Cavoatrial tumor thrombus: single-stage surgical approach with profound hypothermia and circulatory arrest, including a review of the literature.

BACKGROUND: In recent years, heart surgery has been used more frequently to treat diseases that are not primarily of cardiac origin. This is the case for intracardiac extension of infradiaphragmatic tumors, such as renal cell carcinoma, Wilms tumor, uterine tumors, and adrenal tumors, which require radical surgery associated with cavoatrial thrombectomy. METHODS: From April 1987 to April 2001, 13 patients with an infradiaphragmatic tumor with thrombosis of the vena cava, the right atrium, or both underwent surgical resection with cardiopulmonary bypass, arrested circulation, and profound hypothermia. RESULTS: The in-hospital mortality was 0%. The postoperative complications were respiratory failure (1 patient) and a redo operation for bleeding (1 patient). After a mean follow-up time of 33.9 months, 8 (61.5%) patients were alive. CONCLUSIONS: The use of extracorporeal circulation and deep circulatory arrest provide an optimal technique for removing the tumor thrombus in a bloodless field, even in the presence of metastatic disease, and has good early and long-term results.

Bypass grafting with coronary endarterectomy: immediate and long-term results.

BACKGROUND: Increased morbidity and mortality have been associated with coronary artery bypass grafting when an adjunctive coronary endarterectomy is performed. In this study we retrospectively reviewed our experience with coronary bypass and endarterectomy to evaluate the early and late outcome and to determine the independent predictors of early mortality and morbidity of this procedure. METHODS: Between May 1989 and December 2000, 107 patients underwent myocardial revascularization with coronary endarterectomy to achieve a complete revascularization. There were 90 men and 17 women; the mean age was 64 +/- 8.1 years. Sixty-three (58.9%) patients had a previous myocardial infarction, and 29 (27.1%) were operated on on an emergency basis. An ejection fraction of less than 30% was present in 9 (8.4%) patients. The most frequently endarterectomized vessel was the left coronary artery (74.8%). Follow-up information was obtained from 97 patients (100% of the long-term survivors). RESULTS: There were 5 (4.7%) early deaths. The 72-month survival was 91.2% +/- 4.9%. Seventy-seven (83.7%) of the survivors were symptom free, and 15 (16.3%) were in Canadian Cardiovascular Society class II to III. An improvement of the ejection fraction after the operation was shown in the 97 patients who underwent echocardiographic control (P =.03) and angiography. The 30.4-month patency rate of the endarteriectomized coronary arteries was 72% +/- 11%. CONCLUSION: Coronary endarterectomy is a safe and effective procedure for achieving a complete revascularization in patients with end-stage coronary disease.

Antegrade selective cerebral perfusion during operations on the thoracic aorta: factors influencing survival and neurologic outcome in 413 patients.

OBJECTIVE: We retrospectively analyzed hospital mortality and neurologic outcome after operations on the thoracic aorta with the aid of antegrade selective cerebral perfusion to determine a predictive risk model. METHODS: Between October 1995 and May 2001, 413 patients (mean age, 63.0 +/- 11.5 years) underwent operations on the thoracic aorta with antegrade selective cerebral perfusion. Indications for surgical intervention were acute type A dissection in 116 (28.1%) patients, degenerative aneurysm in 227 (55.0%) patients, and postdissection aneurysm in 70 (16.9%) patients. One hundred twenty-five (30.3%) patients were operated on urgently; concomitant procedures were performed in 171 (41.4%) patients. Mean cerebral perfusion time was 63.0 +/- 38.7 minutes (range, 16-220 minutes). Preoperative and intraoperative factors were evaluated by means of univariate and multivariate analysis to identify predictors of hospital mortality and neurologic outcome. RESULTS: The hospital mortality was 9.4%. Stepwise logistic regression revealed urgency status (P =.000; odds ratio, 19.9) and recent history of a recent central neurologic event (P =.004; odds ratio, 8.0) to be independent determinants for hospital mortality. Temporary neurologic dysfunction occurred in 20 (5.1%) patients. Urgency status (P =.005; odds ratio, 7.5), history of a central neurologic event (P =.003; odds ratio, 8.6), and coronary artery bypass grafting (P =.019; odds ratio, 6.0) were independent determinants of temporary neurologic dysfunction. Urgency status (P =.003; odds ratio, 8.6) was the only independent determinant for permanent neurologic dysfunction, and it occurred in 15 (3.7%) patients. CONCLUSION: Antegrade selective cerebral perfusion is an effective method of brain protection. Cerebral perfusion times of longer than 90 minutes were not associated with an increased risk of hospital mortality or poorer neurologic outcome. Urgency status and recent history of central neurologic events were retained as important risk factors for hospital mortality and neurologic outcome.

Repair of a complex aortic arch anomaly associated with cutaneous hemangioma.

Aortic coarctation and cutaneous hemangioma is a rare association. We describe the case of a neonate with abnormal looping of the aortic arch associated with hemangioma of the head and neck who underwent complex surgical repair without cardiopulmonary bypass.

Aortic root replacement with composite valve graft.

BACKGROUND: Composite valve graft replacement is currently the treatment of choice for a wide variety of lesions of the aortic root and the ascending aorta. In this study we report our experience with aortic root replacement using a composite graft. METHODS: Between October 1978 and May 2001, 274 patients (79.6% male and 20.4% female) with a mean age of 53.5 years underwent composite graft replacement of the aortic root. One hundred sixty-one patients (70.8%) had annuloaortic ectasia and 46 (16.8%) aortic dissection. The classic Bentall technique was used in 94 patients (34.3%), the "button technique" in 172 patients (62.8%), and the Cabrol technique in 8 patients (2.9%). RESULTS: The early mortality rate was 6.9% (19 of 274 patients). Cardiopulmonary bypass time longer than 180 minutes and associated coronary artery bypass grafting were found to be independent risk factors of early mortality. The actuarial survival rate was 77.7% at 5 years and 63% at 10 years. The independent risk factors for late mortality were coronary artery disease, chronic renal failure, and postoperative dialysis. The actuarial freedom from reoperation on the remaining aorta was higher among patients without Marfan syndrome (94.6% versus 79.6% at 10 years, p = 0.008). CONCLUSIONS: Composite valve graft replacement can be performed with low hospital mortality and morbidity. The button technique offers some advantages and should be used whenever possible. In case of acute aortic dissection root replacement is usually not necessary. Marfan patients should be treated with early root replacement before dissection occurs.

Surgery for acute type A dissection using antegrade selective cerebral perfusion: experience with 122 patients.

BACKGROUND: Antegrade selective cerebral perfusion (ASCP) has proved to be a reliable method of brain protection during surgery of the thoracic aorta, but its use during aortic dissection surgery still remains controversial. In this study, we present our results after the operative repair of acute type A aortic dissections using ASCP and moderate hypothermic circulatory arrest. METHODS: Between October 1995 and August 2001, 122 patients (76 men, 46 women) underwent repair of acute type A aortic dissection with the aid of ASCP and open distal anastomosis. The average age of the patients was 61 +/- 12 (mean +/- standard deviation). Preoperative complications included cardiac tamponade (n = 34; 27.0%), aortic regurgitation (n = 27; 22.1%), and new neurological deficits (n = 11; 9%). RESULTS: Stepwise logistic regression revealed preoperative cardiac tamponade (p = 0.018) and new neurological deficits (p = 0.017) to be independent determinants for hospital mortality (19.7%). Permanent neurological complications occurred in 7% of the patients. Independent risk factors for temporary neurological dysfunction (11.2%) included cardiac tamponade (p = 0.019) and preoperative neurological deficits (p = 0.000). CONCLUSIONS: In our experience, the surgical treatment of acute type A aortic dissection with the aid of ASCP was associated with acceptable hospital mortality and neurologic morbidity rates.

Brain protection using antegrade selective cerebral perfusion: a multicenter study.

BACKGROUND: To evaluate the results of antegrade selective cerebral perfusion as a method of brain protection during surgery of the thoracic aorta and to determine predictors of hospital mortality and adverse neurologic outcome. METHODS: Between October 1995 and March 2002, 588 patients underwent aortic surgery with the aid of antegrade selective cerebral perfusion. There were 334 men (56.8%); the mean age was 63.7 +/- 11.8 years. One hundred sixty-two patients (27.6%) underwent urgent operation. The separated graft technique was employed to reimplant the arch vessels in 230 patients (65.3%) of the 352 requiring aortic arch replacement. Associated procedures were performed in 254 patients (43.2%). One hundred twelve patients underwent elephant trunk procedure. The mean cerebral perfusion time was 67 +/- 37 minutes. RESULTS: The overall hospital mortality rate was 8.7%. A logistic regression analysis revealed urgent operation, recent central neurologic event, tamponade, unplanned coronary artery revascularization and pump time to be independent predictors of hospital mortality (p < 0.05). The permanent neurologic dysfunction rate was 3.8%. A logistic regression analysis showed tamponade to be independent predictor of permanent neurologic dysfunction (p < 0.05). The transient neurologic dysfunction rate was 5.6%. Recent central neurologic event, tamponade, coronary disease, and aortic valve replacement were indicated as independent predictors of transient neurologic dysfunction by logistic regression (p < 0.05). CONCLUSIONS: In our experience the utilization of antegrade selective cerebral perfusion resulted in encouraging results in terms of hospital mortality and brain complications. Neither the extent of the replacement nor the duration of the cerebral perfusion had an impact on hospital mortality and neurologic outcome.

Separate grafts or en bloc anastomosis for arch vessels reimplantation to the aortic arch.

BACKGROUND: This study compares the results of the separated graft technique and the en bloc technique as a method of arch vessels reimplantation during surgery of the aortic arch and determines the predictive risk factors associated with hospital mortality and adverse neurologic outcome during aortic arch repair. METHODS: Between October 1995 and March 2002, 352 patients (mean age 64.9 +/- 11.3 years; urgent status: 49/352 [13.9%]) underwent surgery of the aortic arch using the separated graft technique (group A: n = 230 [65.3%]) and the en bloc technique (group B: n = 122 [34.7%]) to reimplant the arch vessels. An aortic arch replacement was performed in 32 patients (9.1%), an ascending aorta and arch replacement in 222 patients (53.1%), an aortic arch and descending aorta replacement in 16 patients (4.5%), and a complete replacement of the thoracic aorta in 82 patients (23.3%). Brain protection was achieved by means of antegrade selective cerebral perfusion in all patients. The mean cardiopulmonary bypass time was 204.8 +/- 61.9 minutes (group A: 199.7 +/- 57.0 minutes; group B: 214.5 +/- 69.4 minutes; p = 0.033), the mean myocardial ischemic time was 121.5 +/- 43.2 minutes (group A: 116.7 +/- 38.9 minutes; group B: 130.80 +/- 49.4 minutes; p = 0.003), and the mean antegrade selective cerebral perfusion time was 84.5 +/- 36.4 (group A: separated graft technique 91.3 +/- 36.3 minutes; group B: 70.6 +/- 32.7 minutes; p = 0.000). RESULTS: Overall hospital mortality was 6.8% (group A: 6.5%; group B: 7.4%; p = not significant [NS]). The permanent neurologic dysfunction rate was 3.5% (group A: 4.0%; group B: 2.5%; p = NS). The transient neurologic dysfunction rate was 5.4% (group A: 5.5%; group B: 5.2%, p = NS). Postoperative systemic morbidity was similar in the two groups. A logistic regression analysis revealed preoperative cardiac tamponade (p = 0.011; odds ratio [OR] = 5.9) and cardiopulmonary bypass time (p = 0.010; OR = 1.01/min) to be independent predictors of hospital mortality. None of the analyzed preoperative variables were associated with an increased risk of permanent neurologic dysfunction. Age more than 70 years old (p = 0.029, OR = 5.7), myocardial revascularization (p = 0.001, OR = 2.9), and pump time (p = 0.013, OR = 1.01/min) were indicated as independent predictors of transient neurologic dysfunction by logistic regression. CONCLUSIONS: Antegrade selective cerebral perfusion was confirmed to be a safe method of cerebral protection allowing complex aortic arch operations to be performed with acceptable results in terms of hospital mortality and neurologic outcome. The separated graft technique had no adverse impact on hospital mortality and morbidity.

Operations on the thoracic aorta and antegrade selective cerebral perfusion: our experience with 462 patients.

BACKGROUND: We retrospectively analyzed the hospital mortality and neurologic outcome after surgery on the thoracic aorta with the aid of antegrade selective cerebral perfusion to determine a predictive risk model. METHODS: Between October 1995 and May 2002, 462 patients (mean age 62.7 +/- 11.7 years) underwent surgery on the thoracic aorta using antegrade selective cerebral perfusion. The indication for surgery was acute type A dissection in 132 patients (28.6%), degenerative aneurysm in 258 (55.8%), and post-dissection aneurysm in 72 (15.6%). One hundred and forty-one patients (30.5%) were operated on urgently; concomitant procedures were performed in 190 patients (41.1%). The mean cerebral perfusion time was 63 +/- 39 min. Predictors of hospital mortality and neurologic outcome were identified by univariate and multivariate analysis of the preoperative and intraoperative variables. RESULTS: The hospital mortality rate was 10.2%. Stepwise logistic regression identified an urgency status (odds ratio--OR 5.2, p = 0.001), a history of a central neurologic event (OR 4.1, p = 0.007) and coronary artery bypass graft (OR 3.2, p = 0.039) as being independent determinants for hospital mortality. The transient neurologic dysfunction rate was 6.2%. An urgency status (OR 3.4, p = 0.003) and a history of a central neurologic event (OR 5.1, p = 0.002) were independent determinants of transient neurologic dysfunction. An urgency status (OR 6.0, p = 0.011) was the only independent determinant for permanent neurologic dysfunction (3.8%). A cerebral perfusion time > 90 min was not associated with an increased risk of hospital mortality and permanent or transient neurologic dysfunction. CONCLUSIONS: Antegrade selective cerebral perfusion proved to be a safe method of brain protection allowing complex aortic repair to be performed with encouraging results in terms of hospital mortality and neurologic outcome.

Cardiac anomalies in Turner Syndrome.

This is the case of a 30-year-old woman with Turner Syndrome, with Mosaicism, exhibiting a bicuspid aortic valve with aortic stenosis, ascending aortic dilatation, pseudocoarctation of the aorta, left superior vena cava and lusoria subclavian artery. The successful surgical procedure consisted of the replacement of the aortic root and ascending aorta with a composite valved graft.

[Non-bacterial thrombotic endocarditis: a rare case of recurrent embolic events]. / Endocardite trombotica abatterica: raro caso di duplice tromboembolia periferica.

Non bacterial thrombotic endocarditis is a rare disease. The real incidence is not known and seems to range from 0.9 to 9.3%. Generally it is associated with cancer and rarely diagnosed antemortem. We describe the case of a female patient who suffered from ictus cerebri and acute myocardial infarction. She was admitted with diagnosis of papillary fibroelastoma arising from the right aortic leaflet. Her past medical history was characterized by gastrectomy, splenectomy and partial pancreatectomy for gastric cancer. The patient underwent successful resection of the mass that was attached to the right leaflet of the aortic valve closed to the aortic annulus. The histopathological examination revealed a mass composed of only thrombotic material. At the follow-up 1 year later the patient was in good clinical conditions (NYHA functional class I). Transthoracic echocardiography showed a good ventricular function, a continent aortic valve without recurrent mass. The suspicion of non bacterial thrombotic endocarditis should be aroused when diagnosis of endocardial mass is made in patients with previous cancers.

[Relation between cardiology and cardiosurgery in a center without cardiosurgery: an organizational proposal in the coronary syndromes]. / Rapporti tra cardiologia e cardiochirurgia in un centro non dotato di cardiochirurgia: una proposta organizzativa nelle sindromi coronariche.

A modern cardiology department has very frequent relations with a heart surgery center for the management of stable and unstable patients with coronary artery disease. Therefore, these relations need to be formally defined. This impelling necessity stems from the clinical evidence that a high number of unstable patients need a timely revascularization as well as from the economical pressure to correctly allocate the limited surgical resources available. Thus three main contexts should be clearly defined: 1) surgical support during coronary angioplasty (PTCA), when this activity is performed on-site; 2) timely revascularization of unstable patients admitted to the coronary care unit or the ward; 3) surgical prioritization of stable subjects undergoing diagnostic catheterization. The increased experience in PTCA as well as several technical improvements, namely stents, has dramatically reduced the need for emergency surgical revascularization and has induced an evolution in the stand-by strategy with new concepts such as "surgical back-up" or "next available operating room". Therefore, the role of heart surgery has switched from the emergency treatment of the frequent complications of PTCA to the timely revascularization of subjects not suitable for percutaneous interventions. Thus, PTCA "without on-site" surgical facilities is gaining widespread acceptance. With the aim of defining the requirements to perform PTCA at hospitals without coronary surgery facilities, several aspects are reviewed. Furthermore, the concepts of timely surgical revascularization in unstable patients as well as the management of surgical prioritization for stable subjects submitted to diagnostic catheterization are discussed in detail. Therefore, there is still a tight relation between cardiology and heart surgery in several clinical contexts. However, the main issues of these relations as well as outcomes do not differ significantly whether heart surgery is on-site or off-site.

Papillary fibroelastoma of the right atrium as an unusual source of recurrent pulmonary embolism.

Papillary fibroelastoma is the most common primary tumour of cardiac valves, with the potential for embolic events and obstructive effects. Location in non-valvular endocardium is extremely rare. Transthoracic and transoesophageal echocardiography have greatly increased the ability to make the diagnosis of these surgically treatable tumours in a timely fashion. We report the case of a 70-year-old woman with symptoms and ventilation-perfusion scan evidence of pulmonary embolization from a papillary fibroelastoma of the right atrium. Initial transthoracic echocardiography failed to identify the tumour, whereas transoesophageal echocardiography demonstrated a mobile echodense mass attached to the right atrial free wall. After surgical excision, histopathology revealed papillary fibroelastoma. The epidemiology, aetiology, localization, macroscopy, histopathology, immunohistochemistry, clinical presentation, diagnosis and management of cardiac papillary fibroelastoma are reviewed. The case is unusual with respect to the site of origin of the papillary fibroelastoma as well as its clinical presentation, which is clearly related to pulmonary embolization.

Indications for, timing of, and results of catheter-based treatment of traumatic injury to the aorta.

OBJECTIVE: The optimal treatment for and timing of surgery to repair traumatic aortic injury are still controversial. Endovascular treatment is a viable option in patients with both acute and chronic aortic trauma. However, appropriate patient selection criteria, treatment timing, and long-term durability of endovascular repair remain to be defined. We sought to identify appropriate selection criteria and optimal timing of treatment as well as to assess the long-term durability of endovascular repair. SUBJECTS AND METHODS: From July 1997 to December 2001, 19 patients with traumatic aortic injury (11 patients with acute and eight with chronic injuries) were selected for endovascular treatment. In all patients, the lesions were sited at the proximal segment of the descending aorta at a distance of 10 +/- 17 mm (mean +/- SD) from the left subclavian artery. Nine of the patients with acute injuries were treated after clinical stabilization of other severe associated lesions, whereas two patients, in whom hemodynamic and imaging findings suggested an impending rupture, received emergency treatment. Single-detector helical CT or MR imaging was used for patient selection and stent-graft customization before treatment and for evaluation of patients during the follow-up period. RESULTS: Endovascular stent positioning was successful in all patients. None of the patients developed complications. Aneurysm exclusion and shrinkage were confirmed at followup examinations. A partial covering of the subclavian artery occurred in six patients without interrupting the blood flow. All patients remain asymptomatic after a mean follow-up period of 20 months (range, 1-56 months). CONCLUSION: Endovascular repair represents an alternative, minimally invasive treatment, particularly suitable for use in patients with traumatic aortic injuries. The decision of whether to provide immediate emergency treatment or to delay treatment should be based on the lesion characteristics on imaging and clinical findings. The durability of treatment seems to be related to the absence of alteration to the aortic wall at the extremities.

Clinical outcome of aortic valve replacement in the elderly.

Since elderly patients are being referred for surgery in increasing numbers, we reviewed the clinical outcome of 459 consecutive patients aged 70 to 89 years, who had aortic valve replacement between 1993 and 2000. We subdivided the study population into three groups: in Group 1 we included patients aged 70-74 years old; in Group 2 patients aged 75-79 years old; and in Group 3 patients aged 80 years old or older. An isolated AVR was performed in 289 patients (63%), concomitant coronary artery bypass graft (CABG) in 168 patients (36.6%), an isolated ventricular septal defect (VSD) closure in one patient (0.2%) and an isolated atrial septal defect (ASD) closure in one patient (0.2%). The overall perioperative mortality rate was 7% (32 patients), without significant differences among the three groups (P=0.88). Our study confirms the good outcome of aortic valve replacement in elderly patients even in octagenarians and only concomitant CABG procedures increase the operative risk, reducing long-term survival (P<0.05).