Twenty-four hour hyperinsulinemic-euglycemic clamp improves postoperative nitrogen balance only in low insulin sensitivity patients following cardiac surgery.

BACKGROUND: Critically ill patients often suffer from a protein catabolic state. The aim of this study was to demonstrate that nitrogen balance (NB) in cardiac patients admitted to the intensive care unit (ICU) is related to their insulin sensitivity level and that supraphysiologic doses of insulin can restore anabolism. MATERIALS AND METHODS: Twenty-eight patients that were admitted to ICU in enteral and/or parenteral nutrition have been enrolled in this study. All patients received a standard nutrition protocol for at least 3 days before starting the study. These patients received either enteral or parenteral nutrition based on 1.4 kcal/kg/h and 1.1 g/kg/24 h of proteins. Participants were studied for three 24 h periods (P1 , P2 , and P3 ). Twenty-four hour NB was calculated from urinary urea nitrogen excretion, fixed protein and energy intake during each of the three periods (P1 , P2 , and P3 ). Simultaneous to P2, a 24 h hyperinsulinemic-euglycemic clamp (HEC) was performed to determine patients' insulin sensitivity (IS) or insulin resistance (IR), as well as the impact of high doses of insulin on NB. RESULTS: Nitrogen balance remained consistently positive in the IS group regardless of the clamp. In IR patients, NB was negative before the clamp and became positive during P2 and P3 . Insulin sensitivity improved during the HEC in IR patients (P < 0.001). CONCLUSIONS: A negative NB was found only in insulin resistant patients admitted to the ICU for more than 7 days. A 24-h period HEC improved NB in these patients.

Cryoballoon ablation for atrial fibrillation guided by real-time three-dimensional transoesophageal echocardiography: a feasibility study.

AIMS: Cryoballoon ablation (CBA; Arctic Front, Medtronic) has proven very effective in achieving pulmonary vein isolation. Real-time three-dimensional transoesophageal echocardiography (RT 3D TEE) is a novel technology, which permits detailed visualization of cardiac structures in a 3D perspective. The aim of the present study was to assess the feasibility, advantages, and safety of RT 3D TEE in guiding CBA in a series of patients affected by paroxysmal atrial fibrillation. METHODS AND RESULTS: Forty-five patients (34 males, mean age: 63 ± 12 years) underwent CBA guided by 3D TEE. A total of 190 veins could be documented by TEE. Real-time three-dimensional transoesophageal echocardiography successfully guided the operator to position the CB in the pulmonary vein (PV) ostium and obtain complete occlusion in all 190 (100%) veins. Transoesophageal echocardiography identified leakages in 25 (13%) veins led to successful elimination of PV-left atrium (LA) backflow by guiding correct balloon repositioning. In four (2%) veins, this imaging tool led to perform successful pull-down manoeuvres. After a mean 2.6 ± 1.4 applications, isolation could be documented in 190 (100%) PVs. Median procedural and fluoroscopy times were 145 and 24 min. During a median follow-up of 278 days, 37 (82%) patients did not experience atrial fibrillation recurrence following a 3-month blanking period. CONCLUSION: Cryoballoon ablation is safe and feasible under RT 3D TEE guidance. This imaging tool permits perfect visualization of all PV ostia and neighbouring LA structures. Most importantly, it proved very efficient in guiding the operator to achieve complete occlusion and successful isolation in all veins.

Correlation between pre-operative metabolic syndrome and persistent blood glucose elevation during cardiac surgery in non-diabetic patients.

BACKGROUND: Cardiopulmonary-bypass (CPB) induces hyperglycemia. There is growing evidence that perioperative maintenance of blood glucose within the physiological range improves patients' outcome. Nevertheless, perioperative normoglycemia is often difficult to achieve during surgery with CPB and the response to insulin infusion is characterized by a considerable variability. The aim of this study was to determine to what extent the presence of pre-operative metabolic syndrome (MS) influences the blood glucose and insulin response during cardiac surgery. METHODS: Forty-five patients scheduled for elective cardiac surgery were screened for the presence of MS according to the International Diabetes Federation definition. Patients were then assigned to two groups: those with metabolic syndrome (MSP) and those without (control). During surgery, blood glucose levels were measured in all patients and hyperglycemia was treated with a standard protocol of continuous insulin infusion. RESULTS: The mean blood glucose levels during CPB increased only in the MSP group (P<0.001). Mean blood glucose in control patients did not increase during CPB (P=0.4). Patients with MS received 13.3+/-8.4 IU of insulin during CPB, while the control group did not require insulin treatment (P<0.001). Forty percent of patients in the control group and 100% of those in the MSP group developed post-operative insulin resistance. C-reactive protein was higher in the MSP group before, during and at 48 h after surgery. CONCLUSIONS: The mean blood glucose levels during CPB increased only in patients with MS, while they remained unchanged in patients in the control group.

Effect of aspirin and ticlopidine on plasma tissue factor levels in stable and unstable angina pectoris.

Patients with unstable angina have an increased activation of the coagulation system. Aspirin and ticlopidine given in combination may potentiate each other by the combination of different action mechanisms and may reduce the risk of coronary occlusion and clinical instability. Plasma tissue factor (TF) levels collected into the stenotic coronary artery may be an index of TF expression within the vasculature. In 160 patients undergoing angioplasty for a 81+/-5% coronary lesion, we measured TF in blood samples collected from a vein and from the coronary ostium. Immediately after and 10 minutes after the dilation procedures the samples were withdrawn also beyond the lesion. Heparin 150 U/kg was given as an anticoagulant. All patients were pretreated with 250 mg/day of aspirin. One hundred twenty patients were randomly assigned to receive 24, 48, or 72 hours of ticlopidine treatment (250 mg/twice daily). TF levels did not increase during angioplasty but there was a significantly higher TF expression in unstable than in stable patients, irrespective of the invasiveness of debulking procedures. When ticlopidine was given for 72 hours, TF levels were similar to normal laboratory values both in stable and unstable patients. This combined antiplatelet pretreatment may be of benefit in unstable angina patients, with a favorable cost/benefit ratio.

Chordal plication and free edge remodeling for mitral anterior leaflet prolapse repair: 8-year follow-up.

BACKGROUND: Chordal suture plication and free edge remodeling represent a personal technique for the repair of anterior leaflet prolapse. We report the results of an 8-year experience. METHODS: Sixty-one patients with degenerative mitral regurgitation caused by prolapse of the anterior leaflet (11) or both leaflets (50) underwent anterior leaflet prolapse repair. Twenty patients who had associated cardiac procedures are included. RESULTS: There were two perioperative deaths. Postoperative mitral regurgitation fell to 0.4 +/- 0.7 versus 3.7 +/- 0.4 preoperative (p < 0.0001). Mean follow-up was 40.5 months. There were 3 late deaths and 3 mitral reoperations (1 of 3 repairs, 2 of 3 replacements). Thromboembolism and endocarditis occurred in 1 patient each. Actuarial overall survival, freedom from cardiac death, and freedom from mitral reoperation at 92 months were 85.1% +/- 7.9%, 88.9% +/- 7.7%, and 94.6% +/- 3.0%, respectively. CONCLUSIONS: Our technique of anterior leaflet prolapse repair appears effective, safe, and durable at mid- to long-term follow-up, and may be used in the presence of extensive disease of both leaflets.

Color Doppler echocardiographic assessment of atrial septal defect size: correlation with surgical measurements.

In patients with atrial septal defect (ASD), color flow Doppler echocardiography provides visualization of the transseptal jet, the maximal dimension of which can be assumed to correspond to the maximal dimension of the true orifice. To test whether color flow Doppler echocardiography can provide an alternative method for measurement of ASD size, we studied 63 consecutive patients with echocardiographic evidence of ASD. In 48 patients the maximal dimension of the jet was measured in the parasternal, apical, or subcostal four-chamber view or in the parasternal short-axis view. In the remaining 15 patients transesophageal echocardiography was performed because of transthoracic views were inadequate. The transesophageal studies also measured, from two-dimensional images, the maximal transverse discontinuity in the atrial septum. All patients underwent surgical repair, during which the surgeon directly measured the maximal dimension of ASD. Linear regression equations were performed to compare transthoracic and transesophageal dimensions to those measured at operation. Correlation coefficients were as follows for transthoracic versus surgical measurements: r = 0.745, standard error = 4.35, p less than 0.001. Transesophageal measurements derived from both two-dimensional images and echocardiographic jet width showed similar excellent correlation with surgical measurements (n = 0.91, standard error = 4.33, p less than 0.001; and r = 0.919, standard error = 4.42, p less than 0.001, respectively). We conclude that ASD size derived from color flow Doppler echocardiography shows a good correlation with the anatomic maximal dimension observed at operation. Both transesophageal color flow Doppler echocardiography of jet width and direct surgical measurement of the defect provide an accurate estimation of ASD size.

Six-and-half years' experience with the St. Jude BioImplant porcine prosthesis.

BACKGROUND AND AIMS OF THE STUDY: In this study, we reviewed our experience in heart valve replacement with the St. Jude BioImplant heart valve, which is a low-profile, low-pressure glutaraldehyde-fixed porcine prosthesis mounted on a flexible Delrin stent. METHODS: During the period May 1989-January 1996, 117 patients were implanted with 132 BioImplant prostheses; three patients were lost to follow up and excluded from the series. Mean age was 67.5 +/- 9.8 years (range: 19 to 82 years); myocardial revascularization was performed in 22 (19.3%) patients. In-hospital mortality rate was 6% (7/117 patients). By January 1996, 114 patients (53 males, 61 females), in whom 59 aortic, 35 mitral, 15 mitro-aortic and five tricuspid prostheses had been implanted, were eligible for the analysis. Mean follow up was 40.4 +/- 21.7 months (range: 1 to 76 months). RESULTS: The survival probability of survivors was 72.1 +/- 6.5 at 77 months. Seventeen patients died during follow-up. The mean NYHA class improved from 3.1 +/- 0.6 preoperatively to 1.4 +/- 0.6 postoperatively. The freedom probabilities were respectively 89.5 +/- 5.3% from thromboembolism, 93.2 +/- 3.7% from infective endocarditis, 84.5 +/- 10.3% from structural dysfunction, 99.1 +/- 0.9% from non-structural dysfunction, and 80.1 +/- 10.2% from reoperation. The freedom probability for valve-related events was respectively 75.3 +/- 12.3%, 98.0 +/- 1.9% and 67.2 +/- 17.2% for patients who underwent mitral, aortic and mitro-aortic heart valve replacement (p = 0.05 comparing only patients who underwent mitral or aortic replacement); moreover the freedom probability from valve-related events was 71.6 +/- 11.2% in patients aged < or = 65 years and 90.2 +/- 6.6% in patients aged > 65 years (p = 0.006). CONCLUSIONS: The BioImplant heart valve, in our experience, seems to be a valuable device which shows a mid-term performance similar to that of other porcine prostheses.

Surgical treatment for life-threatening acute myocardial infarction: a prospective protocol.

OBJECTIVE: In this paper we describe the preliminary results of a prospective operative protocol designed in order to define the role of emergent myocardial revascularization in extensive acute myocardial infarction and in post-infarction cardiogenic shock. METHODS: Entry criteria are: age < 75 years; anterior acute myocardial infarction with ST segment elevation > 4 leads, infero-postero-lateral or inferior and right ventricular within 6 h from onset of chest pain; post-infarction cardiogenic shock within 3 h from onset of shock. From November 1994 to July 1995, after emergency coronary arteriography, 23 patients were treated by coronary artery bypass grafting. Fifteen were operated for extensive acute myocardial infarction (group A, mean age 54.1 +/- 9.4 years) and eight for post-infarction cardiogenic shock (group B mean age 65.0 +/- 8.7 years). Mean time from onset was 4.4 +/- 1.3 h in group A and 2.2 +/- 0.8 h in group B. Mean left ventricular ejection fraction was 39.3 +/- 12.7% in group A and 22.6 +/- 3.5% in group B. Six out of eight group B patients needed intraaortic balloon counterpulsation preoperatively, and 2/8 cardiopulmonary resuscitation. RESULTS: Myocardial revascularization consisted in 3.4 +/- 1.1 grafts in group A (vein grafts, except for 8 patients who also received a left internal thoracic artery graft) and 3.3 +/- 1.1 vein grafts in group B. All patients in group B and 3/15 (20%) in group A underwent intraaortic balloon counterpulsation. In-hospital death occurred in 1/15 (6.7%) patients of group A and in 4/8 (50%) patients of group B. At a mean follow-up of 4.1 +/- 3.4 months for group A and 3.9 +/- 2.2 months for group B left ventricular ejection fraction was 43.4 +/- 9.0% in group A and 35.7 +/- 13.1% in group B. CONCLUSIONS: Experience of 9 months with this prospective protocol showed its effectiveness in the management of critically ill patients with acute coronary occlusion leading to low mortality rate in acute myocardial infarction and improved survival rate in post-infarction cardiogenic shock.

Evaluation and treatment of secondary tricuspid insufficiency.

To define the role of functional tricuspid insufficiency and right ventricular (RV) failure in patients with mitral disease, the data of 121 patients with secondary tricuspid insufficiency that underwent mitral valve replacement (MVR) from January 1982 to December 1987 were analyzed. The mitral hemodynamic lesion was: stenosis in 41 patients (33.9%); insufficiency in 11 (9.1%) and mixed stenosis and insufficiency in 69 (57.0%). NYHA functional class was: II in 4 patients (3.3%), III in 78 (64.5%) and IV in 39 (32.2%). In 100 cases (group 1) with tricuspid insufficiency defined as moderate or severe, a De Vega annuloplasty was performed while in 21 (group 2) with mild tricuspid insufficiency, no tricuspid surgical procedure was performed. Hospital deaths occurred in 17 of 121 patients [14% (CL 10.8-17.0)]. There was no significant difference in hospital mortality between group 1 and group 2 (15% vs 9.5%; P = 0.75). Incremental risk factors for hospital mortality as determined by multivariate analysis, include: cardiothoracic ratio (P = 0.0016), total aortic cross-clamp time (P = 0.006), associated cardiac disease (P = 0.0209) and emergency operations (P = 0.0318). Mean follow-up of surviving patients was 50.1 +/- 28.1 months. Late deaths occurred in 16 patients [15.4% (CL 11.7-18.7)]. The actuarial survival rate was 85.6% and 73.8% at 5 and 9 years, respectively. Nine patients [8.6% (CL 5.9-11.3)] required reoperation. There was no significant difference between group 1 and group 2 in the rate of late cardiac related deaths (5.9% vs 5.3%, P = 0.66) and of tricuspid reoperations (4.7% vs 5.3%, P = 0.62).(ABSTRACT TRUNCATED AT 250 WORDS)

Myocardial metabolism studied during warm blood antero-retrograde reperfusion in ischaemic human hearts.

We propose modified warm blood antegrade-retrograde reperfusion (WBARR) of arrested hearts as a metabolic model with which to study substrate exchange and energy metabolism during the recovery phase after 90 min of ischaemia in man. Eleven anaesthetized patients undergoing aorto-coronary bypass were studied during WBARR. The protocol was designed as follows: period 1, a warm blood reperfusion with potassium (3 min); period 2, a warm blood reperfusion without potassium (2 min). The perfusion flow rate averaged 250+/-2 ml/min at the beginning of period 1 and 218+/-19 ml/min at the beginning and at the end of period 2; the perfusion was performed antegradely and retrogradely in the arrested hearts. Samples were simultaneously taken from the coronary venous sinus (CVS) and from the aortic root needle (AR). At the beginning of WBARR lactate release was 85+/-44 micromol/min and at the end it had significantly decreased to 21+/-99 micromol/min (P<0.03). Simultaneously, non-esterified fatty acids (NEFA) and beta-hydroxy-butyrate were initially released (71+/-61 and 22+/-66 micromol/min, respectively), while at the end of the WBARR there was an uptake of both NEFA (20+/-22 micromol/min; P<0.01) and beta-hydroxy-butyrate (12+/-35 micromol/min; P=0.290). Alanine, glycerol and branched chain amino acid balance across the heart did not significantly change. In summary after 90 min of ischaemia the heart energy metabolism is mainly anaerobic and based on glucose consumption, with lactate, NEFA and amino acids, which are mainly released. After 5 min of WBARR (recovery from ischaemia), lactate release is significantly reduced and NEFA becomes the energy supply of the heart. In conclusion, (1) WBARR is a valuable method with which to study myocardial metabolism in anaesthetized humans and may be combined with the use of tracers; (2) the study of myocardial metabolism in arrested hearts eliminates the imprecisions arising from the noncontinuous coronary blood flow; (3) NEFA become an important source of energy utilized by human hearts in the recovery phase from ischaemia.

Pregnancy in patients with mechanical prosthetic heart valves. Our experience regarding 98 pregnancies in 57 patients.

Ninety-eight pregnancies in 57 patients with mechanical (ball or tilting disc) prosthetic heart valves are described. Sixty-one pregnancies developed in 36 patients with a mitral prosthesis, 12 pregnancies in 9 patients with an aortic prosthesis, 17 pregnancies in 10 patients with both mitral and aortic prostheses and 8 pregnancies in 2 patients with mitral and tricuspid prostheses. All patients were in I or in II NYHA class at conception and no significative change was noted during pregnancy. All the patients were treated with oral anticoagulant therapy at conception. Different kinds of antithrombotic and antiembolic prophylaxis were employed. There were 13 voluntary interruptions of pregnancy and 37 spontaneous abortions. In the 47 newborn 2 malformation complications (1 warfarin syndrome, 1 cleft palate) and 4 haemorrhagic complications (without sequelae) were noted. Two fatal thromboses of a mitral prosthesis occurred; systemic embolic complications were noted in 7 cases. These observations suggested different incidences of complications regarding the antithrombotic and anti-embolic prophylaxis. The authors point out the high risk of thrombotic and embolic complications and the low rate of successful outcome of pregnancy in these patients.

Combined carotid endarterectomy and myocardial revascularization: personal experience.

A significant percentage of patients undergoing myocardial revascularization suffer from extracranial cerebrovascular disease; recognition of such combined lesions identifies patients at risk for cerebrovascular accidents during the cardiac procedure. Simultaneous or staged coronary artery bypass graft (CABG) and carotid endarterectomy operations have been performed for the last 20 years, however, the clinical indications and the timing of the procedures remain controversial issues. Between November 1988 and January 1994, 1122 patients underwent myocardial revascularization at our Institute and in 35 cases (3.7%) carotid endarterectomy was simultaneously performed; 502 isolated carotid endarterectomies were performed in the same period. Trivascular coronary artery disease was found in 27 cases and low ejection fraction in six. Each patient received an average of 3.7 coronary grafts. Hospital mortality was 5.7% and major neurologic morbidity 2.8%. We believe that a simultaneous approach is recommended in patients with unstable angina and symptomatic carotid artery disease; in patients with a critical but asymptomatic carotid artery stenosis the indication for operation is subject to individual clinical judgment.

Results of heart valve replacement with the SORIN prosthesis.

From March 1977 to December 1981, 872 patients at our institution underwent valve replacement with a pyrolytic carbon tilting disc prosthesis manufactured in Italy by SORIN-Biomedica. To verify the performance characteristics of this prosthesis, we analyzed the intermediate-term results obtained over a cumulative total of 3,041 patient-years (pt-yr) of follow-up. Three hundred sixty-nine patients underwent mitral valve replacement (MVR), 309 had aortic valve replacement (AVR), and 194 had both mitral and aortic (double) valve replacement (DVR). Expressed in actuarial terms (% [+/- standard error of the mean] free of adverse events at 5 years) and in linearized terms (% pt-yr), respectively, valve-related complications occurred at the following rates: Thromboembolism, 89.9 +/- 1.9% and 2.1 +/- 0.4% pt-yr (MVR); 92.1 +/- 1.9% and 1.7 +/- 0.4% (AVR); 90.5 +/- 5.0% and 2.2 +/- 0.6% (DVR). Anticoagulant-related hemorrhage, 95.2 +/- 1.5% and 1.4 +/- 0.3% (MVR); 95.9 +/- 1.5% and 1.3 +/- 0.3% (AVR); 96.0 +/- 2.0% and 0.9 +/- 0.4% (DVR). Prosthetic valve endocarditis, 99.0 +/- 0.6% and 0.2 +/- 0.1% (MVR); 97.4 +/- 1.0% and 0.6 +/- 0.2% (AVR); 94.5 +/- 1.7% and 1.4 +/- 0.4% (DVR). Reoperation, 92.6 +/- 1.5% and 1.7 +/- 0.3% (MVR); 89.4 +/- 1.9% and 2.4 +/- 0.4% (AVR); 82.3 +/- 2.9% and 4.8 +/- 0.8% (DVR). The total valve-related morbidity and mortality was 79.6 +/- 2.6% and 4.9 +/- 0.6% (MVR); 79.7 +/- 2.6% and 5.1 +/- 0.6% (AVR); 70.5 +/- 4.0% and 7.7 +/- 1.1% (DVR). The 5-year actuarial survival rate without hospital mortality was 86.8 +/- 2.0% (MVR), 91.0 +/- 1.7% (AVR), and 78.8 +/- 3.7% (DVR). The intermediate-term survival and complication rates showed the performance of the SORIN prosthesis to be quite satisfactory.

Chronic traumatic aneurysms of the descending thoracic aorta.

Between 1970 and December 1984, 28 patients with post-traumatic chronic aneurysm of the descending thoracic aorta were consecutively operated on in our Division of Cardiac Surgery. Ages ranged from 16 to 66 years (mean 38 years); 25 were male and three were female. In all cases, a history of a major deceleration injury was documented. The interval between trauma and operation ranged from 2 to 50 years (mean 11.4 +/- 7.8). Twenty-three (82.1%) were asymptomatic. Only one operation was performed on an urgent basis for recurrent episodes of hemoptysis. All patients underwent resection with prosthetic tubulargraft (25 cases) and patch-graft (3 cases) replacements. In all patients but one, left heart bypass was employed. No hospital deaths, late deaths, paraplegia or graft-related complications occurred. Considering the risk of late rupture and the young age of most of the patients, surgery in chronic post-traumatic aneurysms of the descending thoracic aorta is always indicated. We consider left heart bypass a safe technique in preventing renal and medullar ischemic injuries.

Mycotic tuberculous aneurysm of the descending thoracic aorta.

Tuberculous aneurysm of the aorta is a rare and dangerous condition. Despite modern diagnostic and surgical techniques, it remains a challenge to recognize and treat. A successful resection of a false aneurysm of the descending aorta that ruptured into the lung of a 55-year-old woman is reported. A history of the patient and microscopic examination of the specimen indicated a diagnosis of tuberculosis. Antituberculosis chemotherapy was immediately implemented. The patient appears to be in good condition 8 months after operation; however, she remains under treatment for tuberculosis.

Mitral valve replacement with the SORIN valve. Long-term follow-up of 1,161 patients.

From 1 March 1977 through 31 December 1987, 1,252 patients underwent mitral valve replacement with a SORIN-Biomedica 60 degrees tilting-disc prosthesis at our institution. Hospital mortality was 7.3% (91 patients); prosthesis-related deaths, expressed as a percentage of hospital mortality, accounted for 12.1% of these early deaths. The 1,161 patients who survived hospitalization have been followed up for a total of 4,835 patient-years (range, 1 to 128 months; mean, 50.4 +/- 27.3 months). Forty-three (3.7%) of these patients were lost to follow-up. The late mortality was 6.3% (1.5% +/- 0.2% per patient-year), and the 10-year actuarial survival rate, excluding hospital mortality, was 89.1% +/- 1.6%. The 10-year actuarial (and linearized) rates of freedom from valve-related complications were as follows: embolism, 94.4% +/- 1.0% (0.93% +/- 0.1% per patient-year); thrombosis of the prosthesis, 99.8% +/- 0.1% (0.06% +/- 0.03% per patient-year; hemorrhage, 93.7% +/- 1.5% (0.95% +/- 0.1% per patient-year); prosthetic valve endocarditis, 99.3% +/- 0.3% (0.14% +/- 0.05% per patient-year); reoperation, 90.6% +/- 2.1% (1.1% +/- 0.2% per patient-year); and overall complications, 76.6% +/- 2.5% (2.9% +/- 0.2% per patient-year). No structural deterioration was noted. These data not only confirm our previous reports concerning the reliability and durability of the SORIN prosthesis but also reveal a significant reduction, over the long term, in the overall incidence of valve-related complications.

Aneurysm of an aberrant right subclavian artery. Report of a surgically treated case.

A 53-year-old man was admitted for treatment of an aberrant right subclavian artery aneurysm that had been diagnosed 5 years earlier and had recently begun to enlarge. The aneurysm, which involved the right subclavian artery from its origin, measured 47 mm in diameter and about 10 cm in length. Because of the lesion's size and friability, a 2-stage operation was performed. In the 1st stage, the right subclavian and right vertebral arteries were revascularized with double bypass grafts via a right cervical approach. In the 2nd stage, the patient was repositioned and a left thoracotomy incision was made. With the aid of left-heart bypass, the aorta was cross-clamped proximal and distal to the lesion, and the aneurysmal orifice was closed with a Dacron patch. The patient was discharged from the hospital on the 17th postoperative day and remains asymptomatic 24 months later. We recommend the 2-stage technique for similar cases because it prevents limb ischemia and reduces the risk of hemorrhagic and embolic complications.

Timing for surgical treatment in native infective endocarditis. A seven-year experience.

BACKGROUND: Early surgical intervention in infective endocarditis is performed only when there is persistence of sepsis, hemodynamic instability or when arterial embolism has occurred, otherwise a 4-week antibiotic therapy before surgery is considered necessary. Our 7-year experience in the surgical treatment of native endocarditis in 28 patients, is here revised focusing on the timing of surgery. METHODS: Patients were retrospectively divided into group A (n. 16) with blood cultures that became negative before surgery and group B (n. 11) with blood cultures positive at the time of urgent surgery. One patient with constantly negative blood cultures was not assigned to any group. In group A antibiotic therapy was administered until 3 consecutive blood cultures became negative and the patients were then operated on the basis of echocardiographic findings after a mean duration of antibiotic therapy of 17.4 +/- 6.3 days. RESULTS: Twenty-six patients out of 28 underwent replacement of the infected valve (mechanical bileaflets in 16 patients, porcine stented in 7 and porcine stentless in 3). Valve repair was performed in 2 patients. Overall operative mortality was) 7.1% (2/28); death occurred in 2 patients of group B, operated on for cardiogenic shock. Two/26 patients died (1 acute renal failure and 1 stroke) at a mean follow-up of 32.5 +/- 24.8 (range 3-95) months. CONCLUSIONS: Patients who underwent surgery for infective endocarditis after blood culture negativization showed no mortality and no recurrence of disease even if a 4 weeks antibiotic course was not completed. This experience suggests that earlier operations can be performed safely, lowering the incidence of hemodynamic impairment and arterial embolism.

Primary cardiac malignancy presenting as left atrial myxoma. Clinical and surgical considerations.

Primary heart neoplasms occur in 0.002-0.3% of autopsies: 30% are myxomas and 20-30% are malignancies, almost always sarcomas. Cardiac metastases are 10 to 40 times more frequent than primary heart cancer. We describe a case of a left atrial sarcoma erroneously diagnosed as myxomas preoperatively. Standard surgical indication for resection of cardiac myxomas is based on echocardiography. Because of the severity of cardiac malignant lesions than can mimic atrial myxomas at echocardiography, through preoperative investigation should be accomplished, best by magnetic resonance imaging. In case of suspected malignancy, total body computed tomography should be performed to avoid unnecessary cardiac operations in case of disseminated cancer. To date the only good medium and long-term results in the therapeutic management of heart sarcomas have been achieved by transplantation: the probable explanation is that criteria of surgical radicality should be those followed for soft tissue tumors located elsewhere in the organism.

[Repair of anterior mitral leaflet prolapse: state of the art]. / La riparazione del prolasso del lembo anteriore mitralico: stato dell'arte.

Surgical repair of anterior leaflet prolapse has evolved and widely expanded over the past decade. A number of surgical techniques have been developed. In this study a review of all reparative techniques has been provided. A classification has been proposed according to the involvement of valve components and, eventually, to graft employment. For each technique the following points have been detailed: a) advantages and drawbacks; b) likelihood of effective valve repair based on morpho-pathologic variability of degenerative mitral disease; c) long-term outcome as freedom from reoperation. The authors provide indications for early surgical anterior leaflet prolapse repair and recommend that surgeons should be familiar with many reparative procedures to select the right option and improve their operative results.