Long-term results after reconstruction of a new annulus in heavily calcified mitral annulus.

BACKGROUND AND AIM OF THE STUDY: In 2009 our group described a new surgical technique for patients with severe mitral valve calcification undergoing mitral valve surgery. This technique creates a new mitral annulus with plication of the mitral leaflet and the atrial wall. Our objective is to report the long-term results of the experience at our institution. MATERIALS, METHODS, AND RESULTS: From 2007 to 2016, a total of 18 patients (mean age 70.5 ± 7.8 years) underwent mitral valve replacement at our institution with this technique. One patient died on the second postoperative day. Clinical and echocardiographic in-hospital and long-term follow-up (55.5 ± 40.4 months) were performed on all the remaining 17 patients. Functional improvement was achieved in all patients. Two patients died 6 and 8 years after surgery (cancer and hemorrhagic stroke). No prosthetic dysfunction, periprosthetic leak, or annular dehiscence were detected in the long-term echocardiographic examinations. CONCLUSIONS: The reconstruction of the mitral annulus by using our technique in patients with severe calcification of the mitral annulus has low long-term mortality, good functional results, and a lack of prosthetic complications.

[Ecodoppler evaluation on the progress of atherosclerotic disease in patients undergoing contralateral carotid endarterectomy]. / Avaliação por ecodoppler da progressão da doença aterosclerótica em pacientes com endarterectomia carotídea contralateral.

PURPOSE: The clinical utility of monitoring by Doppler ultrasound patients undergoing carotid endarterectomy is not clearly established. Our goal is to evaluate by echo-Doppler the progress of contralateral stenosis in a real environment, in order to assess its usefulness. MATERIAL AND METHODS: Retrospective study with Doppler ultrasound monitoring in patients undergoing carotid endarterectomy for a period of 3 years. We included cases with Doppler echography before and at least one post-surgery. We excluded patients with contralateral thrombosis, contralateral stenosis, established surgical indication or prior carotid surgery. Analysis was performed using Kaplan-Meier curves to estimate the rate of patients free of progression and / or surgery, as well as an analysis of risk factors for progression of contralateral stenosis. RESULTS: We included 119 patients (41.2% symptomatic) age 68.3 +/- 8.41 years. The follow-up was 40.5 +/- 23.2 months, with a mean of 2.64 +/- 1.58 scans per patient. The likelihood of progression of contralateral carotid stenosis was estimated at 91, 86, 81 and 79% at one, two, three and four years respectively. The only significant risk factor for progression was the presence of moderate or greater contralateral stenosis (30% or more) at the time of surgery. CONCLUSIONS: The evolution of the contralateral carotid atherosclerosis is relatively common. The degree of stenosis correlates with early progression, the study by echo-Doppler plays an important role in monitoring these patients.

[Our experience in the surgical management of bull horn vascular injuries]. / A nossa experiência nos traumatismos vasculares causados por cornos de touros.

Vascular trauma caused by bull horn injuries can be regarded as a subgroup of vascular traumatology, due to its particular etiology, mechanism of action, associated injuries and surgical management. In this paper, the authors report their experience in the management of 56 such injuries, for the last 20 years, analysing the annual frequency (more common in summer time), the nature of the injury, the most commonly affected vessels and the surgical reconstruction or revascularization methods employed. The quality of results are discussed according some variable, such as is the case of the precocity of the repair, the degree of contamination, the occurence of post operative infections and the nature of the reconstructive or revascularization method employed. Finnaly, a comparison with similar reports already published in the literature is made.

[Evaluation of ischemic injury of the spinal cord following endoprosthesis implantation in the thoraco-abdominal aorta on a rat model]. / Avliação da isquémia medular após implantação de endoprótese na aorta toraco-abdominal do rato.

INTRODUCTION: Spinal cord ischemia is one of the most dreaded complication which may occur after conventional surgery of the thoraco-abdominal aorta, as well as following endoprostheses implantation. A better understanding of its pathogeny and physiopathology may lead to the introduction of means or measures for its prevention. The widespread utilization of the endovascular management of thoraco-abdominal aortic pathology stimulated the search for new alternatives to overcome the problem. MATERIAL AND METHODS: An experimental study was conducted, using Wistar-Lewis rats. Thirty-six animals were employed to assess the spinal cord consequences following the implantation of PTFE endoprosthesis in the thoraco-abdominal aorta. The endoprostheses were introduced through a distal aortotomy and advanced until the limits of the subclavian artery, down to the celiac axis. A similar group of animals underwent the conventional surgical management. To evaluate the neurologic repercussions, a sensor was placed in the spinal cord aimed at the registry of the bioelectric potentials, every two hours, until a limit of eight hours, in subgroups of six animals. Finally, the spinal cord was removed for histological examination. RESULTS AND DISCUSSION: The collected data revealed that significant ischemic alterations occurred eight hours after the implantation of the endoprostheses and that 48 hours later some signs of recovery could be observed, probably by means of collateral blood flow arising from the spinal cord itself or from branches of the thoraco-abdominal vasculature. However, it must be stressed that these results were obtained in healthy animals, with normal arteries, and that the resistance of the nervous tissues to the ischemia is certainly lower than in individuals with previous arterial pathology.

[Analysis of intrasac pressure after the implantation of endoprotheses with different diameters, in an animal model of abdominal aortic aneurysm]. / Análise da pressão do saco aneurismático após a implantação de endoproteses de diâmetros diferentes, num modelo animal em aneurismas da aorta abdominal.

PURPOSE: The effect of a plain 48-wire self-expanding flexible stent (Wallgraft Boston Scientific) on abdominal aortic aneurysms has been studied in a new animal model. We performed this study in order to analyze the mechanical properties of a bare-metal Wallgraft endoprostheses to investigate their responses to hemodynamic forces. METHODS: Aneurysms were created by interposing fusiform segments of PTFE into the infrarenal aortas of 12 Large White pigs. The pigs were assessed after 2 weeks by telemetry pressure, ultrasonography and arteriography methods. Endovascular placement of the stents, 2 weeks after aneurysm creation, was performed under arteriographic control in the half of pigs (second group of study). These pigs were assessed by telemetry pressure, ultrasonography and arteriography methods, weekly after stenting; they were then sacrificed for pathological examination. RESULTS: At 6 weeks the aneurysms in the first group were pulsatile with partial endothelialisation and no mural thrombus. Placement of the stent of different sizes in the second group was easily accomplished. Stenting resulted in an immediate reduction in wall pulsatility of all aneurysms and thrombosis of the excluded aneurysm sac occurred in three cases. In the other three cases the pulse pressure in the sac was reduced. In all cases there was a significant reduction in the maximum aneurysm diameter when measured weekly after stenting. DISCUSSION AND CONCLUSIONS: A pulsatile, non-thrombogenic aortic aneurysm model approaching human dimensions has been successfully developed for the study of endoprostheses prior to their clinical use. Endovascular placement of a plain, multiple-wire Wallgraft was associated with reductions in aneurysm pulsatility, pulse pressure within the sac and maximum aneurysm diameter over the study period. Stenting was associated with thrombosis of the excluded aneurysm sac in 50% of the cases.

[Histological evaluation of ischemic injury to the spinal cord. Experimental study in the rabbit]. / Avaliação histológica das lesões isquémicas na medula espinal. Estudo experimental no coelho.

Sometimes in clinical practice the spinal cord is subjected to a more or less prolonged period of ischemia, after which cellular lesions may occur, causing paraplegia. The purpose of this paper is to quantify morphologically the damage of the spinal cord after an induced ischemia. Seventy male adult rabbits were used. They were divided into three groups: one group was used for evaluation of spinal cord ischemia at 3 hours, the second at 12 hours and the third at 24 hours. The recovery periods ranged from 3, to 12 and 24 hours. At the end of this period, the animals were anesthetized and killed. A clinical evaluation was made using the Tarlov method and criteria. The spinal cord was subjected to a histological evaluation. The results revealed different changes according to the multiple groups of study. The authors discuss the data of the present study and compare to the reports published in the bibliography on the subject.

Efficacy of atorvastatin in prevention of atrial fibrillation after heart valve surgery in the PROFACE trial (PROphylaxis of postoperative atrial Fibrillation After Cardiac surgEry).

BACKGROUND: To evaluate the efficacy of perioperative atorvastatin administration for prophylaxis of postoperative atrial fibrillation (POAF) after heart valve surgery. METHODS: Our study included 90 patients with heart valve disease who were scheduled to undergo elective cardiac surgery. Cases with previous AF or preoperative beta-blocker therapy were excluded. Patients were randomized into the atorvastatin group, which included 47 patients who received 40 mg/day of atorvastatin 7 days before and after the surgery and the control group, which included 43 patients. Primary endpoint was the occurrence of POAF. Secondary endpoints included modifications in the preoperative and postoperative levels of the markers of inflammation (C-reactive protein [CRP]), myocardial injury (ultrasensitive troponin T and creatinine phosphokinase MB [CPK-MB]), and cardiac dysfunction (pro-brain natriuretic peptide [proBNP]) related to POAF and changes in the echocardiographic parameters, such as atrial electromechanical interval, A wave, E/A ratio, and Doppler imaging systolic velocity wave amplitude, related to POAF. RESULTS: No relationship between atorvastatin administration and reduction in the incidence of POAF was observed (42.6% in the atorvastatin vs. 30.2% in the control group) (p=0.226). No difference in the levels of CPK-MB, ultrasensitive troponin T, CRP, or proBNP and in the analyzed echocardiographic parameter was detected between both groups. CONCLUSIONS: Atorvastatin in the described dose, was not adequate for the prophylaxis of POAF after heart valve surgery. It was ineffective in controlling the inflammatory phenomena, myocardial injury, and echocardiographic predictors of POAF.

Surgical resection of lung metastases from epithelial tumors.

BACKGROUND: One of the main characteristics of malignant tumors is the capability to disseminate, giving rise to local or distant metastases. Pulmonary metastases occur in almost 30% of all oncology patients, and secondary lung tumors are more frequent than primary ones. Surgical resection of metastases is now a well-established procedure, but the results vary with the histologic type of the primary tumor. We wished to identify factors affecting late survival after pulmonary metastasectomy for epithelial tumors. METHODS: We have reviewed retrospectively data for 78 patients who underwent 101 curative resections of epithelial pulmonary metastases between January 1988 and December 2000 at our department. Potential prognostic factors affecting late survival, namely histology of the primary tumor, disease-free interval, number and size of resected lung metastases, involvement of lymph nodes, use of nonsurgical adjuvant therapy, and relapse of pulmonary metastases, were investigated. RESULTS: There was no operative mortality, and the postoperative course was uneventful in 91.1% of the procedures. The mean disease-free interval was 48.2 +/- 59.8 months, and the mean follow-up after the first pulmonary metastasectomy was 40.8 +/- 31.5 months. Mean overall survival was 81.0 +/- 10.0 months, and 5-year and 10-year survival rates were 47.4% and 37.7%, respectively. By univariate and multivariate analyses, the disease-free interval and the prognostic grouping system proposed by the International Registry of Lung Metastases were found to significantly influence the long-term survival. Presence of symptoms also showed an important influence. CONCLUSIONS: Resection of epithelial pulmonary metastases is safe and effective, and is associated with very low perioperative morbidity and mortality and a reasonable 5-year and 10-year survival. In the present study, the disease-free interval influenced significantly the long-term survival. Our results did not differ significantly from (and in many cases compared favorably with) those described in the literature.

Fulminant mediastinitis due to extended-spectrum beta-lactamase-producing Klebsiella pneumoniae: atypical presentation and spreading following cardiac surgery.

Mediastinitis due to Klebsiella pneumoniae, related to thoracic wall contamination after cardiac surgery, has rarely been described. We aim to report a case of fulminant mediastinitis due to extended-spectrum beta-lactamase-producing K. pneumoniae, secondary to a disseminated concomitant pulmonary infection. The patient remained pauci-symptomatic until clinical manifestations of sepsis acutely appeared.

Mitral approach in prosthetic endocarditis with calcified annulus and abscess.

Abscess resection and prosthesis reimplantation is the only effective treatment for mitral prosthesis endocarditis with extensive annular abscess, but it has high morbidity and mortality when associated with severe mitral annular calcification in the atrial and ventricular walls. We describe a technique that allows repair of the abscess cavity, reconstruction of the annulus, and implantation of a new mitral prosthesis when there is severe adjacent myocardial calcification, so decreasing the reoperation risk.

Impact of preoperative anemia on cardiac surgery in octogenarians.

OBJECTIVES: Preoperative anemia has been related with adverse outcomes in elective valve replacement and CABG surgery. Impact of preoperative anemia on outcome in octogenarians submitted to cardiopulmonary bypass (CPB) has not yet been precisely described. METHODS: We analyzed association between preoperative hemoglobin level, minimum intraoperative and immediate postoperative hematocrit (HCT), and other co-morbidities and occurrence of adverse outcomes in 227 octogenarians who underwent cardiac surgery. RESULTS: Frequency of preoperative anemia was 41.9% (40.4% in male and 43.5% in female patients). Postoperative mortality was 13.2% (9% in non-anemic patients vs. 18.9% in anemic). 44.5% of patients suffered at least one postoperative adverse outcome (43.1% non-anemic vs. 46.3% anemic). In multivariate analysis (after adjusting independent preoperative risk factors for operative mortality and EuroSCORE) preoperative creatinine level [odds ratio (OR), 2.29; 95% confidence interval (CI), 1.06-4.98; P=0.035], immediate postoperative HCT <24% (OR, 2.78; 95% CI, 1.04-7.38; P=0.039), perioperative red blood cell (RBC) transfusion (OR, 1.58; 95% CI, 1.24-2.00; P=0.0001), peripheral vascular disease (OR, 4.92; 95% CI, 1.45-16.69; P=0.012) and urgent surgery (OR, 10.57; 95% CI, 2.54-43.91; P=0.0001) were identified as independent predictors for in-hospital mortality. CONCLUSIONS: Mortality and adverse postoperative outcome increase in anemic octogenarians undergoing cardiac surgery. Although mortality is directly related to immediate postoperative anemia, adverse outcomes mainly depend on associated co-morbidities.