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Restarts Stranamore...How will we see the conductor?

Restarts Stranamore...How will we see the conductor that has been for several months in an almost terminal stage?

Let's try to understand what has happened to him considering that we don't have the clinical facts but we can only presume some thinks based on informations that have been reported in that period from the press…that is what I have concluded reading the same journals and magazines as you did.


Alberto Castagna suffered from aortic insufficiency: this means that the aortic valve (the most powerful valve mechanism of the body) didn't function well. Let's see which is exactly the function of the aortic valve.
The heart acts as a pump of oxygenated lung blood. The oxygenated blood accumulates in the ventricle (that is an accumulating space) and when it gets full, it discharges its content towards the aorta.

The aorta is the largest artery of the body, originates from the heart and starts immediately to give branches, in order to drive the oxygenated blood to every part of the body, starting from the vessels that deliver oxygen to the brain, the arms and also the heart, which as every other organ needs oxygen to live and work. Because of that, this muscle also (although it drives all that blood to the tissues) receives blood from the coronary arteries of the aorta. In the normal adult at rest the ventricle performs this operation 70 times per minute.
When the ventricle is full the contraction starts, the pressure in it raises and thus the blood flows to the aorta. After the contraction the ventricle relaxes, the pressure in it gets much lower and the blood would return to the ventricle if the aortic valve didn't function. The aortic valve's functions consists in closing and preventing the return of the blood to the ventricle, allowing that way it's delivery to the tissues. 
If this valve functions well all of the blood "wringed" from the ventricle will be delivered to the peripheral tissues. On the other hand, if it didn't absolutely work, that is in an insufficiency of 100% (naturally this event wouldn't allow the patient to survive) all of the blood would turn back and it wouldn't be possible to deliver oxygen to any tissue. Having said all that it becomes quite clear that there is a large variety of intermediate conditions that can allow the survival of the patient although they do create serious problems.
As we all know the heart doesn't always pump with the same rhythm but when an organ (for example a muscle) needs more oxygen the heart starts to beat more quickly so as to deliver a higher quota of oxygenated blood. 
When does an organ need more oxygen?
Normally, during stress, for example during jogging.In a patient that suffers from aortic insufficiency, a part of the blood turns back. Because of that, the heart has to raise its rhythm (pump more) so as to deliver the quantity of oxygen required by the metabolising tissues. The higher the quantity of blood that turns back (that is the greater is the grade of insufficiency of the aortic valve) the greater is the work that has to do the heart (raising the rhythm of its beats) in order to meet the oxygen needs; 
In the more serious forms, the heart beats the highest that it can even if the patient is at rest and because of that cannot raise its rhythm. This has as a result a very bad quality of life. This is one of the reasons that can lead to a surgical operation but it's not the only one.
The second reason is that as the oxygen needs can vary not only depending on physical activity but also on other factors, such as an emotion, the patient's life is in a great and constant danger.
The third reason is that the disease can't get better, on the contrary can only get more serious. That is why when there is the indication of a surgical procedure on the aortic valve the patient shouldn't delay it but should accept it, as did Alberto Castagna.

Actually he has had a very successful surgical procedure, but after three weeks has been recovered urgently for a much more serious clinical condition that if not confronted surgically immediately is fatal. The rupture of the dissecting aneurysm of the aorta.

As we have already mentioned the aorta is the largest artery of the body. It seems as a large tube that towards the periphery gets thinner. The calibre, very large where it originates at the heart (left ventricle), gets thinner as it gives branches in the arteries that deliver blood to every organ of the human body, starting from the heart, the brain, the arms, internal organs as stomach and bowel and at the end it divides in two iliac arteries that deliver oxygenated blood to the organs of the abdominal and pelvic area and the inferior arts.
It is like a tube but it is not made as a tube, the structure is much more complex and this is necessary for the functions that has to achieve. 
The inner wall of a tube is made of gum while that of the arteries has three layers (these are intimal layer, medial layer and adventitial layer) everyone with a function well defined and naturally in the aorta they are thicker as they have to support a lot of overwork.
During the rupture of the dissecting aneurysm of the aorta the blood flows between the three layers and in some areas the wall can be much more thinner and because of that very vulnerable: a rupture of the wall causes a bleeding almost certainly lethal. 
Some schemes can help us understand better what happens. 

Aorta lumen where the blood flows
Intimal layer 
(endothelial)
Medial layer 
(muscular)
Adventitial layer 
(external)

Scheme of a section of the normal aorta (the proportions have NOT been respected).

In normal conditions the blood (in red) flows in a thick wall vessel made of three layers (intimal, medial and adventitial).

 
il sangue oltre che  all'interno  scorre
 nello spessore della aorta.
Intimal layer 
(endothelial)
Medial layer
(muscular)
Adventitial layer 
(external)
Scheme of a section of an aneurysm of the aorta (the proportions have NOT been respected).

The blood (in red) not only flows in the lumen of the aorta but also flows in the space between the three layers. In some areas the vessel wall is extremely thin and this can lead easily to dissection.
The aneurysm from which has suffered Mr. Castagna has started at the aortic arch (at the initial part) and has afterwards extended in several relapses to the abdominal aorta. Because of that has been necessary to substitute the aorta with an graft made of a biocompatible material. The substitution takes place by removing the section of the aorta containing the aneurysm and suturing (sewing) the graft. 

The technical difficulties depend on the fact that the most important arteries of the body originate directly from the aorta and will have to be sewn with the graft (we can say that should be created an anastomosis). Mr. Castagna has many of these. Which are the risks? Although the graft cannot be destroyed (it will survive more than the patient!), it is made of an inert material. What does it mean? It means that the graft has not the intrinsic properties of the aorta, which can respond to the infections.

A graft infection would extend easily and could be controlled with great difficulty with the antibiotics. It would probably progress to the suture with the normal part.The suture is the vulnerable part: it will for always connect the graft to the normal part and the patient's life will depend on the force of the suture. Generally, it is strong enough but an infection could damage it having as a result a great risk for the patient's life. 

 

A series of infections has complicated Mr. Castagna's postoperative course and has made obligatory for the surgeons to operate more times and give him intense antibiotic therapies. There has been many times a fear for his life but at the end Alberto Castagna has made it. The quality of his life can't be the same any more: he has to perform constantly medical controls and anyway he has to confront the eventual remaining lesions.

20/02/2001    Dott. Domenico Alfieri