The Actis-gouge: a simple cutting tool for proper muscular resection in hypertrophic cardiomyopathy.

BACKGROUND: Surgical treatment of hypertrophic cardiomyopathy (HC) may be challenging for the risk of surgical complications or insufficient resection. We present our cutting tool to perform proper muscular resection in HC. MATERIAL AND METHODS: Ten patients (5 males, mean age 43,1 +/- 19,6 years, range 9-70 years) were operated on for HC using this semicircular cutting device. Combined procedures were : mitral valve repair (n = 1), mitral valve replacement (n = 2), right ventricular myectomy (n = 1), aortic valve replacement (n = 1), mitral and aortic replacement (n = 1). RESULTS: There was one early death. All the surviving patients are alive over a variable follow up from 2 to 8 years, with consistent reduction of symptoms: in fact, no patient had residual angina with significant reduction of the NYHA class from 3,2 +/- 0,6 to 1,3 +/- 0,5 postoperatively (p < 0,05). Muscular resection was effective with significant reduction of sub-valvular gradient from 84.5 + 33,4 mmHg to 14,1 +/- 17,6 mmHg (p < 0,05) without complications such as complete atrio-ventricular block or ventricular septal defects. CONCLUSION: Our semicircular myotome is an effective tool to perform a safe myectomy and it avoids surgical complications such as atrio-ventricular blocks or sub-valvular injuries. Our experience suggests that this cutting tool offers a reproducible method for muscular resection and it shows appreciable effects in the reduction of sub-valvular gradient with promising results in terms of morbidity and mortality.

Transmyocardial laser revascularization. Personal experience.

BACKGROUND: Indirect revascularization is a therapeutic approach in case of severe angina not suitable for percutaneous or surgical revascularization. Transmyocardial revascularization (TMR) is one of the techniques used for indirect revascularization and it allows to create transmyocardial channels by a laser energy bundle delivered on left ventricular epicardial surface. Benefits of the procedure are related mainly to the angiogenesis caused by inflammation and secondly to the destruction of the nervous fibers of the heart. PATIENTS AND METHOD: From September 1996 up to July 1997, 14 patients (9 males - 66.7%, mean age 64.8±7.9 years) underwent TMR. All patients referred angina at rest; Canadian Angina Class was IV in 7 patients (58.3%), III in 5 (41.7%). Before the enrollment, coronarography was routinely performed to find out the feasibility of Coronary Artery Bypass Graft (CABG): 13 patients (91,6%) had coronary arteries lesions not suitable for direct revascularization; this condition was limited only to postero-lateral area in one patient submitted to combined TMR + CABG procedures. RESULTS: Mean discharge time was 3,2±1,3 days after surgery. All patients were discharged in good clinical conditions. Perfusion thallium scintigraphy was performed in 7 patients at a mean follow-up of 4±2 months, showing in all but one an improvement of perfusion defects. Moreover an exercise treadmill improvement was observed in the same patients and all of them are in good clinical conditions, with significantly reduced use of active drugs. CONCLUSION; Our experience confirms that TMR is a safe and feasible procedure and it offers a therapeutic solution in case of untreatable angina. Moreover, it could be a hybrid approach for patients undergoing CABGs in case of absence of vessels suitable for surgical approach in limited areas of the heart.

Risk of recurrence after reoperation for prosthetic valve endocarditis.

Reoperation after a surgical procedure for prosthetic valve endocarditis (PVE) is often required due to the existence of either septic recurrence or sterile para-prosthetic leak (PL). The aim of this study was to assess the risk to patients of undergoing a second operation after PVE. Thirty-six patients underwent operation for active PVE at our institution. The operative mortality rate was 11.2%. Among the 32 patients discharged, six underwent a second operation (in two cases due to persisting sepsis) and two underwent a third procedure. Multivariate analysis demonstrated increased probability of further operation for: inability to identify the infecting organism (p = 0.005); drug addiction (p = 0.007); existence of annular abscess (p = 0.016); and early occurrence of PVE (p = 0.018). In the case of mechanical prostheses, PVE was not an independent risk factor (p = 0.206). Nonetheless, 58.3% of patients with mechanical prostheses compared with 5.3% of those with bioprostheses showed annular abscesses, while 41.7% of the former versus 5.6% of the latter suffered one or more recurrences.

Ventricular septal rupture after a myocardial infarction: clinical features and long term survival.

BACKGROUND: Ventricular septal defect (VSD) represents a serious complication after acute myocardial infarction (AMI) with an incidence of 1-2%. Surgical treatment is often mandatory in the early period after AMI because of the worsening of the hemodynamic and clinical conditions. METHODS: We reviewed 34 patients complicating AMI who underwent surgical treatment at our Institution from January 1988 to December 1994 (23 males, 11 females, mean age 64.2+/-7.96, range 45-78). The localization of the AMI was anterior in 47.05% but inferior in 52.95% of the patients (p=NS). The mean time between AMI and VSD was 5.24+/-9.31 days. The preoperative NYHA functional class was III-IV in 93% of the patients. QP/QS ratio was 2.7+/-0.65 and the diameter of VSD ranged from 1 to 8 (mean 2.5+/-0.35). In 26 patients (76.4%) an intraortic balloon pump (IABP) was inserted before surgery. Surgical treatment was done after 10+/-17.7 days after VSD appearance through a left ventriculotomy. Ten patients received a concomitant myocardial revascularization. RESULTS: Overall surgical mortality was significantly higher (p<0.05) in patients operated on in the early period after AMI (1+/-1.4 days) and with VSD complicating an inferior AMI. A complete follow-up was possible in all the survivors with a cumulative FU of 1453 month/patients. Two patients received a redo procedure after 30 and 40 days after the first correction because of a residual shunt. We observed 3 late deaths for re-AMI and one for complications after bronchial pneumonia. The actuarial survival rate is 70% at 1 year, 68% at 2 years and 65% at 7 years. NYHA functional class after operation is 1-11 in 91% of the patients. CONCLUSIONS: The major determinant of hospital survival in VSD after AMI in our patient population was the anatomical localization and the early timing of the operation. We believe that a prompt diagnosis and immediate cardiac support (IABP or ventricular assist device) is recommended to obtain a hemodynamic stabilization and to achieve the shaping of stronger cicatricial tissue before surgery. Nevertheless surgical repair of VSD is mandatory when clinical and hemodynamic condition becomes unacceptable. The results in the long term assessment are very satisfying.

[Is coronary angioplasty less costly than aortocoronary bypass?]. / L'angioplastica coronarica è meno costosa del bypass aortocoronarico?

We retrospectively compared the cost-benefit ratio of coronary bypass grafting (CABG) and percutaneous coronary angioplasty (PTCA). Data were obtained on 40 CABG's and 40 PTCA's patients treated from 15/2/86 to 15/9/86. All patients had at last 1-year follow-up. PTCA and CABG groups had similar baseline clinical and angiographic criteria. We analyzed the following cost components: real estate, biomedical products, drugs, hospital charges, medical fees, cardiac and non-cardiac tests. Total cost of CABG exceeds that of PTCA by a factor of 1.64: 15,095,000 vs 9,201,346 Italian liras (ILit). Taking into account early and late medical and surgical complications, the factor decreases to 1.39: 15,746,500 vs 11,323,000 ILit. After 1 year of follow-up the factor decreases to 1.18: 16,613,500 vs 14,027,500 ILit. Our data show that the initial savings were reduced when complications and follow-up are considered, but PTCA's patients had shorter hospitalization, earlier return to work, lower psychosocial stress.

Reoperations on heart valve prostheses: an analysis of operative risks and late results.

To evaluate risks and complications of reoperations on heart valve prostheses, we reviewed data on 183 patients who underwent reoperation because of prosthetic valve malfunction. The incremental effect of the redo procedure on hospital mortality and morbidity was studied by comparing primary and reoperative procedures and analyzing a series of possible predisposing factors. Late survival after first and second reoperations was computed, and possible determinants of late mortality were examined. Overall operative mortality was 8.7%; emergency operation (p = 0.0001), previous thromboembolism (p = 0.05), and advanced New York Heart Association functional class (p = 0.031) were the independent determinants. In a series of 1,355 patients having primary or secondary isolated valve replacement, the redo procedure was a significant risk factor in the univariate analysis (p = 0.025) but not in the multivariate analysis except for the subset of patients having mitral valve replacement (p = 0.052). The postoperative course was quite complicated, as evidenced by the long mean stay in the intensive care unit (mean stay, 3.8 days; longer than 2 days for 26% of the survivors). Nevertheless, postoperative complications were not significantly greater after a redo procedure than after a primary operation. Actuarial survival at 7 years was 57.3% +/- 8%. A comparison with a nonhomogeneous series from our institution did not demonstrate significant differences. In the subset of 16 patients having a second reoperation, late survival was 37.8% +/- 16% at 2 years. Advanced New York Heart Association class (p = 0.0001), double prosthetic valve dysfunction (p = 0.003), and any indication other than primary tissue failure (p = 0.06) were determinants of late mortality.(ABSTRACT TRUNCATED AT 250 WORDS)

Morphological comparison of primary tissue failure (PTF) in porcine mitral and aortic bioprostheses in the same patient.

Clinical and pathological studies have not clearly demonstrated whether primary tissue failure (PTF) in porcine bioprostheses occurs more often in the mitral than in the aortic position. We have studied morphological alterations in both positions in the same individual in 15 patients (14 mitroaortic and 1 mitroaortotricuspid) reoperated upon for PTF. Bioprostheses explanted were photographed, radiographed and observed in transmitted polarizing light. All lesions received a score on the basis of morphological criteria. The creep of the stent was measured. Calcification was slightly heavier and the degree of creep was significantly greater in the mitral position. Tears, infiltration and pannus growth did not differ between the two positions. According to our study, there is no conclusive demonstration that bioprostheses degenerate earlier and more extensively in the mitral than in the aortic position.

[Clinical results and modification of left ventricular function after emergency revascularization for acute myocardial infarction]. / Risultati clinici e modificazioni della funzione ventricolare sinistra dopo rivascolarizzazione d'emergenza per infarto miocardico acuto.

Results of emergency revascularization for evolving myocardial infarction have been evaluated in 43 consecutive patients operated between January 1985 and March 1988. Time interval between onset of symptoms and coronary bypass averaged 6.7 +/- 0.5 hours (0.75-48). Intravenous or intracoronary thrombolysis was attempted pre-operatively in 26 cases. Overall hospital mortality was 6.9% (3/43) but this decreased to only 2.7% if patients in cardiogenic shock were excluded. Follow-up averaged 20.6 +/- 9.5 months (4-42). Actuarial survival was 82.9 +/- 7.3% at 36 months. Of the 36 survivors, 28 were free from angina and reinfarction at control. Nineteen patients were evaluated with angiography at follow-up (averaging 10.1 +/- 5.7 months). Left ventricular and regional ejection fraction were calculated on pre- and post-operative angiograms; regional ejection fraction was determined with the centerline method. Left ventricular ejection fraction increased from 0.49 +/- 0.15 to 0.52 +/- 0.19 (NS), regional ejection fraction improved from 0.20 +/- 0.1 to 0.27 +/- 0.16 (35% increment, p less than 0.05). The analysis of left ventricular and regional ejection fraction variations with the time elapsed from the onset of symptoms to surgery identified two subgroups of patients: those operated within and after six hours. In the first subgroup, left ventricular ejection fraction increased from 0.52 +/- 0.16 to 0.62 +/- 0.13 (p less than 0.005) and regional ejection fraction from 0.19 +/- 0.08 to 0.36 +/- 0.14 (89% increment, p less than 0.0005). In the second subgroup, both left ventricular and regional ejection fractions decreased from 0.44 +/- 0.13 to 0.36 +/- 0.11 (NS) and from 0.20 +/- 0.13 to 0.12 +/- 0.08 (NS), respectively. These results lead to the conclusion that improved left ventricular performance may be achieved in selected groups of patients if they undergo surgery within six hours of the onset of pain.