Feasibility of mitral valve surgery using minimal extracorporeal circulation.

AIM: Using minimal extracorporeal circulation (MECC) in isolated coronary artery bypass grafting or aortic valve replacement has been proven to be safe, feasible and superior compared to standard cardiopulmonary bypass (CPB) in terms of postoperative complications, total hospital stay and blood product transfusions. This feasibility study evaluates the clinical outcomes of mitral valve surgery performed with MECC. METHODS: From March 2006 to January 2011, seventy-five patients who underwent mitral valve surgery performed with MECC (n=75) in our institution were retrospectively evaluated. Demographic characteristics, operative data and clinical outcomes were collected in a prospectively designed database. RESULTS: The mean age was 68.8 ± 10.2 years with a EuroSCORE of 7.0 ± 2.3. Thirty-seven patients had a moderate left ventricular function (with a range of 30-40%). All patients except two had severe mitral valve incompetence (MI). Surgery was successful in all procedures. The mean duration of surgery was 210 ± 44 min (range 118-356 min). The mean CPB time was 128 ± 30 (range 67-249) min. The cross-clamp time was 99 ± 26 (range 48-205) min. There were no intraoperative perfusion problems or airlocks reported. The mean intensive care unit (ICU) length of stay was two days. Subsequent analysis showed a first postoperative haemoglobin value of 9.4 g/dL ± 1.7. There were no peroperative neurological complications. One patient developed an ischaemic cerebrovascular accident (CVA) on the forth postoperative day due to inadequate anticoagulation. Other postoperative complications included eight patients with pneumonia, one superficial wound infection, temporary renal insufficiency in two patients and four patients needed re-exploration for excessive postoperative leakage. Overall in-hospital mortality was four percent. CONCLUSION: Our results show, for the first time, that isolated or combined mitral valve surgery using MECC is feasible and safe.

Thoracoabdominal aortic aneurysm repair: results of conventional open surgery.

OBJECTIVES: The aim of this study is to report our experience in the surgical repair of thoracoabdominal aortic aneurysms (TAAAs) over the last 27 years against the background of evolving surgical techniques. METHODS: We reviewed the prospectively collected data of 571 patients who underwent open TAAA repair between 1981 and 2008. Data were analysed using univariate and multivariate analysis (logistic regression). Pre-, intra- and postoperative risk factors were used to develop risk models for in-hospital mortality, spinal cord deficit and renal failure. Recent published series were used to highlight the different treatment modalities and explore results. RESULTS: Seventy patients (12.3%) died in the hospital, the 30-day mortality was 8.9%, 37 patients (6.5%) required postoperative dialysis and 47 patients (8.3%) developed paraplegia or paraparesis. The incidence of paraplegia in the left heart bypass group was 4.4%. The predictors for hospital mortality were increasing age (odds ratio 1.096 per year, 95% confidence interval (CI): 1.05-1.14) and the need for haemodialysis (odds ratio 10, 95% CI: 4.7-21.1). For postoperative spinal cord deficit, we found three protecting factors: age above 75 years (odds ratio 0.14, 95% CI: 0.19-1.09), the presence of a post-dissection aneurysm (odds ratio 0.4, 95% CI: 0.17-0.94) and the combined use of cerebrospinal fluid drainage and motor-evoked potentials (odds ratio 0.28, 95% CI: 0.14-0.56). The urgency of procedure (odds ratio 4, 95% CI: 1.8-9) and preoperative serum creatinine level (odds ratio 1.007 per micromole per litre, 95% CI: 1.0-1.01) were significant risk factors for renal failure. CONCLUSIONS: Open TAAA repair intrinsically has substantial complications, of which spinal cord ischaemia and renal failure are the most devastating, despite major progress in our understanding of the pathophysiology and operative strategy. An overview of the results of recently published series is given along with an analysis of our data.

Diagnostic and therapeutic approach of congenital solitary coronary artery fistulas in adults: Dutch case series and review of literature.

BACKGROUND: Coronary artery fistulas (CAFs) are infrequent anomalies, coincidentally detected during coronary angiography (CAG). AIM: To elucidate the currently used diagnostic imaging modalities and applied therapeutic approaches. MATERIALS AND METHODS: Five Dutch patients were found to have CAFs. A total of 170 reviewed subjects were subdivided into two comparable groups of 85 each, treated with either percutaneous 'therapeutic' embolisation (PTE group) or surgical ligation (SL group). RESULTS: In our series, the fistulas were visualised with several diagnostic imaging tests using echocardiography, multidetector computed tomography, and CAG. Four fistulas were unilateral and one was bilateral; five originated from the left and one originated from the right coronary artery. Among the reviewed subjects, high success rates were found in both treatment groups (SL: 97% and PTE: 93%). Associated congenital or acquired cardiovascular disorders were frequently present in the SL group (23%). Bilateral fistulas were present in 11% of the SL group versus 1% of the PTE group. The fistula was ligated surgically in one and abolished percutaneously in another. Medical treatment including metoprolol was conducted in two, and watchful waiting follow-up was performed in one. CONCLUSIONS: Several diagnostic imaging techniques are available for assessment of the anatomical and functional characteristics of CAFs.

Diffuse atherosclerosis of thoracic aorta involving supraaortic and coronary arteries: single-stage surgical revascularization.

Arterial occlusive disease of supraaortic vessels, particularly the subclavian and innominate arteries, is infrequent. Hemodynamically significant proximal lesions of all supraaortic arteries are uncommon and the combination with coronary artery disease is even rarer. So far, the surgical management and operative timing of patients with coexisting severe disease of brachiocephalic and heart vessels is still a matter of debate. We report the case of a patient with severe polydistrectual atherosclerosis treated with single-stage aorto-carotid, carotid-subclavian and aortocoronary bypass.