Impact of bridging with perioperative low-molecular-weight heparin on cardiac and bleeding outcomes of stented patients undergoing non-cardiac surgery.

When patients with coronary stents undergo non-cardiac surgery, bridging therapy with low-molecular-weight heparin (LMWH) is not infrequent in clinical practice. However, the efficacy and safety of this approach is poorly understood. This was a retrospective analysis of patients with coronary stent(s) on any antiplatelet therapy undergoing non-cardiac surgery between March 2003 and February 2012. The primary efficacy endpoint was the 30-day incidence of major adverse cardiac or cerebrovascular events (MACCE), defined as the composite of cardiac death, myocardial infarction, acute coronary syndrome leading to hospitalisation, or stroke. The primary safety endpoint was the 30-day composite of Bleeding Academic Research Consortium (BARC) bleedings ≥ 2. Among 515 patients qualifying for the analysis, LMWH bridging was used in 251 (49 %). At 30 days, MACCE occurred more frequently in patients who received LMWH (7.2 % vs 1.1 %, p=0.001), driven by a higher rate of myocardial infarction (4.8 % vs 0 %, p< 0.001). This finding was consistent across several instances of statistical adjustment and after the propensity matching of 179 pairs. Patients bridged with LMWH also experienced a significantly higher risk of BARC bleedings ≥ 2 (21.9 % vs 11.7 %, p=0.002) compared to those who were not, which remained significant across different methods of statistical adjustment and propensity matching. In conclusion, LMWH bridging in patients with coronary stents undergoing surgery is a common and possibly harmful practice, resulting in worse ischaemic outcomes at 30 days, and a significant risk of bleeding.

Aortic balloon dilatation for congenital aortic stenosis: report of 90 cases (1986-98).

OBJECTIVE: To review 12 years of experience of balloon aortic valvoplasty in childhood. DESIGN: Early and mid-term clinical and instrumental evaluation of 104 consecutive balloon aortic valvoplasties performed from 1986 to 1998. SETTING: A tertiary referral centre for congenital heart disease. PATIENTS: 90 patients with congenital aortic stenosis: 20 neonates (group 1), 16 infants (group 2), and 54 children (group 3). INTERVENTIONS: Balloon aortic valvotomy. MAIN OUTCOME MEASURES: Doppler and peak to peak aortic gradient before and after valvoplasty, degree of aortic regurgitation before and after valvoplasty, early and late mortality, need for repeat intervention or surgery. RESULTS: Balloon aortic valvoplasty produced a gradient reduction of > 50% in 59 patients, 12 having a residual peak to peak gradient of > 50 mm Hg. Early mortality included three procedure related and six procedure unrelated deaths. There were no intraprocedural deaths. Grade III aortic regurgitation occurred in 20 patients. Five non-lethal complications occurred. At a mean follow up of 5.1 (group 1), 5.7 (group 2), and 7.6 years (group 3), survival was 75%, 88%, and 96%, respectively. Redilatation was performed in three patients in group 1, one in group 2, and 10 in group 3. Surgery was necessary for six in group 1, one in group 2, and eight in group 3. Freedom from events at last follow up was 50%, 75%, and 64%, respectively. There was a residual maximum Doppler gradient of < 30 mm Hg in 22 patients and > 60 mm Hg in 23; 50 patients have mild to moderate aortic regurgitation. CONCLUSIONS: Balloon aortic valvoplasty is effective and repeatable and offers good palliation for congenital aortic stenosis in childhood.

[Emergency surgery of acute coronary insufficiency]. / La chirurgia d'urgenza nell'insufficienza coronarica acuta.

In our centre, during the last five years, emergency operations (within 6 hours) and urgent operations (within 72 hours) have represented 1/4 of all coronary surgery. 295 patients (pts) have been operated on since 1972: of these, 279 with simple revascularization, 5 with combined major surgery, and 11 as a consequence of mechanical complications of acute myocardial infarction. These last were all in cardiogenic shock: the overall 30-day mortality rate was 5.4% (3.6% in those pts with simple revascularization, 20% in those with combined major surgery, and 45.4% in pts with cardiogenic shock). In the subgroup with simple revascularization, the incidence of non fatal perioperative acute myocardial infarction (AMI) was 4.7% in 253 pts with unstable angina, 52.2% in 23 pts with abrupt closure during coronary angioplasty, and obviously 100% in 3 pts surgically treated during evolving AMI. We were able to identify in the univariate analysis as the only 30-day risk mortality factors: 1) a reduced ejection fraction (< 30%) and 2) the combination with endarterectomy. Other factors (female sex, age > 70, severity of angina, diffuse coronary artery disease and more than 3 by pass grafts) have shown a tendency to increase the mortality rate without statistical significance. No deaths occurred in pts revascularized in emergency situations due to coronary angioplasty complications. In recent years emergency and urgent coronary surgical operations have been increasing, with an increase in pts with higher risk factors. In pts with simple revascularization, 30-day mortality and incidence of myocardial infarction are similar to those of elective surgery. In pts with abrupt closure as a consequence of coronary angioplasty the mortality rate seems very low, while the incidence of infarction remains extremely high. These observations have allowed the development of an integrated protocol of intervention in acute unstable coronary syndromes.

[Circulatory assistance in high-risk coronary angioplasty]. / Assistenza circolatoria nell'angioplastica coronarica ad alto rischio.

Femoral vein to artery cardiopulmonary by-pass was used during coronary angioplasty in five high risk patients. In four patients the target vessel supplied more than half of the viable myocardium; in one of these, the ejection fraction of the left ventricle was less than 20%. In one patient the relative contraindications for surgery were the patient's age and the presence of concomitant renal failure. Cardiopulmonary support was established by using cut-down cannulae insertion in three patients and by using the percutaneous system in two. In the latter, the support was stand-by, but the abrupt closure of the artery ten minutes after the end of the successful procedure, required the prompt activation of the support and the patient was treated with emergency saphenous graft. The use of the cardiopulmonary support either as a prophylactic or as a stand-by, enabled coronary angioplasty to be performed on these high-risk patients. The clinical and anatomical data relative to the five patients as well as the possible use of the cardiopulmonary support system either as a prophylactic or standby application during high-risk PTCA are discussed.

[Total anomalous pulmonary venous drainage: is a surgical correction possible on the sole basis of echocardiography?]. / Ritorno venoso polmonare anomalo totale; è possibile la correzione chirurgica sulla base della sola diagnosi ecocardiografica?

Between April '83 and August '89, 33 patients with total anomalous pulmonary venous drainage were studied at the department of Cardiology in Bergamo. There were 18 males and 15 females, aged between three days and 8 months (average: two months). In this study only cases of isolated total anomalous pulmonary venous drainage were taken into consideration. The patients underwent echocardiographic examination with ATL MK 600, Vingmed 700, ATL Ultramark 9 with 3.5; 5; 7.5; MHz transducers; in the last three years the echocardiographic examination was integrated by continuous and pulsed wave Doppler and, in the last year, by color Doppler. The morphologic diagnosis was routinely established by means of the sequential approach method. A common feature in all types of total anomalous pulmonary venous drainage was the impossibility of defining the connections of the pulmonary veins with the left atrium. Furthermore, patients had a volume overload of the right heart, and atrial septal defects of various sizes. The site of anomalous drainage of the pulmonary veins was assessed by means of multiple cuts from subcostal, precordial and suprasternal windows. The echocardiographic diagnosis was exact and complete in 29 cases (87.9%), and in four cases it was incomplete but basically correct (12.1%). The anatomical findings were confirmed during cardiac surgery in 32 cases and by autopsy in one case of supracardiac total anomalous pulmonary venous drainage in a critically ill patient, who died before surgery. Of the 32 patients who underwent surgical correction, 20 (62.5%) had only an echocardiographic diagnosis, which resulted correct in all cases. The majority of patients with isolated TAPVD can be confidently diagnosed by means of echocardiography, thus, avoiding preoperative catheterization.

[Congenital coronary fistulae. Comments on 9 surgical cases]. / Fistole coronariche congenite. Considerazioni su 9 casi operati.

The authors relate their experience concerning the surgical correction of congenital coronary fistula. Between May 1971 and June 1986, 9 patients (4 boys and 5 girls) aged from 17 days to 49 years were operated upon at the Division of Cardiac Surgery of Bergamo (Ospedali Riuniti). All the patients, except three who were asymptomatic, showed early cardiac failure or dyspnoea on effort and angina in the elderly. At the physical examination a continuous murmur was heard in 8 cases; the chest x-ray showed significant cardiomegaly and on the electrocardiogram a right/left ventricular hypertrophy pattern was detected in 5 patients. All the patients underwent cardiac catheterization and a coronary angiography. The left-to-right shunt ranged from 60% to 250% of the cardiac output. The anomalous communication affected the right coronary artery in 7 cases and the left in 2, opening into the right atrium in 4 patients, into the right ventricle in 3 and into the pulmonary artery in 2. All patients but one, in whom division and suture were the only necessary procedures, underwent correction by means conventional cardiopulmonary by-pass with moderate hypothermia. In 3 cases closure through the coronary artery was preferred, in 1 through the right ventricle and in 2 transpulmonary. There was only 1 late death which occurred in a 3 year-old patient due to renal failure. After a mean follow-up of 6 years, 7 patients are to be asymptomatic while 1 patient had to be reoperated for a significant residual shunt.

Cross-sectional echocardiographic study of criss-cross hearts and superoinferior ventricles.

From August 1982 to October 1985, 8 consecutive patients, aged 4 months to 8 years (mean 2.6), with criss-cross or superoinferior ventricles, or both, were studied. Seven patients had usual atrial arrangement and 1 had mirror-image arrangement. In 5 patients there was atrioventricular (AV) concordance with crossed AV streams, the ventricular septum was horizontal in 4 and sagittal in 1, and the ventriculoarterial connections were discordant in all. The 3 patients with AV discordance had superoinferior ventricles, but a criss-cross AV relation was not present; the ventriculoarterial connections were concordant in 2 and double-outlet right ventricle in 1. The sequential connections and spatial relations of the cardiac chambers, as well as the associated anomalies, were accurately assessed by echocardiography. The diagnosis was confirmed by angiography in all patients, by surgery in 3 and by autopsy in 2.

[Echocardiographic diagnosis of total anomalous pulmonary venous return]. / Diagnosi ecocardiografica di ritorno venoso polmonare anomalo totale.

Between March 83 and November 84, 20 patients with TAPVC were studied by cross-sectional echocardiography. The diagnosis was confirmed by catheterization, surgery or autopsy in each case. The anomalous drainage of the pulmonary veins was supracardiac in 10 patients, to the coronary sinus in 5, infracardiac in 4, mixed (supracardiac and infracardiac) in 1. The correct diagnosis was prospectively achieved in 17 patients (85); the echocardiographic examination could not show the precise site of the drainage in 2 (10); in only one patient (5) with right isomerism, double inlet indeterminate ventricle and severe pulmonary stenosis, the diagnosis of TAPVC infracardiac was missed. Seven patients (4 with TAPVC supracardiac, 3 to the coronary sinus) were sent to surgery without preoperative catheterization; the diagnosis was confirmed in all. Cross-sectional echocardiography proved to be a reliable diagnostic tool in the assessment of TAPVC. The patients in which the site of anomalous drainage is clearly identified by echo, can be sent to surgery without invasive investigation.

[Aortic coarctation and associated abnormalities in the first year of life. Echocardiographic diagnosis]. / Coartazione aortica e anomalie associate nel primo anno di vita. Diagnosi ecocardiografica.

Thirty-eight cases of "Aortic Coarctation Syndrome" presenting in the first year of life (66% under 3 months of age) were studied with cross-sectional echocardiography. Direct imaging of the coarctation was achieved in 75% of cases. Patent ductus arteriosus was present in 60% (80% before three months). Associated anomalies were present in 63%; VSD 29%, Aortic stenosis 16%, Mitral stenosis 16%, AV Canal 5%, Taussig Bing type of DORV 5%, Corrected transposition with VSD 3%, Ebstein anomaly 3%, Univentricular A-V connection 3%. The results were compared with angiographic and/or surgical and/or autoptic findings. The echocardiographic diagnosis proved to be very reliable in most cases. The policy of sending to surgery most neonates and infants with coarctation of the aorta without preoperative catheterization is discussed.

VSD formation in corrected TGA. Management of a previously undescribed complication after tricuspid valve replacement.

Disruption of the membranous ventricular septum following replacement of the tricuspid systemic atrioventricular valve in corrected TGA has not, to our knowledge, been reported in the literature. Our experience with this uncommon complication, which we observed and treated in two patients, is therefore presented. In the first case the native value anulus was large in relation to the largest available prosthetic valve. VSD formation occurred on the fifth postoperative day, probably due to "push and pull" forces acting on the membranous ventricular septum during the cardiac cycle. Fixation of the prosthetic sewing ring to the atrial tissue well above the adjacent membranous ventricular septum may invalidate the push and pull forces and thus be a preventive measure. In the second case the membranous ventricular septum remained intact following the primary valve replacement. When the outgrown prosthesis was excised 11 1/2 years later, disruption of the membranous septum resulted from attempts to widen the native valve anulus. This complication may be avoided if part of the sewing ring is cut away from the prosthetic valve and left in situ along the adjacent membranous ventricular septum. Sutures can be placed through the remnant of the sewing ring with minor or no risk of ventricular septal disruption.

Tetralogy of Fallot with absent pulmonary valve: definitive diagnosis by two-dimensional echocardiography.

A case is presented of a 27-day-old boy with Tetralogy of Fallot and absent pulmonary valve. The two-dimensional echocardiographic examination demonstrated: subaortic ventricular septal defect, overriding aorta, absence of the pulmonary valve with restrictive anulus, and massive dilatation of the pulmonary artery. These anatomic details were then confirmed by angiography and surgery. The echocardiographic features of Tetralogy of Fallot with absent pulmonary valve are typical, and allow the correct diagnosis to be made noninvasively. The haemodynamic investigation becomes obviously easier, and angiocardiography may be devoted to the study of possible additional defects, that are difficult to detect by echocardiography, like multiple ventricular septal defects, or peripheral pulmonary branch anomalies.

[Atrioventricular connection anomalies associated with Fallot's tetralogy: bidimensional echocardiographic study]. / Anomalie di connessione atrioventricolare associate a tetralogia di Fallot: studio ecocardiografico bidimensionale.

From January 1979 to December 1981, 62 patients with Tetralogy of Fallot were studied by two-dimensional echocardiography (2-D Echo). In 10 cases various types of atrioventricular connection anomalies were found: type C atrioventricular canal in 8 cases, straddling tricuspid valve in 1 case, straddling and overriding tricuspid valve in 1 case. These associated anomalies usually are not suspected by means of clinical, electrocardiographic and radiological findings, whereas 2-D Echo appears to have a unique diagnostic value. Apical and subcostal four chamber views were the most helpful to detect the anomalies of the atrioventricular junction; in all cases with complete atrioventricular canal, the ostium primum atrial septal defect, the common atrioventricular valve and the inlet septal defect were clearly seen. In one case an overriding tricuspid valve was clearly demonstrated; in this and in another patient the straddling of the tricuspid valve could be only suspected, whereas its confirmation was obtained subsequently by angiography and surgery. A through 2-D echo evaluation of these anomalies is useful to select the most appropriate views for angiographic confirmation and to ensure optimal surgical planning.

[Deep hypothermia for the correction of a congenital cardiac defect complete with atrioventricular block]. / Ipotermia profonda di superficie per la correzione di una cardiopatia complessa con BAV completo congenito.

The techniques of deep hypothermia for correction of congenital cardiac defects are well known in many cardiac centers and many cases can be treated even if there are pre-existing rhythm troubles. Our patient had the following diagnosis: left atrial isomerism, dextrocardia; left sided azygos continuation of inferior vena cava; left and right superior venae cavae, hepatic veins, pulmonary veins, all draining into a common atrium; d-loop with normally related ventricles; ventriculo-arterial concordance, small VSD. In addition complete a-v block was present. The patient, 40 days old and 3.4 kg., in heart failure, was paced with a temporary transvenous catheter at 130/min and, afterwards, catheterized. Surgery was undertaken three days post-catheterization using surface deep hypothermia. A Mustard operation, including enlargement of the new left atrium with PTFE (Goretex), was performed during total circulatory arrest. At the end, a permanent pacemaker was positioned in the abdomen and epicardial wires were left on the right ventricle. The postoperative period was uneventful and the patient is doing well 3 months latter. The interest of the case is that even in a complex congenital cardiac malformation with complete a-v block, the technique of surface deep hypothermia can be used because all the physiological parameters remain stable during the procedure in spite of the very low heart rate.