Pericardial effusion mimicking left atrial thrombus after coronary bypass surgery.

This report describes a patient in whom pericardial effusion, two months after coronary bypass surgery, mimicked the presence of a left atrial mass on both echocardiography and cardiac angiography.

Taussig-Bing anomaly: total repair with closure of ventricular septal defect through the pulmonary artery.

Total surgical repair of a Taussig-Bing malformation in an 8-year-old boy was accomplished successfully after previous palliative procedures. The child had undergone a Rashkind septostomy when he was 10 days old, banding of the pulmonary artery and division of a patent ductus arteriosus when he was 2 weeks old, and a Blalock-Hanlon septectomy when he was 1 year old. Complete repair involved patching the ventricular septal defect (VSD), debanding and patching the pulmonary artery, and rerouting the venous return by performing a Mustard procedure. Because of its high location, the VSD could not be reached properly through the tricuspid valve and was approached through the pulmonary arteriotomy. Excellent exposure was obtained by retracting the pulmonary valve, and patch closure of the defect was achieved without difficulties. We believe this approach to the VSD is preferable because no incision is necessary in the right ventricle. This is important since the right ventricle becomes the systemic ventricle after the Mustard operation.

Major sternal wound infection after open-heart surgery: a multivariate analysis of risk factors in 2,579 consecutive operative procedures.

From January, 1979, to December, 1984, at the Cardiac Surgery Department of the University of Torino Medical School, major sternal wound infections developed in 48 (1.86%) of 2,579 consecutive patients. These patients underwent open-heart procedures through a midline sternotomy and survived long enough for infection to appear. Possible risk factors were evaluated by means of a multivariate analysis. For the group of patients, we considered age, sex, hospital environment (different locations of our surgical facilities over the years), interval between hospital admission and operation, antibiotic prophylaxis, type of surgical procedure, elective or emergency surgical procedure, reoperation, duration of surgical procedures, duration of cardiopulmonary bypass, amount of blood transfused, postoperative blood loss, chest reexploration, rewiring of a sterile sternal dehiscence, duration of mechanical ventilation, and days of treatment in the intensive care unit. Univariate analysis indicated that age, sex, type and mode of surgical procedure, antibiotic prophylaxis, and duration of mechanical ventilation were not significantly associated with wound infection. For all other predisposing factors, a p value of less than .05 was demonstrated. These variables were entered in a multiple stepwise logistic regression. Six emerged as significant: hospital environment (p = .0001), interval between admission and surgery (p = .041), reoperation (p less than .0001), blood transfusions (p = .031), early chest reexploration (p less than .0001), and sternal rewiring (p less than .0001). Contamination of patients may occur before, during, and after operation, and any kind of reintervention may predispose to wound infection.

Results of total correction of tetralogy of Fallot performed in adults.

Today, total correction of tetralogy of Fallot is rarely performed in adults. In a 10-year period, 40 patients aged 20 to 67 years underwent intracardiac repair in our institution. Twenty-eight of them had had a palliative procedure 11 to 30 years earlier. Preoperatively, 23 patients were in New York Heart Association (NYHA) Functional Class II, 14 were in Class III, and 3 were in Class IV. Operative mortality was 2.5% (1/40). Follow-up ranged from 1 year to 11 years (average, 3 years). One patient died of a noncardiac cause 4 years after operation. Residual cardiac defects were observed in 4 patients. Postoperatively, 30 patients were in NYHA Functional Class I, 8 were in Class II, and 1 was in Class III. Major ventricular arrhythmias were recorded in 7 (35%) of 20 patients. Radionuclide angiography demonstrated impaired right ventricular function in 8 patients. Left ventricular impairment was present in 2. Total correction of tetralogy of Fallot can be performed safely in adults with low mortality and good functional improvement. The incidence of residual cardiac defects is low. The long-term importance of impaired ventricular function and arrhythmias remains to be ascertained.

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)

Porcine cardiac bioprostheses: evaluation of long-term results in 990 patients.

Clinical results with porcine bioprostheses were reviewed for 990 patients who underwent heart valve replacement from January, 1974, to December, 1980. Eight hundred and seventy-four Hancock, 283 Carpentier-Edwards, and 10 Liotta bioprostheses were used. In 23 patients, 26 mechanical prostheses were implanted as well. Overall operative mortality was 60 out of 990 (6.06%): 30 out of 506 (5.9%) for mitral valve replacement (MVR), 13 out of 287 (4.5%) for aortic valve replacement (AVR), 1 out of 4 (25%) for tricuspid valve replacement, 0 out of 2 for pulmonary valve replacement, and 16 out of 191 (8.4%) for multiple valve replacement. Cumulative follow-up covered 1,793 patient-years. (Actuarial survival at 7 years was 76.6 +/- 3% for MVR. At 6 years, it was 83.2 +/- 2.8% for AVR and 55 +/- 13.5% for multiple valve replacement.) Prosthesis-related survival at 7 years was 91.7 +/- 1.9% for MVR, and at 6 years, it was 96.6 +/- 1.5% for AVR and 95.1 +/- 2.2% for multiple valve replacement. Bioprosthesis survival, considering deaths or complications that led to reoperation as final events, was 84.2 +/- 3.7% at 7 years for mitral valves and 87.7 +/- 3.8% at 6 years for aortic valves. Emboli per 100 patient-years numbered 3.2 for MVR, 0.5 for AVR, and 1.6 for multiple valve replacement. Twenty-seven patients underwent reoperation, 12 for perivalvular leak, 5 for endocarditis, 6 for valve thrombosis, and 4 for primary tissue failure (linearized rates of 0.7, 0.3, 0.3, and 0.2% per patient-year, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of pleurotomy on pulmonary function after coronary artery bypass grafting with internal mammary artery.

Coronary artery by-pass grafting with internal mammary artery (IMA) has become the graft conduit of choice, due to improved survival and its long term patency rate. However, some studies have shown that, in comparison with saphenous vein grafts, after IMA grafting, there is increased postoperative impairment of pulmonary function, possibly due to the frequent performance of pleurotomy. In 57 consecutive patients, admitted for elective CABG with IMA, we prospectively evaluated the early (2nd and 6th day) postoperative chest X-ray complications and the late (2 months) respiratory function tests changes. Thirty-two patients had been subjected to pleurotomy (group 1) and 25 not (group 2). The incidence of pulmonary atelectasis and pleural effusion in 2nd and in 6th postoperative days was not different in the two groups: 22 vs. 19%, 74 vs. 52% in 2nd, and 29 vs. 19%, 48 vs. 38% in 6th postoperative day respectively. The incidence of elevated hemidiaphragm in 6th postoperative day was not different in the two groups (18.5 vs. 14%). Two months after surgery the mean values of spirometric tests were significantly lower than the preoperative values: VC from 88.5 +/- 1.26 to 80 +/- 1.65% of predicted, P < 0.001, FEV1 from 96.1 +/- 1.27 to 84.7 +/- 1.73% of predicted, P < 0.001, MEF50 from 84.9 +/- 3.14 to 69.2 +/- 3.18% of predicted, P < 0.001. No significant changes were detected in RV and in AaPO2.(ABSTRACT TRUNCATED AT 250 WORDS)

Endocarditis in patients with bioprostheses: pathology and clinical correlations.

We studied 13 porcine bioprostheses removed from patients with endocarditis at our institute during the last 4.5 years. All bioprostheses had been removed at reoperation and were analyzed using anatomical and histological techniques. Each bioprosthesis was found to have developed rather constant lesions which were not related to the type of bioprosthesis. The stage of infection was not related to the duration of implantation. The presence of perivalvular abscesses was an ominous finding, often being the seat of persistent endocarditis. Our good clinical results of reoperation lead us to suggest that this be performed early once valvular or prosthetic malfunction is detected. Bioprostheses are, in our experience, the best choice in the surgical treatment of prosthetic valve endocarditis.

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.

Protection of the heart by nifedipine cardioplegia during coronary artery surgery. A clinical-haemodynamic evaluation.

This study was undertaken to evaluate the myocardial preservation obtained by adding a Ca++ channel blocker, nifedipine, to cold potassium cardioplegia (4 mcg/Kg/L) in 24 patients undergoing coronary artery surgery. They were randomly divided into a treated (N) and a control (C) group. Significant differences between the two groups were noted in the cardiac arrest time (p less than 0.001), in the mechanical recovery mode (p less than 0.01) and in the inotropic support needed (p less than 0.01). Cardiac index increased significantly in group N but decreased in group C (p less than 0.01). Peripheral delta P/delta t and endocardial viability ratio (EVR) decreased in both groups. Coronary sinus and serum CK and CK-MB release were significantly lower in the treated group. ECG ischaemic changes occurred in 8 patients in group C but only in 1 case in group N (p less than 0.001). Arrhythmias occurred in 3 cases in group C (p less than 0.05). The incidence of perioperative myocardial infarction was not significant (2 cases in group C). These data suggest that nifedipine can protect the myocardial cell from ischaemic injury without depressing myocardial contractility or AV conduction.

Williams-Beuren syndrome. Long-term results of surgical treatments in six patients.

To settle long-term outcome after surgery for supravalvular aortic stenosis in the Williams-Beuren syndrome, we reviewed the records of 6 patients who had repair of the localized form (n = 5) or diffuse form (n = 1) at our Institution from 1965 to 1971. Four patients were females and 2 males, ages at operation ranged from 9 to 16 years (mean = 13 +/- 2.37 years). In all the patients was present the typical elfin facies with mental retardation and reduced I.Q. Preoperative omeral pressure was different between left and right arm (89 +/- 7/67 +/- 8 vs 105 +/- 8/77 +/- 4). Chest X-ray showed and enlargement of the cardia silhouette in all the patients. Cardiac catheterization, performed in all the patients, allowed diagnosis of supravalvular aortic stenosis and, in one case of subaortic stenosis associated. Intraoperatively a coronary tree enlargement was found in all cases with particular involvement of the right coronary in two patients. The mean diameter of the ascending aorta was 5.67 +/- 1.97 mm but the smallest (3 mm) was in the diffuse group. In group with localized stenosis the aortic root was enlarged with a teardrop patch in Dacron (n = 4) or a simple transverse suture after a longitudinal incision (n = 1). A pantaloon-shaped patch was necessary in the diffuse form case. There were no operative deaths and all the patients were discharged from the hospital after 2 weeks. A clinical follow-up was possible in all the patients (10%) extended from 25 to 30 years (mean = 27.7 +/- 2.19 years); there were no late deaths and at presents time the mean age of the patient is 40 +/- 3 years. All patients were in functional class I or II. There was no significant difference between patients with a teardrop-shaped or pantaloon-shaped patch in terms of late gradient, survival, or aortic insufficiency studied by Echocardiography and color-Doppler. Of six patients two are living with parents or relatives but four are in a farm-college for disable people working and having some responsibility. We conclude that surgery for the correction of supravalvular aortic stenosis in Williams-Beuren syndrome is mandatory and both the procedures with patch techniques provide excellent long-term results of gradients and aortic valve competence. Moreover the patients after the operation can have a normal activity with a satisfactory style and expectation of life.

Traumatic rupture of the thoracic aorta. (Report of two unusual cases).

Two unusual cases of traumatic aneurysm of the aorta are described. Both presented several days after thoracic trauma sustained in a car accident. The presenting features were progressing dysphagia and displacement of the oesophagus in the first case and a coarctation-like syndrome in the second. Diagnosis was confirmed in each case by aortography and emergency resection of the aneurysm with a dacron prosthesis was carried out. Aortic rupture should be considered in all cases of thoracic trauma, especially when severe, even several days after the trauma itself. Patients should be evaluated with serial chest roentgenograms and an aortography should be performed in any suspicious case. Treatment is surgical and the operative mortality and morbidity is acceptably low.

Coronary artery bypass grafting for unstable angina. Risk factors of operative mortality.

In order to identify factors affecting early mortality in patients undergoing CABG for unstable angina, several risk factors have been analysed in a group of 120 patients. Systemic hypertension and left ventricular impairment were shown to be significant risk factors (Systemic hypertension, P less than 0.01; EF less than or equal to 0.35, P less than 0.01; LVEDP greater than or equal to 20 mmHg, P less than 0.025). Overall mortality rate was 5% (6/120). No influence could be recognized for age, sex, previous MI, emergency surgery, extension of coronary disease, completeness of revascularization and mode of onset of symptoms.

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.

The De Vega tricuspid annuloplasty. Perioperative mortality and long term follow-up.

One hundred and fifty-three patients undergoing De Vega tricuspid annuloplasty, with or without other associated cardiac procedures between January, 1979, and June, 1987, were evaluated. There were 136 hospital survivors. The follow-up was 98.1% complete for a mean of 3.7 years/patient. Operative mortality was 11.1%; preoperative NYHA class and length of CPB were significant risk factors of perioperative mortality. The actuarial survival of operative survivors at 9 years was 73.5 +/- 11.8%. There were 7 late cardiac deaths among a total of 12 late deaths. Eleven patients required reoperation (2.1 +/- 0.6% patient-year). In seven patients it was necessary for recurrence of tricuspid regurgitation; six of these had also a mitral prosthesis malfunction or a periprosthetic leak. Residual tricuspid regurgitation was judged as mild, moderate or severe in 29.9%, 11.9% and 4.3% of the patients respectively. De Vega tricuspid annuloplasty is the method of choice for mild and moderate tricuspid insufficiency; in selected cases, with a more severe degree of regurgitation, better results could be achieved with a different surgical approach.

Aortocoronary bypass results: a discriminant multivariate analysis of risk factors of operative mortality.

Clinical results of coronary artery bypass surgery have been evaluated analyzing operative mortality and its related risk factors. Four hundred and thirty seven consecutive patients undergoing coronary artery bypass surgery between January 1979, and December 1983, form the clinical material of this study. The gender of patients was male in 89% of the cases, the age ranged from 34 to 78 years with a mean of 54.8 +/- 8.2 (SD); patients with combined surgical procedures were excluded. The operative mortality was 5.49% (24 patients); no significant difference was found between years of the observation period. Death was due to cardiac causes in 75% of cases. Statistical analysis carried on 14 clinical, angiographic and surgical variables identified as significant risk factors of operative mortality age (p = 0.002) and cross-clamp time (p = 0.016). Both of these increased their weight when entered in a stepwise logistic regression. The EF also showed a value close to statistical significance (p = 0.06).

Successful treatment of acute postoperative right heart failure with low-dose prostaglandin e(1) and assisted circulation.

Immediately after undergoing emergency mitral valve replacement, a 60-year-old woman suffered acute postoperative right heart failure and could not be weaned from cardiopulmonary bypass, despite treatment with multiple drugs. Circulatory assistance was instituted by means of femoro-femoral bypass with a roller pump and a hollow-fiber oxygenator; inotropic drugs and drugs aimed at reducing pulmonary vascular resistance (nitroprusside, moxaverine, and isoproterenol) were also given. The patient's systolic pulmonary pressure underwent a progressive decrease, but her systolic systemic pressure remained below 60 mmHg until 8.5 hours after aortic clamp release, when we were able to begin an infusion of prostaglandin E(1), a drug not readily available in our hospital. Fifteen minutes after the infusion was started, at 5 ng/kg/min, the patient's systolic systemic pressure reached 85 mmHg and her systolic pulmonary pressure decreased to 55 mmHg. During the next 2 hours, epinephrine treatment was discontinued, and the assisted circulatory flow was reduced to 0.5 L/min/m(2), while the PGE(1) infusion was increased to 10 ng/kg/min. Assisted circulation was soon discontinued, and the patient's hemodynamic condition remained stable.

Ascending aortic aneurysms: composite conduit replacement.

From July 1980 to February 1984, 26 patients underwent composite replacement of ascending aortic aneurysm and aortic valve with coronary reimplantation. This group included 14 patients with dissecting aneurysm (ten and four respectively, belonging to Types I and II), and 12 patients with chronic aneurysm (six atherosclerotic aneurysms, two Marfan's syndrome and four annuloaortic ectasia cases). Hospital mortality was 35.7% (5/14) in the dissection subgroups and 16.6% (2/12) in the chronic aneurysm subgroup (difference NS). No operative risk factor was recognized. The 19 survivors have been followed up for a total of 393 patient-months (range 5 to 49 months). Controls included echocardiography and computed tomography scanning. Two patients died because of rupture of a persistently dissected aorta; another patient died of an unknown cause. Total actuarial survival rate at 4 years was 58.3 +/- 10.4% (83.3 +/- 10.7% for chronic aneurysms and 42.3 +/- 13.4% for dissecting aneurysms). Among late survivors, there were no paravalvular leaks, new dissections, or thromboembolisms, although two perigraft hematomas and a persistent dissection were later disclosed. When appropriate, composite conduit replacement of the ascending aorta can increase the survival rate, and can also be useful in high-risk patients.

Diltiazem cold cardioplegia in coronary artery surgery: effects on myocardial function and ischemia.

This study was undertaken to evaluate the myocardial preservation obtained by adding a calcium channel blocker, diltiazem (200 mcg/kg of body weight) to cold potassium cardioplegia in 24 patients with coronary artery disease who underwent myocardial revascularization, and were randomly divided into a treated Group D and a Control Group C. No significant differences were noted between the groups in cardiac electrical arrest and recovery time, recovery rhythm, mechanical function recovery, inotropic support, stroke index, or cardiac index. After cardiopulmonary bypass, the stroke index decreased by 13.1% in Group D and by 20.7% in Group C; cardiac index increased in both--18.6% and 14.0%, respectively--but the results were possibly from compensatory heart rate increases. Peripheral deltaP/deltat and endocardial viability ratios decreased in both groups. Coronary sinus enzymes and serum CK were slightly lower in the treated group. Serum CK-MB, however, was significantly higher in the Control Group. Electrocardiographic ischemic changes occurred in four patients, all in Group C (p =.046). Hyperkinetic arrhythmias occurred in five of the controls, but in none of the treated patients (p =.018). One perioperative myocardial infarction was diagnosed in the Control Group. These data suggest that diltiazem has no negative side effects on hemodynamics or cardiac rhythm and does not reduce impairment of myocardial function due to ischemia, but it does decrease the incidence of ischemic lesions in patients undergoing coronary artery bypass procedures.

[Classification of congenital aortic stenosis]. / Classificazione delle stenosi aortiche congenite

Recent epidemiological data relating congenital stenosis of the aorta are cited. An anatomical criterion is used in the formation of three classification groups, each containing a number of different types. There are no clear-cut clinical pictures corresponding to these anatomical varieties, however, so that differential diagnosis is dependent on the haemodynamic and contrastographic data. There are, on the other hand, clinical signs that serve as pointers to the site of the stenosis.