RESUMO
Background: Pseudoaneurysm (PSA) of the left ventricle (LV) is a rare peri-annular complication of infective endocarditis (IE), and it is associated with high risk of free wall rupture. The diagnosis is challenging because the exact incidence and the pathogenesis are still unclear. Case summary: A 69-year-old lady underwent prosthetic mitral valve replacement for IE secondary to Staphylococcus aureus sepsis complicated by multiple embolizations. In the post-operative period, the patient developed persistent low-grade fever with negative blood culture. Transoesophageal echocardiography (TOE) revealed complete posterior valve detachment and a PSA sac arising from the antero-lateral commissure; the colour flow Doppler showed massive mitral regurgitation. Thoracic computed tomography (CT) scan confirmed the echo data and the exact localization of the cardiac rupture. The patient underwent reoperation, a pericardial patch was sutured to exclude the PSA sac, and a mechanical prosthesis valve was finally implanted. A follow-up TOE revealed the exclusion of the PSA; two leakages with mild peri-valvular mitral regurgitation were found, with no haemodynamic impact. Discussion: In our case, the patient developed a PSA of the LV as a consequence of peri-annular extension of IE on the mitral valve. Pseudoaneurysm is a potentially lethal complication, if not promptly treated. Multimodality imaging including echocardiography and CT scan is recommended, in order to plan surgery ad hoc.
RESUMO
Currently, minimally invasive cardiac surgery (MICS) has been developing and has been largely approved for mitral valve surgery. The more development of MICS, the more the entire surgical setup needs to be appropriate. We developed a homemade tool for mitral annular sizing that is simple and fits the mini surgical access. It is a plastic-based foldable paper that can be easily inserted through the minithoracotomy, using a surgical forceps.
Assuntos
Implante de Prótese de Valva Cardíaca , Anuloplastia da Valva Mitral , Insuficiência da Valva Mitral , Humanos , Insuficiência da Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/cirurgia , Anuloplastia da Valva Mitral/métodos , Valva Mitral/diagnóstico por imagem , Valva Mitral/cirurgia , Toracotomia/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Resultado do Tratamento , Implante de Prótese de Valva Cardíaca/métodosRESUMO
Nowadays, despite the rapid advancements in interventional cardiology, open surgery still deals with aortic root diseases, to assure the best "ad hoc" treatment. In case of middle-aged adult patients, the optimal operation still represents a matter of debate. A review of the last 10-year literature was conducted, focusing on patients below 65 to 70 years of age. Because of the small sample and the heterogeneity of the papers, no metanalysis was possible. Bentall-de Bono procedure, valve sparing, and Ross operations are the surgical options currently available. The main issues in the Bentall - de Bono operation are lifelong anticoagulation therapy and cavitation in case of mechanical prosthesis implantation and structural valve degeneration in case of biological Bentall. As transcatheter procedures are currently performed as valve in valve, biological prosthesis may be preferable, if the diameter may prevent postoperative high gradients. Conservative techniques, such as remodeling and reimplantation, preferred in the young, guarantee physiologic aortic root dynamics and impose surgical analysis of the aortic root structures to get a durable result. The Ross operation, which shows excellent performance, involves autologous pulmonary valve implantation and is performed only in experienced and high-volume centers. Due to its technical difficulty, it requires a steep learning curve and presents some limitations in specific aortic valve diseases. All three have advantages and downsides, and no ideal solution has still been reported.
RESUMO
BACKGROUND AND AIM OF THE STUDY: Periareolar minithoracotomy represents an interesting option in minimally invasive cardiac surgery and it is our preferred approach for women. Our aim is to assess the results in female patients, in terms of nipple postoperative pain, local sensitivity, and eventual alterations in mammography after surgery. METHODS: Fifty-seven female patients underwent periareolar incision, as minithoracotomy approach, from December 2018 to December 2021. Their mean age was 56 ± 12 years, their body mass index was 22.5 ± 4.8; their surgery was elective in 93%, with mean Euroscore II about 2 ± 1.3. RESULTS: Of 57 patients, 87.7% (50 patients) underwent mitral valve repair, whose six with associated procedures; 8.8% (five patients) underwent mitral valve replacement whose two with tricuspid annuloplasty associated and 3.5% (two patients) had isolated tricuspid surgery. The cardiopulmonary bypass and aortic cross-clamp time were 123.2 ± 30.2 and 101.3 ± min respectively. There were no conversions to either full sternotomy or larger thoracotomy approach. There were no in-hospital and follow-up deaths. No strokes or wound infections were observed. Mean follow-up was 16± 9 months. Within the investigated follow-up, 100% of the patients were satisfied with the esthetic result, no remarkable postoperative pain was reported, two patients had slight hyposensitivity in the nipple area. About 50% IThad mammography as prevention screening after surgery and no abnormalities were found. CONCLUSIONS: Periareolar minithoracotomy is a feasible surgical option in female patients, with excellent healing and cosmetic results and preserving the tissues of the mammary gland.
Assuntos
Procedimentos Cirúrgicos Cardíacos , Implante de Prótese de Valva Cardíaca , Adulto , Idoso , Procedimentos Cirúrgicos Cardíacos/métodos , Feminino , Implante de Prótese de Valva Cardíaca/métodos , Humanos , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Valva Mitral/diagnóstico por imagem , Valva Mitral/cirurgia , Dor Pós-Operatória , Estudos Retrospectivos , Toracotomia/métodos , Resultado do Tratamento , Valva Tricúspide/diagnóstico por imagem , Valva Tricúspide/cirurgiaRESUMO
AIMS: Low-gradient aortic stenosis is a challenging entity that needs accurate preoperative evaluation. For this high-risk patient population, ad hoc predictive scores are not available and profile risk is currently revealed by the EuroSCOREs. Aims of this study are to verify the suitability of the ES II as predictor of mortality in low-gradient aortic stenosis and to analyse the role of surgery as a treatment. METHODS: From June 2013 to August 2019, 414 patients underwent surgical aortic valve replacement for low-gradient aortic stenosis. Mean age was 75.78â±â6.77 years and 190 were women. The prognostic value of Logistic EuroSCORE and EuroSCORE II were compared by receiver-operating characteristics (ROC) curve analysis. RESULTS: In-hospital, 30-day and 1-year mortality rates were respectively 3.4, 2.9 and 4.8% (14, 12 and 20 patients over 414). In-hospital mortality risk calculated by the Additive EuroSCORE was 7.2â±â2.7%, by the Logistic EuroSCORE was 9â±â5.2% and by the ES II was 4.13â±â2.56%. The prognostic values of the EuroSCORE II and of the EuroSCORE were analysed in a ROC curve analysis for the prediction of in-hospital mortality [area under the curve (AUC): 0.62 vs. 0.58], 30-day mortality (AUC: 0.63 vs. 0.64) and 1-year mortality (AUC: 0.79 vs. 0.65). Both scores did not show significant differences with the only exception of 1-year mortality, for which EuroSCORE II had a better predictive ability than the Logistic EuroSCORE (Pâ<â0.05). CONCLUSION: In low-gradient aortic stenosis undergoing surgery, the EuroSCORE II is a strong predictor of 1-year mortality.
Assuntos
Estenose da Valva Aórtica , Implante de Prótese de Valva Cardíaca , Próteses Valvulares Cardíacas , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/cirurgia , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Humanos , Masculino , Medição de RiscoRESUMO
BACKGROUND: The number of elderly patients undergoing cardiac surgery is increasing. Age greater than 80âyears has been identified as a strong independent risk factor for shortand long-term survival. The current study is aimed to identify the impact of preoperative comorbidities on early and late outcomes in older patients undergoing cardiac surgery. METHODS: Baseline characteristics, procedurals and postoperative complications of all patients undergoing cardiac surgery at our institution are collected. The current analysis is focused on patients aged at least 80âyears at the time of intervention and treated from January 2010 to December 2019. RESULTS: In-hospital mortality resulted as 6.3%. Redo intervention [odds ratio (OR) 2.49, 95% confidence interval (CI) 1.13-5.48], chronic obstructive pulmonary disease (COPD) (OR 2.99, 95% CI 1.75-5.12) and peripheral arterial disease (PAD) (OR 2.23, 95% CI 1.30-3.81) were independent baseline predictors of outcome in the multivariate analysis. Prolonged extracorporeal circulation time, need for transfusion and prolonged intubation time strongly and independently predicted in-hospital mortality. During a mean follow-up of 3.6âyears 34.3% of patients died and unplanned admission (HR 1.33, 95% CI 1.05-1.67), NYHA class III-IV (HR 1.35, 95% CI 1.12-1.64), diabetes (HR 1.27, 95% CI 1.01-1.59), COPD (HR 1.60, 95% CI 1.25-2.04) and PAD (HR 1.32, 95% CI 1.03-1.71) resulted as independent predictors of all-cause death. CONCLUSION: Cardiac surgery is feasible in octogenarians, with an acceptable risk of mortality. Chronological age itself should not be the main determinant of choice while referring patients for cardiac surgical intervention. Comorbidities such as COPD, PAD and diabetes need to be taken into account for risk stratification.
Assuntos
Procedimentos Cirúrgicos Cardíacos , Doença Pulmonar Obstrutiva Crônica , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Comorbidade , Humanos , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Resultado do TratamentoRESUMO
The present case highlights the crucial role of hybrid setting for diagnosis and treatment of refractory coronary spasms.
Assuntos
Vasoespasmo Coronário , Angiografia Coronária , Vasoespasmo Coronário/diagnóstico por imagem , Vasoespasmo Coronário/terapia , Humanos , EspasmoRESUMO
Post-sternotomy surgical site infections may be serious complications responsible for increased morbidity, mortality and length of hospital stay. A variety of wound-healing strategies can be used over closed surgical incisions, including negative pressure wound therapy (NPWT). The aim of the study is to assess sternal wound complications after heart surgery using NPWT in patients at risk for surgical site complication. Considered risk factors affecting wound healing were type 2 diabetes, Body Mass Index (BMI) >30, chronic obstructive pulmonary disease (COPD), chronic renal failure (CRF) and myocardial revascularization by double mammary artery harvesting. With these premises, 90 patients were selected: 30 patients received traditional gauze dressings, 30 advanced dressings (hydrocolloid and carboxymethyl cellulose) and 30 patients NPWT. Thirty-four patients (37.7%) had two risk factors, 41 patients (45.5%) were affected by three risk factors and 15 patients (16.6%) by four risk factors. The NPWT group had lower rates of diabetes and CRF and only one patient presented four risk factors. With regard to surgical times and types of surgical procedure, no significant differences were observed within the three groups. The patients who received NPWT over closed incision experimented a significantly lower rate of deep sternal complication over traditional gauze and hydrocolloid and carboxymethyl cellulose dressings.
Assuntos
Diabetes Mellitus Tipo 2 , Tratamento de Ferimentos com Pressão Negativa , Humanos , Esternotomia/efeitos adversos , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/prevenção & controle , CicatrizaçãoRESUMO
AIM: Aortic valve replacement (AVR) using sutureless prosthesis is a reasonable alternative in those patients with aortic stenosis who would benefit from reduced cross clamp time, such as elderly and high-risk patients. Actually, excellent performances have been demonstrated in hemodynamic outcomes and safety, but some questions remain open regarding long-term durability and the need for postoperative pacemaker implantation. METHODS: Between January 2014 and August 2019, all 436 patients [male 40.6%, median age 78 years interquartile range (73-82)] treated with sutureless AVR with a Perceval prosthesis were included in our analysis. RESULTS: The univariate logistic regression showed previous aortic valve surgery [Pâ=â0.028; odds ratio (OR) 3.248], dialysis (Pâ=â0.036; OR 6.435), renal insufficiency (Pâ=â0.021; OR 2.75), EuroSCORE II (Pâ=â0.016; OR 1.051) and year of operation (Pâ<â0.01; OR 0.658) as factors associated with the development of atrioventricular type II or type III block or junctional block requiring pacemaker implantation. The overall incidence of pacemaker implantation after sutureless AVR was 7.1% in the current study, but it dropped to 3.8 and 4.7%, respectively, in 2018 and 2019. CONCLUSION: The Perceval aortic valve is associated with encouraging postoperative results. The incidence of pacemaker implantation is strictly linked to the surgeons' experience, decreasing year by year after an adequate sizing, reaching a percentage comparable with sutured valve.
Assuntos
Estenose da Valva Aórtica/cirurgia , Arritmias Cardíacas/prevenção & controle , Implante de Prótese de Valva Cardíaca/métodos , Curva de Aprendizado , Marca-Passo Artificial , Complicações Pós-Operatórias/prevenção & controle , Procedimentos Cirúrgicos sem Sutura/métodos , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/complicações , Arritmias Cardíacas/etiologia , Feminino , Humanos , Masculino , Complicações Pós-Operatórias/etiologia , Desenho de Prótese , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Single-inflow coronary bypass through left internal thoracic artery and Y graft is effective in myocardial revascularization, but left sublavian diseases may affect its safety. AIM OF THE STUDY: To assess that, in presence of a composite Y graft, issues involving the origin of the left internal thoracic artery are relatively easy to manage, even in reoperations. METHODS: A critical stenosis of the subclavian artery involving the origin of a bilateral internal thoracic artery Y graft was bypassed using a free radial artery graft. RESULTS: Bypass was performed between the left thoracic artery and the ascending aorta, off-pump and with excellent results. CONCLUSIONS: In consideration of the excellent long term results of total arterial revascularization, radial artery is a feasible graft option, even in case of a composite Y graft in place.
Assuntos
Artéria Torácica Interna , Angiografia Coronária , Ponte de Artéria Coronária , Humanos , Revascularização Miocárdica , Artéria Radial , Resultado do TratamentoRESUMO
OBJECTIVES: Our goal was to assess the safety, outcomes and complication rate of axillary artery cannulation for venoarterial extracorporeal membrane oxygenation (VA-ECMO). METHODS: A retrospective analysis was conducted on data obtained from the review of medical charts of all consecutive patients undergoing VA-ECMO implantation between January 2013 and December 2017 at a teaching hospital. Only patients with right axillary VA-ECMO implantation in a non-emergency setting were included. Post-procedural outcomes and local and systemic complications were analysed. RESULTS: One hundred and seventy-four [131 male (75.3%), 43 female (24.7%); mean age 56.8 ± 15.1 years] patients underwent femoral-axillary VA-ECMO. Indications were cardiogenic shock from any cause (n = 78, 44.8%) or post-cardiotomy syndrome (n = 96, 55.2%). Fifty-three (30.5%) patients died while on VA-ECMO support. At the time of VA-ECMO ablation, 89 (51.1%) patients had recovered; 13 (7.5%) patients were bridged to a long-term mechanical support device and 19 (10.9%) patients underwent heart transplants. Thirty-day and 1-year mortality was 36.2% (n = 63) and 49.4% (n = 86), respectively. The 1-year survival rate of patients who were weaned from VA-ECMO support was 72.7% (n = 88). The complications of axillary cannulation were bleeding (n = 7, 4%), local infection (n = 3, 1.7%), upper limb ischaemia (n = 2, 1.1%) and brachial plexus injury (n = 1, 0.6%). Left ventricle unloading was required for 9 (5.2%) patients. The median duration of VA-ECMO support was 7 (range 1-26) days. CONCLUSIONS: Right axillary artery cannulation is a safe and reliable method for VA-ECMO support with a low rate of local complications. In the absence of a control group with femoro-femoral cannulation, no definitive conclusion about the superiority of axillary over femoral cannulation can be drawn.
Assuntos
Oxigenação por Membrana Extracorpórea , Adulto , Idoso , Artéria Axilar/cirurgia , Cateterismo , Oxigenação por Membrana Extracorpórea/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Choque Cardiogênico/terapiaRESUMO
BACKGROUND: Ministernotomy and right minithoracotomy are well-known minimally invasive approaches for aortic valve replacement (AVR); however, controversial opinions exist for their utilization in obese patients. The aim of this study is to check a potential positive role of minimally invasive surgery in this population. METHODS: From January 2010 to November 2019, 613 obese patients (defined by a body mass index ≥30) underwent isolated AVR at our institution. Surgical approach included standard median sternotomy (176 patients), partial upper sternotomy (271 patients), or right anterior minithoracotomy (166 patients). Intra- and postoperative data were retrospectively collected. RESULTS: Patients treated with minimally invasive approaches had shorter cardiopulmonary bypass time (p = .012) and aortic cross-clamp time (p = .022), mainly due to the higher utilization of sutureless valve implantation. They also presented advantages in terms of reduced postoperative ventilation time (p = .010), incidence of wound infection (p = .009), need of inotropic support (p = .004), and blood transfusion (p = .001). The univariable logistic regression showed the traditional full sternotomy approach as compared with ministernotomy (p = .026), active smoking (p = .009), peripheral vascular disease (p = .003), ejection fraction (p = .026), as well Logistic European system for cardiac operative risk evaluation (EuroSCORE; p = .015) as factors associated with hospital mortality. The multivariable logistic regression adjusted for the logistic EuroSCORE revealed that surgical approaches do not influence hospital mortality. CONCLUSIONS: Obese patients with severe aortic valve pathology can be treated with minimally invasive approaches offering a less biological insult and reduced postoperative complications, but without impact on hospital mortality.
Assuntos
Valva Aórtica , Implante de Prótese de Valva Cardíaca , Valva Aórtica/cirurgia , Humanos , Procedimentos Cirúrgicos Minimamente Invasivos , Obesidade/complicações , Estudos Retrospectivos , Esternotomia , Resultado do TratamentoRESUMO
Coronary perforation is a rare complication of percutaneous coronary interventions and a challenging scenario which imposes prompt recognition and treatment. Although it may be successfully managed percutaneously, a surgical treatment may be preferable in some cases. We report the case of a patient with a coronary perforation with initial percutaneous treatment complicated with extravascular implantation of a covered stent and liver laceration, who was succesfully treated by cardiac surgery. This case suggests the importance of the proximity of an onsite cardiac surgery center when complex coronary artery percutaneous interventions are performed in hospitals with offsite surgical support.
Assuntos
Valva Aórtica/anormalidades , Valva Aórtica/cirurgia , Anuloplastia da Valva Cardíaca/educação , Cardiologia/educação , Educação de Pós-Graduação em Medicina/métodos , Doenças das Valvas Cardíacas/cirurgia , Técnicas de Sutura/educação , Aorta Torácica/cirurgia , Doença da Válvula Aórtica Bicúspide , HumanosAssuntos
Valva Aórtica/diagnóstico por imagem , Fibroma/diagnóstico , Neoplasias Cardíacas/diagnóstico por imagem , Doenças das Valvas Cardíacas/diagnóstico , Ventrículos do Coração/diagnóstico por imagem , Valva Aórtica/cirurgia , Procedimentos Cirúrgicos Cardíacos/métodos , Diagnóstico Diferencial , Ecocardiografia Transesofagiana , Doenças das Valvas Cardíacas/cirurgia , HumanosRESUMO
OBJECTIVES: Patients undergoing major surgery are at increased risk of developing infections due to resistant organisms, including carbapenem-resistant Klebsiella pneumoniae (CR-Kp). In this study, we assessed risk factors for CR-Kp infections after open heart surgery in a teaching hospital in northern Italy. METHODS: A retrospective study was conducted from January to December 2014. The primary outcome measure was postoperative CR-Kp infection, defined as a time-to-event end-point. The effect of potentially related variables was assessed by univariable and multivariable analyses. Secondary end-points were in-hospital mortality and 180-day postoperative mortality. RESULTS: Among 553 patients undergoing open heart surgery, 32 developed CR-Kp infections (6%). In the final multivariable model, CR-Kp colonization [hazard ratio (HR) 227.45, 95% confidence intervals (CI) 67.13-1225.20, P < 0.001], cardiopulmonary bypass time in minutes (HR 1.01, 95% CI 1.01-1.02, P < 0.001), chronic obstructive pulmonary disease (HR 3.99, 95% CI 1.61-9.45, P = 0.004), SOFA score (HR 1.29, 95% CI 1.08-1.53, P = 0.007), preoperative mechanical ventilation (HR 8.10, 95% CI 1.31-48.57, P = 0.026), prolonged mechanical ventilation (HR 2.48, 95% CI 1.08-6.15, P = 0.032) and female sex (HR 2.08, 95% CI 1.00-4.36, P = 0.049) were associated with the development of CR-Kp infection. Increased in-hospital mortality and 180-day mortality were observed in patients who developed CR-Kp infections in comparison with those who did not. CONCLUSIONS: In our cohort, CR-Kp colonization was an important predictor of CR-Kp infection after open heart surgery. CR-Kp infection after surgery significantly affected survival. Preventing colonization is conceivably the most effective current strategy to reduce the impact of CR-Kp.
Assuntos
Carbapenêmicos/farmacologia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Infecções por Klebsiella/epidemiologia , Klebsiella pneumoniae/isolamento & purificação , Infecção da Ferida Cirúrgica/epidemiologia , Resistência beta-Lactâmica , Idoso , Feminino , Mortalidade Hospitalar/tendências , Humanos , Itália/epidemiologia , Infecções por Klebsiella/tratamento farmacológico , Infecções por Klebsiella/microbiologia , Klebsiella pneumoniae/efeitos dos fármacos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Infecção da Ferida Cirúrgica/tratamento farmacológico , Infecção da Ferida Cirúrgica/microbiologia , Taxa de Sobrevida/tendênciasRESUMO
BACKGROUND: To evaluate the impact of patient-prosthesis mismatch (PPM) on survival, functional status, and quality of life (QoL) after aortic valve replacement (AVR) with small prosthesis size in elderly patients. METHODS: Between January 2005 and December 2013, 152 patients with pure aortic stenosis, aged at least 75 years, underwent AVR, with a 19 or 21âmm prosthetic heart valve. PPM was defined as an indexed effective orifice area less than 0.85âcm/m. Median age was 82 years (range 75-93 years). Mean follow-up was 56 months (range 1-82 months) and was 98% complete. Late survival rate, New York Heart Association functional class, and QoL (RAND SF-36) were assessed. RESULTS: Overall, PPM was found in 78 patients (53.8%). Among them, 42 patients (29%) had an indexed effective orifice area less than 0.75âcm/m and 17 less than 0.65âcm/m (11.7%). Overall survival at 5 years was 78â±â4.5% and was not influenced by PPM (Pâ=âNS). The mean New York Heart Association class for long-term survivors with PPM improved from 3.0 to 1.7 (Pâ<â0.001). QoL (physical functioning 45.18â±â11.35, energy/fatigue 49.36â±â8.64, emotional well being 58.84â±â15.44, social functioning 61.29â±â6.15) was similar to that of no-PPM patients (Pâ=âNS). CONCLUSION: PPM after AVR does not affect survival, functional status, and QoL in patients aged at least 75 years. Surgical procedures, often time-consuming, contemplated to prevent PPM, may therefore be not justified in this patient subgroup.