Skeletonized right gastroepiploic artery used for coronary artery bypass grafting.

The right gastroepiploic artery has been definitively recognized as a reliable conduit for coronary artery bypass grafting with excellent clinical results and midterm patency. Our experience with internal thoracic artery skeletonization and the similarities between the gastroepiploic and internal thoracic arteries prompted us to modify the gastroepiploic artery harvesting technique. The purpose of this report is to present the advantages of the skeletonized gastroepiploic artery graft.

Early and late risk factors in surgical treatment of acute type A aortic dissection.

BACKGROUND: Morbidity and mortality of emergency repair of type A dissecting aneurysms of the aorta are high. This is an attempt to investigate the risk determinants of early and late results. METHODS: A series of preoperative and operative variables were retrospectively collected from the clinical records of 291 patients operated on between January 1, 1979, and December 31, 1995. Risk factors for surgical death were investigated with univariate analysis and stepwise logistic regression. Follow-up was conducted between December 1995 and February 1996. Analysis of late results was conducted by means of actuarial survival curves (life method). After removing the surgical deaths, risk factors for late deaths were analyzed by a Cox model. RESULTS: The in-hospital mortality rate was 36.1%. Significant independent determinants of operative or early death were preoperative shock, preoperative neurologic impairment, operation before 1986, perioperative bleeding, and prolonged clamping time. The 10-year survival rate was 36.9% +/- 4.4%. Twenty-six patients required repeat operation. The long-term prognosis was significantly worse in patients who needed reoperation. CONCLUSIONS: Growing awareness of this disease and quicker diagnosis have increased the number of patients with acute dissection of the ascending aorta who are taken early to operation. This new challenge must be met by better preoperative support and intraoperative monitoring, and by surgical techniques that focus on lowering the rate of late complications, for which lifelong follow-up must be provided.

An unusual myxoid leiomyosarcoma of the heart.

We report a case of myxoid leiomyosarcoma originating from the interventricular septum in the outflow tract of the right ventricle. Although the gross features suggested a benign myxoma, histologic examination demonstrated features of a smooth muscle tumor, which was characterized by low mitotic index and a bland degree of atypia with few cells immunoreactive for cell cycle-associated Ki-67 antigen. The tumor relapsed twice, and the patient (a 61-year-old woman) died 18 months after the first diagnosis. This case demonstrates that myxoid leiomyomatous proliferations of the heart must be considered potentially malignant, even when the gross features and degree of cellular atypia seem to suggest otherwise.

Complicated removal of a hydatid cyst of the interventricular septum.

In a 27-year-old woman with a large hydatid cyst of the liver, an asymptomatic cardiac cyst located in the interventricular septum was discovered as well. The diagnosis was based upon echocardiography, computerized axial tomography and nuclear magnetic resonance. There was no evidence of damage to the atrioventricular conduction system or to the cardiac valves. At operation, however, the left posterior papillary muscle and chordae were firmly adherent to the cyst. Patch closure of the resulting ventricular septal defect, and mitral valve and chordae repair were necessary. The patient is alive and well 6 months after the operation, with mild residual mitral regurgitation. Precise anatomical delineation of the hydatid cyst localization within the heart, particularly in the interventricular septum, and its relations with the various cardiac structures is a difficult task, in spite of all the imaging techniques available. The surgical approach therefore has to be very careful and mindful of the potential complications.

Early and late results after surgical therapy of postinfarction left ventricular aneurysm.

From 1979 to 1993, 139 patients had reduction of left ventricular aneurysm (LVA) by plication (PL) (25 cases) linear repair (74 cases) or ventricular reconstruction (VR) (40 cases). Coronary bypass grafting was performed in 89 patients. We retrospectively reviewed our experience in order to identify predictore of early and late outcome and determine whether ventricular reconstruction (VR) can improve postoperative and late prognosis. Operative mortality (OM) was 7.2%. Among 129 hospital survivors, 48 died during FU (LM). OM was related to a more recent myocardial infarction (p=0.0001), a higher residual score (RS) (p=0.02), a lower EF (p=0.038), a higher left ventricular score (p=0.059), a three-system disease (TSD) (p=0.09) and a right coronary disease (RCD) (p=0.13). At Multivariate Analysis (Stepwise Logistic Regression) TSD (p=0.001), RCD (p=0.008) and RS (p=0.04) are independent risk factors. Actuarial survival rate at 15 years is 33.5+/-6.9% (OM included). According to the comparison of the Actuarial Curves (Tests of Mantel and Breslow, OM excluded) the most significant risk factors were: non use of left internal mammary artery (LIMA) (p=0.004), VR (p=0.01), TSD (p=0.03) and higher NYHA class (p=0.019). Multivariate Analysis (Co Model) confirms that late prognosis is influenced by non use of LIMA (p=0.03) and TSD (p=0.04); outcome is also affected by preoperative arrhythmias (p=0.022). Five-year survival after VR is 87.5+/-5.7% vs 64.9+/-5.5% after simple linear closure or PL (p=0.1075 and p=0.2252). Our results confirm that OM and LM are influenced by extent of myocardial ischemic damage; in agreement with the majority of Authors we advocate a complete revascularization using IMA, when appropriate, on left anterior descending artery. Our limited experience with VR fails to demonstrate this technique as an independent factor of late survival.

Morphological comparison of mitral and aortic bioprostheses explanted from the same patient for primary tissue failure.

Host factors might influence the fate of tissue prostheses. We have analyzed the tissue failure phenomenon in mitral and aortic porcine bioprostheses explanted from the same patient so as to avoid the bias of host factors. The 50 bioprostheses of this study were explanted from 25 patients reoperated on because of malfunctioning due to primary tissue failure. Bioprostheses explanted were photographed, radiographed and observed in polarizing light. All lesions analyzed received a score on the basis of morphological criteria. No difference was observed in the occurrence of pannus, tears or cells infiltrates. Calcifications occurred more extensively in mitral position (p=0.0031). Creep of the stent was significantly greater in mitral position (p=0.0324). Since the model of our study removed other individual factors, we may conclude that there is evidence for an earlier and more extensive calcific degeneration in the mitral than in the aortic position.

Histopathologic and clinical characterization of cardiac myxoma: review of 53 cases from a single institution.

BACKGROUND: Cardiac myxomas have varying clinical presentation, uncertain histogenesis, and debatable immunohistochemical profile. A few malignant cases have been previously reported. METHODS: Fifty-three consecutive cardiac myxomas were histologically investigated and results compared with clinical data. The main goal of the study was to investigate the immunohistochemical differentiation and the clinicopathologic correlations. RESULTS: Stromal cells were characterized by the expression of the von Willebrand factor endothelial marker (12 of 53 cases) and diffuse cytoplasmic neuropeptides such as protein gene product 9.5 (50 of 53 cases), S100 protein (47 of 53) and neuron-specific enolase (30 of 53), all of which were expressed in 30 (57%) of 53 tumors. Stromal cells did not show endocrine granules, epithelial, or smooth muscle immunoreactivity. Non-cardiac-related symptoms were observed in 7 of 53 patients and promptly disappeared after tumor excision; median values and percentages of total immunoreactivity scores for neuropeptides were higher in these 7 cases, but data analysis showed no statistical significance. Glands were detected in 2 myxomas, and they showed epithelial (cytokeratins and carcinoembryonic antigen), protein S100, and neuron-specific enolase immunoreactivity; this pattern has been previously detected in human gut. All tumors showed benign behavior, and no mitosis was detected. CONCLUSIONS: The results of this study support the hypothesis that stromal cells originate from multipotent mesenchyme capable of neural and endothelial differentiation; rare myxoma glands would represent entrapped foregut rests. A correlation could exist between neuroendocrine differentiation and non-cardiac-related symptoms.

[Conservative surgical treatment of rheumatic mitral stenosis]. / Terapia chirurgica conservativa della stenosi mitralica reumatica.

We prospectively evaluated 50 patients with mitral stenosis (43 women and 7 men; mean age 45 years) to assess the results of surgical reconstruction of the mitral valve. All patients underwent a complete echocardiographic examination before and after operation. Surgical reconstruction was extensive, and included commissurotomy, thinning of the valvular leaflets, calcification removal, splitting of subvalvular apparatus, and posterior annuloplasty. Surgical reconstruction resulted in increasing mitral functional area from 0.89 +/- 0.23 to 2.07 +/- 0.42 cm2. NYHA functional class decreased from 2.76 +/- 0.55 to 1.52 +/- 0.71. Before discharging, 10% of patients had moderate mitral insufficiency. All patients were followed at 6-month intervals in our clinic. Mean follow-up was 37 +/- 18 months. During follow-up 5 patients (10%) developed severe mitral incompetence, which required mitral valve replacement. Chi-square and Student t-test were used to analyze the correlation between variables and outcome. The occurrence of severe mitral incompetence was correlated with: the degree of enlarged left atrium; chronic atrial fibrillation; postoperative more than mild mitral regurgitation. No correlation was found with anatomical parameters detected by echocardiography, or intraoperative anatomy. In conclusion, surgical reconstruction of mitral stenosis provides satisfactory short-term results. We believe that the low mortality rate and the low incidence of complications justify an effort to save the native mitral valve before considering prosthetic replacement. More attention to the development of residual mitral incompetence with intraoperative control may improve long-term results.