Paradoxical embolism with thrombus stuck in a patent foramen ovale: a review of treatment strategies.

OBJECTIVE: Paradoxical embolism represents a rare condition occurring when a thrombus originating from venous system produces pulmonary embolism and systemic embolization through an intracardiac or pulmonary shunt. The evidence of a thrombus entrapped in a patent foramen ovale (PFO) is an even more rare condition. There is uncertainty about the optimal treatment strategy. PATIENTS AND METHODS: A 58-year-old male patient was admitted to our Internal Medicine Unit with the diagnosis of bilateral bronchopneumonia. During hospitalization, the co-occurrence of chest pain and amaurosis led us to hypothesize a paradoxical embolism. RESULTS: Transthoracic echocardiography showed the presence of a thrombus stuck over the interatrial septum. A contrast-enhanced chest CT scan showed multiple pulmonary embolisms and brain CT scan documented a hypodense area, of ischemic significance, in the left occipital lobe near tentorium. In order to prevent further embolization, emergency cardiac surgery (right atriotomy, removal of thrombus and closure of the PFO, pulmonary thrombectomy) was performed without complications. CONCLUSIONS: Although rare, the evidence of a thrombus stuck in a patent foramen ovale represents a clinical emergency. The optimal therapeutic approach is still debated. The surgical correction seems to be a safe and effective option for these patients.

[Rupture of the right ventricular wall closed with Daflon patching and biological glue]. / Rottura della parete ventricolare destra chiusa con patching in daflon e colla biologica.

In this paper we present a rare case of Dacron patch closure of tear in right ventricular myocardial at outflow level, caused by stroke of hypoplastic right coronary artery occlusion, in patient with non-obstructive hypertrophic cardiomyopathy caused by hypertension and aortic stenosis, surgically treated by implantation of mechanical prostheses, and pericarditis postcardiotomy. Our purpose is to trace evidence from postmortem identification of pathogenic mechanisms occurring in causing fatal event. The severe myocardial hypertrophy observed is supposedly based on valvular or hypertensive, is compatible with a significant reduction of the diastolic function and with the genesis of acute pulmonary edema as a trigger: the latter case may result in death for the reduction of contractile reserve of the right ventricle, induced by the presence of the patch surgically implanted.

Chronic frontal sinus disease: combined use of platelet-rich plasma and calvarial bone grafts for sinus obliteration in aggressive and secondary cases.

INTRODUCTION: The surgical management of chronic frontal sinusitis can be challenging. The most effective way to treat this condition is sinus obliteration. Several methods have been published. We evaluated the feasibility of a combined treatment, consisting of platelet-rich plasma (PRP) and autologous calvarial bone chips, in chronic frontal sinus diseases (CFSD). PATIENTS AND METHODS: From January 2001 to June 2006, seven patients (four women and three men) were admitted presenting with signs and symptoms of CFSD. Their ages ranged from 35 to 67 years. Two patients presented with signs of frontal osteomyelitis and a cutaneous fistula, while endoscopic drainage had failed for five patients. All patients were treated by sinus obliteration though bicoronal access. Free autologous calvarial bone graft combined with PRP was used to repair the frontal sinus. RESULTS: The frontal sinus repair was successful in all seven patients with progressive resolution of symptoms without perioperative complication. The CT scans at 12 postoperative months showed complete obliteration of sinuses. DISCUSSION: Combined PRP and autologous bone graft is a safe and reliable procedure for frontal sinus obliteration. The low rate of complications and the absence of donor site morbidity support using this technique in secondary and particularly complex cases.

Temporomandibular joint dysfunction following shotgun injury.

Shotgun injuries to the maxillofacial region may have minor or, more often, devastating consequences. The most important factor in determining the extent of injury is the distance of the victim from the muzzle of the gun: usually, the longer the distance, the less severe the damage. Here is reported a case of shotgun injury sustained from a distance of approximately 10 m in which the deeper penetration of a single lead pellet led to significant involvement of the temporomandibular joint.

Myocardial revascularization through a mini-thoracotomy with thoracoscopic assistance.

OBJECTIVE: Left internal mammary artery harvesting through a mini-thoracotomy makes gaining the proximal portion of this vessel very difficult and exposes the patient to the risk of chest wall trauma due to excessive spreading of the ribs. The adoption of video thoracoscopic assistance can give several advantages to the procedure. METHODS: With the patient in a 30 degrees left-side-up thoracotomy position, a 8-12 cm anterior thoracotomy is performed in the left fourth or fifth intercostal space. Two thoracoscopic ports are inserted in the third and fourth left intercostal spaces in the midaxillary line. Complete mobilization of the left internal mammary artery is performed with a mixed surgical and thoracoscopic technique. RESULTS: Since July 1996, 12 patients underwent myocardial revascularization with the left internal mammary artery through a mini-thoracotomy, with the aid of video assisted thoracoscopy. There were no deaths or perioperative infarctions. Mean hospital stay was 4 days (3-6). In nine patients a postoperative angiographic study was performed: in all cases the length of the mammary artery pedicle was adequate; one patient underwent a successful angioplasty on a narrowed anastomosis on the left anterior descending artery. In another patient the left internal mammary artery had been grafted to a diagonal branch. In all other cases angiography showed good results. CONCLUSIONS: Thoracoscopic assistance helps achieving complete mobilization of the left internal mammary artery, maximizing its useful length, without an extended thoracotomy.

[Weaning in cardiopulmonary bypass patients with compromised cardiac function. Comparison of enoximone and dopamine]. / Weaning dal bypass cardiopolmonare di pazienti coronaropatici a funzionalità cardiaca compromessa. Confronto tra enoximone e dopamina.

OBJECTIVE: Evaluate the effects of enoximone and dopamine in patients with impaired left ventricular function after cardiopulmonary bypass (CPB). DESIGN: Prospective study on a consecutive series of patients subdivided into two groups: enoximone (Group E) and dopamine (Group D). SETTING: Policlinico Umberto I, University La Sapienza of Rome. PATIENTS AND METHODS: Thirty patients undergoing elective myocardial revascularization. Before weaning from CPB the patients received inotropic drugs as follows: Group E: enoximone: bolus: 1 mg/kg in 10 min, and continuous infusion of 5 mcg/kg/min; Gruppo D: dopamine: continuous infusion of 5 mcg/kg/min. Hemodynamic measurements were made using a Swan-Ganz catheter inserted before the induction of anaesthesia. RESULTS: Enoximone has proved to be effective in decreasing pre-load and after-load of both right and left ventricle by a positive lusitropic effect and a reduction of systolic stress, thereby increasing the cardiac index. In group D patients maintenance of cardiac output has been demonstrated to be dependent on a chronotropic effect. As a consequence in group D the increase in rate-pressure product has reached potentially dangerous values, reflecting a marked increase in myocardial oxygen consumption. On the contrary in Group E the increase in rate-pressure product has been much more limited. Finally both drugs have proven effective, since all patients have been easily weaned from CPB. CONCLUSIONS: Enoximone is a useful and easily-handled drug to facilitate weaning from CPB of patients with preoperative impaired ventricular function.

["Multiorgan failure" in surgery: its physiopathology, prevention and treatment. A review of the literature]. / La "MultiOrgan Failure" in chirurgia: fisiopatologia, prevenzione e trattamento. Revisione della letteratura.

At present multiorgan failure (MOF) is the complication with the highest mortality after emergency or elective general surgery. The syndrome seems to find its pathogenesis out of the very complex interactions of endogenous and exogenous mediators; instead the physiopathology seems to depend on cellular oxygen deficiency. The authors refer the common criteria defining organ and/or system damage during MOF and analyse the available possibilities for their treatment. In this regard they stress the role of prevention, which relies on the opportune treatment of earlier stage of shock, constantly preceding the syndrome, and on the intensive organ/systems functions monitoring to obtain an early and rational correction of the alterations taken away.

[THe surgical treatment of aneurysmatic lesions of the ascending aorta: the immediate and long-term results in 40 patients]. / Trattamento chirurgico delle lesioni aneurismatiche dell'aorta ascendente: risultati immediati e a distanza in 40 pazienti.

From January 1981 to January 1991, 40 patients underwent operation for acute ascending aorta dissection (AAD, 14 patients), chronic ascending aorta dissection (CAD, 9 patients) or aortic ectasia (AE, 17 patients), with simultaneous aortic valve replacement in 30 cases (75%). Average age was 54 years with a 3:1 M/F ratio. In 20 cases (50%) a composite graft bearing a mechanical bileaflet valve was inserted with coronary artery reattachment (Bentall operation). In 16 cases (40%) the ascending aorta was replaced by a woven dacron graft alone (7 cases) or associated with aortic valve substitution (7 cases) or resuspension (2 cases). In 1 case (2.5%) a sutureless ring graft replacement of ascending aorta was carried out and 3 patients (7.5%) underwent aortoplasty with aortic valve substitution. Postoperative mortality rate was 21% for AAD group, 11% for CAD group and 6% for AE group. Non-fatal postoperative complications developed in 36% of AAD patients and in 78% and 29% of CAD and AE patients respectively. These complications occurred in 45% of patients who underwent Bentall operation, in 44% of those who underwent ascending aorta replacement associated with aortic substitution or resuspension, and in 14% of those operated of simple ascending aorta replacement. Average follow-up was 41.6 months (range 1.7-107.4 months). During this period 5 deaths occurred for a long-term mortality rate of 14.2%. Out of 30 survivors 21 (70%) underwent CT-study to evaluate the natural course of the false channel and the risk of redissection or late aneurysm formation.(ABSTRACT TRUNCATED AT 250 WORDS)

[Reconstruction after pancreaticoduodenectomy for cancer: Whipple-Child vs Traverso-Longmire technique (a National questionnaire 1990 on data of 1,095 cases of surgery)]. / Ricostruzione dopo cefaloduodenopancreatectomia per cancro: Whipple-Child v.s. Traverso-Longmire (questionario nazionale 1990 per una raccolta di 1.095 esperienze).

The Authors report the results of a National multicentric experience in 1.095 cases of pancreaticoduodenectomy for cancer. In order to evaluate the reliability of pyloric preservation mortality, morbidity, and functional results are discussed.

Total gastrectomy in the treatment of adenocarcinoma of the cardia. Review of the results in 73 resected patients.

Between January 1, 1971, and December 31, 1978, 73 patients with adenocarcinoma of the cardia were treated by total gastrectomy with distal esophagectomy. The continuity of the alimentary tract was restored by esophagojejunostomy using a Roux-Y procedure in 32 patients and jejunal loop interposition in 41 patients. The early postoperative mortality rate was 18 percent. The overall 5 year survival rate was 26.7 percent, and the 5 year survival rate for stage I and II disease was 91.6 percent and 25 percent, respectively, whereas none of the stage III and IV patients survived more than 4 years. Fifty-eight percent of the patients without nodal involvement lived more than 5 years. The 5 year survival rate was only 9.3 percent in the presence of nodal metastases. Our 5 year survival rates suggest the value of elective total gastrectomy for stage I or II adenocarcinoma of the cardia. Jejunal loop interposition is a time-consuming but functionally superior procedure in comparison to other reconstructive procedures after total gastrectomy.