Performance of 21-mm size perimount aortic bioprosthesis in the elderly.

BACKGROUND: Aortic valve replacement in elderly patients with a small aortic annulus may pose difficult problems in terms of prosthesis selection. We have evaluated the hemodynamic performance of the 21-mm Carpentier-Edwards Perimount bioprosthesis implanted in elderly patients. METHODS: From July 1996 to June 1998, 19 patients (17 women and 2 men, mean age 76+/-4 years and mean body surface area 1.73+/-0.13 m2), had aortic valve replacement with a 21-mm Carpentier-Edwards Perimount bioprosthesis. The hemodynamic performance of the valve was evaluated in 16 patients, who completed at least a 6-month follow-up interval, with transthoracic color-Doppler echocardiography with particular reference to peak and mean transprosthetic gradients, effective orifice area index, and regression of left ventricular mass index. RESULTS: There were no late deaths and no major postoperative complications. At a mean follow-up of 12+/-7 months, compared to discharge, all patients showed clinical improvement with a significant reduction of peak gradient (from 23+/-4 to 21+/-6 mm Hg, p = 0.04) and left ventricular mass index (from 181+/-23 to 153+/-20 g/m2; p<0.001), whereas mean gradient (from 13+/-3 to 13+/-4 mm Hg, p = not significant) and effective orifice area index (from 1.12+/-0.34 to 1.13+/-0.28 cm2/m2, p = not significant) remained substantially unchanged. CONCLUSIONS: The use of a 21-mm Carpentier-Edwards Perimount bioprosthesis is associated with low transprosthetic gradients and significant reduction in left ventricular hypertrophy after aortic valve replacement. The results of our study suggest that a 21-m Carpentier-Edwards Perimount bioprosthesis should be considered a valid option in elderly patients with aortic valve disease and a small aortic annulus.

The Edwards Prima stentless valve: hemodynamic performance at one year.

BACKGROUND: The Edwards Prima stentless valve (EPSV) is a porcine aortic root cylinder with resected coronary ostia, fixed in glutaraldehyde at low pressure. The purpose of this study was to evaluate the hemodynamic performance of the EPSV 1 year after aortic valve replacement. METHODS: From December 1994 to February 1996, 29 patients underwent aortic valve replacement with EPSV used in the subcoronary position (group 1, n = 23) or as a root replacement (group 2, n = 6). Hemodynamic performance of EPSV was assessed by two-dimensional Doppler echocardiography at 1 week, 6 months, and 1 year by calculating peak transprosthetic velocity, peak and mean gradients, effective orifice area, degree of aortic regurgitation, and regression of left ventricular hypertrophy. RESULTS: There were no operative deaths. One patient in group 2 died after 3 months at reoperation for endocarditis. In group 1 early mean gradient (25+/-5 mm Hg for 23 mm and 19+/-5 mm Hg for 25 mm) decreased at 6 months and 1 year in the 23-mm size (17+/-7 mm Hg and 15+/-4 mm Hg, p < 0.01) and at 1 year in the 25-mm size (14+/-4 mm Hg, p = 0.03) without modifications of the effective orifice area in both sizes. A significant reduction in left ventricular hypertrophy occurred at 6 months and 1 year in both sizes. In group 2 lower early gradients were recorded with subsequent improvement at follow-up; reduction in left ventricular hypertrophy occurred as well. CONCLUSIONS: The EPSV used in the subcoronary position has shown high early gradients, which partially regressed at 6 months, with further improvement at 1 year. Gradients are attributed to inward folding of the Dacron cloth at the right coronary ostium, being more evident in patients with aortic stenosis without dilatation of the aortic root and coronary ostia close to the annulus. In such patients a better early hemodynamic result can be obtained by using the EPSV as a root replacement.

Early results of transmyocardial revascularization with a holmium laser.

BACKGROUND: Transmyocardial laser revascularization (TMLR), a surgical technique designed to improve perfusion in the ischemic myocardium by creating transmural channels, has been performed thus far using a carbon dioxide laser, with apparently gratifying early results. We have investigated clinically TMLR using a holmium laser as sole therapy for patients with coronary artery disease that is not amenable to traditional treatment such as coronary artery bypass grafting or percutaneous transluminal coronary angioplasty. METHODS: From November 1995 to December 1996, 16 patients underwent TMLR using a holmium laser. Their mean age was 68 +/- 6 years and 75% were men. Previous coronary artery bypass grafting or percutaneous transluminal coronary angioplasty had been performed in 81% and 31% of the patients, respectively. Before operation, their mean anginal class was 3.4 +/- 0.5 and their mean left ventricular ejection fraction was 0.49 +/- 0.06. Six patients had unstable angina. RESULTS: There were no operative deaths. The mean duration of TMLR was 27 +/- 13 minutes and the mean duration of the entire operation was 120 +/- 40 minutes. There were no major postoperative complications and the mean hospital stay was 8 +/- 4 days. There were 2 late deaths, 1 that occurred 40 days after TMLR as a result of stroke and 1 that occurred 4 months after TMLR as a result of myocardial infarction. Current survivors have been followed up for a mean of 10 +/- 4 months (range, 3 to 15 months), with 7 patients followed up for 1 year. At last follow-up, the mean anginal class had decreased to 1.8 +/- 0.7 (p = 0.001) and the patients had increased exercise tolerance and a reduced number of hospitalizations. However, no statistically significant changes in the percentage of segments with fixed or reversible ischemia and no statistically significant differences in the viability scores of lased and nonlased segments were observed. CONCLUSIONS: Transmyocardial laser revascularization using a holmium laser is a simple technique with low operative risk and low morbidity. Early results confirm that clinical improvement is obtained in most patients, although significant changes in myocardial perfusion are not evident in the short term.

Survival despite almost complete occlusion by chronic thrombosis of a Björk-Shiley mitral prosthesis.

We report a patient who was successfully reoperated because of almost complete thrombosis of a Björk-Shiley tilting disc mitral prosthesis. Considering the usually acute presentation and the frequently catastrophic consequences of most similar cases in the literature, the unusual feature of this case is that the patient survived until reoperation with minimal symptoms despite almost total prosthetic occlusion by a chronic thrombus.

Reoperation for prosthetic thrombosis and acute neurologic injury.

Open-heart surgery in patients with recent cardiogenic embolic stroke represents a difficult management problem. We present a patient who developed thrombosis of a mitral tilting-disc prosthesis complicated by repeat cerebral embolic episodes that resulted in acute neurologic injury. We believe that in such patients the indication for reoperation must be individually evaluated but it is justified in young subjects, even in the presence of severe neurologic damage.

Enlargement of the aortic annulus with glutaraldehyde-fixed bovine pericardium during aortic valve replacement.

BACKGROUND AND AIMS OF THE STUDY: Aortic valve replacement in patients with a small aortic annulus may represent a surgical challenge. We have evaluated a simplified technique to enlarge the aortic annulus which consists of extending the aortotomy incision to divide the commissure between the left and non-coronary cusps into the interleaflet triangle without opening the left atrium. METHODS: This technique was used in 16 patients (15 women, one man; mean age 66 +/- 9 years) who underwent aortic valve replacement between August 1994 and February 1996. Aortic stenosis was the predominant valvular lesion. A mechanical prosthesis was implanted in 13 patients (81%) (21 mm in six, 23 mm in seven) while three received a bioprosthesis (21 mm in one, 23 mm in two). In all patients it was possible to insert a prosthesis at least one size larger than the original aortic annulus diameter. RESULTS: There were no operative deaths and no late deaths. Mean follow up was 20 +/- 6 months (range: 12 to 30 months). Echocardiographic controls at 12 months postoperatively showed no evidence of periprosthetic leaks or mitral regurgitation. Comparison with preoperative data showed no significant variations of mean aortic diameter at the sinus level (30.7 +/- 2.2 mm versus 31.3 +/- 2.6 mm) or at the sinotubular junction (33.6 +/- 2.7 mm versus 34.3 +/- 2.9 mm) (p = NS). Significant reduction of left ventricular mass was observed (314 +/- 57 g versus 260 +/- 45 g; p < 0.001). CONCLUSIONS: This technique is simple, reproducible and effective in allowing adequate enlargement of the aortic annulus and provides excellent clinical and hemodynamic results. Glutaraldehyde-fixed bovine pericardium used as a patch material showed no tendency to aneurysmal dilatation with progression of time at a maximum follow up of 30 months.

Mitral valve annuloplasty for degenerative disease: assessment of four different techniques.

BACKGROUND AND AIM OF THE STUDY: Mitral valve repair (MVR) is the treatment of choice in patients with degenerative valve disease. However, controversy persists as to whether mitral valve annuloplasty should always be included as part of the reconstructive procedure. METHODS: The records of 62 consecutive patients undergoing MVR for degenerative disease between January 1994 and December 1996 were reviewed. Four different annuloplasty techniques were associated with various MVR procedures: local posterior annuloplasty (group 1, n = 10), rigid Carpentier ring (group 2, n = 20), Duran ring (group 3, n = 17), and posterior annular plication with autologous pericardium (group 4, n = 15). The four patient groups were similar in terms of preoperative clinical and echocardiographic characteristics. Serial clinical and echocardiographic follow up was performed to assess functional status and stability of repair. RESULTS: There were no early or late deaths. Mean follow up in the entire patient series was 31 +/- 12 months. One patient in group 2 required reoperation 14 months after MVR. In all groups there was a significant improvement in NYHA functional class (from 2.7 +/- 0.6 to 0.9 +/- 0.5, p <0.001), with a reduction of left ventricular end-diastolic and end-systolic volumes (154 +/- 50 ml to 105 +/- 33 ml, p <0.001; and 64 +/- 23 ml to 52 +/- 22 ml, p <0.001). In patients of groups 2, 3 and 4, residual mitral incompetence at follow up (0.8 +/- 0.9 in group 2, 0.8 +/- 0.7 in group 3, and 0.2 +/- 0.6 in group 4) was not significantly different from discharge. However, in group 1, a higher degree of residual mitral regurgitation was present at discharge (0.9 +/- 0.6) with a trend to progress at follow up (1.6 +/- 0.5). CONCLUSION: In patients with degenerative mitral valve disease, MVR provides clinical and functional improvement. Techniques of stabilization of the entire posterior mitral annulus achieve better early and medium-term results, and should be always considered as part of MVR. Autologous pericardium appears to be an excellent annuloplasty material, though its apparent superiority over synthetic rings must be confirmed at longer follow up.

Hemodynamic performance of the Edwards Prima stentless valve.

BACKGROUND AND AIM OF THE STUDY: Stentless porcine valves are considered to have a superior hemodynamic performance when compared with stented bioprostheses. In the present study we report our initial experience with the Edwards Prima stentless valve (EPSV), focusing on the hemodynamic performance of this device evaluated by means of transthoracic two-dimensional (2D) Doppler echocardiography. METHODS: Between December 1994 and August 1995, 23 patients underwent aortic valve replacement with the EPSV implanted in the subcoronary position. Evaluation of hemodynamic performance of the EPSV was assessed before discharge (one week) and at six months follow up by means of transthoracic 2D echocardiography. RESULTS: There were no operative deaths and no major postoperative complications. Hemodynamic data were available for comparison at one week and six months in 18 patients (23 mm, n = 8; 25 mm, n = 10). For 23 mm EPSV, peak gradient varied from 42.7 +/- 10.2 mmHg at one week to 29.7 +/- 9.8 mmHg at six months (p = 0.01); for 25 mm EPSV, peak gradient varied from 33.6 +/- 10.6 mmHg at one week to 29.5 +/- 6.5 mmHg at six months (p = N.S.). CONCLUSIONS: The EPSV, when used in the subcoronary position, has been associated with high early transprosthetic gradients which only partly regress at six months. Gradients are probably caused by the inward folding of the Dacron cloth beneath the right coronary ostium and were recorded especially in patients with aortic stenosis in whom the right coronary ostium was close to the aortic annulus. In such patients alternative implantation techniques should be considered.

Ascending aorta dissection after aortic valve replacement.

BACKGROUND AND AIMS OF THE STUDY: The surgical management of patients with aortic valve disease associated with ascending aortic dilatation is a controversial issue. Structural abnormalities of the aortic wall predispose to further aortic enlargement and possibly to ascending aortic dissection (AAD). Indications to concomitant replacement of aortic valve and ascending aorta have not yet been clearly defined. METHODS: We reviewed eight consecutive patients (seven males and one female) among 2202 patients who underwent aortic valve replacement (AVR) between 1982 and 1996. These eight were subsequently reoperated on because of AAD, between November 1987 and November 1996. Indications for initial AVR were aortic regurgitation due to annular ectasia in five patients, combined aortic stenosis and regurgitation in two, and isolated aortic stenosis in one patient. RESULTS: The interval between AVR and AAD ranged from four months to 10.5 years. Five patients presented with acute AAD, and three with chronic AAD. Retrospectively, four patients showed progressive increase in ascending aortic diameter after AVR, with a mean diameter of 72+/-9 mm at reoperation. Histological examination showed cystic medial necrosis in three patients, atherosclerotic degeneration in one patient, and normal aortic wall structure in one. There was one operative death due to low cardiac output; the hospital mortality rate was 13%. There were no late deaths and no major adverse events during a mean follow up of 5+/-3 years (range: 8 months to 10 years). CONCLUSIONS: In patients with ascending aortic dilatation (> or = 55 mm diameter), AVR alone may not prevent progression of aortic root enlargement. In these patients, the ascending aorta should be concomitantly replaced. Following AVR, all patients with mildly or moderately dilated aortic root should be periodically controlled to detect signs of progression of aortic dilatation.

Cardiopulmonary exercise testing in patients with 21mm St. Jude Medical aortic prosthesis.

BACKGROUND AND AIM OF THE STUDY: Small-sized prostheses may be associated with high transprosthetic gradients, particularly in patients with a body surface area (BSA) >1.70m2, affecting left ventricular mass regression, symptom improvement and long-term survival. However, the influence of such gradients on exercise tolerance has not been clearly defined. The study aim was to verify the utility of cardiopulmonary exercise testing (CPX) in detecting patient-prosthesis mismatch, and to identify the clinical and echocardiographic data that predict exercise tolerance at CPX in patients with a 21mm St. Jude Medical (SJM) aortic prosthesis. METHODS: Twenty patients (one male, 19 females; mean age 66 +/- 9 years) with a 21 mm SJM prosthesis were evaluated by means of 2D echocardiography and CPX at 36 +/- 10 months after operation. Patients were divided into groups on the basis of a BSA of <1.70 m2 (group 1, n = 12) or > or =1.70 m2 (group 2, n = 8). RESULTS: At echocardiography, left ventricular mass reduction was 16 +/- 10% versus 9 +/- 6% in groups 1 and 2, respectively, mean gradient (MG) was 15 +/- 6 versus 17 +/- 4 mmHg (p = NS), effective orifice area index (EOAi) 0.86 +/- 0.10 versus 0.79 +/- 0.09 cm2/m2 (p = 0.05). At CPX, group 2 patients showed a significantly lower exercise duration (p = 0.02), maximum workload (p = 0.02), peak O2 uptake (p = 0.01), anaerobic threshold (AT) (p = 0.03), ventilatory equivalent for CO2 at AT (p = 0.007), and O2 cost of work (p = 0.03). Group 1 patients showed a ventilatory origin for their effort dyspnea, while group 2 patients showed a significant circulatory component. At multivariate analysis, BSA, age, EOAi and MG were independent predictors of CPX results. CONCLUSIONS: In patients with a 21 mm aortic SJM prosthesis and a BSA > or =1.70m2, CPX allows detection of patient-prosthesis mismatch, in terms of impaired exercise tolerance due to circulatory causes. CPX results can be anticipated on the basis of the patient's BSA, age, EOAi and MG. In these patients, technical solutions allowing implantation of a larger prosthesis should be considered whenever an active lifestyle is anticipated after aortic valve replacement.

Aortic valve replacement for quadricuspid aortic valve incompetence.

Quadricuspid aortic valve is an uncommon cause of aortic regurgitation. We report two patients who underwent aortic valve replacement because of severe aortic incompetence; the presence of a quadricuspid aortic valve was an accidental surgical finding. In one patient the aortic valve comprised two equal-sized larger cusps and two equal-sized smaller cusps, while in the other it comprised three cusps of similar size and a small accessory cusp between the right and non-coronary cusps. This report confirms the rarity of the disease and the fact that patients with quadricuspid aortic valves characterized by cusps of different sizes are more prone to develop progressive aortic incompetence because of unequal distribution of stresses on the valve. Therefore, such patients should undergo periodic, life-time echocardiographic assessment once this malformation is detected.

Post-traumatic ventricular septal defect following coronary bypass surgery.

A 60-year-old patient underwent triple coronary artery bypass grafting following an inferoseptal myocardial infarction and early onset of exertional angina. Four years later he was involved in a car accident during which he sustained an abdominal and thoracic trauma. Approximately 1 month after discharge, a ventricular septal defect was diagnosed by two-dimensional Doppler echocardiography with patency of all grafts at coronary angiography. Closure of the septal defect was successfully accomplished through a right atrial approach. Rupture of the ventricular septum following blunt chest trauma in a patient with previous myocardial revascularization has not been previously reported.

Evaluation of pulmonary vascular pressures in cardiac patients: the role of the chest roentgenogram.

In 77 patients (34 with left heart valvulopathy, 17 with dilated cardiomyopathy, and 26 with chronic coronary artery disease) pulmonary vascular pressures were estimated from the chest film by means of a new scoring system. Standard chest x-ray films taken immediately before diagnostic right and left cardiac catheterization were analyzed independently by three readers without knowledge of the hemodynamic findings. The radiographic signs were subdivided into three groups as follows, and to each one a score derived from a retrospective statistical analysis was attributed: (A) signs of interstitial edema, (B) patterns of pulmonary blood flow distribution, and (C) alterations in the pulmonary arteries. The sum of the scores of groups A and B x-ray findings correlated well with pulmonary wedge pressure, and the sum of the scores of groups A, B, and C correlated more strongly with the mean pulmonary artery pressure. These results confirm that it is possible, in patients with chronic heart disease, to assess accurately the pulmonary artery and wedge pressures by means of the noninvasive and easily performed chest roentgenogram.

Recurrent myxoma of the left ventricle. Case report and review of the literature.

A 29-year-old female was found to have a left ventricular mass while in the 14th week of gestation. Seven years earlier she had undergone removal of a left ventricular myxoma. At re-operation, after elective interruption of pregnancy, a recurrent left ventricular myxoma was successfully excised. According to a review of the literature recurrence of an isolated, localized left ventricular myxoma has not been previously reported.

Post-traumatic tricuspid valve insufficiency. 2 cases of delayed clinical manifestation.

We present 2 cases of tricuspid insufficiency following blunt chest trauma: 1 was diagnosed 5 months after the trauma and the other, 20 years after the trauma. In both patients, the tricuspid valve was replaced with a porcine bioprosthesis, because valve repair was not considered feasible. These cases emphasize the variability of clinical presentation of post-traumatic tricuspid valve insufficiency and indicate the need for close follow-up of patients after major thoracic trauma.

Surgical angioplasty for isolated coronary ostial stenosis.

Patch angioplasty has been reported as a suitable surgical option for patients with isolated coronary ostial stenosis, but controversy still exists concerning its effectiveness. We report the cases of 4 additional patients in whom this procedure was performed, including that of a patient with bilateral ostial stenosis; and we review the literature pertaining to bilateral ostial stenosis. Four patients, 3 with isolated stenosis of the left main coronary ostium and 1 with bilateral ostial stenosis, had direct surgical ostioplasty from January through November 1994. We considered the cause of ostial stenosis to be aortitis (of suspected syphilitic origin) in 1 patient, atherosclerotic plaque in 2 patients, and a fibrous membrane in the 4th. Ostioplasty was performed with a patch of autologous pericardium in 3 patients (fresh pericardium in 2 and glutaraldehyde-fixed in 1) and a patch of saphenous vein in 1. There were no operative deaths. One patient underwent successful reoperation for left main coronary artery restenosis after 3 months. All other patients are asymptomatic at 16, 18, and 24 months postoperatively. In the patient who underwent bilateral ostioplasty, coronary angiography showed patent ostia at 1 year. Surgical ostioplasty should be considered in the treatment of patients who have isolated ostial stenosis but no distal coronary disease. Careful patient selection seems to be a prerequisite for surgical success.

Time-domain analysis of exercise-induced ST-segment elevation in Q-wave myocardial infarction: a useful tool for the screening of myocardial viability.

BACKGROUND: Exercise-induced ST-segment elevation in Q-wave leads has been traditionally associated with passive stretching of the infarct wall, perinecrotic ischemia and, according to recent scintigraphic studies, with myocardial viability. At present, however, no definitive conclusions are available. We evaluated the potential role of a time-domain analysis of exercise-induced ST-segment elevation for the identification of viable myocardium and residual ischemia in patients with previous Q-wave myocardial infarction. METHODS: Sixty patients with a previous Q-wave myocardial infarction underwent a bicycle exercise stress test, dobutamine stress echocardiography, coronary arteriography and left ventriculography. RESULTS: Patients with exercise-induced ST-segment elevation in Q-wave leads (n = 36) showed more severe impairment of resting left ventricular function, when evaluated in terms of wall motion score index at echocardiography (1.62 +/- 0.33 vs 1.41 +/- 0.22, p < 0.01) and in terms of wall motion score at ventriculography (5.9 +/- 1.6 vs 4.1 +/- 1.5, p < 0.03), compared to patients without ST-segment shift (n = 24). No differences between the two groups were seen in the severity and extension of coronary artery disease. The two groups of patients did not differ in the overall incidence of viability (50% in patients with vs 62% in those without ST-segment elevation, p = NS) and homozonal ischemia (39 vs 26%, p = NS), when evaluated with dobutamine echocardiography. However, a time-domain analysis of the ST-segment changes during exercise showed that the duration of exercise up to 0.1 mV ST-segment elevation was significantly lower in patients with viability (6.2 +/- 3.3 min) than in those without (10.2 +/- 2.2 min) (p < 0.001). Accordingly, ST-segment elevation occurred within 3 and 6 min of exercise in 7/18 and in 12/18 patients with viability respectively, but in only 0/18 (p < 0.01) and in 1/18 (p < 0.01) patients without viability. Thus, ST-segment elevation occurring within the first two stages of the exercise test was, respectively, 39 and 67% sensitive and 100 and 94% specific for viability. Early onset ST-segment elevation (within 3 and 6 min) was also more frequent in patients with high-dose dobutamine-induced homozonal ischemia than in those without (sensitivity for ischemia 50 and 67%; specificity 95 and 74%, respectively). CONCLUSIONS: After myocardial infarction, ST-segment elevation in Q-wave leads at the peak of exercise is associated with severe resting left ventricular dysfunction but fails to identify patients with a viable myocardium or residual ischemia. Instead, ST-segment elevation occurring in the early phases of exercise is a highly specific, although not very sensitive marker of dobutamine-assessed viability in the infarct area and may be indicative of residual ischemia.

[Thrombocytopenia induced by heparin: report of a clinical case]. / Trombocitopenia indotta da eparina: descrizione di un caso clinico.

Heparin-induced thrombocytopenia (HIT) is a possible complication of heparin administration consequent to an immunological reaction. It usually resolves without clinical sequelae with discontinuation of the drug. However, sometimes it causes severe platelet activation with thrombosis. The therapeutic strategy for HIT has only recently been established. In particular, in view of a possible worsening of the thrombotic status, some concerns have been raised about the early use of oral anticoagulation. We report a case of a 57-year-old woman in whom severe HIT occurring after a few days of heparin treatment for pulmonary embolism was treated using low doses of warfarin. The recent literature on HIT is reviewed and the lack, at the present, of valid pharmacological alternatives in Italy is emphasized.