Extended vertical transseptal approach versus conventional left atriotomy for mitral valve surgery.

BACKGROUND AND AIM OF THE STUDY: Mitral valve surgery requires optimal exposure of the valvular apparatus, particularly when a conservative procedure is used. Retrospectively, we compared surgical results in patients who underwent mitral valve surgery using the vertical transseptal approach (which has been adopted routinely in our institute) with those in patients undergoing conventional left atriotomy. METHODS: A total of 172 consecutive patients operated on for mitral procedures were allocated to either group A (those operated on through a longitudinal left atriotomy; n = 62), or group B (mitral valve exposure achieved through an extensive vertical transseptal approach; n = 110). RESULTS: In group A, there were 24 valvular reconstructions and 38 valvular replacements. Mean (+/- SD) cardiopulmonary bypass (CPB) time was 65.9 +/- 17 min and mean ischemia time 37.4 +/- 13 min. Total postoperative bleeding was 277 +/- 171 ml. There was no surgical re-exploration for bleeding. One patient in this group died (mortality rate 2%). Among 40 patients in atrial fibrillation preoperatively, four had one episode of temporary junctional rhythm, six had temporary sinus rhythm and two had stable sinus rhythm. Among patients with preoperative sinus rhythm, six (27%) had episodes of atrial fibrillation and two (9%) temporary atrioventricular block. In group B, 46 mitral reconstructions and 64 mitral replacements were performed. Mean CPB time was 67.9 +/- 20 min and mean ischemia time 48.1 +/- 17 min. Total postoperative bleeding was 400 +/- 189 ml. Three patients in this group died (mortality rate 2.7%). Among 60 patients with preoperative atrial fibrillation, six (10%) had one episode of temporary junctional rhythm, 14 (24%) had temporary sinus rhythm and two (3%) had conversion to stable sinus rhythm. Among those in sinus rhythm preoperatively, 16 (32%) had episodes of temporary junctional rhythm, two (4%) had temporary atrial fibrillations, and four (8%) had stable atrial fibrillation. In group B patients, the incidences of ischemia time and total postoperative bleeding (p = 0.004), and postoperative junctional arrhythmia in those with preoperative sinus rhythm (p < 0.001), were greater than in group A patients. CONCLUSIONS: No technique-related deaths occurred; neither were causes of re-exploration for bleeding related to technique, and there was no evidence of residual interatrial shunt. In conclusion, transseptal extended atriotomy provides excellent exposure for mitral valve surgery. Disadvantages of minimally increased ischemia time and surgical bleeding are minor compared with the superior and more complete surgical reconstruction achieved. The advantages of the technique are undermined by the higher incidence of junctional arrhythmia which, even if temporary, requires strict postoperative monitoring.

Sudden appearance of echocardiographic changes in a case of acute massive pulmonary embolism.

We report a case of a 68-years-old woman who developed during hospitalization a massive pulmonary embolism. Since the patient had undergone routine cardiac examination, comparison between the echo features immediately preceding and following the event allowed to detail the time interval required for the occurrence of the anatomical and functional changes of the heart chambers.

Mercury contamination-what we have learned since Minamata.

Atmospheric cycling of mercury and other pollutants has become a major concern as industrialized countries have eliminated point discharges, sometimes by relocating the industries to underdeveloped and developing countries where point sources have become problems. Such circumventions may be to no avail in the long run as pollution continues to elevate levels of methylmercury in fish in waterways that are remote from direct contamination as well as where the source can be readily identified. Much has been learned about the cycling of mercury in the environment since human disabilities and deaths at Minamata, Japan, initially drew attention to the problem of methylmercury poisoning from the consumption of contaminated seafood in the 1950s. In that instance, methylmercury produced industrially concentrated to toxic levels in fish. As this manufacturing process was not used outside Japan, concern did not become immediate in other developed nations until the 1960s when it was established that mercury was not only biomethylated by microorganisms but also biomagnified through the food chain. Point sources to the waterways may have been eliminated too late to return the levels in fish to background because of the geochemical cycling of mercury through the environment. Despite decreases in domestic, industrial and agricultural point source releases over the last two decades, large quantities from non-point sources such as fossil fuel combustion, smelters, and incinerators are still being released. Much of this mercury is transported from the atmosphere to aquatic ecosystems and stored in sediments until it is again released to the water and atmosphere.

Transesophageal echocardiographic diagnosis of a dehisced Carpentier mitral ring.

We describe an unusual case of gross dehiscence of a Carpentier mitral ring, not due to bacterial endocarditis, causing severe mitral valve insufficiency and cardiac failure. Diagnosis was made by transesophageal echocardiography (TEE). Mitral valve replacement was then performed.

Left ventricular diastolic function with epirubicin therapy: an echodoppler study.

Thirty patients undergoing epirubicin therapy for primary lung cancer were studied by echocardiography and Doppler echocardiography. 2 D ejection fraction (EF) and Doppler left ventricular filling parameters (peak E, peak A, E/A ratio) were calculated before and after the completion of therapy. No differences in the mean values of these parameters were observed. However, 6 out of 30 patients (20%) showed left ventricular filling abnormalities; in 2 of them a slight reduction of EF was also noted. These abnormalities seem to be dose related. A longer term prospective study will be required to evaluate whether these findings are irreversible and to establish the clinical implications of our observations.

Evaluation of cardiac structures and function in systemic sclerosis by Doppler echocardiography.

Ventricular diastolic filling was investigated in a series of 51 consecutive patients with systemic sclerosis by means of Doppler echocardiography. Peak flow velocity in early (peak E) and late (peak A) diastole, E/A ratio, slope of the early diastolic flow velocity and isovolumic relaxation period were calculated. Nine out of the 51 patients showed abnormalities of ventricular filling dynamics in the absence of left ventricular systolic dysfunction at rest and after provocation. The abnormal diastolic filling pattern in these patients was detected in spite of the absence of systemic hypertension, left ventricular hypertrophy or other clinically evident myocardial disease. These diastolic abnormalities might represent an isolated evidence of the underlying myocardial fibrosis not yet clinically apparent.