Early fitting in cochlear implant surgery: preliminary results.

PURPOSE: Cochlear implants are usually activated 3-5 weeks after surgery; to date, no universal protocol exists regarding switch on and fitting of these devices. The aim of the study was to assess safety and functional results of activation and fitting of cochlear implant within 24 h following surgery. METHODS: In this retrospective case-control study, 15 adult patients who underwent cochlear implant surgery, for a total of 20 cochlear implant procedures were analyzed. In particular, clinical safety and feasibility were investigated by examinating patients at activation and at each follow-up. Values of electrodes' impedance and most comfortable loudness (MCL) were analyzed from the time of surgery to 12 months after activation. Free-field pure tone average (PTA) was also recorded. RESULTS: No major or minor complications were reported and all patients could perform the early fitting. Activation modality influenced impedance values only in the short term but the differences were not statistically significant (p > 0.05). Mean MCL values in the early fitting group were lower than MCL of the late fitting in all follow-up sessions, and the difference was statistically significant (p < 0.05). The mean PTA was lower in the early fitting group but the difference was not statistically significant (p < 0.05). CONCLUSIONS: Early fitting of cochlear implants is safe, allows for an early rehabilitation and can have possible beneficial effects on stimulation levels and dynamic range.

Simultaneous coronary artery bypass grafting and carotid endarterectomy in an awake Jehova's witness patient without endotracheal intubation.

Complex surgical procedures are associated with a major risk of peri-operative bleeding. Jehova's witnesses (JW) necessitate a tailored strategy warranting the optimal surgical management, in observance to their religion principles. In this report, we present a JW female patient, who underwent combined coronary artery bypass grafting and carotid endarterectomy, with neither endotracheal intubation nor general anaesthesia. Patient had previously undergone bilateral endarterectomy and required a reoperation on the left side. She was also scheduled for revascularization of left anterior descending coronary artery. After an extensive evaluation of all the possible operative strategies, we planned to perform CABG via a mid-line sternotomy, followed by CEA, in the awake patient. There were no intra-operative complications. Hb level, monitored by blood gases controls, maintained above 10 g/dl. The post-operative course was uneventful. In this patient, for the first time, a high-risk CABG procedure and a high-risk CEA were carried out simultaneously, in the awake setting. This approach represented a meeting point between surgical requirements and specific patient's needs. We believe it could be a safe alternative management applicable to high risk candidates to combined carotid and coronary artery surgery, presenting with bleeding-related issues.

Totally endoscopic robotic-guided pulmonary veins ablation: an alternative method for the treatment of atrial fibrillation.

In patients affected by isolated atrial fibrillation, epicardial pulmonary veins ablation can be performed with minimally invasive robotic-guided cardiac surgery techniques. This approach might become a feasible alternative to percutaneous transcatheter procedures. In this case report, we present a totally endoscopic robotic-guided pulmonary veins microwave ablation, on beating heart. A 64-year old male patient affected by paroxysmal atrial fibrillation was scheduled for an epicardial ablation procedure. Through three 1 cm-length port accesses, the "da Vinci" robotic system's camera and arms were introduced in the patient's chest. The pericardial reflections along the superior and inferior vena cava, as well as the transverse sinus, were dissected. Through an additional 0.5 cm-length port, a guidewire was advanced gradually across the transverse sinus, the diaphragmatic surface of the heart and the oblique sinus, finally surfacing outside the thoracic wall through the same port. Once tied to the microwave probe, the guidewire was pulled out carrying the probe inside the chest up to encircle the pulmonary veins. Once in place, a box lesion of the pulmonary veins was produced by microwave. At the 3-month follow up the patient is in sinus rhythm and so far did not longer experienced paroxysmal arrhythmic episodes.

First Italian robot-enhanced coronary bypass.

This case report presents the first totally endoscopic coronary artery bypass performed with a robotic system in Italy at the Department of Cardiovascular Surgery of Padua University in December 2001. A 66-year-old male, with an indication to a single bypass of the left anterior descending coronary artery using the left mammary artery, was considered eligible for a robot-assisted myocardial revascularization using the da Vinci robotic system. The left internal mammary artery takedown was performed through three 1 cm ports on the thoracic wall. The "end-to-side" anastomosis between the mammary artery and the target coronary artery was totally performed endoscopically on a beating heart by means of a stabilizing device introduced through an additional subxiphoid port. Angiographic follow-up at 1 year showed patency of the graft. Since September 2001, robot-enhanced left mammary artery harvesting has been performed in another 18 patients without complications.

[Prevention and control of respiratory tract infections in the network of Italian Centers for Cystic Fibrosis]. / Prevenzione e controllo delle infezioni da patogeni respiratori nei centri italiani per la cura della fibrosi cistica: risultati di un'indagine.

Infections caused by respiratory pathogens such as Burkholderia cepacia and Pseudomonas aeruginosa are associated with an increased morbidity and mortality in people affected by cystic fibrosis, the most common lethal genetic disease in Caucasian populations. Preventing the acquisition of these pathogens is paramount for these patients. The goal of this survey was to assess the distribution and the prevalence of the measures adopted for the prevention and control of infections caused by respiratory pathogens in the 28 italian centres for cystic fibrosis. 21 questionnaires were returned and some important differences can be observed in the adoption of segregation measures. Although results may be influenced by other factors, specific segregation policies appear to be more directly associated than other measures (e.g., intensive disinfection; behavioural rules to minimise patient' contacts) with lower prevalence of Pseudomonas aeruginosa (OR 0.36 CI95% 0.31-0.42), of multidrug-resistant Pseudomonas aeruginosa (OR 0.30 CI95% 0.22-0.40), and of methicillin-resistant Staphylococcus aureus (OR 0.67 CI95% 0.48-0.94).

Antiplatelet therapy in patients receiving aortic bioprostheses: a report of clinical and instrumental safety.

OBJECTIVE: The main advantage of bioprostheses, avoidance of anticoagulant therapy, is compromised during the early postoperative period; in fact, warfarin is often administered during the first 3 postoperative months. METHODS: We analyzed 250 patients undergoing tissue aortic valve replacement between January 2002 and December 2005. The patients received either aspirin (group 1) or oral anticoagulation (group 2) during the first 3 months. In a subgroup of these patients, we investigated the possible presence of clinically silent microembolization by means of transcranial Doppler for microembolic signal detection. RESULTS: Thirty-day mortality was 0%. No major neurologic events occurred. Two episodes of bleeding were observed in both groups. Follow-up time was 24 +/- 14 months. Overall late mortality rate was 0.8% in group 1 versus 12% (mainly cancer related) in group 2. In group 2, 2 deaths were due to major ischemic neurologic events; overall, 3 major neurologic episodes occurred (international normalized ratio was within therapeutic range). There were no neurologic events in group 1 (P = .12). Stroke-free survival did not reach statistical significance between the 2 groups. Transcranial Doppler was performed after a mean interval of 55 +/- 19 days, with no detection of microembolic signals in patients receiving either aspirin or warfarin. There were no episodes of bleeding or neurologic events. CONCLUSIONS: Aspirin therapy appears to be the appropriate response to both cardiac surgeons' and patients' needs in the early postoperative course after aortic valve replacement with tissue valves, demonstrating adequate antithromboembolic efficacy with no added risk for bleeding as well as ease of administration.

Angiographic long-term follow-up of primary apical ballooning of the left ventricle.

Acute and reversible left ventricular apical wall motion abnormalities presenting with chest pain, electrocardiographic (EKG) changes and cardiac markers release, in the absence of coronary artery stenosis, have already been identified as a possible distinct clinical entity: the so-called Tako-Tsubo syndrome. A 65-year-old man with history of hypertension, hypercholesterolemia and smoking, was admitted at the emergency room of a secondary referral institution with a severe and prolonged (45 min) chest pain, irradiated to the left arm, associated with neurovegetative syndrome. The clinical presentation suggested an acute myocardial infarction (AMI). Interestingly no coronary artery stenoses or vasospasm reaction to administration of acetylcholine could be detected. A slow flow phenomenon was present. The left ventricle angiography confirmed a mild depression of left ventricle systolic function (EF 45%), with akinesia of antero-lateral wall and the typical apical ballooning-like profile. At 3-month follow-up, the patient continued to be asymptomatic and the echocardiogram showed a progressive normalization of left ventricle segmental motion and ejection fraction with a complete restoration only after 6 months. At 1 year the coronary angiography confirmed the absence of coronary stenosis, with complete regression of the ventricular apical ballooning at left ventricle catheterization. At two-year follow-up the patient is still asymptomatic. A slow resolution of the syndrome should be included in the diagnostic criteria for apical ballooning.

How to deal with recipients of valves prone to structural failure in the 2000s: Padua experience with the TRI Technologies valve.

BACKGROUND: TRI Technologies (TT) valves evidenced a propensity to structural failure, consisting in fracture of the pivoting system, leading to leaflet escape. At our institution, between 2000 and 2002, 36 TT valves were implanted in 34 patients. Here we report the final results of the Tritech survey program. METHODS: In February 2002, the first valve-related death occurred. After the event, patients were enrolled in the TT valve survey program and strictly followed up. The option of a reintervention was advised to each patient and weighed against the redo operative risk. The prophylactic TT valve replacement program took place in two time frames, dependent on each patient's personal choice: between September 2002 and October 2003 (first phase), and between September 2004 and October 2004 (second phase). Overall, 22 (10 women, 12 men) patients underwent reoperation. Mean time interval between TT valve implantation and replacement was 23 +/- 11 months. Patients' mean age was 59 +/- 11 years (median age, 64 years). RESULTS: All recipients adhering to the program successfully underwent reoperation. Operative mortality was 0%. CONCLUSIONS: We believe that the timing of the second surgery was fundamental for the favorable outcome of each patient and the absence of operative mortality. We are convinced that the tailored programming of the reintervention, together with the strong motivation of each patient, contributed in minimizing the risks related to surgery. The circumscribed cohort of patients involved was compatible with a tailored therapeutic plan. We strongly advise prophylactic reoperation of recipients of TT valves.