Atherosclerotic aneurysm of the left main coronary artery. Case report and review of the literature.

Coronary artery aneurysms involve the right coronary artery, the left anterior descending and the left circumflex coronary arteries in descending order of frequency; aneurysms involving the main left coronary artery are extremely rare. Atherosclerosis is the most common cause. Only eleven patients surgically treated with atherosclerotic left main coronary artery aneurysms are reported. We observed the twelfth case of atherosclerotic aneurysm of the left main coronary artery, successfully treated. In a 65-year-old man we found a large aneurysm originating at the distal segment of the left main coronary artery. A thromboendarterectomy was per-formed and was extended back into the left main and down the left anterior descending artery. An aneurysmorrhaphy and a three-vessel coronary artery bypass grafting were also performed. Three years later the patient was asymptomatic. Management of these cases is still controversial and based on anedoctal experience rather than controlled trials. Although surgery has been recommended to prevent complications, there are no available data comparing medical and surgical management. We feel that coronary bypasses should be performed in coronary artery aneurysm patients only when indicated by the severity of stenosis or progressive angina despite medical therapy. It is our opinion that anurysmorraphy should preserve native flow as much as possible.

Normothermic versus hypothermic perfusion during cardiopulmonary bypass. A randomized study on 132 patients.

BACKGROUND: A prospective randomized trial to compare normothermic CPB with hypothermic CPB has been performed. METHODS: 132 patients undergoing CPB were randomized into two groups: group 1 underwent normothermic CPB and group 2 hypothermic CPB (between 26 and 30 degrees C). RESULTS: Any significant difference was observed between the groups with regard to hospital mortality, blood transfusions, incidence of neurologic deficits and hematocrit, blood hemoglobin levels, platelet counts, plasma concentrations of glutamic-pyruvic transminase, glutamic-oxaloacetic transaminase, creatine kinase, valued at the 12th and 24th postoperative hour and at the 2nd, 3rd, and 4th postoperative day. A significant difference was observed between the groups with regard to tracheal extubation time, discharge time from the intensive care unit and inotropic drug infusion. The normothermic CPB patients group needed shorter time for tracheal extubation and discharge from the intensive care unit: this difference may be ascribed to a shorter inotropic drug infusion. Any increased surgical risks have been observed. CONCLUSIONS: In conclusion, we think that normothermic CPB is favourable because it can reduce costs, it can improve the management of a cardiac surgery unit and it is more comfortable for patients.

Elective coronary and valve surgery without blood transfusion in patients treated with recombinant human erythropoietin (epoetin-alpha).

BACKGROUND: This study evaluates the real effectiveness of epoetin-alpha associated with ferrous sulphate, in reducing blood transfusion in patients undergoing elective open heart surgery not treated with autologous donation. METHODS: Sixty patients had been divided into 2 groups: group A (30 patients) treated with 525 mg ferrous sulphate three time a day per os for 3 weeks; group B (30 patients) treated with epoetin-alpha 10,000 UI twice a week and 525 mg ferrous sulphate 3 times a day. Grouping of patients has been randomized. In both groups hemoglobin, hematocrit, reticulocytes, iron values, ferritine, transferrine, and serological values, have been evaluated sequentially before treatment, before surgery, day of operation, 1st, 2nd, 3rd, 7th postoperative days and at discharge. RESULTS: In group A 86% patients needed blood transfusion (26 out of 30); in group B only 3% of patients needed blood transfusion (1 patient). One year follow up didn't show side effects related to epoetin-alpha. CONCLUSIONS: This study confirms the real effectiveness of epoetin-alpha in reducing the postoperative need for homologous blood transfusion. No side effects due to epoetin-alpha treatment have been proved. The conclusion is drawn that epoetin-alpha can be used as an alternative to blood transfusion or in association with predeposit and in the treatment of basal anemia.

Left ventricular rupture after mitral valve replacement in a patient with osteogenesis imperfecta tarda.

We describe the case of a patient with osteogenesis imperfecta tarda (Lobstein's syndrome) and mitral valve insufficiency. The course after mitral valve replacement was complicated by rupture of the left ventricular posterior wall, which caused massive bleeding and sudden death. The pathologic findings and the operative problems are discussed.

Stanford type A aortic dissection. A new surgical approach.

We describe a new surgical technique adopted for the repair of Stanford type A aortic dissection. In order to minimize the risk of malperfusion caused by retrograde flow during cardiopulmonary bypass, we avoid femoral artery cannulation. On the hypothesis that it is best not to interfere with the hemodynamics of the dissection, we cannulate the dissected ascending aorta, in either the true or false lumen. We here report 2 cases of successful surgical treatment of Stanford type A aortic dissection. In both cases, the false lumen was cannulated under deep hypothermic circulatory arrest, without clamping the aorta. While the patient was cooling, a 10-mm GORE-TEX side arm was sutured to a Dacron graft prosthesis. Repair of the aortic arch was carried out 1st. The aortic cannula was inserted into the GORE-TEX side arm, the tubular prosthesis was cross-clamped, and cardiopulmonary bypass was reinstituted. After this, the aortic bulb was repaired as usual and the tubular prosthesis was sutured to the bulb. No postoperative cerebral complication occurred. Our experience must be confirmed by more cases and a longer follow up.

Subacute left ventricular free wall rupture complicating acute myocardial infarction. Successful surgical repair with a sutureless technique.

The high mortality index related to surgical therapy with direct suture of rupture of left ventricular free wall following acute myocardial infarction, suggested we analyze and use alternative techniques. So we applied sutureless technique described by Padro to two patients. We used a Teflon patch fixed to the ventricular wall with a biocompatible synthetic glue, an ethyl-2-cyanoacrylate monomer, without any direct suturing of the infarcted myocardium. The two patients survived the operation and were discharged from the hospital 12 and 14 days after surgery. The sutureless technique allows, in our opinion, a more confident and safe aggressive attitude to subacute left ventricular free wall rupture.

Circumferential dissection of the ascending aorta with intimal intussusception. Case report and review of the literature.

The present report describes an unusual case (apparently the 10th in the world literature) of a type-A aortic dissection with full circumferential detachment of the ascending aortic intima and intussusception thereof into the aortic arch and descending aorta, partly occluding the arch vessels. Computed tomographic scanning and 2-dimensional echocardiography failed to detect an intimal flap and a false lumen in the ascending aorta. Aortic dissection was visualized by aortography. The ascending aorta was surgically repaired and the aortic valve resuspended. The pertinent literature is reviewed.

The "fully no-touch" technique for the internal thoracic-coronary artery anastomosis.

Extreme technical accuracy is crucial in coronary artery surgery. Although late graft patency depends mostly upon the patient's own biochemical status in chronic ischemic patients who have undergone elective surgery, graft disease is certainly promoted by an inaccurate technique or by careless arterial harvesting, which may cause both intimal lesions and anastomotic strictures. We describe a technique of internal thoracic-coronary artery anastomosis that fully prevents contact between vessels and surgical instruments. In order to enable the suturing of a fully dilated vessel, intracoronary papaverine is injected into the clamped aortic root while the heart is still beating and before systemic cooling begins. The suturing technique applies some microvascular principles, the chief being a high number of stitches incorporating the least amount of tissue, to avoid bulk.

Initial experience of mitral valve replacement with total preservation of both valve leaflets.

We compared a series of 7 consecutive patients who underwent mitral valve replacement with preservation of both leaflets to a control group of 97 patients who underwent standard mitral valve replacement at our institution during the same period. Use of inotropic drugs and duration of postoperative intensive care were compared and shown to be markedly reduced in the study group; however, statistical analysis was not applied due to the small number of patients. Comparison of the available pre- and postoperative echocardiographic values showed a decrease in left ventricular end-diastolic and end-systolic diameters in patients with preserved leaflets, particularly in those with mitral regurgitation of degenerative origin.

[Doppler echocardiographic evaluation of functional parameters of mechanical and biological valve prostheses]. / Valutazione tramite ecocardiografia-Doppler dei parametri funzionali di protesi valvolari meccaniche e biologiche.

We studied and compared functional parameters in 314 valvular prostheses. The following parameters have been calculated: mean transvalvular gradients for aortic and mitral prostheses and functional area by Pht (pressure half time) for mitral prostheses. All patients with important depression in myocardial function, tachycardia or malfunctioning prostheses were excluded. 173 prostheses were in aortic position and 141 in mitral position. Mitral prostheses were: 31 biological and 110 mechanical. We subdivided mechanical prostheses in monoleaflet (Omnicarbon, Sorin-Carbocast and Allcarbon, Medtronic, Bjork-Shiley) and bileaflet (Sorin-Bicarbon, St. Jude). These three groups were compared: mean transvalvular gradients and area showed no differences. Aortic prostheses were: 33 biological and 140 mechanical; mechanical prostheses were subdivided in two groups: monoleaflet (Sorin Allcarbon e Carbocast, Bjork-Shiley, Medtronic, Omnicarbon) and bileaflet (Sorin-Bicarbon, St. Jude). Mean transvalvular gradients of these three groups were compared within each group for every size: bileaflet prostheses demonstrated inferior gradients than biological and monoleaflet for 19-21 and 23 sizes; in superior sizes there were no significant differences. Further analysis showed a significant correlation among gradients and body surface area in the 21 size prostheses (p = 0.004). Bileaflet prostheses in this subgroup showed less increase in mean gradient with surface area than mechanical and biological ones.

[Serial Doppler echocardiography follow-up studies in the postoperative evaluation of severe pulmonary hypertension following surgery for mitral and mitral-aortic defects]. / Valutazione postoperatoria del comportamento della ipertensione polmonare grave nei vizi mitralici e mitroaortici tramite controlli seriati con ecocardiografia Doppler.

Between January 1987 and December 1991 26 patients with mitral and mitro-aortic disease and severe pulmonary hypertension (> or = 60 mmHg) were subjected to surgery. In 22 patients we have studied systolic pulmonary pressures by echocardiography-Doppler examination at 3-6 and 12 months from surgery. We noticed a decrease in pulmonary pressure values in all patients within 3 months from surgery (mean values pre-op 75 +/- 12.14; mean values post-op 42 +/- 11.26); within 6 months from surgery physiological values were reached in all patients (mean values 35 +/- 5.3). We have further divided patients in two subgroups: group A with pulmonary pressures superior or equal to 80 mmHg (mean values 90.00 +/- 17.32) and group B With pressure values between 60 and 79 mmHg (mean values 69.12 +/- 3.64). The first Doppler evaluation demonstrated a greater decrease in group B (mean values 37.8 +/- 6.5 versus 57 +/- 12.4); at the second control there was no statistically significant difference between the two groups (group A 36 +/- 5.48, group B 33.33 +/- 5.37). The only two operative deaths were caused by the pre-op cardiogenic shock. There has been no late mortality among survivors, 22 in NYHA Class I and 2 in NYHA Class II. Pulmonary hypertension decreases after surgery independently of the adopted procedure (replacement, repair or lysis).

Emergency surgical treatment for total left main coronary artery occlusion. A report of 2 cases.

Treatment of total left main coronary artery occlusion is rarely reported (84 chronic and acute cases in the world literature), due to the high mortality rate from massive myocardial infarction. Acute occlusions have been treated with intracoronary streptokinase, with percutaneous transluminal coronary angioplasty, or with both. To date, there has been no report of successful surgical revascularization in an acute case. We present 2 cases of surgically treated patients who survived total left main coronary artery occlusion that appears to have been acute, or acutely evolving. Both patients had an 80% or greater stenosis of the right coronary artery, yet have remained in New York Heart Association functional class I or II postoperatively. We attribute this not only to the aggressive surgical approach, which enabled reperfusion to be achieved within 2 hours of total occlusion, but to the protective effect in these patients of right coronary-to-left anterior descending collaterals.

Surgical management of intracardiac myxomas. A 16-year experience.

Twenty-six patients with an intracardiac myxoma underwent surgical resection at our institution from 1977 through 1992. Left atrial myxoma was diagnosed in 22 patients, left ventricular in 1, right atrial in 2, and right ventricular in 1. Six patients were asymptomatic; preoperative symptoms included dyspnea, arrhythmias, embolic episodes, and syncope. The diagnosis was established with transthoracic echocardiography in all cases but one. Surgery was performed in all cases with the aid of cardiopulmonary bypass with moderate hypothermia and cold crystalloid cardioplegia. One patient with a left ventricular myxoma died in a comatose state during the immediate postoperative period. Long-term clinical and echocardiographic evaluation was performed in 19 patients; results were excellent (all the patients were in New York Heart Association functional class I or II), and no recurrences were documented. The clinical characteristics, diagnostic methods, and surgical approach are presented and discussed.

Ten years of surgery of aortic dissections and aneurysms. Clinical experience and original contributions.

From January '82 to April '91, 117 patients with aortic disease were operated upon at our University Hospital in Genoa, Italy. Thirty-seven had arch dissections or aneurysms; 66 had acute aortic dissection type A and 14 had aortic dissections or aneurysms type B, acute and chronic. Patients with arch or type B aortic pathology but without surgical indication and cases of post-traumatic aortic transections are not included. There were 84 male and 33 female patients with a mean age of 52 (6 min and 74 max). In the acute patients, the mean interval between clinical onset and surgery was 34 hours (6 min-72 max). All patients with primary arch disease had surgical repair with the aid of deep hypothermia and circulatory arrest (17-96 min). Type A dissections were treated with standard CPBP at 28 degrees C. Surgical techniques included direct suture of intimal tear alone, direct suturing of the two aortic stumps; interposition of Dacron tubular prosthesis; Bentall repair; separated valve and aortic replacement; an original aortic bulb aortoplasty with valve repair; arch replacement with resuturing of one or more aortic trunks. Human fibrin glue (Tissucol) was employed either as haemostatic agent, widely spread over the suture lines or as tissue adhesion agent between dissected aortic layers. Human fibrin glue is adopted because it gathers high glueing capacity and maintenance of the elastic property of the vessel wall. Hospital mortality (30 days) has been 25% in ascending aortic dissections (16/66 patients) and 50% in patients with arch disease (18/37 patients) who needed circulatory arrest. Late mortality 5/83 (6%). Reoperations for aortic valve insufficiency or re-dissection have been 7 (8.4%). Early diagnosis (increasing reliability of 2D-Echo and CT scans), aggressive surgery, meticulous myocardial and cerebral protection and introduction in clinical use of biological glues seem to be the milestones of present and further improvements in surgical results.

Coronary occlusion secondary to blunt chest trauma: a first attempt at balloon angioplasty.

There have been only 58 angiographically documented reports of transmural myocardial infarction due to closed-chest trauma. None of these cases has been treated by percutaneous transluminal coronary angioplasty. We report the case of a 40-year-old man who developed an anterior-wall myocardial infarction secondary to blunt chest trauma suffered in an automobile accident. Angiographic study performed 2 months after the injury revealed an isolated total obstruction of the left anterior descending coronary artery. The patient was judged a good candidate for balloon angioplasty, but total reocclusion occurred within 24 hours of the procedure and a 2nd attempt did not restore patency. Surgical revascularization was performed a week later. A year after his injury, the patient remains asymptomatic and is back at work. Despite the failure of percutaneous transluminal coronary angioplasty in its 1st application to coronary artery repair after blunt chest trauma, we believe it to be the treatment of choice in young patients and in single-vessel disease.

[Surgical results in mitral insufficiency: prognostic value of the indices of left ventricular function]. / Risultato operatorio nell'insufficienza mitralica: valore prognostico degli indici di funzione ventricolare sinistra.

Left ventricular function is a major prognostic factor in patients with mitral regurgitation, but the ability of echocardiographic and hemodynamic parameters to predict the surgical result is controversial. We investigated the prognostic role of various pre-operative indices of left ventricular function in 23 consecutive patients who underwent successful surgical correction of chronic mitral regurgitation. At a mean follow-up of 20 +/- 16 months, patients underwent echocardiography and radio-nuclide angiography and were grouped according to the post-operative left ventricular ejection fraction. Group A was made up of 16 patients with a left ventricular ejection fraction greater than or equal to .45: they showed post-operative reduction of the left ventricular end-diastolic diameter (from 36.3 +/- 3.2 to 30.5 +/- 4.5 mm/m2; p less than .001) and of the radius/thickness ratio (from 3.5 +/- 0.6 to 2.9 +/- 0.6; p less than .01). In 7 patients (group B), post-operative left ventricular ejection fraction was less than .45 and no significant changes in the left ventricular end-diastolic diameter (from 41.5 +/- 2.7 to 36.9 +/- 6.1 mm/m2; NS) or the radius/thickness ratio (from 3.9 +/- 0.9 to 3.4 +/- 1.0; NS) were observed. During the follow-up all group A patients remained asymptomatic or minimally symptomatic, whereas 2 group B patients died of refractory left ventricular failure. Pre-operative left ventricular volumes and diameters, both at end-diastole and end-systole, were significantly greater in group B patients.(ABSTRACT TRUNCATED AT 250 WORDS)