Perfusion techniques for minimally invasive valve procedures.

In this paper, we present, in detail, the simplified perfusion technique that we have adopted since January 2009 and that we have utilized in 200 cases for cardiac minimally invasive valvular procedures that were performed through a right lateral mini-thoracotomy in the 3(rd)-4(th) intercostal space. Cardiopulmonary bypass was achieved by means of the direct cannulation of the ascending aorta and the insertion of a percutaneous venous cannula in the femoral vein. A flexible aortic cross-clamp was applied through the skin incision and cardioplegic arrest was obtained with the antegrade delivery of a crystalloid solution. Gravity drainage was enhanced by vacuum-assisted aspiration. There were no technical complications related to this perfusion technique that we have adopted in minimally invasive surgical procedures.

Reduced transfusion requirements with a closed cardiopulmonary bypass system.

AIM: The aim of this investigation is to reduce blood transfusion in cardiac surgery patients with preoperative conditions predictive for transfusion requirements. We compared the amount of blood transfused in two groups of patients undergoing cardiopulmonary bypass (CPB) with two different circuit systems. METHODS: Sixty patients undergoing cardiac surgery were randomly assigned to two groups: in group A (N=30) cardiopulmonary bypass was accomplished with an open circuit and in group B (N=30) with a closed circuit. The open circuit consisted of a cardiotomy reservoir, a membrane oxygenator and an arterial line filter, while the closed circuit was made up of a collapsible venous reservoir, a membrane oxygenator, an arterial line filter and a cardiotomy reservoir. The amount of transfused packed red cells in each patient was measured until discharge from the hospital. RESULTS: Groups were similar regarding age, gender, body surface area (BSA), New York Heart Association (NYHA) class and comorbidity risk factors. Moreover, there were no significant differences between groups regarding the type of procedures, CPB and aortic cross-clamp times, total amount of cardioplegia and urinary output during CPB. Priming volume was 1180+/-84 mL (group A) and 760+/-72 mL (group B) (P<0.001). Significant differences in transfusion requirements emerged in the two groups: the total volume of packed red cells transfused for each patient was significantly higher in the open system group compared to the closed system group (717+/-486 mL versus 378+/-364 mL) (P=0.003). Clinical outcomes were similar in both groups. CONCLUSION: In patients with preoperative conditions predictive for the need of transfusions, the use of a closed cardiopulmonary bypass circuit can diminish the amount of transfused blood products.

[Off pump total arterial revascularization--clinical and technical considerations]. / Revascularizarea coronariana off pump integral arteriala--consideratii tehnice si clinice.

Integral arterial myocardial revascularization seems to become the standard method in coronary surgery, but the international experience is still limited. We are communicating our results in arterial off pump coronary artery grafting (OFF CABG) in a centre specialized in "on pump" total arterial revascularisation. Between January 2004 and June 2006 we performed off pump CABG in 58 patients, using skeletonized arterial grafts; the vein grafts was rarely used. In 94.95% of cases we used only arterial grafts, and we achieved complete arterial revascularization in 47 (81.03%) of cases. We didn't noted major postoperative complications, the mean UCU stay was 1.7 days, mean hospital stay was 7.3 days, and no postoperative deaths were noted. The off pump CABG using arterial grafts is a secure method, without postoperative complications, which offers viable solutions of complete revascularization of the heart.

Technique of sequential grafting the left internal mammary artery (LIMA) to the circumflex coronary system.

The most common grafting technique performed with the IMA's is to anastomose the LIMA to the Left Anterior Descending (LAD) coronary system. With the expanded use of this conduit, the Right IMA (RIMA) can be used to graft the LAD system and the LIMA can be routed to the Circumflex (Cx) coronary system. This is the most common graft design in case of coronary disease affecting the LAD and the circumflex systems. The technique used at the Medical Center "The Klokkenberg" since 1989 to route the LIMA to the marginal arteries through a pericardial window is described in detail.

Current results of coronary bypass surgery after failed angioplasty.

Percutaneous Transluminal Coronary Angioplasty (PTCA) is a technique in continuous development. Since its introduction indications, number, quality of stenosis amenable to treatment and device employed have evolved leading to a change in the population undergoing treatment. Therefore surgical results obtained in the early 80's may not apply to the beginning of the 90's. This reason prompted us to review our recent experience. In the last 4 years (1989-1992) among 2563 PTCA procedures performed in our Institution, 114 patients (4.3%, CL 3.5%-5%) underwent urgent surgical revascularization because of failed angioplasty. Thirty-four patients (30%, CL 21%-38%) were older than 65 years; 68 patients (60%, CL 50%-68%) had multiple vessel disease; 63 patients (55%, CL 46%-64%) had previous Myocardial Infarction (M.I.); 20 patients (17%, CL 10%-24%) had already undergone a PTCA and 3 patients (2%, CL 0%-6%) had had coronary surgery. In 21 patients (18%, CL 11%-25%) the left ventricular Ejection Fraction (EF%) was below < 50%. Complete revascularization was always performed with an average of 2.2 +/- 1 graft/patient. A Left Internal Mammary Artery (LIMA) was implanted in 20 patients (17%, CL 10%-25%) of the patients and in 52% of cases requiring LAD grafts in the last two years. There were 2 deaths (1.7%, CL 0%-4%), both patients were in cardiac arrest before surgery (p < 0.001), 2 patients required a LVAD to be weaned from ECC and 7 patients (6%, CL 1%-10%) had an IABP inserted at the moment of surgery. Twenty-five patients (21%, CL 14%-29%) showed evidence of a new myocardial infarction.(ABSTRACT TRUNCATED AT 250 WORDS)

Congenital quadricuspid aortic valve with displacement of the right coronary orifice.

To date only five patients have undergone surgery for severe incompetence due to quadricuspid aortic valve (5-9). This report describes a new case of congenital quadricuspid aortic valve with severe regurgitation and associated displacement of the right coronary orifice, in which the abnormal valve was excised and replaced by a Björk-Shiley tilting disc valve prosthesis.

Preliminary experience with a percutaneous cardiopulmonary support system.

Percutaneous cardiopulmonary bypass has been introduced to support circulation in critical patients. In our preliminary experience we resuscitated two patients who sustained a prolonged cardiac arrest (52 min. and 31 min.) after coronary angiography and elective cardiac surgery, respectively. Cannulation was achieved percutaneously within 10 min. in both cases. Pump flow ranged from 2 to 31/m. Total support lasted from 52 min. to 180 min.. Both patients were successfully weaned. Patient 1 was declared brain dead and expired 17 days later. Patient 2 was discharged from the hospital and is doing well. Cannulation was attempted in a third patient after 30 min. of cardiac arrest. Despite surgical cut down of the femoral vessels, it was impossible to advance the arterial cannula because of bilateral occlusive disease. We conclude that PCPS is a powerful technique in selected patients to recover a stable cardiac function after prolonged cardiac arrest.

New technique for retrograde cerebral perfusion during arch aneurysm repair.

Many techniques are used to reduce brain damage during surgery for dissecting aneurysms of the ascending aorta and arch. Recently, new techniques of protection were proposed, consistent with hypothermic circulatory arrest in association with retrograde cerebral perfusion via superior vena cava. We propose a simple, time-saving method, which does not require any manipulation of the heart. We use a multilumen cannula for cardioplegia (D 860-DIDECO FUNDARO') with pressure transducer. This cannula is inserted in superior vena cava by means of a simple purse-string, and linked to the arterial line with a "Y" derivation, allowing retrograde perfusion of the brain and monitoring the perfusion pressure at every moment. The superior vena cava placed downstream from the cannula is closed by a small vascular clamp, to avoid blood reflux in the right atrium. This method is time- and money-saving, is readily available, and can be prepared whenever necessary, also in the middle of the surgical procedure.

Aortic coarctation, aortic valvular stenosis, and coronary artery disease: combined one-stage surgical therapy operation.

The presentation of simultaneous severe coarctation of the descending aorta and severe aortic valve disease is uncommon. We describe the management of simultaneous association of aortic coarctation, aortic valve disease, and ischemic cardiomyopathy and describe a one-stage surgical approach for the correction of all pathologies. After performing the aortic valve replacement and myocardial revascularization, coarctation was solved by means of a prosthesis between the ascending aorta and the abdominal aorta. There were no evidence of myocardial ischemia during exercise testing and the blood pressure is normal.

Surgical correction of congenital left coronary-pulmonary artery fistula and rheumatic mitral valve disease. Case report.

A 56-year-old woman with stenosis and incompetence of the mitral valve and clinical signs of congestive heart failure was found to have a communication between the left anterior descending coronary artery and the pulmonary trunk. A mitral valve prosthesis was inserted and the fistula was closed from within the pulmonary artery.

Surgical treatment of cardiac arrhythmias.

This report describes 20 consecutive patients who underwent surgical procedures for treatment of cardiac arrhythmias. 16 patients have been operated for WPW syndrome, always using the epicardial approach, without extracorporeal circulation. Three patients underwent surgery for atrio-ventricular nodal reentrant tachycardia, using a discrete perinodal cryotreatment, during normothermic extracorporeal circulation. In one case we used cryoablation of the atrial myocardium below the coronary sinus to treat atrial flutter. This operation was performed under normothermic extracorporeal circulation. In our observations, there was no early or late death; postoperative complications developed in 1 patient (5%) due to pericarditis. Ablation of the AP was completely successful in all the cases (100%) operated for WPW as well as for AVNRT syndromes and atrial flutter.

[Results of surgical treatment in supraventricular tachycardias]. / Risultati del trattamento chirurgico delle tachicardie sopraventricolari.

From May 1989 to May 1992, 44 patients (mean age 41 years, range 15-66) underwent surgery for supraventricular tachycardias: in 35 patients with atrioventricular reentrant tachycardia or atrial fibrillation associated with accessory pathway and refractory to medical treatment, the epicardial approach was used; in 8 with atrioventricular nodal reentrant tachycardia, a perinodal cryosurgery of the atrioventricular node was used, and in 1 patient with atrial flutter a cryosurgical ablation around the orifice of the coronary sinus and surrounding tissues was performed. All 38 accessory pathways were successfully ablated in 35 patients and no recurrences of delta wave or tachycardia were observed during a mean follow-up of 17 +/- 10 months. Atrial perforation during surgery and pericarditis were the only complications observed. All 8 patients with atrioventricular nodal reentrant tachycardia were successfully treated: in 2 patients dual pathways persisted after surgery but tachycardia was no longer inducible. No recurrences were observed during a mean follow-up of 15 +/- 4 months. Since surgery (15 months), the patient with atrial flutter has been free of recurrent episodes of atrial flutter. In conclusion, surgical treatment of supraventricular tachycardias is highly successful, with no mortality and very low morbidity. Should transcatheter ablation fail, surgery should be the treatment of choice in patients with frequent and symptomatic supraventricular tachycardias.