Echocardiographic evaluation of mitral tethering for 'chordal cutting' procedure.

'Chordal cutting' is a recently proposed surgical option for the treatment of functional mitral regurgitation due to leaflet tethering. With this technique the surgeon sections second order chordae, restores leaflet's convexity towards the left atrium and eliminates mitral incompetence. Preoperative assessment of tethering mechanism, degree of leaflet distortion, surface of coaptation, annular dilation, origin and quantification of valve incompetence by echocardiographic means is essential in indicating this surgical option. Intraoperative transesophageal evaluation is crucial to assess the morphology and the absence or degree of residual incompetence after procedure.

Heterotopic heart transplantation: a single-centre experience.

INTRODUCTION: Orthotopic heart transplantation (OHTx) represents the therapy of choice for end-stage heart disease not treatable with medical or conservative surgical approach. Heterotopic heart transplantation (HHTx) is a surgical procedure in which the graft is connected to the native heart in a parallel fashion and it was especially employed in precyclosporine era. The aim of this paper is to present our experience with HHTx. METHODS: From November 1985 till May 2003, 713 heart transplanted patients included 12 (1.7%) received HHTx. Eleven were male, mean age was 50.7 +/- 5.8 years. Five patients suffered from dilated cardiomyopathy and seven from ischemic cardiomyopathy. Indication for HHTx was: a body size mismatch in 11 cases and availability of a marginal organ in one case. RESULTS: Mean ischemic time was 149 +/- 48 minutes and mean cross-clamp time was 82.3 +/- 19.1 minutes. In four cases left ventricle aneurysm resection was associated with HHTx. Hospital mortality was 8.3% (one patient due to multiorgan failure). The actuarial survival rates were 92% and 64% at 1 and 5 years, respectively. The causes of death were: liver cancer, liver cirrosis, aortic dissection, cerebrovascular accident, and chronic rejection. CONCLUSIONS: In our experience, HHTx survival rate is comparable to OHTx. Because of the scarcity of donors, use of an undersized or marginal graft is a valid option to increase the number of transplanted patients. The major disadvantages of HHTx are the need for anticoagulant therapy, the more difficult hemodynamic and immunologic follow-up, and the presence of the diseased native heart.

Heart transplantation in patients with amyloidosis: single-center experience.

INTRODUCTION: Amyloidosis is a systemic disease. Heart transplantation in this subset of patients is contraindicated by the majority of authors. In our center, patients with heart failure due to amyloidosis have been evaluated for cardiac transplantation since 1991. The aim of this study was to analyze the outcome of these patients waiting for transplant and the effectiveness of this therapy. MATERIALS AND METHODS: Since 1991, eight patients affected by amyloidosis have been evaluated and enrolled on the waiting list for transplant: five affected by AL lambda type; two by APO A1; and one by TTR. Four were transplanted, three died waiting for a donor (two from cardiac failure, one from sudden death), and one has been recently transplanted after 17 months on waiting list. RESULTS: Since 1985, 713 patients underwent heart transplantation in our center, five of whom were affected by amyloidosis (0.7%). Two are still alive (60 and 41 months) without evidence of cardiac amyloidotic infiltration. One patient recently underwent a combined heart-liver transplantation. Two patients died after the intervention: one sudden death after 23 months with amyloidotic infiltration of transplanted heart, and one multiple organ failure (MOF) due to progression of the systemic disease. CONCLUSIONS: Despite the small size of the group preventing us from drawing definitive conclusion, heart transplantation may prevent therapy to arrest organ damage in patients with isolated cardiac involvement. Cardiac events are the main cause of death. Patients must be followed-up for evolution of systemic disease. The midterm survival is encouraging.

Primary cardiac tumors. A clinical experience of 12 years.

From January 1980 through December 1992, we performed operations on 31 patients with primary cardiac tumors. There were 12 male and 19 female patients; the ages ranged from 7 to 71 years (mean, 47.7 +/- 18.3 years); 29 were adults and 2 were children. Twenty-six (83.9%) of the tumors were benign, and 5 were malignant. The most frequently encountered benign tumor was myxoma (22), and the most frequently encountered malignant tumor was fibrosarcoma (4). The most common symptoms at clinical presentation were those associated with cardiac insufficiency or embolization. Definition of the tumor was accomplished in all patients by echocardiography; cardiac angiography was performed in only 4 patients. All patients survived the operative procedure and were discharged from the hospital, but 4 patients with malignant disease died within 30 days. Follow-up for myxoma patients ranged from 16 to 151 months (mean, 68.5 +/- 36 months). Among the 26 patients with benign tumors, there was 1 death, 72 months after the surgical procedure, of right-heart failure due to recurrence of the myxoma.

Simultaneous surgery for obstructive coronary artery disease and ulcerated gastric cancer.

A patient with ulcerated gastric cancer causing mild anaemia and simultaneous three-vessel coronary artery disease (CAD) underwent "off pump" coronary artery bypass grafting (OP-CABG) and total D2 gastrectomy.

Multidetector CT and coronary artery bypass grafts.

The aim of this review is to provide--starting from anatomical, surgical and pathophysiological data--elements for evaluating the status of coronary artery bypass grafts with multidetector computed tomography (CT), taking into consideration the most common conduits used (left and right internal mammary arteries, saphenous vein, radial artery, gastroepiploic artery) and early and late complications (stenosis or obstruction, vasospasm, aneurysms and pseudoaneurysms, malposition). Some of the major problems regarding the examination technique and image analysis are also discussed. Finally, we offer general guidelines for reporting the examination results.

Midterm follow-up of patients receiving radial artery as coronary artery bypass grafts using 16-detector-row CT coronary angiography.

PURPOSE: The study was undertaken to evaluate the 3-year outcome of patients undergoing coronary artery bypass grafting (CABG) involving the use of the radial artery (RA) in comparison with the left internal mammary artery (LIMA) and saphenous vein (SV) grafts by using 16-slice multidetector computed tomography (MDCT). MATERIALS AND METHODS: Fifty-one patients underwent electrocardiogram (ECG)-gated 16-MDCT 32+/-4 months after surgery. A total of 50 LIMA grafts, 55 SV grafts and 51 RA grafts were studied. Approximately 68.6% or RAs were free, 21.5% sequential and 9.8% composite. Grade 0 was defined as complete patency, grade 1 as focal stenosis (>70%) and grade 2 as graft occlusion. The Fisher exact test was used to analyse variables (p<0.05 significant). Concordance between readers for the detection of patency was calculated by the kappa-value. RESULTS: LIMA had the best patency rate (94.0%), followed by SV (83.6%) and RA (74.5%). Regarding RA, the patency rate by territory was 79.4% in the left circumflex coronary artery (LCX), 72.7% in the left anterior descending (LAD) and 50% in the right coronary artery (RCA); the occlusion rate was 20.0% among free grafts, 18.2% among sequential grafts and 20.0% among composite grafts. The kappa-value was 0.86. CONCLUSIONS: Sixteen-slice MDCT scanners enable accurate analysis of CABG status and are a useful noninvasive diagnostic tool for midterm clinical follow-up of patients who have undergone CABG involving the use of RA.

Echocardiographic images in mitral valve repair by "edge to edge" technique.

The "edge to edge" or "double orifice" technique is a new surgical option of mitral repair when functional valve insufficiency is present, due to ischemic or dilated cardiomyopathy. This technique is not frequently used and radically changes mitral anatomy and hemodynamic. Therefore, echocardiographic examination is completely different and implies good experience to evaluate postoperative valve function. For these reasons we present a case report of a patient who underwent this repair and was evaluated in the follow up by standard transthoracic echocardiography: the anatomical and functional assessment that was satisfactory compared with transesophageal examination is documented.

[Presentation of a consecutive series of 400 aortocoronary bypass patients without hospital mortality]. / Presentazione di una serie consecutiva di 400 pazienti operati di by-pass aorto-coronarico senza mortalità ospedaliera.

Four-hundred consecutive patients were operated of coronary artery bypass between July 1980 and November 1982 without any hospital mortality. Clinical and coronarographic characteristics and surgical techniques are presented. Eighteen cases were complicated by peri-operative myocardial infarction. Follow-up data, were available for 91% of the discharged patients, ranged between 5 and 33 months (mean 17,6). Two hundred and sixty-one patients were asymptomatic, 66 had improved clinical conditions, but angina was still present; 25 were unchanged while 5 had worsened. There were seven late deaths; 6 due to cardiac disease and 1 to a mesothelioma.

Embolizing fibroelastoma of the aortic valve.

Papillary fibroelastomas are very rare cardiac tumours that can present with embolization of coronary and peripheral arteries and sudden death. The diagnosis can be made by two-dimensional or transoesophageal echocardiography. A 53-year-old man with an aortic valve papillary fibroelastoma who presented with several transient ischaemic attacks is reported.

[Effects of medical and surgical therapy on the long-term survival of patients with variant angina]. / Effetti della terapia medica e chirurgica sulla sopravvivenza a distanza nell'angina variante.

To determine the effects on survival of the medical and surgical treatment of variant angina, we compared the prognosis of 75 surgically treated subjects with that of 75 medically treated patients, selected from a series of 340 consecutive patients observed between January 1969 and December 1982. The patients were selected on the basis of a developed computer program to match each medically treated patient with one surgically treated patient so that each pair was similar according to the following clinical and angiographic variables: sex, age, previous myocardial infarction, severe ventricular arrhythmias during pain, site of ST elevation (anterior or inferior), coronary artery disease (single or multivessel), left ventricular function (normal or abnormal). Patients who were considered unoperable because of poor ventricular function or distal vessel disease were not included in this study. Mantel-Haenszel log-rank analysis demonstrated a significantly better prognosis in surgically treated patients, particularly in those with multivessel disease as well as in those with ST elevation in anterior leads. However survival in 63 medical patients who were treated with calcium-antagonists was not significantly different from that of their surgical matched patients. During the follow-up period, anginal symptoms were more frequently found in medically treated patients (p less than 0.05). We conclude that in patients with variant angina surgical treatment does not improve survival as compared to medical treatment with calcium blocking drugs. Coronary artery bypass surgery can be carried out at low risk and is particularly indicated in those patients with angina refractory to medical treatment.

[Different clinical and prognostic aspects of angina pectoris in unstable phase]. / Differenti aspetti clinici e prognostici dell'angina pectoris in fase instabile.

The purpose of this study was to focus on the clinical and angiographic characteristics of 113 patients with crescendo angina (Group I) as compared to 187 patients with angina of new onset (Group II), selected from a series of 474 consecutive subjects, admitted to our clinic between January 1976 and July 1983 because of recurrent episodes of spontaneous angina, who underwent cardiac catheterization and coronary angiography within one month of hospitalization. Group I patients showed a greater incidence of prior transmural myocardial infarction (p less than 0.01), arterial hypertension (p less than 0.01), multivessel disease (p less than 0.01) and a lower value of left ventricular ejection fraction (p less than 0.01) than Group II patients. In the latter group of patients anginal episodes were more frequently associated with S-T segment elevation than with S-T segment depression (p less than 0.001), while the opposite was found in patients with crescendo angina. Survival curves up to five years showed that medically treated patients with crescendo angina had a worse long-term prognosis than patients with unstable angina of new onset (p less than 0.01). On the contrary no difference was found between the surgically treated patients of the two groups. Our data suggest that the more diffuse involvement of the coronary tree associated with a more depressed left ventricular function may result in an unfavorable long-term prognosis in patients with crescendo angina as compared to those with unstable angina of new onset. Such a difference between the two groups was abolished by surgical treatment.

Color Doppler diagnosis of mechanical prosthetic mitral regurgitation: usefulness of the flow convergence region proximal to the regurgitant orifice.

In prosthetic or paravalvular prosthetic mitral regurgitation, transthoracic color Doppler flow mapping can sometimes fail to detect the regurgitant jet within the left atrium because of the shadowing by the prosthetic valve. To overcome this limitation, we assessed the utility of color Doppler visualization of the flow convergence region (FCR) proximal to the regurgitant orifice in 20 consecutive patients with mechanical prosthetic mitral regurgitation documented by surgery and cardiac catheterization (13 of 20 patients). In addition, we studied 33 patients with normally functioning mitral prostheses. Doppler studies were performed in the apical, subcostal, and parasternal long-axis views. An FCR was detected in 95% (19 of 20) of patients with prosthetic mitral regurgitation. A jet area in the left atrium was detected in 60% (12 of 20) of patients. In 18 of 19 patients with Doppler-detected FCR, the site of the leak was correctly identified by observing the location of the FCR. A trivial jet area was detected in eight patients with a normally functioning mitral prosthesis; in none was an FCR identified. Thus color Doppler visualization of the FCR proximal to the regurgitant orifice is superior to the jet area in the diagnosis of mechanical prosthetic mitral regurgitation. Moreover, FCR permits localization of the site of the leak with good accuracy.

Echo-controlled endomyocardial biopsy.

Endomyocardial biopsy is an essential procedure for the diagnosis and grading of rejection in heart transplant patients. Direct control of the bioptome positioning has classically been obtained by fluoroscopy. Starting in June 1988, at our institution an alternative approach involving the use of two-dimensional echocardiography was introduced in clinical practice. In 125 patients 1591 biopsies have been performed: 445 under echographic control and 1146 under fluoroscopic control with 3.6 and 4.5 samples/biopsy, respectively. The percentages of inadequate samples caused by biopsy site sampling were 0.4% and 1.3%, respectively, in the two groups. Cardiac perforation has occurred twice in the fluoroscopic group; it has not been observed in the echographic group. One case of iatrogenic tricuspid regurgitation was detected in each group. We now consider echocardiography the method of choice to guide the bioptome. We prefer it to fluoroscopy because it eliminates the risks of x-ray exposure, increases the number of sampling sites in cases of echocardiographic evidence of rejection, can be easily performed as a bedside procedure, allows choice and variation of sampling sites, and permits monitoring of cardiac complications during and after the procedure. A randomized clinical trial is probably needed to assess with statistical significance the superiority of the echographic-controlled biopsy.

Effects of surgical versus medical treatment on long-term prognosis in angina at rest: an observational non-randomized study of 400 patients.

The effect of surgical versus medical treatment on long-term prognosis in angina at rest was assessed using the Cox regression model for survival analysis in 400 patients complaining of recurrent episodes of resting chest pain associated with transient repolarization changes. The surgical group included 185 patients, and the medical group 215. Surgically treated patients more frequently had two- and three-vessel disease, while single-vessel disease prevailed in medically treated patients (P less than 0.01). No difference between the two groups was found in mean values of left ventricular end diastolic pressure and ejection fraction. Three variables were identified as independent predictors of prognosis in all patients: left ventricular end-diastolic pressure (P less than 0.001), age greater than 45 years (P less than 0.05), and number of diseased vessels (P less than 0.05). Treatment modality did not result in different long-term survival in the entire population. However, patients with three-vessel disease had a better outcome with surgical than with medical therapy (P less than 0.05). Although our conclusions must be tempered by consideration of the limitations of non-randomized studies, these results show that surgical treatment may improve survival in patients with angina at rest and three-vessel disease.

Echo-controlled endomyocardial biopsy in orthotopic heart transplantation with bicaval anastomosis.

Starting in January 1995, we performed heart transplantation, randomly using standard and bicaval techniques. In the latter technique, the anatomy of the right atrium is maintained, since the venae cavae are anastomosed. In 38 patients who received heart transplantation with bicaval anastomosis, 339 endomyocardial biopsies (EMB) were performed. EMB was done under echocardiographic control in 309 cases, whereas the remaining 30 were done under fluoroscopy. When EMB was echo-guided there was one major complication, namely right hemothorax in a 29-year-old man, who had had heart transplantation one week before, and this required surgical exploration. Other complications, correlated to venipuncture were: left hemothorax in a 65-year-old woman determined by arterial puncture, treated by means of chest tube drainage; pneumothorax (1 case). Echocardiographic guidance during EMB allows a better choice of biopsy site, reduces the risk of damaging cardiac structures and allows immediate monitoring of heart performance. Moreover the risk of X-ray exposure to both patient and operators is reduced. In any case, because the superior vena cava suture line is not visualized by two-dimensional echocardiography, if the bioptome cannot be introduced easily through superior vena cava, fluoroscopic control should be immediately applied, particularly in the early post-operative period when cicatrization is not complete.