Should octogenarians be denied access to surgery for acute type A aortic dissection?

AIM: Outcomes after surgery for acute type A aortic dissection in the octogenarian are controversial. To analyze this issue further, the authors reviewed their experience in the hope of finding ways to improve results in these high-risk patients. METHODS: Between April 1990 and November 2006, 319 consecutive patients underwent emergency surgery for acute type A aortic dissection at the San Martino University Hospital of Genoa (Italy). Among them, 23 (7%) patients were aged 80 years or older (mean age 82 years, range 80 to 86 years) and represent the study population. On admission 7 patients (30%) had preoperative shock, 1 needed cardiopulmonary resuscitation, 7 (30%) had a neurological deficit, 2 (9%) had acute renal failure. Deep hypothermic circulatory arrest was performed in 19 patients (83%). Surgical procedures included isolated replacement of the ascending aorta in all patients associated with root replacement in 2 (9%) and total aortic arch replacement in 5 (22%). Median follow up was 4.1 years (range 3 to 83 months). RESULTS: Hospital mortality was 61% (14 of 23 patients). Late mortality was 11% (1 of 9 survivors). Stepwise logistic regression identified the extension of surgery to the arch as independent risk factors for hospital death. Fourteen patients (61%) had 1 or more postoperative complications. Overall survival was 39+/-10% and 33+/-10% after 1 and 5 years respectively. CONCLUSIONS: Surgery for acute type A aortic dissection in the octogenarian shows high hospital mortality but satisfactory long-term survival among discharged patients. A less aggressive approach should increase the outcomes of surgically managed patients.

Isolated lung perfusion with platinum in the treatment of pulmonary metastases from soft tissue sarcomas.

A multimodality approach including operation and isolated lung perfusion with platinum was used in six patients with lung metastases from soft tissue sarcomas. Staged thoracotomies were used in two patients with bilateral lesions. The inclusion criteria generally applied for surgical excision were adopted in this study. The pulmonary artery and a portion of the left atrium were isolated from systemic circulation and cannulated. The cannulas were then connected to a perfusion circuit and normothermic isolated lung perfusion was done for 60 minutes. The lung was then flushed and metastasectomy was done. Serial blood (systemic and pulmonary), tissue (normal lung and tumor), and urine samples were obtained for platinum content measurement by flameless atomic absorption spectroscopy. Lung damage was assessed by light and electron microscopy examination and by serial respiratory tests. Isolated lung perfusion was accomplished in all patients without any death, operative complication, or systemic toxicity. After operation, interstitial and alveolar edema developed in two patients (48 hours after treatment), necessitating respiratory support in one case. Total platinum concentrations in pulmonary plasma were about 43 times greater than those in systemic plasma. No differences in platinum concentrations between normal lung and metastatic tissue were found. Thus the proposed isolated lung perfusion technique is feasible and safe enough to be offered as a valid model to study combined chemosurgical approaches in the treatment of lung metastases.

Branched-chain amino acid metabolism in chronic renal failure.

Interorgan exchange of branched-chain amino acids (BCAA) in the postabsorptive state was evaluated in 16 patients with chronic renal failure (CRF) and in 20 subjects with normal renal function, by measuring arterial-venous differences of BCAAs across the leg, brain, hepato-splanchnic (HS) bed, and kidney. In CRF, arterial blood levels of valine are significantly reduced, whereas leucine and isoleucine levels are not different from controls; valine and leucine levels are directly related to GFR. In CRF, a significant decrease in the release of valine by the leg is observed; the leucine release tends to be lower; for both these amino acids, leg release is directly related to their arterial levels. Both ratios of valine and leucine release to total amino acid release by the leg are significantly reduced in CRF. Furthermore, in CRF cerebral uptake and fractional extraction of valine and isoleucine are decreased. In normal subjects, valine and leucine are significantly extracted by the HS bed, whereas in CRF the HS uptake of valine and its fractional extraction fall significantly and leucine uptake is unchanged. The kidney releases significant amounts of leucine both in CRF and in controls. In conclusion, in CRF in the postabsorptive state the exchange of BCAAs, mainly valine, is altered rather early at the major sites of production and utilization, and the flux of these amino acids among the organs is decreased. The primary defect is the decreased output by peripheral tissue, which reduces the supply of BCAAs to the brain and HS bed. Regional metabolic disturbances further impair BCAA utilization.

Normal echocardiographic characteristics of the Sorin Bicarbon bileaflet prosthetic heart valve in the mitral and aortic positions.

Doppler echocardiographic characteristics of normally functioning Sorin Bicarbon prostheses were prospectively assessed in 226 consecutive patients (135 male and 91 female patients, mean age 61 +/- 10 years) with 233 valves in the mitral (n = 67) and aortic (n = 166) positions whose function was considered normal by clinical and echocardiographic evaluation. Patterns of "normal" transprosthetic leakage were assessed with transthoracic echocardiography in all valves and with transesophageal echocardiography in six selected mitral valve prostheses. For the mitral valve prostheses, we found that peak and mean gradient, as well as pressure half-time, were not significantly different in either the 25 or the 31 mm valves (median values from 15 to 10 mm Hg, from 4 to 4 mm Hg, and from 70 to 83 ms; p = Not significant for all). On transthoracic study, 12 patients (17%) with a Sorin Bicarbon valve in the mitral position showed minimal transprosthetic leakage. On transesophageal study, all patients showed a transprosthetic leakage whose spatial distribution had a complex pattern: in planes orthogonal to the leaflet axis, two to four jets arising from the hinge points and converging toward the center of the valve plane could be visualized; in planes parallel to the leaflet axis, there were three jets, the two lateral ones diverging and the central one perpendicular to the valve plane. For the aortic valve prostheses, there was a significant decrease in transprosthetic gradients and an increase in effective orifice areas as prosthesis size increased. Peak and mean gradients decreased from a median value of 25 and 13 mm Hg in the 19 mm valves to 9 and 5 mm Hg in the 29 mm valves, respectively. Effective prosthetic valve area calculated with the continuity equation increased from a median value of 0.97 cm2 for the 19 mm size valves to 3.45 cm2 for the 29 mm size. With analysis of variance, effective prosthetic aortic valve area differentiated various valve sizes (F = 40.9, p < 0.0001) better than peak (F = 10.3, p < 0.0001) or mean (F = 8.04, p < 0.0001) gradients alone did. Furthermore, effective prosthetic aortic valve area correlated better than peak and mean gradients with prosthetic size (r = 0.76, r = -0.45, and r = -0.39, respectively). On transthoracic study, 109 patients (66%) showed minimal transprosthetic leakage. These normal values, obtained in a large number of patients with normofunctioning mitral and aortic Sorin Bicarbon valves, may help to identify Sorin Bicarbon prosthesis dysfunction.

The association between rhabdomyolysis and acute renal failure in patients undergoing cardiopulmonary bypass.

OBJECTIVE: The authors describe 9 cases of rhabdomyolytic acute renal failure (ARF) as a complication of cardiopulmonary bypass. EXPERIMENTAL DESIGN: Retrospective research between June 1992 and March 1994. SETTING: Department of Cardiac Surgery. PATIENTS: 931 consecutive patients undergoing major cardiac surgery. INTERVENTIONS: Patients affected by rhabdomyolytic ARF were treated with pharmacological therapy and/or plasmapheresis/continuous arteriovenous hemofiltration. In seven patients indirect cannulation of the femoral artery was used. MEASURES: Incidence, risk factors of syndrome results obtained with pharmacological treatment, CAVH and plasmapheresis were evaluated. Statistical analysis was performed with ANOVA, Tukey Kramer test and chi2 test (p<0.05 as significant). RESULTS: The syndrome occurred in 0.96% (9/931 patients) of the total cases; 11.3% (6/53 -p<0.0000) in patients undergoing a direct femoral artery cannulation for cardiopulmonary bypass and 9.5% (2/21, p<0.01) in patients in which the aortic balloon pump was used. Six patients develop acute anuric renal failure and underwent plasma exchange and hemodialysis (1 case) or CAVH (5 cases); 3 patients underwent early medical treatment and developed developed acute renal failure (ARF) with preserved diuresis. Early medical therapy appeared to prevent the evolution towards anuric ARF. The indirect cannulation of the femoral artery does not seem to produce a rhabdomyolytic ARF syndrome. In patients with direct femoral artery cannulation risk factors appear to be: arteriopathy (p<0.001), prolonged extra corporeal circulation (p<0.001), low cardiac output syndrome (p<0.001), continuous i.v. infusion of epinephrine (p<0.0001). CONCLUSIONS: Rhabdomyolytic acute renal failure is a severe complication, early identification of patients ¿at risk¿ is most important. The preventive measures and the therapy adopted proved efficient.

Removal of iatrogenic foreign bodies within cardiac chambers with a new snare catheter.

A technique for extracting an embolized venous catheter lodged in the pulmonary artery is described. A Deyhle-Seuberth catheter, which is generally used to excise gastrointestinal polyps, was used successfully to accomplish the extraction.

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.

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.

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.

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.

[Indications for permanent cardiac pacemaking]. / Le indicazioni alla stimolazione cardiaca permanente.

Technical improvements have considerably extended the indications for the implantation of pacemakers. Nearly all forms of bradyarrhythmia and some forms of tachycardia, including sinus node disease, have gradually been added alongside stable A-V blocks, while preventive implantation is now commonly indicated in asymptomatic forms and bradycardia due to drugs. The recent appearance of rapid-pulse and scanning pacemakers has further extended their indication to cover other forms of ectopic and reciprocating tachycardia.

[Left endoatrial myxoma. Notes on a case]. / Mixoma endoatriale sinistro. Considerazioni su un caso.

A case of left endoatrial mixoma, ecocardiographically discovered and successfully operated, is reported. The usefulness of ecocardiography, especially to discover intracardiac masses, is considered.

[Theory concerning a possible mechanism of displacement of intracavitary electrode catheters]. / Ipotesi su un possibile meccanismo di dislocazione dei cateteri-elettrodo endocavitari

Reference is made to three cases in proposing an explanation for the shifting of endocavitary catheters, namely traction of the lead attached to the lower side of the stimulator owing to movement of the apparatus, resulting in displacement of the tip. It is pointed out that the intravasal length of the displaced catheter is markedly decreased in 3 out of 4 cases. Attention is therefore drawn to the importance of the relation between catheter and stimulator in causing a high percentage of the case of displacement observed.

[Anti-arrhythmic effects of cardioplegic myocardial protection]. / Effetti antiaritmici della protezione miocardica cardioplegica.

Cardioplegia gave excellent results in a preliminary series of 33 cases in which it was used during surgery. The fact that a sinus rhythm was re-established at the end of extracorporeal circulation in patients in atrial fibrillation suggests that it exerts an antiarrhythmic action at the atrial a level.

[Catheter embolism. Method of bloodless extraction]. / Embolie da cateteri. Metodi di estrazione incruenta.

A detailed review and analysis of world literature on the techniques employed for the retrieval of polythene catheter fragments, metal spindles or Pudenz catheters from the heart or large vessels is presented. Non-surgical retrieval techniques are discussed on the basis of 174 cases reported in the literature. 2 personal cases of the retrieval of foreign bodies from the heart using a Deyhle-Seubert catheter are presented.

Anaemia, osteogenesis imperfecta and valve diseases. The preoperative treatment with epoetin-alpha to increase haematocrit and haemoglobin levels in patients with high risk of perioperative bleeding.

The case of a patient with Osteogenesis imperfecta is reported who underwent surgery for mitral valve replacement. Osteogenesis imperfecta is a hereditary disease of the connective tissue, associated with bone fragility, bluish colouring of the sclerae, loss of hearing and dental anomalies. Osteogenesis imperfecta is included in a group of hereditary pathologies with Ehlers-Danlos syndrome, Hurler syndrome, pseudoxanthoma elasticum and Marfan syndrome. In the literature there are few cases of patients with osteogenesis imperfecta operated for mitral valve disease secondary to such disease. The patient also has a positive family history and a severe anaemia: this was treated with epoetin-alpha and ferrous sulphate during the three weeks before surgery. The response to epoietin treatment was good while clinical outcome was poor due to rupture of the posterior ventricular wall in the 12th postoperative hour. The use of epoietin-alpha is discussed.

Epoetin alpha in elective coronary and valve surgery in Jehovah's Witnesses patients. Experience in 45 patients.

BACKGROUND: The religious beliefs of Jehovah's Witnesses who refuse homologous and autologous blood transfusion poses serious problems for surgeons when operating on patients requiring a mean transfusion requirement of =/>2 units of blood. METHODS: After a number of encouraging studies in a randomised sample of patients 2-3 and after the treatment of some Jehovah's Witnesses 1, a group of 45 patients (23 females and 22 males) underwent elective heart surgery between June 1998 and December 2000. The patients, who were all Jehovah's Witnesses, received pre-treatment with epoetin alpha and ferrous sulphate. In the light of recent studies, it was also decided to repeat medullary preconditioning using the same intervals but with a higher dose. The patients underwent surgery involving myocardial revascularisation, mitral and/or aortic valve replacement, associated interventions, valvuloplasty and ascending aortic aneurysms. After obtaining informed and signed consent, the treatment protocol comprised the administration of 140 IU/kg epoetin alpha three times a week for 3 weeks associated with oral ferrous sulphate 3 times a day. Hematochemical levels (hemoglobin, free hemoglobin, hematocrit, ferritin, transferrin, haptoglobin, reticulocytes, iron levels) were monitored from admission to Day Hospital to discharge. RESULTS: No patient in the study required blood transfusion. CONCLUSIONS: The short, medium and long-term follow-up reconfirmed the substantial reliability of this drug linked to the absence of collateral effects.

Minimally invasive thoracotomy for myocardial revascularisation. A study of 32 cases.

BACKGROUND: This study aimed to evaluate the advantages offered by a myocardial revascularisation technique proposed by Kolessov in 1967: minimally invasive thoracotomy for myocardial revascularisation. The aim was to assess its short and medium-term benefits. During the course of the 1980s, the problems linked to extracorporeal circulation (ECC) and the contraindications for traditional myocardial revascularisation led to a renewed popularity of "beating heart" revascularisation techniques. METHODS: The largest and most extensive series of patients in the literature undergoing myocardial revascularisation during left mini-thoracotomy was reported by Calafiore et al. In this study we report the series treated by our centre which, albeit involving only 32 cases, obtained good results in the short and medium term. This surgical procedure can only be applied to patients presenting monovasal obstructive coronary disease affecting the anterior interventricular artery (IVA) which must not present small calibre, calcified walls or a lateralised or intramyocardial anatomic position. RESULTS: Invasive and non-invasive instrumental tests carried out to control the distal anastomoses of the left internal mammary artery (IMA) did not reveal angulations and/or stenosing tractions before the anastomosis of IMA to a significant extent also for treatment, when isolating IMA, able to obtain the longest possible length and the best mobility. No infection of surgical wounds was reported postoperatively, as sometimes occurs in median longitudinal sternotomy. CONCLUSIONS: The 2-year follow-up showed the resolution of angina in 100% of the patients studied, as well as a satisfactory and rapid renewal of social relations.

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.