Huge ascending aorta and aortic arch aneurysm in ultra octogenarian.

Giant ascending aorta aneurysms (AAA), which are larger than 10 cm, are rarely been reported (1-7). We hereby present the case of a giant AAA of about 11 cm in a very old women who was successfully operated on for ascending aorta and aortic arch replacement under deep hypothermic circulatory arrest.

Two cases of right atrial myxoma in redo patients. A mere coincidence?

We describe two cases of right atrial myxoma in redo patients who had previously undergone to coronary artery by-pass grafting (CABGs) and mitral valve replacement respectively. Both of patients experienced effort dyspnea and were assessed by trans-thoracic echocardiography, revealing the right atrial masses. They were operated on for myxoma resection and postoperative course was uneventful. Our report deals with the interesting topic of the location of benign masses that are usually more common in the left atrium. Should we hypothesize that the right atrial manipulation during the previous surgery induces the onset of the right atrial mass? It is an interesting matter to debate.

Transcutaneous insertion of the Chitwood® clamp in case of minimally invasive cardiac surgery. Personal experience.

We describe a simple trick consisting of an insertion of a trans-thoracic Chitwood® clamp (Scanlan International, Inc, St Paul, MN, USA) through a small skin incision (<1cm), via the second intercostal space along the anterior axillary line, in case of minimally invasive mitral surgery, through right thoracotomy. This trick has been used in more than 100 patients and no complication or discomfort have been reported so far.

Additional applications of the Foley catheter in cardiac surgery.

We describe an additional use of the Foley catheter for preoperative and postoperative evaluation of the regurgitant mitral valve.

Aortic valve replacement through the upper ministernotomy: preliminary experience with modified technique.

Minimally invasive approach for aortic valve surgery has been developed since 1995, reducing the complications related to the full sternotomy. We have introduced a new method for central cannulation that reduces the length of surgical incision for the aortic valve replacement through upper mini-sternotomy. To improve the surgical view without enlargement of the incision, two small additional incisions are performed for both arterial and atrial cannulation. We have used the modified technique in 60 patients without sternal infection or other surgical complications and with good cosmetic results.

Upper body balance control strategy during continuous 3D postural perturbation in young adults.

We explored how changes in vision and perturbation frequency impacted upright postural control in healthy adults exposed to continuous multiaxial support-surface perturbation. Ten subjects were asked to maintain equilibrium in standing stance with eyes open (EO) and eyes closed (EC) during sinusoidal 3D rotations at 0.25 (L) and 0.50 Hz (H). We measured upper-body kinematics--head, trunk, and pelvis--and analyzed differences in horizontal displacements and roll, pitch, and yaw sways. The presence of vision significantly decreased upper-body displacements in the horizontal plane, especially at the head level, while in EC the head was the most unstable segment. H trials produced a greater segment stabilization compared to L ones in EO and EC. Analysis of sways showed that in EO participants stabilized their posture by reducing the variability of trunk angles; in H trials a sway decrease for the examined segments was observed in the yaw plane and, for the pelvis only, in the pitch plane. Our results suggest that, during continuous multiaxial perturbations, visual information induced: (i) in L condition, a continuous reconfiguration of multi-body-segments orientation to follow the perturbation; (ii) in H condition, a compensation for the ongoing perturbation. These findings were not confirmed in EC where the same strategy--that is, the use of the pelvis as a reference frame for the body balance was adopted both in L and H.

Primary cardiac tumors: early and late results of surgical treatment in 91 patients.

BACKGROUND: Between March 1980 and September 1997, 91 patients underwent evaluation and treatment for primary cardiac neoplasms. METHODS: Tumors were grouped into three categories: atrial myxomas, benign nonmyxomas, and malignant tumors. Survivors were contacted; no one was lost to follow-up. The mean follow-up for this series is 7 +/- 5 years. RESULTS: Eighty-three patients were diagnosed with atrial myxomas (Male/Female: 29/54), average age 55 +/- 13 years. The hospital mortality was 3.6% (3/83), the late mortality was 6.5% (5/80). No recurrent myxomas have been identified clinically or by echocardiography in any patient. Three patients were diagnosed with benign nonmyxoma tumors. (Male/Female: 2/1), average age 64 +/- 8 years. There were no perioperative deaths and 1 patient died 4 years postoperatively from fibroma, with no linked causes. No recurrent tumors have been identified. Five patients were diagnosed with malignant tumors. (M/F: 1/4), average age 53 +/- 16 years. The hospital mortality was 20% (1/5); in 3 patients a redo-operation was necessary after 8, 11, and 12 months because of tumor recurrence. All patients died within 3 years of the first operation (mean 13 +/- 14 months). CONCLUSIONS: Surgical resection, when possible, is the treatment of choice for all primary cardiac tumors. Patients with benign tumors are probably cured by resection and in our experience there was no known tumor recurrence. Effective palliation is possible with resection of malignant tumors, but more effective adjuvant therapy will be necessary to improve long-term prognosis.

Risk stratification for open heart operations: comparison of centers regardless of the influence of the surgical team.

BACKGROUND: Risk-adjusted mortality was previously used to compare institutions as a whole or surgeons. Because the same surgical team is working in two different hospitals, the aim of our study was to assess whether the institution can make a difference in surgical mortality. METHODS: Preoperative data of 554 patients in institution A and 500 in institution B were prospectively collected during the same period of time. All patients were operated on by the same surgeon with the same first assistant and anesthesiology staff in both institutions. Patient population was stratified according to Parsonnet's predictive model, in five risk groups, and mortality was adjusted by the direct standardization method. RESULTS: At institution A it was observed that in-hospital mortality was 2.3% (95% confidence interval, 1.3% to 4.0%), and in institution B 4.0% (95% confidence interval, 2.5% to 6.1%). The difference between the two mortality rates (1.7%; 95% confidence interval, -0.5% to 3.8%) is not statistically significant (p = 0.16), nor is the difference within each class. The standardized mortality ratio was 3.6% (95% confidence interval, 2.7% to 4.8%) and 5.8% (95% confidence interval, 4.6% to 7.2%), respectively. The difference of 2.2% (95% confidence interval, 0.5% to 3.8%) is statistically significant (p = 0.01). CONCLUSIONS: The institution can affect mortality of patients undergoing open heart operations, regardless of the influence of the surgical team.

Risk of recurrence after reoperation for prosthetic valve endocarditis.

Reoperation after a surgical procedure for prosthetic valve endocarditis (PVE) is often required due to the existence of either septic recurrence or sterile para-prosthetic leak (PL). The aim of this study was to assess the risk to patients of undergoing a second operation after PVE. Thirty-six patients underwent operation for active PVE at our institution. The operative mortality rate was 11.2%. Among the 32 patients discharged, six underwent a second operation (in two cases due to persisting sepsis) and two underwent a third procedure. Multivariate analysis demonstrated increased probability of further operation for: inability to identify the infecting organism (p = 0.005); drug addiction (p = 0.007); existence of annular abscess (p = 0.016); and early occurrence of PVE (p = 0.018). In the case of mechanical prostheses, PVE was not an independent risk factor (p = 0.206). Nonetheless, 58.3% of patients with mechanical prostheses compared with 5.3% of those with bioprostheses showed annular abscesses, while 41.7% of the former versus 5.6% of the latter suffered one or more recurrences.

Vascular complications associated with a large cardiac fibroma.

A case is reported of a 30-year-old patient with an intrapericardial tumour with heart failure. After the diagnostic protocol, surgery was performed initially without extra-corporeal circulation (ECC). Due to the location, size and to the large connection with the most important vascular structures, the ascending aorta ruptured accidentally during resection and was replaced after using ECC in emergency. The post-surgical course was regular and the tumour was identified histologically as a fibroma.

Ventricular septal rupture after a myocardial infarction: clinical features and long term survival.

BACKGROUND: Ventricular septal defect (VSD) represents a serious complication after acute myocardial infarction (AMI) with an incidence of 1-2%. Surgical treatment is often mandatory in the early period after AMI because of the worsening of the hemodynamic and clinical conditions. METHODS: We reviewed 34 patients complicating AMI who underwent surgical treatment at our Institution from January 1988 to December 1994 (23 males, 11 females, mean age 64.2+/-7.96, range 45-78). The localization of the AMI was anterior in 47.05% but inferior in 52.95% of the patients (p=NS). The mean time between AMI and VSD was 5.24+/-9.31 days. The preoperative NYHA functional class was III-IV in 93% of the patients. QP/QS ratio was 2.7+/-0.65 and the diameter of VSD ranged from 1 to 8 (mean 2.5+/-0.35). In 26 patients (76.4%) an intraortic balloon pump (IABP) was inserted before surgery. Surgical treatment was done after 10+/-17.7 days after VSD appearance through a left ventriculotomy. Ten patients received a concomitant myocardial revascularization. RESULTS: Overall surgical mortality was significantly higher (p<0.05) in patients operated on in the early period after AMI (1+/-1.4 days) and with VSD complicating an inferior AMI. A complete follow-up was possible in all the survivors with a cumulative FU of 1453 month/patients. Two patients received a redo procedure after 30 and 40 days after the first correction because of a residual shunt. We observed 3 late deaths for re-AMI and one for complications after bronchial pneumonia. The actuarial survival rate is 70% at 1 year, 68% at 2 years and 65% at 7 years. NYHA functional class after operation is 1-11 in 91% of the patients. CONCLUSIONS: The major determinant of hospital survival in VSD after AMI in our patient population was the anatomical localization and the early timing of the operation. We believe that a prompt diagnosis and immediate cardiac support (IABP or ventricular assist device) is recommended to obtain a hemodynamic stabilization and to achieve the shaping of stronger cicatricial tissue before surgery. Nevertheless surgical repair of VSD is mandatory when clinical and hemodynamic condition becomes unacceptable. The results in the long term assessment are very satisfying.

Left atrial approach to big myxoma with angiographically visible neovascularity. Report of one case.

In this article, we report a 65-year-old man with a large atrial myxoma arising from the posterior wall and from the base of the right inferior pulmonary vein. The big neoplastic mass showed a large implant site. A rare atrial myxoma neovascularity arising from the atrial circumflex artery was very clearly visualized by selective coronary arteriography. The surgical approach used to resect this tumor was an isolated left atriotomy that provided excellent exposure and safe excision.

Experimental evaluation of indoor magnetic distortion effects on gait analysis performed with wearable inertial sensors.

Magnetic inertial measurement unit systems (MIMU) offer the potential to perform joint kinematics evaluation as an alternative to optoelectronic systems (OS). Several studies have reported the effect of indoor magnetic field disturbances on the MIMU's heading output, even though the overall effect on the evaluation of lower limb joint kinematics is not yet fully explored. The aim of the study is to assess the influence of indoor magnetic field distortion on gait analysis trials conducted with a commercial MIMU system. A healthy adult performed gait analysis sessions both indoors and outdoors. Data collected indoors were post-processed with and without a heading correction methodology performed with OS at the start of the gait trial. The performance of the MIMU system is characterized in terms of indices, based on the mean value of lower limb joint angles and the associated ROM, quantifying the system repeatability. We find that the effects of magnetic field distortion, such as the one we experienced in our lab, were limited to the transverse plane of each joint and to the frontal plane of the ankle. Sagittal plane values, instead, showed sufficient repeatability moving from outdoors to indoors. Our findings provide indications to clinicians on MIMU performance in the measurement of lower limb kinematics.

Compensation to whole body active rotation perturbation.

The aim of the present study is the exploration of the compensation mechanisms in healthy adults elicited by superimposing a horizontal perturbation, through a rotation of the support base, during a whole body active rotation around the participant's own vertical body axis. Eight healthy participants stood on a rotating platform while executing 90° whole body rotations under three conditions: no concurrent platform rotation (NP), support surface rotation of ± 45° in the same (45-S) and opposite (45-O) directions. Participants' kinematics and CoP displacements were analyzed with an optoelectronic system and a force platform. In both 45-S and 45-O conditions, there was a tendency for the head to be affected by the external perturbation and to be the last and least perturbed segment while the pelvis was the most perturbed. The observed reduced head perturbation in 45-S and 45-O trials is consistent with a goal-oriented strategy mediated by vision and vestibular information, whereas the tuning of lumbar rotation is consistent with control mechanisms mediated by somato-sensory information.

Early right coronary vasospasm presenting with malignant arrhythmias in a heart transplantation recipient without allograft vasculopathy.

In heart transplant recipients, the aetiology of coronary vasospasm is largely unknown but it has been reported to be related to coronary vasculopathy or allograft rejection. We report a case of acute, reversible coronary vasospasm which caused malignant arrhythmias in a cardiac transplant recipient one month after transplantation without evidence of coronary vasculopathy or allograft rejection. The patient had a normal post-operative course with no other complications; this case supports the hypothesis that coronary vasospasm is not necessarily related to epicardial coronary artery disease or allograft rejection, but rather may be due to an abnormal reversible vasoreactivity.

Does everolimus associated with a low dose of cyclosporine in long-term cardiac transplant recipients improve renal function? Initial experience.

BACKGROUND: Cyclosporine (CsA) renal toxicity is a well-known side effect. Various immunosuppressive strategies have been developed to minimize renal insufficiency. The use of everolimus associated with low levels of CsA can be an alternative strategy. METHODS: From October 2007 to April 2008, everolimus was started with a lower dose of cyclosporine (trough levels from 109.3 +/- 27.5 to 93.7 +/- 30.1 ng/mL after 45 days) in 21 cardiac transplant recipients (18 male and 3 female patients, mean age 56.4 +/- 10.7 years). Pre-everolimus therapy creatinine levels, creatinine clearances, and glomerular filtration rates were 1.9 +/- 0.9 mg/dL, 54.2 +/- 18.1 mL/mins and 44.3 +/- 16.5 mL/min/m(2), respectively. RESULTS: We observed a significant reduction in creatinine levels (from 1.9 +/- 0.9 to 1.4 +/- 0.3 mg/dL, P = .022) as well as a significant improvement in creatinine clearances (from 54.2 +/- 18.1 to 69.0 +/- 19.0 mL/min, P = .020) and glomerular filtration rates (from 44.3 +/- 16.5 to 57.1 +/- 16.3 mL/min/m(2), P = .010) after 7 days of everolimus therapy. Upon univariate analysis patient age, pretransplantation creatinine clearance, creatinine clearance after everolimus introduction, glomerular filtration rate at 45 days, and time from transplantation were associated with renal improvement. Upon multivariate analysis, only creatinine clearance at 7 days was related to the renal improvement. CONCLUSIONS: These preliminary data suggested that everolimus with a low dose of CsA may be safe and effective to reduce CsA-related renal insufficiency among selected, heart transplant patients.

Role of oral sildenafil in the treatment of right ventricular dysfunction after heart transplantation.

OBJECTIVE: Right ventricular dysfunction (RVD) after heart transplantation is a major complication, especially in patients with pulmonary hypertension (PH). Herein we have presented our initial experience with oral sildenafil for RVD following heart transplantation. MATERIALS AND METHODS: From February 2006 to February 2008, 10 patients (7 males and 3 females) of overall mean age of 56.7 +/- 9.5 years suffered from acute RVD immediately after heart transplantation. Preoperative hemodynamic data before and after a vasodilatation test (sodium nitroprusside; NTP) showed: systolic pulmonary arterial pressure (SPAP) 59.5 +/- 12.9 and 44.2 +/- 12.4 mm Hg; cardiac output (CO) 3.3 +/- 0.9 and 3.7 +/- 0.8 L/min; transpulmonary gradient (TPG) 11.7 +/- 3.9 and 8.7 +/- 3.6 mm Hg; and pulmonary vascular resistance (PVR) 3.9 +/- 2.1 and 2.4 +/- 1.3 wood units (WU), respectively. All patients required inotropes and inhaled nitric oxide (iNO) to be weaned from cardiopulmonary bypass (CPB). RESULTS: Intravenous (IV) or inhaled vasodilators could be weaned using oral sildenafil in all patients. The hemodynamic data obtained during IV or inhaled drugs (between postoperative days 5 and 10) compared with those obtained on sildenafil therapy alone (about 1 month after transplantation) showed a significant decrease in SPAP (39.0 +/- 8.2 vs 32.0 +/- 6.5 mm Hg; P = .049). CONCLUSION: These data suggested that oral sildenafil may have a role in the treatment of RVD after heart transplantation.

A novel device to evaluate the stiffness of ankle-foot orthosis devices.

The evaluation of mechanical behavior of plastic Ankle-Foot Orthosis (AFO) is important since AFO can provide an efficient support to patients with disabilities in locomotion. This paper reports on a novel testing apparatus that allows: (a) the evaluation of AFO stiffness in sagittal and frontal planes; (b) the conduction of semi-automatic trials; and, finally, (c) a global accuracy associated to the AFO stiffness values always less than 4%. The stiffness values are determined by the measurements of the imposed relative displacements between the foot and the shank of the orthosis and the induced reaction forces. The data collected together in an exact 2-D approach, together with those provided by gait analysis systems, allows to better understand gait alteration induced by ankle orthosis, and to improve clinical management of patients.