human serum albumin (rHSA) to replace foetal calf serum, and deswelled-transported in the xeno-free medium Cornea Trans®., Methods: Prospective, multicentre, open-label study. We evaluated the endothelial cell loss (ECL) as the percentage variation of the endothelial cell density (ECD, cells/mm 2 ) between 6 and 12 months after surgery, corneal transparency and thickness at 12 months, and adverse events within 12 months. Endothelial lenticules of mean 89 μm, ECD ≥ 2300 cells/mm 2 , minimum signs of cell mortality or morphology alterations, were dissected by microkeratome in the eye bank, and grafted in patients ≥ 18 years without corneal neovascularisation, conjunctivalization, or blinking impairment., Results: Thirty-five patients underwent UT-DSAEK, 3 showed primary failure, 1 late failure, and 2 skipped the 6-month visit. We analysed data from 29 patients, 27 with Fuchs endothelial corneal dystrophy (FECD) and 2 with pseudophakic bullous keratopathy (PBK). The median ECL between 6 and 12 months was 2.6% ( p  = .054, CI 0 to 12.5) and the absolute mean (SD) was 158.4 (364.1) cells/mm 2 . After 12 months, 96.5% of corneas were clear, with mean pachymetry of 585.9 (50.4) µm., Conclusions: The ECL rate after UT-DSAEK match overall that observed in DSAEK or UT-DSAEK models of endothelial survival and the overall safety compared that reported for similar follow-up. Corneas maintained in Cornea Syn® and Cornea Trans® did not affect the ECD and functional outcomes of UT-DSAEK up to 12 months.

Purpose: To evaluate postoperative safety of femtosecond laser deep anterior lamellar keratoplasty performed with an innovative anvil profile in keratoconus patients., Methods: This is a single-center, retrospective cohort study. We reviewed medical records of 89 keratoconus patients that underwent femtosecond laser deep anterior lamellar keratoplasty surgery (46 eyes) and manual deep anterior lamellar keratoplasty (47 eyes). Inclusion criteria required: age > 18 years old, best-corrected visual acuity < 0.3 LogMAR, continuous suture of the graft, postoperative immunomodulant regimen with dexamethasone 0.1% for 6 months and at least 12 months follow-up. Previous eye surgery, hydrops, and other ocular disease were excluded. The main outcome measures were postoperative events: rejections, persistent epithelial defects, and graft failures., Results: During the follow-up (20 ± 6 months) graft rejection was diagnosed in 0 of femtosecond laser deep anterior lamellar keratoplasty versus 6 (17%) of manual deep anterior lamellar keratoplasty [ p 0.027], persistent epithelial defect in 0 of femtosecond laser deep anterior lamellar keratoplasty versus in 4 (11%) of manual deep anterior lamellar keratoplasty [ p 0.048] and graft failure occurred in 4 (11%) of manual deep anterior lamellar keratoplasty. The best-corrected visual acuity, after removal of sutures, was better in the femtosecond laser deep anterior lamellar keratoplasty group 0.09 ± 0.08 LogMAR versus 0.16 ± 0.13 LogMAR in manual deep anterior lamellar keratoplasty [ p 0.035] group although refractive spherical equivalent and cylinder, topographic average keratometry and cylinder were similar., Conclusions: Anvil-shaped femtosecond laser deep anterior lamellar keratoplasty in keratoconus surgery increases safety and readiness of recovery, decreasing the incidence of corneal rejection, epithelial defects, graft failures, and producing better best-corrected visual acuity after removal of sutures.

Purpose: To compare the clinical findings and outcomes of vitrectomy for lamellar macular holes (LMH) versus epiretinal membrane foveoschisis (ERMF)., Materials and Methods: This retrospective study enrolled 36 eyes of 35 patients with a minimum follow-up of 6 months. Spectral domain optical coherence tomography (SD-OCT) parameters and best-corrected visual acuity (BCVA) were analyzed preoperatively and postoperatively., Results: The 19 (52.8%) ERMF and 17 (47.2%) LMH were included. Preoperatively, eyes with LMH were characterized by a lower central foveal thickness (CFT) (102.18 ± 31.44 µm vs 159.37 ± 25.25 µm, p  < 0.001) and a greater incidence of outer retinal disruption ( p  < 0.001). Primary anatomical success was achieved in 34/36 eyes (94.4%). Preoperative BCVA was better in ERMF (0.16 - IQR 0.09 - logarithm of the minimal angle of resolution (LogMAR) - 20/28 Snellen) than LMH (0.40 - IQR 0.30 - LogMAR, 20/50 Snellen) ( p  = 0.008). At 6 months after surgery, BCVA significantly improved in the ERMF group ( p  < 0.001), but showed insignificant change in LMH ( p  = 0.125). Two cases, both in the LMH group, developed full thickness macular hole after surgery., Conclusion: Eyes with LMH showed visual stabilization after surgery, whereas the eyes in the ERMF group were susceptible to functional improvement. These differences in BCVA outcomes may be the consequence of a higher damage in the outer retina in the LMH group; an accurate SD-OCT examination is a fundamental step when deciding to proceed or not to the surgery.

Purpose: To report a series of novel optical coherence tomography (SD-OCT) foveal abnormalities, that we called "T-sign," that were noticed after a complicated cataract surgery with posterior capsule rupture and vitreous loss., Methods: Retrospective case series of persistent foveal changes that incurred after anteroposterior vitreo-foveal traction secondary to phacoemulsification in presence of posterior capsule rupture., Results: The study included three eyes of three patients that incurred in complicated cataract surgery and intraoperative vitreo-foveal traction. During 8-month follow-up period peculiar abnormalities in fundus examination and in OCT scans were reported in all cases., Conclusion: Phacoemulsification in presence of posterior capsule rupture could induce a vitreo-foveal strain that could be transmitted to the cone outer segment tips (COST line) and inner-outer segment (IS/OS) junction. This focal stress is liable for "T-sign," a persistent SD-OCT abnormality that induce a visual impairment and a slight metamorphopsia in the fixation point., Summary Statement: All over the world, more than 9.5 million cataract surgeries are completed each year. 1 During surgery, many intraoperative complications could occur, and capsule rupture with vitreous loss is a frequent event. Phacoemulsification in presence of a wide posterior capsule rupture and vitreo-macular adhesion could induce a typical modification of the foveal structure and a permanent visual impairment.

Objectives: The aim of this study was to describe the radiological features of chronic thromboembolic pulmonary disease (CTEPD), not yet systematically described in the literature. Furthermore, we compared vascular scores between CTEPD and chronic thromboembolic pulmonary hypertension (CTEPH) patients, trying to explain why pulmonary hypertension does not develop at rest in CTEPD patients., Methods: Eighty-five patients (40 CTEPD, 45 CTEPH) referred to our centre for pulmonary endarterectomy underwent dual-energy computed tomography pulmonary angiography (DE-CTPA) with iodine perfusion maps; other 6 CTEPD patients underwent single-source CTPA. CT scans were reviewed independently by an experienced cardiothoracic radiologist and a radiology resident to evaluate scores of vascular obstruction, hypoperfusion and mosaic attenuation, signs of pulmonary hypertension and other CT features typical of CTEPH., Results: Vascular obstruction burden was similar in the two groups (p = 0.073), but CTEPD patients have a smaller extension of perfusion defects in the iodine map (p = 0.009) and a smaller number of these patients had mosaic attenuation (p < 0.001) than CTEPH patients, suggesting the absence of microvascular disease. Furthermore, as expected, the two groups were significantly different considering the indirect signs of pulmonary hypertension (p < 0.001)., Conclusions: CTEPD and CTEPH patients have significantly different radiological characteristics, in terms of signs of pulmonary hypertension, mosaic attenuation and iodine map perfusion extension. Importantly, our results suggest that the absence of peripheral microvascular disease, even in presence of an important thrombotic burden, might be the reason for the absence of pulmonary hypertension in CTEPD., Key Points: • CTEPD and CTEPH patients have significantly different radiological characteristics. • The absence of peripheral microvascular disease might be the reason for the absence of pulmonary hypertension in CTEPD., (© 2021. The Author(s).)

Aims: Aim of the study was to verify the feasibility, safety and efficacy of pulmonary endarterectomy (PEA) in octogenarian patients with chronic thromboembolic pulmonary hypertension., Methods: We retrospectively analyzed 635 chronic thromboembolic pulmonary hypertension patients who underwent PEA at our center and were followed-up for at least 1 year. The end-points of the study were in-hospital mortality, hemodynamic results at 1 year and long-term survival., Results: In-hospital mortality was 4, 10 and 17%, respectively, for 259 patients under the age of 60 years, 352 aged between 60 and 79 years and 24 octogenarians (P = 0.006 octogenarians vs. <60 years). At multivariable analysis, age and pulmonary vascular resistances were independent risk factors for mortality (P = 0.021 and P < 0.001, respectively). At 1 year, the improvement in cardiac index was lower and the distance walked in 6 min was poorer for octogenarians than for the other two groups (both P = 0.001). Survival after hospital discharge was similar over a median follow-up period of 59 months (P = 0.113). Although in-hospital mortality and long-term survival are similar in octogenarians as compared with patients aged between 60 and 79, the improvement in cardiac index and in functional capacity at 1 year are lower in this very elderly population., Conclusion: Age over 80 years should not be a contraindication to PEA surgery in selected patients operated on in referral centers., (Copyright © 2021 Italian Federation of Cardiology - I.F.C. All rights reserved.)

Background: Few studies addressed the issue of risk stratification in patients with residual pulmonary hypertension (PH) after pulmonary endarterectomy (PEA). This study tested the potential added value of parameters that have not been included in existing risk models., Methods: We evaluated 546 consecutive patients with chronic thromboembolic pulmonary hypertension who underwent PEA and were followed-up for a median period of 58 months., Results: Among the 242 with residual PH, 27 died and had 127 a clinical worsening event. At univariable analysis, the parameters associated with poor survival were pulmonary vascular resistance (PVR) ≥425 dyn·s·cm -5 (p ≤ 0.001), mean pulmonary artery pressure (mPAP) ≥38 mmHg (p = 0.003) and pulmonary artery compliance (CPA) ≤1.8 ml/mmHg (p = 0.014). In the bivariable models including either PVR or mPAP as first parameter, the addition of CPA was not statistically significant. The parameters associated with poor clinical worsening were CPA ≤1.8 ml/mmHg (p < 0.001), PVR ≥425 dyn·s·cm -5 (p = 0.002), arterial oxygen tension (PaO2) ≤ 75 mmHg (p = 0.003), mPAP ≥38 mmHg (p = 0.008). In a multivariable analysis which included PVR ≥425 as the first parameter, the addition of both CPA ≤1.8 ml/mmHg and of PaO2 ≤ 75 mmHg significantly improved prognostic stratification (Harrel's C of the model = 0.64, p < 0.001). Noticeably, the lower tertile of the model's predictor index identified a subgroup of 91 patients who had an event rate numerically similar to that of patients without residual PH., Conclusions: Risk stratification in residual PH can be refined if CPA and PaO2 are considered in association with standard hemodynamic parameters., Competing Interests: Declaration of competing interest Stefano Ghio and Andrea Maria D'Armini performed consulting work for Actelion Pharmaceuticals, Ltd. and Merck Sharp Dohme. The other authors have no conflicts of interest to disclose., (Copyright © 2021 Elsevier B.V. All rights reserved.)

An increased need of extracorporeal membrane oxygenation (ECMO) support is going to become evident as treatment of SARS-CoV-2 respiratory distress syndrome. This is the first report of the Italian Society for Cardiac Surgery (SICCH) on preliminary experience with COVID-19 patients receiving ECMO support. Data from 12 Italian hospitals participating in SICCH were retrospectively analyzed. Between March 1 and September 15, 2020, a veno-venous (VV) ECMO system was installed in 67 patients (94%) and a veno-arterio-venous ECMO in four (6%). Five patients required VA ECMO after initial weaning from VV ECMO. Thirty (42.2%) patients were weaned from ECMO, while 39 (54.9%) died on ECMO, and six (8.5%) died after ECMO removal. Overall hospital survival was 36.6% (n = 26). Main causes of death were multiple organ failure (n = 14, 31.1%) and sepsis (n = 11, 24.4%). On multivariable analysis, predictors of death while on ECMO support were older age (p = 0.048), elevated pre-ECMO C-reactive protein level (p = 0.048), higher positive end-expiratory pressure on ventilator (p = 0.036) and lower lung compliance (p = 0.032). If the conservative treatment is not effective, ECMO support might be considered as life-saving rescue therapy for COVID-19 refractory respiratory failure. However warm caution and thoughtful approaches for timely detection and treatment should be taken for such a delicate patients population., Competing Interests: Disclosure: The authors have no conflicts of interest to report., (Copyright © ASAIO 2021.)

To evaluate the effect of donor-to-recipient sex mismatched (male donor corneas to female recipients) on the incidence of rejection episodes and failures up to 1 year after corneal transplantation. Prospective observational cohort study, with donor corneas randomly assigned and surgeons blind to the sex of donor. A unique eye bank retrieved and selected the donor corneas transplanted in 4 ophthalmic units in patients with clinical indication for primary or repeated keratoplasty for optical reasons, perforating or lamellar, either anterior or posterior. Rejection episode defined as any reversible or irreversible endothelial, epithelial or stromal sign, with or without development of corneal edema, and graft failure as a permanently cloudy graft or a regraft for any reason detected or acknowledged during a postoperative ophthalmic visit at any time up to 1 year after surgery were recorded.156 (28.6%) patients resulted donor-to-recipient gender mismatched for H-Y antigen (male donor to female recipient). During the 12 months follow-up, 83 (14.7%, 95% CI 12.0-17.9) grafts showed at least 1 rejection episode and 17 (3.2%, 95% CI 2.0-5.0) failed after immune rejection, among 54 (9.6%, 95% CI 7.4-12.3) grafts failed for all causes. No significant differences between matched and mismatched patients were found for cumulative incidence of both rejection episodes (15.2% and 13.5%) and graft failures following rejection (3.2% and 2.6%), respectively. Multivariable analyses showed that H-Y matching either is not a predictive factor for rejection or graft failure nor seems to influence incidence of failures on respect to patient's risk category. The lack of influence of donor-to-recipient mismatched on the rate of rejections and graft failures resulting from this study do not support the adoption of donor-recipient matching in the allocation of corneas for transplantation.

We report the case of a woman with pulmonary embolism due to a cardiac mass. Echocardiography, computed tomography scan, and cardiac magnetic resonance raised the suspicion of right atrial myxoma and confirmed the presence of pulmonary embolism. The patient was sent to the University of Pavia School of Medicine, where the atrial myxoma was excised, and, using interrupted periods of circulatory arrest, extraction of the myxoma emboli from the pulmonary arteries was performed. No adjuvant chemotherapy was required as surgical treatment is an effective therapy in cases of pulmonary embolism of a benign neoplastic mass., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the safety and effectiveness of ex vivo autologous cultured limbal stem cell transplantation (CLET)., Methods: We reviewed the clinical records of 59 consecutive patients treated with 65 CLETs. Efficacy was graded 1 year after surgery as successful, partially successful or failed. A safety analysis was performed considering side effects and complications that were recorded during the first year after CLET and those reported later than 1 year, including the events related to subsequent treatments., Results: The mean post-CLET follow-up was 6.0±4.1 years. 69% of CLETs had either one or more adverse events (AEs), or adverse drug reactions (ADRs), within 1 year of surgery, with inflammation being the most common (42%), followed by corneal epithelium defects/disepithelialisation (31%), and blood coagula under the fibrin (24%). One year after surgery, 41% of the 59 primary CLET procedures were successful, 39% partially successful and 20% failed. The most common ADRs recorded for the primary unsuccessful CLETs were ulcerative keratitis, melting/perforation, and epithelial defects/disepithelialisation. Six failed CLETs required reconstructive penetrating keratoplasty (PK). Among CLETs with a favourable outcome, 13 underwent corrective PK (mean 4.8±3.4 years), and thereafter seven eyes maintained integrity of the corneal epithelium, five showed corneal surface failure, and one had recurrent epithelial defects. Corneal graft rejection episodes were reported in 71% and 58% of patients following corrective or reconstructive PK, respectively. Seven primary CLETs with a favourable outcome worsened thereafter, and the overall 3-year long-term effectiveness was 68%., Conclusions: This study addresses important issues regarding possible risks associated with disarray of the ocular surface homeostasis following autologous CLET in patients with limbal stem cell deficiency, despite the fact that the majority of patients experienced a favourable long-term benefit., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Purpose. To compare the effect of 60 kHz and 150 kHz femtosecond (FS) laser on the corneal stromal bed surfaces (SBS). Methods. Sixteen human donor corneal tissues unsuitable for transplantation were used. Anterior and posterior lamella was obtained using 60 kHz and 150 kHz FS laser. A standard depth of 400  μ m was set for anterior lamellar keratoplasty (ALK) and endothelial lamellar keratoplasty (ELK). The quality and smoothness of the SBS post-FS laser dissection were graded for statistics. Results. No intraoperative complications were found. The side cuts were straight, and the SBS appeared smoother in cuts obtained using 150 kHz. The average values of the SBS quality of the anterior lamellar cut were found to be 2.25 (±0.28) for 60 kHz and 3.125 (±0.25) for 150 kHz (P = 0.0039). Whereas, 2 (±0.4) for 60 kHz and 2.75 (±0.28) for 150 kHz (P = 0.0273) was the quality observed in endothelial cuts. No significant difference was found between anterior and posterior cuts performed using the same FS laser (60 kHz or 150 kHz) (P > 0.05). Conclusions. The 60 kHz and 150 kHz FS lasers are equally effective in performing lamellar dissection for ALK and ELK. 150 kHz FS laser allows a tighter spot and layer separation which creates a slightly smoother SBS.

Purpose. To evaluate effects of corneal transplantation on the health-related quality of life and patients' satisfaction. Methods. Patients scheduled for elective penetrating or anterior lamellar keratoplasty completed by telephone interview the SF-12 Health Survey, before and one year after surgery, and a 6-item questionnaire on the satisfaction for graft outcomes. Results. The two questionnaires were answered by 1,223 patients. Transplantation did not influence the PCS-12 in males (ES = -0.01) and had a negative effect in females (ES = -0.18). Both sexes improved their MCS-12 (ES = 0.18 and 0.23, resp.). The majority of patients (83.1%) were satisfied by the outcome of the graft. Conclusions. This is the first report on the use of the SF-12 and one of the few that assess quality of life in patients after corneal transplantation. We showed that grafting improves patients' health-related quality of life results of patients, influencing mental health (i.e., psychological attitude, social interaction, and emotions) with minor effects on physical health (limitation, pain, and vitality).

Purpose: To evaluate preliminary clinical results and lamellar and side cut obtained with a 60-kHz femtosecond laser (IntraLase) using a new software designed to create penetrating cuts for keratoplasty to perform the donor and recipient dissection in femtosecond laser-assisted endothelial keratoplasty., Design: Prospective interventional case series., Methods: A femtosecond laser set in a raster spot pattern was used to create the posterior lamellar dissection and posterior side cut in 4 donor corneas and in 4 recipient human eyes of 4 patients with endothelial decompensation. The laser cut was performed to obtain a 150-μm thick and 9-mm wide posterior lamellar disk from the donor and the recipient eyes. Postoperatively, patients underwent slit-lamp examination and Snellen visual acuity evaluation, Visante optical coherence tomography, optical pachymetry, and endothelial microscopy analysis. Three residual donor corneas were analyzed by scanning electron microscopy and transmission electron microscopy to observe the stromal bed surface, the side cut, and the effects of the laser dissection on the cornea ultrastructure., Main Outcome Measures: Thickness of the implanted donor lamella, adhesion and clarity of the transplanted cornea in the postoperative follow-up, and smoothness of the interface., Results: All the patients showed good adhesion and fit of the donor disk to the recipient and a circle side cut observed at the slit-lamp examination. Visante optical coherence tomography evaluation confirmed the adhesion and the precalibrated thickness of the implanted lamella. A good corneal transparency was achieved within the first 2-3 weeks. The scanning electron microscopy analysis showed a smooth stromal residual surface and a precise side cut. The transmission electron microscopy images showed that the laser randomly modified the structural design of the collagen fibers for approximately 10-μm depth, although below a regular stromal structure was maintained., Conclusions: The 60-kHz IntraLase femtosecond laser creates a smooth stromal bed and precise side cut for endothelial keratoplasty. The posterior lamellar cut performed at the same depth in both the donor and the recipient makes it possible to create a corneal disk from the donor that fits exactly with the cut in the recipient.

Background: Although the port-access technique has been shown to be an effective and safe approach for cardiac surgery procedures it has never become routine practice, and it is still limited to few and selected centers. Furthermore, such technique has rarely been applied to treat left ventricle disease. In 1999 we introduced left ventricle aneurysm repair through a left minithoracotomy using the port-access technique. Here we present the results in terms of early and medium-term follow-up using such technique as a routine first choice approach for left ventricle endoplasty., Methods: From 1999 to date, out of 38 patients undergoing left ventricle endoplasty (+/-associate procedures), mini-left thoracotomy and port-access techniques have been used in 32 patients (84%). All patients underwent endoventricular patch-repair with ventricular reshaping and associated procedures were performed in 8 patients., Results: All patients survived the operation and were discharged from the hospital (30 days mortality 0%). Two patients (6.2%) experienced prolonged mechanical ventilations and 3 patients (9.3%) prolonged intensive care unit stay. Mean follow-up was 40+/-34 months (range, 2 to 105). One patient died during follow-up (cumulative mortality 3.3%). Follow-up revealed an improvement of hemodynamic performances (left ventricular ejection fraction 0.44+/-0.09 compared with 0.34+/-0.09 preoperatively, p=0.004) and improved clinical conditions (New York Heart Association class 1.4+/-0.5 compared with 2.3+/-1 preoperatively, p=0.003)., Conclusions: The port-access technique can be safely applied to perform left ventricle endoplasty through a left minithoracotomy. Such approach allows optimal surgical view and therefore optimal surgical correction. Based on our satisfactory experience we support left minithoracotomy as a valuable alternative approach for left ventricle endoplasty in view of an extended use of minimally invasive techniques., (Copyright (c) 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Cardiac retransplantation represents the gold standard treatment for a failing cardiac graft but the decision to offer the patient a second chance is often made difficult by both lack of donors and the ethical issues involved. The aim of this study was to evaluate whether retransplantation is a reasonable option in case of early graft failure. Between November 1985 and June 2008, 922 patients underwent cardiac transplantation at our Institution. Of these, 37 patients (4%) underwent cardiac retransplantation for cardiac failure resulting from early graft failure (n = 11) or late graft failure (acute rejection: n = 2, transplant-related coronary artery disease: n = 24). Survival at 1, 5 and 10 years of patients with retransplantation was 59%, 50% and 40% respectively. An interval between the first and the second transplantation of less than (n = 11, all in early graft failure) or more than (n = 26) 1 month was associated with a 1-year survival of 27% and 73%, and a 5-year survival of 27% and 65% respectively (P = 0.01). The long-term outcome of cardiac retransplantation is comparable with that of primary transplantation only in patients with transplant-related coronary artery disease. Early graft failure is a significant risk factor for survival after cardiac retransplantation and should be considered as an exclusion criteria.

The minimally invasive Heartport (HP)-assisted technique has become first choice option for mitral valve surgery in many centres.The pool of patients potentially treated using HP techniques, however, is still limited by the presence of peripheral vessel disease, expecially in the elderly population. Alternative approaches to using the HP technique safely in such a subset of patients, therefore, should be evaluated. Here, we present our preliminary experience using the axillary artery as an alternative site of cannulation for HP-assisted redo mitral valve surgery in patients with concomitant peripheral vessel disease.

Rationale: There are few follow-up studies on long-term cardiopulmonary function after pulmonary endarterectomy (PEA), the operation of choice for chronic thromboembolic pulmonary hypertension (CTEPH)., Objectives: To prospectively evaluate long-term outcome of patients with CTEPH treated with PEA., Methods: Between 1994 and 2006, 157 patients (mean age 55 yr) were treated with PEA at Pavia University Hospital. The patients were evaluated before PEA and at 3 months (n = 132), 1 year (n = 110), 2 years (n = 86), 3 years (n = 69), and 4 years (n = 49) afterward by NYHA class, right heart hemodynamic, spirometry, carbon monoxide transfer factor (Tl(CO)), arterial blood gas, and treadmill incremental exercise test., Measurements and Main Results: Cumulative survival was 84%. Within 3 months, 18 patients died in-hospital and 2 had lung transplantation; during long-term follow-up, 6 died, 1 had lung transplantation, and 3 had a second PEA (2.5 events per 100 person-years). NYHA class III-IV was the most important predictor of late death, lung transplant, or PEA redo (hazard ratio, 3.94). Extraordinary improvement in NYHA class, hemodynamic, and Pa(O(2)) were achieved in the first 3 months (P < 0.001) and persisted during follow-up; exercise tolerance progressively increased over time (P < 0.001). At 4 years, although 74% of the patients were in NYHA class I and none was in class IV, 24% had pulmonary vascular resistance greater than 500 dyne.s/cm(5) or Pa(O(2)) less than 60 mm Hg; they were significantly older and were more frequently in NYHA class III-IV 3 months after surgery than the others., Conclusions: After PEA, long-term survival and cardiopulmonary function recovery is excellent in most patients.

Acute pulmonary embolism is the third most common cardiovascular disease in Italy with approximately 65 000 new cases a year. Appropriate medical therapy does not necessarily prevent evolution of acute pulmonary embolism into chronic thromboembolic pulmonary hypertension (CTEPH), which occurs in 0.1-4.0% of cases. In our country, there are approximately up to 2600 new CTEPH patients a year. CTEPH is a progressive and potentially lethal disease. Medical therapy is palliative and only surgery can modify its natural history. Pulmonary endarterectomy (PEA) is the treatment of choice and lung transplantation should be considered only when PEA is contraindicated. Currently, nearly 4000 PEAs have been performed worldwide. Approximately ten centers are able to carry out this intervention with excellent and permanent results. Solid experience and close multidisciplinary collaboration allow appropriate patient selection, rigorous surgical technique, and adequate postoperative management. All these aspects represent the key to the success in the treatment of CTEPH. After PEA, quality and expected length of life are similar to the age-matched general population and the only therapy required is oral anticoagulation.