Patient's Peak Skin Dose evaluation using Gafchromic films in interventional cardiology procedures and its correlation with other dose indicators.

OBJECTIVE: Number and complexity of interventional cardiology procedures have increased during last years and can result in patient skin dose high enough to cause deterministic skin effects. The aim of the work is to investigate the correlation between Peak Skin Dose (PSD) and the dosimetric indicators directly registered by the radiological equipment and provide the physicians a tool to identify patients at risk of deterministic effects and include them into a follow-up program. METHODS: PSD was measured in vivo using radiochromic Gafchromic XR-RV3 films, properly calibrated. DAP, Cumulative Dose at the interventional reference point (CD) and exposure time of each procedure were retrieved from the Radiation Dose Structured Reports created by an Allura Clarity Xper FD20 angiographic system. Linear correlation between PSD and both DAP and CD was investigated. RESULTS: 42 interventional cardiology procedures (16 CA and 26 PTCA) were involved in the study. The dosimetric indicators values for PTCA are generally higher than those for CA, due to the different levels of procedure complexity. Mean PSD values were (103 ±â€¯64) and (526 ±â€¯436) mGy for CA and PTCA procedures. For CA, we found strong correlation both between PSD and DAP (r = 0.753) and PSD and CD (r = 0.782). For PTCA, good correlation both for DAP (r = 0.648) and CD (r = 0.649) was found. CONCLUSIONS: DAP and CD show strong correlation with PSD measured with Gafchromic films during interventional procedures. The proposed method allows the physician to estimate patient's PSD from the dosimetric indicators that the radiological equipment display and record at the end of the procedure.

Innovative DES technologies from Meril.

Technological advances and rise in global urbanity have paradoxically led to an increase in the incidence of metabolic syndrome and thankfully also in diagnosis and treatment of coronary artery disease. "Necessity is the mother of invention" - remarked Plato and this statement could not have had a better place than in the field of angioplasty and stenting. Interventional cardiology still continues to remain a busy place for smart, iterative changes leading to better treatment options. This article sketches contemporary trends in coronary stent engineering borne out of unmet clinical needs ranging from novel ultra-thin strut designs marrying biodegradable polymeric drug eluting platforms to anatomically tapered stents and finally the intuitive bioresorbable vascular scaffolds which promise freedom from full metal jacket.

Safety of percutaneous left heart catheterization directly performed by cardiology fellows: a cohort analysis.

BACKGROUND: No previous study has analyzed the possible responsibility of fellows-in-training in terms of the risk of complications during cardiac catheterization. Thus, we sought to identify possible risk factors for access site complications following cardiac catheterization procedures, with particular attention to the role of cardiology fellows. METHODS: A total of 1,288 left heart catheterization procedures (both diagnostic and interventional), performed over a 1-year period at a university hospital, were retrospectively evaluated to determine the incidence of local complications (pseudoaneurysm, arterio-venous fistula, major hematoma or bleeding, vascular dissection). Several clinical (age, gender, previous coronary artery bypass surgery, indication to the exam) and procedural (procedure performed by the fellow, access site, type of procedure, urgent setting, use of glycoprotein IIb/IIIa inhibitors, simultaneous right heart catheterization, use of closure devices) covariables were considered. Major adverse cardiovascular and cerebrovascular events (MACCE: death, myocardial infarction, cerebrovascular event) were also assessed. RESULTS: The overall access site complication rate was 2.6%. On multivariate regression analysis, the only two predictors of local complications were female gender (odds ratio [OR] 3.2, 95% confidence interval [CI] 1.6-6.5) and femoral approach (OR 3.9, 95% CI 1.2-12.1). The rate of MACCE was 1.2%, mainly after percutaneous coronary interventions, with only 1 death overall (0.07%). Procedures performed by cardiology fellows were not associated with an increased incidence of either complication. CONCLUSIONS: Cardiology fellows can safely perform cardiac catheterization procedures without an increase in the rate of local and major cardiovascular complications. Of course, the presence and watchful supervision of an attending physician is still essential to ensure both patient safety and optimal training.

Prevalence and severity of airway obstruction in an Italian adult population.

BACKGROUND: This study sets out to estimate the prevalence and the degree of severity of bronchial obstruction in an adult population with three different diagnostic criteria: the European Respiratory Society (ERS), the American Thoracic Society (ATS), and the World Health Organization (WHO) defined as Global Obstructive Lung Disease (GOLD). METHODS: 1514 subjects underwent complete medical evaluation and spirometry. RESULTS: The prevalence of bronchial obstruction was respectively 27.5 % (ERS), 33% (GOLD), and 47.3 % (ATS). The prevalence of bronchial obstruction in the smoker group was 33.4% (ERS), 38.1% (GOLD), and 52.3% (ATS). The prevalence of obstruction in the ex-smoker group was 33% (ERS), 41.4% (GOLD), and 57.1% (ATS). The prevalence of obstruction in the non-smoker group was 21.1% (ERS), 24.9% (GOLD), and 38.6% (ATS). CONCLUSIONS: The results show that the prevalence of airway obstruction increases proportionally with age; the cigarette smoking represents an important conditioning factor. These observations warrant the necessity of a more complete and multi-parametric analysis in the evaluation of patients with airway obstruction using methodologies that explore the functional state and the risk factors that cause the airway obstruction.

Cyclooxygenase-2 expression in oral squamous cell carcinoma.

Cyclooxygenase (COX), the key enzyme in prostaglandin cascade, is expressed in two isoforms: the constitutive COX-1 and the inducible COX-2. Hyper-expression of COX-2 has been implicated in the pathogenesis of colon-rectal cancer in humans but it appears to play a significant role as a tumour progression factor also in other forms of human cancer, including oral cancer. The aim of this study was to analyze the expression of COX-2, at the protein level, in 45 cases of oral squamous cell carcinoma. Standard immunohistochemical streptavidin-biotin peroxidase analysis was carried out with highly specific antibody against human COX-2 and cell specific markers, in 45 oral squamous cell carcinomas. Our study revealed a moderate to high COX-2 expression in 35 out of the 45 oral squamous cell carcinoma specimens (77.8%). COX-2 expression appeared particularly abundant in the superficial ulcerated layers of relatively well differentiated carcinomas. However, we were unable to assess any statistically significant association between COX-2 hyper-expression and tumor site, tumor grading, tumor size, presence of lymph node metastases, tumor stage and age at onset, respectively. Interestingly, COX-2 expression was detected not only in areas of epithelial dysplasia adjacent to the primary layers (86% of the cases) but also in normal-appearing epithelium at the boundaries of squamous cell carcinoma (77%), indicating a possible involvement in tumour progression by the apparently normal tissue surrounding the lesion. Moreover, intense COX-2 staining was observed in endothelial cells of intra-tumour vessels and extra-tumour vessels adjacent to the tumour nests, in a high proportion of cases (82%). COX-2 positivity was associated with CD34 and VEGF positivity, indicating that these vessels were probably neo-formed ones. From this study as well as from other works, it appears that indeed COX-2 is over-expressed in this important human malignancy. However, further studies are necessary to understand the exact magnitude of this over-expression and, mostly, the possible role of COX-2 in the pathogenesis and progression of oral cancer.

Radial versus femoral approach for percutaneous coronary diagnostic and interventional procedures; Systematic overview and meta-analysis of randomized trials.

OBJECTIVES: We sought to compare, through a meta-analytic process, the transradial and transfemoral approaches for coronary procedures in terms of clinical and procedural outcomes. BACKGROUND: The radial approach has been increasingly used as an alternative to femoral access. Several trials have compared these two approaches, with inconclusive results. METHODS: The MEDLINE, CENTRAL, and conference proceedings from major cardiologic associations were searched. Random-effect odds ratios (ORs) for failure of the procedure (crossover to different entry site or impossibility to perform the planned procedure), entry site complications (major hematoma, vascular surgery, or arteriovenous fistula), and major adverse cardiovascular events (MACE), defined as death, myocardial infarction, emergency revascularization, or stroke, were computed. RESULTS: Twelve randomized trials (n = 3,224) were included in the analysis. The risk of MACE was similar for the radial versus femoral approach (OR 0.92, 95% confidence interval [CI] 0.57 to 1.48; p = 0.7). Instead, radial access was associated with a significantly lower rate of entry site complications (OR 0.20, 95% CI 0.09 to 0.42; p < 0.0001), even if at the price of a higher rate of procedural failure (OR 3.30, 95% CI 1.63 to 6.71; p < 0.001). CONCLUSIONS: The radial approach for coronary procedures appears as a safe alternative to femoral access. Moreover, radial access virtually eliminates local vascular complications, thanks to a time-sparing hemostasis technique. However, gaining radial access requires higher technical skills, thus yielding an overall lower success rate. Nonetheless, a clear ongoing trend toward equalization of the two procedures, in terms of procedural success, is evident through the years, probably due to technologic progress of materials and increased operator experience.

Bronchial hyperresponsiveness in adults with seasonal and perennial rhinitis: is there a link for asthma and rhinitis?

Epidemiological studies have shown that asthma and rhinitis often coexist in the same patients and the prevalence of asthma is greater in patients with rhinitis. The aim of this study was to evaluate the differences in bronchial reactivity in subjects with seasonal and perennial rhinitis. We enrolled 128 subjects with seasonal or perennial allergic rhinitis divided into three groups: A with perennial rhinitis and allergy to Dermatophagoides Pteronissynus; B with seasonal rhinitis and allergy to Graminae and Parietaria, who underwent methacholine challenge test (MCHt) during the exposure period (fron March until May); C with seasonal rhinitis and allergy to Graminae and Parietaria, who underwent MCHt during the non exposure period (from June until February). The PC20 mean values of group A (1774.8 ± 20.7) and group B (1740.7 ± 38.8) were not significantly different, but significantly lower than those of group C (3010.0 ± 56.9) (p=0.001). The subjects with group A were positive to the MCHt in 54.54%, against 29.28% of group B and 11.62% of group C (p=0.007). The results show differences in the degree of bronchial responsiveness. The dose-response curves documented a lower value of PC20 in the group with perennial rhinitis and a statistically significant difference of bronchial hyperresponsiveness prevalence between the three groups (p=0.007).

The role of antileukotrienes in the treatment of asthma.

Cysteinyl leukotrienes (Cys-LTs) are mediators released in asthma and are both direct bronchoconstrictors and proinflammatory substances that mediated several steps in the pathophysiology of chronic asthma, including inflammatory cells recruitment, vascular leakage, and possibly airway remodelling. Available evidence from clinical trials and real world experience derived from managing patients with asthma justifies a broader role for antiLTRAs in asthma management than that recommended in the National Asthma Education and Prevention Programm (NAEPP) and National Health Lung and Blood Institute (NHLBI) treatment guidelines. Leukotriene-receptor antagonist drugs (LTRAs) seem to be effective alternatives to inhaled corticosteroids (ICS) either as monotherapy or as adjunctive therapy that reduces the need for higher doses of ICS in patients with mild-to-moderate persistent asthma. LTRAs may be used as adjunctive therapy for al levels of disease severity because they are effective in combination with ICS during long-term maintenance therapy. The agents seem especially effective in preventing aspirin-induced asthma, exercise-induced asthma (EIA) and they may provide an additional advantage of reducing nasal congestion in patients with both asthma and rhinitis.

Seasonal variability of non-specific bronchial responsiveness in asthmatic patients with allergy to house dust mites.

The aim of the study was to assess the seasonal variability of non-specific bronchial responsiveness to methacholine in allergic asthma. One hundred sixty-five patients (83 male and 82 female) entered the study: 86 subjects (group A) with allergy exclusively to mites and 79 (group B) with concomitant allergy to pollens, e.g., "Graminae" and "Parietaria." Inclusion criteria were the absence of sensitization to other allergens, no smoking habit, withdrawal from steroids, bronchodilators, sodium cromoglycate, and antihistamines for at least four weeks before enrollment, FEV1 > 70% of the predicted value, and absence of other respiratory diseases and of upper and lower respiratory tract infections for at least one month before the methacholine challenge. None of the patients had been previously treated with specific immunotherapy. Subjects of each group (A and B) underwent methacholine challenge at first visit and were divided into four subgroups according to the period when the challenge was performed. Subgroups A1 and B1 performed the challenge in December, January, and February; subgroups A2 and B2 in March, April, and May; subgroups A3 and B3 in June, July, and August; subgroups A4 and B4 in September, October, and November. PD20 values were expressed as the natural logs of the cumulative dose of methacholine causing at least a 20% fall in FEV1. Statistical analysis was carried out using multiple group analysis and Student's t-test. Results showed that the highest non-specific bronchial responsiveness was observed in autumn (ln PC20 = 4.54 +/- 1.51) in patients allergic to mites only (group A), and in summer (ln PC20 = 4.72 +/- 2.11) in those of group B. Multiple group analysis showed statistical significant differences between subgroups within each group (group A, p = 0.039; group B, p < 0.001). In patients allergic exclusively to house dust mites (group A), multiple comparisons and Student's t-test showed statistically significant differences between non-specific bronchial responsiveness (NSBR) assessed in autumn and those of other seasons (winter, p = 0.002; spring, p < 0.001; summer, p = 0.082). These results confirm that the level of allergen exposure may influence NSBR. Mite-allergic patients showed an increase of NSBR in autumn, possibly as a consequence of higher indoor mite concentration. However, mite- and grass-allergic patients had wider variations of NSBR, possibly reflecting changes in seasonal pollen concentration.

Zafirlukast versus budesonide on bronchial reactivity in subjects with mild-persistent asthma.

Asthma is one of the most common chronic diseases in children and adults. Recent studies have shown that in asthmatic patients treated with inhaled corticosteroids there is a better disease’s control when adding a second drug, than increasing the corticosteroid’s dose. The aim of this study has been to evaluate the effectiveness and tolerance of zafirlukast, a leukotriene receptor antagonist, versus budesonide in clinically steady patients with mild persistent bronchial asthma. We have enrolled 36 subjects non smokers, with mild persistent bronchial asthma and 12 healthy subjects as control group. At the beginning of this study and at the end of the treatment (8 weeks), all patients underwent complete clinical work-up, pulmonary function testing (FEV1, PEF and FVC) and methacholine challenge test. The patients were divided into 3 groups: group A) 20 mg of zafirlukast twice a day; group B) 400 mg of budesonide twice a day; group C) 20 mg of zafirlukast twice a day and 400 mg of budesonide twice a day. Basal FEV1 and PEF presented no significant statistical differences between control subjects and patients of group A, B and C. After eight weeks there were no significant changes for FEV1 and PEF among the three groups. After therapy a strong significant increase of PD20 was documented in group A (p<0.005), group B (p<0.001) and group C (p<0.005), respect to baseline values. The antileukotriene drugs could be taken as an alternative drug, or in association with low-dose inhaled corticosteroids, in patients with mild persistent asthma, both for their clinical effectiveness and their easy ingestion, which is confirmed in compliance studies on inhaled steroids.

A prospective randomized trial comparing stenting to internal mammary artery grafting for proximal, isolated de novo left anterior coronary artery stenosis: the SIMA trial. Stenting vs Internal Mammary Artery.

OBJECTIVE: To compare coronary artery bypass grafting (CABG) with percutaneous transluminal coronary angioplasty (PTCA) in patients with proximal, isolated de novo left anterior descending coronary artery disease and left ventricular ejection fraction of 45%. PATIENTS AND METHODS: In the multicenter Stenting vs Internal Mammary Artery (SIMA) study, patients were randomly assigned to PTCA and stent implantation or to CABG (using the internal mammary artery). The primary clinical composite end point was event-free survival, including death, myocardial infarction, and the need for additional revascularization. Secondary end points were functional class, antianginal treatment, and quality of life. Analyses were by intention to treat. RESULTS: Of 123 patients who accepted randomization, 59 underwent CABG, and 62 were treated with stent implantation (2 patients were excluded because of protocol violation). At a mean +/- SD follow-up of 2.4+/-0.9 years, a primary end point had occurred in 19 patients (31%) in the stent group and in 4 (7%) in the CABG group (P<.001). This significant difference in clinical outcome is due to a higher incidence of additional revascularization in the stent group, the incidence of death and myocardial infarction being similar (7% vs 7%, respectively; P=.90). The functional class, need for antianginal drug, and quality-of-life assessment showed no significant differences. CONCLUSIONS: Both stent implantation and CABG are safe and highly effective treatments to relieve symptoms in patients with isolated, proximal left anterior descending coronary artery stenosis. Both are associated with a low and comparable incidence of death and myocardial infarction. However, similar to PTCA alone, a percutaneous approach using elective stent placement remains hampered by a higher need for repeated intervention because of restenosis.

Coronary stenting in unstable angina: angiographic and clinical implications.

BACKGROUND: The pathogenesis of unstable angina involves the presence of intracoronary thrombus which may have potential bearing on the therapeutic efficacy of intracoronary stenting to reduce acute complications and restenosis rate. METHODS: In order to evaluate in-hospital and long-term outcome of coronary stenting in patients with unstable angina, we retrospectively examined our experience in 311 consecutive patients. Braunwald class III angina (B or C) was present in 35% of the cases. Three hundred seventy one stents were implanted in 315 lesions, most of them (62.4%) with complex morphology. Angiography identified an intraluminal thrombus in 22 target sites. Stent indication was elective in 146 cases (46.9%), for suboptimal results in 149 (47.9%) and for bail-out in 16 (5%). RESULTS: Procedural success was obtained in 96.3% of the study population. Major complications occurred in 12 (3.7%) patients: myocardial infarction in 6 (1.9%) cases, emergency bypass surgery in 3 (0.9%) and death in 3 (0.9%), none of them related to acute stent thrombosis. Vascular complications occurred in 5 patients (1.6%). The mean hospital stay after stenting was 2.8 +/- 1.6 days. Subacute stent thrombosis occurred in one patient and led to a Q-wave anterior myocardial infarction. Follow-up (9 +/- 5 months) status was ascertained in 216 patients and revealed an overall clinical success rate of 87.3%. Restenosis occurred in 23.5% of 157 patients who underwent angiographic follow-up. Late events included 3 non-fatal myocardial infarction, 6 new PTCA, 3 elective bypass surgery and 1 cardiac death. CONCLUSIONS: Intracoronary stenting appears safe and effective in patients with unstable angina, despite the presence of a thrombogenic milieu. Optimal immediate angiographic results, related to the mechanical properties of stents, together with a vigorous antithrombotic regimen, contributes to the favorable outcomes in this adverse setting.

[Isolated infarction of the right ventricle caused by occlusion of the non-dominant right coronary artery. Role of sequential atrioventricular stimulation]. / Infarto isolato del ventricolo destro da occlusione di un'arteria coronaria destra non dominante. Ruolo della stimolazione atrioventricolare sequenziale.

AIM: Description of a case report. PATIENT: The case of a 66-year old woman with cardiogenic shock due to isolated acute right ventricular infarction caused by occlusion of a diminutive right coronary artery is described. RESULTS: Her ECG showed the presence of junctional rhythm and ST elevation in V1-V2 and right precordial leads. Despite infusion of plasma expanders, atropine and inotropic agents, clinical conditions did not improve, but success was only achieved by means of atrioventricular (AV) sequential pacing which allowed good hemodynamic stabilization of the patient. CONCLUSIONS: It is noteworthy that occlusion even of a diminutive right coronary artery can induce cardiogenic shock, and that restoration of the physiological AV synchrony--although somewhat impaired by prolonged atrial stunning--has a markedly positive effect on the hemodynamic balance.

[Coronary rotational atherectomy: initial experience at a hospital without a special department for heart surgery]. / Aterectomia rotazionale coronarica: esperienza iniziale in un ospedale privo di cardiochirurgia.

BACKGROUND: Percutaneous transluminal coronary angioplasty (POBA) of complex lesions is hindered by a lower success rate and a higher risk of complications. New devices are now available for treatment of this type of lesions (type B-C of the modified AHA/ACC classification). We present our experience in the treatment of calcified, ostial, angled and long coronary lesions by means of percutaneous transluminal coronary rotational ablation (PTCRA, Rotablator Heart Technology, Bellevue, Washington). MATERIAL AND METHODS: From June 1991 to November 1995 we performed 71 procedures of rotational atherectomy on 72 lesions in 62 patients. Twenty-three patients presented stable angina, 30 patients unstable angina and 9 silent myocardial ischemia. Thirty-five patients had single, 16 double and 11 triple vessel coronary artery disease. Left ventricular mean ejection fraction was 58 +/- 8%. The lesions attempted were classified as type A in 2 cases, B1 in 23 cases, B2 in 31 cases and C in 16 cases according to the AHA/ACC modified classification. Calcifications detected at coronary angiography were present in 66 lesions; 53 lesions were longer than 10 mm; 12 were more than 45 degrees angulated; 9 were at a bifurcation site and 3 were ostial in location. The vessels treated were in 1 case a protected Left Main Trunk, in 40 the Left Anterior Descending, in 9 the Circumflex and in 22 the Right Coronary Artery. We did not treat lesions containing visible thrombus or located on old saphenous vein grafts because of the high risk of peripheral embolization. An average of 2 +/- 1 burrs was used; the mean burr/vessel diameter ratio was 0.59 +/- .07. "Complementary" low pressure PTCA was performed in all but 4 cases ("stand alone procedure"). RESULTS: Primary success was obtained in 62/71 procedures (92%) and in 67/72 lesions (94%). There were two major cardiac events during the hospital stay: one death and one acute myocardial infarction which occurred respectively at four days and 48 hours after the procedure due to late occlusion of the vessel treated with primary success. In three cases the procedure was unsuccessful but uncomplicated: In one the stenosis could not be crossed, in a second case a residual stenosis > 50% was present, in a third case the procedure resulted in dissection and occlusion of a vessel served by good intercoronary collaterals. No emergency or elective coronary artery bypass surgery was necessary. Coronary spasm occurred in 6 cases (9%). In two of them spasm was refractory to intracoronary nitrates and Verapamil, and stent implantation was required. Urapidil, a selective alpha 1 blocker, completely abolished the occurrence of coronary vasospasm in the last 16 cases. A no reflow phenomenon was observed in two cases associated with mild CK-MB elevation. In conclusions: our experience suggests that rotational atherectomy performed on lesions with complex morphology, most of them calcified, is a safe and effective procedure which therefore can be undertaken even in hospitals without on site cardiac surgery. Our data on late restenosis are inconclusive because of the lack of angiographic follow up.

[Coronary angioplasty in an Italian hospital without on-site cardiac surgery: the results and outlook]. / Angioplastica coronarica in un ospedale italiano non provvisto di cardiochirurgia: risultati e prospettive.

BACKGROUND: The concept of the absolute need of surgical standby for coronary angioplasty, although still strongly supported by the Task Force of the AHA and ACC, has been changing over the years according to the developments of PTCA equipment and the introduction of autoperfusion balloon catheters and coronary stents. In many European countries and in Canada, due to the relative lack of institutions performing cardiac surgery, almost 40% of cardiac laboratories are now performing PTCA without on-site surgical standby. METHODS AND RESULTS: Following a previous experience in another institution with on-site cardiac surgery, since January 1991 until February 1994, 742 Patients underwent PTCA in our Hospital not provided with on-site cardiac surgery. Surgical standby was requested in 99 cases to nearby surgical centers and it was utilized in 6 cases. Primary success was achieved in 91% of stenoses (94% in non occlusive and 69% in totally occlusive lesions). The mortality rate in cases other than cardiogenic shock was 0.13%, the myocardial infarction rate was 1.2% and the rate of emergency coronary bypass operation was 0.8%. CONCLUSIONS: PTCA in our view, as well as others', can be successfully performed in Institutions without on-site surgical support, provided the cardiac team has achieved a satisfactory experience and skill, the correct equipment for treatment of occlusive complications is available and a nearby surgical institution is alerted for procedures considered at particular risk, due to the amount of myocardium in jeopardy in case of irreversible arterial occlusion.

[Does coexistence of involvement of the right dominant coronary artery differentiate clinical features of disease of the common trunk from disease of 3 coronary vessels?]. / La coesistenza di compromissione di una coronaria destra dominante discrimina il quadro clinico della malattia del tronco comune da quello della malattia dei tre vasi coronarici?

We have studied clinical and ECG stress features of 119 patients with left main disease and 113 matched patients with three vessels coronary disease. Clinical features and ECG stress test do not differentiate the two groups as a whole. Exercise time duration was shorter, ST criteria were more positive, and peak heart rate was lower in the subgroups of patients with left main and involvement of a right dominant coronary artery. However due to a large overlap these criteria do not seem to be clinically useful. In conclusion, in an individual patient angina and stress ECG criteria do not differentiate the patients with left main from those with three vessels coronary artery disease.

[The long-term results in multiple procedures on the heart valves]. / Risultati a lungo termine nelle procedure multiple sulle valvole cardiache.

In the period 1972-1988, 209 patients (81 males, 128 females, mean age 42.4 +/- 11.9, range 20-71 years) underwent surgery for multiple valve repair (MVR) at the Italian Institution of Cardiac Surgery. Ninety-five patients had previously undergone mitral commissurotomy (MC). NTHA function class was III-IV in 89% of the patients. The procedures were: aortic valve replacement (AVR) + MC (63 patients; 30.2%), mitral valve replacement (MVR) + tricuspid valvuloplasty (TRVPL) (57 patients; 27.4%), AVR + MVR (50 patients; 24%), AVR + MVR+TRVPL (22 patients; 10.5%), AVR + CM + TRVPL (6 patients; 2.8%), AVR + mitral valvuloplasty (6 patients; 2.8%), AVR-TRVPL (2 patients; 0.9%), AVR + MVR + tricuspid valve replacement (2 patients; 0.9%), AVR + MVR + TRVPL + ventriculoplasty (1 patients; 0.5%). The inserted valves were mostly (147/209) Bjork-Shiley tilting disc type. The mean cardiopulmonary bypass (CPB) time was 119.6 +/- 53.9 and the mean aortic clamp time was 69.2 +/- 31.6. A complete follow-up was possible in 158/209 patients (75%) with a mean observation time of 8.11 +/- 4.92 years (total of 778 patients years). Thromboembolism was defined as the cause of any new focal neurologic deficit. All cases of peripheral embolisation were considered to be valve-related. The valve related early and late complication are as follow: fifteen patients in NYHA class III-IV, died perioperatively (7%). We had a thrombotic encapsulation of valve in one patient who required a redo operation after 8.25 years, 6 cases of thromboembolism in patients who interrupted anticoagulants (2 deaths), 4 cases of prosthetic leak, 8 cases of prosthetic valve endocarditis (1 death) 9 cases of anticoagulant-related hemorrhage (2 deaths).(ABSTRACT TRUNCATED AT 250 WORDS)

[Autohemotransfusion in cardiac reoperations]. / Autoemotrasfusione nei reinterventi in cardiochirurgia.

OBJECTIVE: To evaluate the efficacy of intraoperative autotransfusion with hemodilution (AHT) to reduce postoperative transfusion of blood or blood products (BT) after cardiac surgery reoperation. DESIGN: Retrospective study, follow-up control. SETTING: Italian Institution of Cardiac Surgery (IICC). PATIENTS: 169 patients (51 males, 118 females; mean age 49.5 years) undergoing a reoperation from May 1982 to December 1991. INTERVENTIONS: 143 patients single valve replacement, 16 patients double valve replacement and 10 patients radical correction for tetralogy of Fallot. AHT (mean 620.2 +/- 226.9 ml) was performed in all patients. The shed blood was reinfused at the end of the surgery. PT, PTT, TT, TT Coagulase, FDP, pre- and postoperative platelet count, bleeding and needs for BT were recorded. RESULTS: Preoperatively: PT 71.3 +/- 8.1, PTT (sec.) 36.9 +/- 3.5, TT (sec.) 16.2 +/- 2.3, TTC (sec.) 16.9 +/- 1.7, FDP (ng% ml) 3.8 +/- 2.7, Platelet count (No./mu 11 170 +/- 58. Postoperatively: PT 36.5 +/- 6.5, PTT(sec.) 49.5 +/- 8.7, TT(sec.) 19.1 +/- 1.8, TTC(sec.) 18.9 +/- 2.1, FDP (ng% ml) 13.5 +/- 8.9, Platelet count (No./mu 11) 85 +/- 34. We had one reentry because of bleeding. The mean units of blood or blood products need after surgery were 2.2 +/- 1.02. Bleeding from the drainage was 105.2 +/- 103.8. Two patients died in the postoperative period because of low output syndrome. In a period of one year of F.U. we had only one patient with hepatitis B. CONCLUSIONS: These data suggest that AHT is a safe method, reduces needs for banked blood or blood products, risks of infectious disease transmission and of immunologic reactions and presents hemorheologic benefits because of the diminished blood viscosity.

Long-term follow-up of cardiac myxomas (7-31 years).

Between 1961 and 1985, 14 patients (9 males, 5 females; mean age 42.3 +/- 7.26 years) underwent surgery for excision of cardiac myxoma. Origin of the neoplasm was left atrium in all patients. In the last 7 cases diagnosis was obtained by echocardiographic examination. The clinical manifestations were dyspnea in 8 cases, palpitation in 5 and neurological symptoms in 3. One patient with concomitant mitral and aortic incompetence died on the 13th postoperative day because of low-output syndrome. All 13 operative survivors are alive and well without echocardiographic evidence of neoplastic recurrence at a follow-up ranging from 7 to 31 years. These results indicate a low incidence of recurrence with a complete tumor excision even without its extension to the normal atrial endocardium.

[The optic pathways: a magnetic resonance study at 1.5 tesla. I. Anatomy]. / Le vie ottiche: studio mediante Risonanza Magnetica da 1,5 tesla. Prima parte: anatomia.

The authors retrospectively examined one hundred and twenty-nine patients who had undergone MR examination of the sellar, parasellar and orbital regions, to evaluate MR capabilities in demonstrating the optic pathways and their relationship to the most important anatomical structures nearby. T1-weighted images allowed a very good evaluation not only of the optic pathways as a whole, but also of the intracanalicular and intracranial segments of the optic nerve; the optic tracts and geniculate bodies were also clearly demonstrated. Optic radiations were clearly visible on both T1- and T2-weighted images. The orbital portion of the optic nerve could be evaluated with T1-weighted images, which showed its external profile. However, only multi-echo T2-weighted images allowed the nerve to be differentiated from perineural spaces, filled with cerebrospinal fluid, thus giving a true cisternographic effect.