Left cardiac sympathetic denervation in the Netherlands for the treatment of inherited arrhythmia syndromes.

INTRODUCTION: Treating therapy-resistant patients with inherited arrhythmia syndromes can be difficult and left cardiac sympathetic denervation (LCSD) might be a viable alternative treatment option. We provide an overview of the indications and outcomes of LCSD in patients with inherited arrhythmia syndromes in the only tertiary referral centre in the Netherlands where LCSD is conducted in these patients. METHODS: This was a retrospective study, including all patients with inherited arrhythmia syndromes who underwent LCSD in our institution between 2005 and 2013. LCSD involved ablation of the lower part of the left stellate ganglion and the first four thoracic ganglia. RESULTS: Seventeen patients, 12 long-QT syndrome (LQTS) patients (71 %) and 5 catecholaminergic polymorphic ventricular tachycardia (CPVT) patients (29 %), underwent LCSD. Most patients (94 %) were referred because of therapy-refractory cardiac events. In 87 % the annual cardiac event rate decreased. However, after 2 years the probability of complete cardiac event-free survival was 59 % in LQTS and 60 % in CPVT patients. Two patients (12 %) had major non-reversible LCSD-related complications: one patient suffered from a Harlequin face post-procedure and one severely affected LQT8 patient died the day after LCSD due to complications secondary to an arrhythmic storm during the procedure. CONCLUSION: LSCD for inherited arrhythmia syndromes, which is applied on a relatively small scale in the Netherlands, reduced the cardiac event rate in 87 % of the high-risk patients who had therapy-refractory cardiac events, while the rate of major complications was low. Therefore, LSCD seems a viable treatment for patients with inherited arrhythmia syndromes without other options for therapy.

"Patient participation" and related concepts: A scoping review on their dimensional composition.

OBJECTIVES: Several concepts on collaboration between patients and healthcare systems have emerged in the literature but there is little consensus on their meanings and differences. In this study, "patient participation" and related concepts were studied by focusing on the dimensions that compose them. This review follows two objectives: (1) to produce a detailed and comprehensive overview of the "patient participation" dimensions; (2) to identify differences and similarities between the related concepts. METHODS: A scoping review was performed to synthesize knowledge into a conceptual framework. An electronic protocol driven search was conducted in two bibliographic databases and a thematic analysis was used to analyse the data. RESULTS: The search process returned 39 articles after exclusion for full data extraction and analysis. Through the thematic analysis, the dimensions, influencing factors and expected outcomes of "patient participation" were determined. Finally, differences between the included concepts were identified. CONCLUSION: This global vision of "patient participation" allows us to go beyond the distinctions between the existing concepts and reveals their common goal to include the patient in the healthcare system. PRACTICE IMPLICATIONS: This scoping review provides useful information to propose a conceptual model of "patient participation", which could impact clinical practice and medical training programs.

Aortic graft infections: treatment with arterial allograft.

Since its reintroduction by Kieffer in 1991, many authors have used arterial allografts for surgical management of vascular prosthetic graft infection. During a decade, 25 patients with aortic graft infection were treated using in situ revascularization with arterial allograft. There were 23 male and 2 female patients of mean age of 65.7 +/- 8.8 years (range, 43-78). Antibiotic therapy was administered for a mean time of 26 +/- 5 days (range, 21-45) in the postoperative period. The mean follow-up time was 2.3 +/- 3 years (range, 22 days-8.7 years). The mean in-hospital postoperative stay was 29.6 +/- 14 days (range, 9-68). An aorto-enteric fistula (AEF) was present in 11 patients (44%), producing gastrointestinal bleeding. The overall mortality rate was 13 of 23 (56.5%) patients. The allograft-related mortality rate was 5 of 23 (22%). The overall allograft-complicated patient rate was 15 of 23 (65%); we observed 18 allograft ruptures in 12 patients and 8 allograft thromboses in 6 patients. The overall amputation rate was 8.7% (2 of 23). Age of the recipient older than 69 years (P = .02), positive preoperative marked-leukocyte scanning (P = .04), and persistent postoperative leukocytosis (P = .03) were significant variables associated with an increased risk of allograft-related complications. The use of arterial allografts for aortic graft infections represents an interesting alternative for the treatment of graft infection. Nevertheless, there are some problems related to the durability of this type of graft, which can still be considered as a "bridge transplant."

Neoplastic thrombosis of the inferior vena cava and right atrium due to kidney cancer. Three surgically treated cases.

Extension into vena cava and right atrium of tumor thrombus from a renal cell carcinoma presents a surgical challenge. The use of cardiopulmonary by-pass, hypothermia and cardiac arrest with temporary exsanguination has allowed the successful surgical excision of this tumor. During 1986 and 1987 3 patients with cancer of kidney invading the vena cava were operated on with this surgical technique. No deaths occurred. The possibility of curing this type of cancer with minimal operative risk and good results is discussed.

Nineteen year experience on the treatment of aneurysms of the abdominal aorta: a survey of 832 consecutive cases.

832 patients with abdominal aortic aneurysm were admitted to our Hospital, at the University of Milan, from 1965 to 1983. 238 patients were operated on as an emergency for rupture of the aneurysm while 541 underwent elective surgery. The overall postoperative mortality was 7% for the patients operated on electively and 54.3% for the ruptured aneurysm operated on as an emergency.

Intracavitary heart fibroma. A case of successful total excision.

Tumors of the heart are relatively rare events and fibromas represent no more than 5% of these. A central source of peripheral embolization suggests the possibility to kept in mind in the absence of other causes and is therefore worthy of closer investigation.

Acute aortic dissection. Personal experience.

Aortic dissection is a catastrophic event with a high mortality rate for untreated patients. One hundred and thirteen patients with acute aortic dissection were observed in the IInd Surgical Department of Milan University from 1974 to 1985; 55 had type I and II aortic dissection and 58 had type III aortic dissection. All patients with type I and II and about 50% of patients with type III aortic dissection underwent surgical correction. In the second type III group the aortic lesion was surgically corrected only when visceral ischaemia or ischaemia of the lower limb was recognized. In the other type III cases, medical treatment was preferred. The mortality rate was lower after medical treatment (15%) than after surgical treatment (37%). Follow-up was performed for the majority of patients and was recently completed with non-invasive techniques like Magnetic Resonance. It accurately shows the residual dissection and follows, the development of occlusion of the false lumen without any risk to the patients.

Internal mammary artery to pulmonary artery fistula.

A rare case of arteriovenous fistula between an internal mammary artery and a pulmonary artery is presented. The clinical history of recurrent bronchitis and dyspnoea during exercise, the presence of right parasternal murmur with normal heart size and normal blood gases justified the execution of an arteriovenous thoracic angiography which revealed the presence of a cirsoid aneurysm supplied by the internal and external mammary arteries. Diagnostic investigation and surgical indication in patients with the rare fistulous communication between the internal mammary artery and the systemic or pulmonary circulation are analysed.

Surgical treatment of thoracic aortic aneurysms. Personal experience.

A series of 262 observed cases of aneurysm of the thoracic aorta is examined in which 216 cases of surgical correction were performed between 1974 and 1987. Dissecting aneurysms and post-traumatic pseudoaneurysms, although of different aetiology and morbid anatomy, are also included since the surgical technique adopted is similar in all groups. Clinically different aspects of acute and chronic lesions are analyzed. Of all preoperative examinations, angiography is preferred as it gives the most precise definition of the aortic lesion. This is especially necessary in the case of acute dissection or rupture of thoracic aorta although the role of CAT scan is becoming progressively more important. In cases of aortic dissection with massive aortic valve insufficiency, the substitution of the ascending aorta and aortic valve with reimplantation of coronary arteries, in accordance with Bentall's technique is also indicated. The improvement in surgical results is emphasized, since surgical mortality has decreased from 30.6% to 22% in the last eight years. This is due to improvement in surgical technique, to extra corporeal circulation and myocardial protection.

Acute ruptures of the thoracic aorta. Personal experience.

The statistical incidence, etiopathogenesis, diagnostics and surgical treatment of acute ruptures of the thoracic aorta are described. A personal series of 7 cases is reported; surgical techniques, benefits and risks of extracorporeal circulation during surgical treatments are analysed and discussed.

Xibornol: multiple dose pharmacokinetics and diffusion in lung, tonsillar tissue and laryngeal mucosa.

In ten patients with severe chronic bronchitis and in a further 23 with planned resection of lung, tonsils or larynx, 500 mg doses, single or multiple, of xibornol (6-isobronyl-3, 4-xylenol) were administered for an antibacterial effect. The pharmacokinetics and diffusion of the drug in the tissues were studied. A high diffusion and distribution value of xibornol was observed, with levels in the tissues constantly higher than that in the serum. The concentrations reached within the respiratory tract were adequate for their antibacterial effect.

Ciprofloxacin: multiple-dose pharmacokinetic and clinical results in patients with hypercrinic bronchopulmonary diseases.

Ciprofloxacin, a 4-quinolone derivative with a wider spectrum of activity as compared to classic quinolones employed in the therapy of urinary tract infections, was studied in view of its possible application in the therapy of bronchopulmonary infections. An oral dose of 500 mg every 12 h was administered and both the clinical response and the pharmacokinetic profile were investigated. A complete recovery was reached in 87.5% of patients and an improvement in 12.5%; no failure was recorded. A very good penetration in sputum was confirmed by the sputum/serum area under curve ratio, providing evidence for a high bioavailability in bronchial secretion. Lung tissue concentrations confirmed the good peripheral distribution of ciprofloxacin. A twelve-hour administration schedule allows high peripheral concentrations to be obtained superior or equal to the minimum inhibitory concentrations for many pathogens.

Treatment of Buerger's disease with electrical spinal cord stimulation--review of three cases.

Buerger's disease or obliterating thromboangiitis is an inflammatory pathologic condition affecting the distal vascular segments; it strikes young adults, especially males and heavy smokers. Medical and surgical treatment often fail to heal these patients, especially considering the frequent relapse of this disease linked with tobacco abuse--definitive healing often involves limb amputation. Electrical spinal cord stimulation is evaluated in this study with an analgesic aim and for improvement in skin microcirculation, with the goal of long-term healing of diseased limbs.

[Hyperplasia of the adrenal medulla]. / L'iperplasia della midollare surrenalica.

A case of arterial hypertension due to suprarenal medulla hyperplasia is reported. Having accepted the existence of this form, the problem of its recognition is stressed, in the presence of catecholamine pathology, even though the type or site of its anatomo-pathological substrate cannot be identified, explorative surgery and possible removal of the suprarenal glands can be indicated.

[Massive pulmonary embolism. Clinical aspects and treatment]. / L'embolia polmonare massiva. Clinica e trattamento.

The frequency of pulmonary embolization seems to be increasing. Venostasis, intimal damage and hypercoagulability of blood are the more recognized causes of pulmonary thromboembolism. It is especially threatening to the elderly, obese, immobilized (for an accident or an operation) patients. Pulmonary isotopic scans or angiograms are most often relied upon to establish the diagnosis. A properly performed pulmonary angiography is necessary to establish or refute the diagnosis in almost every case. With the exception of the patients suddenly dying for a massive pulmonary embolism, the period of time between onset of symptoms and death is usually adequate for substantiating a diagnosis and promptly beginning a fit anticoagulation therapy using continuous intravenous heparin or fibrinolytic agents infusion. Although it is not proper to separate surgical and medical treatment of thromboembolism, the Authors, on the ground of their experience on 5 patients affected by massive pulmonary embolism, in 3 of whom was performed a successful embolectomy, think that heparin anticoagulation treatment is at any rate to apply for treating pulmonary embolism, but in patients in whom the shock is unresponsive to vasopressors or in whom anticoagulation therapy is controindicated, the surgical removal of pulmonary emboly, with the support of a pump oxygenator, is the treatment of choice for the acute massive pulmonary thromboembolism.

Brain involvement in extracranial internal carotid artery aneurysms.

BACKGROUND: No prospective study of extracranial internal carotid artery aneurysms (EICAA) has been reported to date. The aim of this study was to evaluate central nervous system complications associated with surgical intervention for EICAA. PATIENTS AND METHODS: A total of seven patients, representing all cases observed at our institution from December 1997 to December 1998, were entered in this prospective study. Three patients had bilateral involvement. The aneurysms were both atherosclerotic and dysplastic. All patients were males, with mean age of 70 years (range 65 to 74). Internal or common carotid artery to EICAAs diameter ratios were calculated on the angiograms. The transverse diameter as well as the craniocaudal extension of the lesions were accurately measured intraoperatively. Follow-up evaluations were performed at three, six and twelve months postoperatively, and consisted of a clinical evaluation by both a neurologist and a vascular surgeon who were not part of the primary surgical team. RESULTS: Six patients presented with neurological symptoms ranging from non-hemispheric TIAs to hemispheric stroke. One patient was asymptomatic. The severity of symptoms was correlated with the size of the aneurysm. Preoperative symptoms were more severe in EICAAs of > or = 3 cm in transverse diameter. One case had a postoperative stroke, no perioperative deaths occurred. All the internal carotid arteries operated on were patent during follow-up evaluations. No new neurologic event was observed during follow-up. CONCLUSIONS: The severity of central neurologic symptoms seems to depend on the size of the aneurysmatic lesion. Prompt surgical management of small EICAAs may reduce the occurrence of severe CNS complications, both preoperatively and postoperatively, due to the lower risk of embolization associated with small aneurysms compared to larger lesions.

Vascular prosthetic graft infection: epidemiology, bacteriology, pathogenesis and treatment.

UNLABELLED: Vascular prosthetic graft infection remains a major surgical challenge. Prevention of risk factors and antibiotic therapy can reduced but not eradicate it. Management of infected vascular grafts depends on several factors, including the location of the infected prosthesis, the extent of infection, and the underlying micro-organism. Classic treatment consists of extra-anatomic bypass grafting. The disappointing results due to the high mortality and amputation rate have kindled interest in alternative approaches, such as in situ reconstruction with antibiotic-bonded prostheses, autogenous veins or arterial allografts. PURPOSE: We focused on the treatment of aortic graft infection by means of both fresh and cryopreserved arterial allograft. Here, the experience of the Italian Collaborative Vascular Homograft Group is reported. METHODS: Between March 1994 and December 2000 seventy-nine patients with aortic graft infection were treated. The results of 68 patients are analysed. Eleven patients were treated with fresh, and 57 with cryopreserved homograft. Emergency surgical procedures were performed in 12 patients (17%). Aortoenteric fistula was diagnosed in 22 patients. The mean interval between the first procedure and the insertion of a homograft for patients with infected aortic graft was 3 years (range 1-15). The mean duration of follow-up was 30 months (range 1-68). Clinical and duplex scanning evaluation were routinely performed. Computer tomography (CT), magnetic resonance (MR), or arteriography were performed on the basis of duplex scanning results. RESULTS: The analysis was performed on 68 cases for which there were sufficient reliable data. Eleven deaths occurred during the early postoperative period (30 days), a mortality rate of 16%. There were also seventeen late deaths, a mortality rate of 25%. Eleven patients had graft occlusion; six cases were successfully treated with thrombectomy. In three cases leg amputation was necessary. The results of fresh and cryopreserved homografts were compared. No significant differences of early postoperative mortality, late mortality, homograft-related mortality, graft failure were observed. The presence of aortoenteric fistula is a negative predicting factor of perioperative early mortality, which causes a rapid decline in the survival curve. Thirty-six months after the surgery the actuarial survival of the patients was 57% and the actuarial patency of the allograft was 41%. CONCLUSION: No significant difference in terms of clinical outcome was observed when using fresh, rather than cryopreserved homografts. The only factor that significantly influenced the survival rate appeared to be the aorto-enteric fistula.

[Behavior of the local lymphatic system after aorta-iliaco-femoro-popliteal reconstruction]. / Il comportamento del sistema linfatico distrettuale dopo interventi di ricostruzione aorto-iliaco-femoro-poplitea

As a result of the observation of oedemas of the lower extremities and lymphorrhoea in the immediate postoperative course of surgical reconstruction of the aorto-iliaco-femoro-popliteal arterial axis (and on the basis of similar cases in the literature), the participation of the lower extremity return circulation in this facet of vascular surgery has been documented. The venous system was never impaired whereas the local lymphatic system was always damaged by surgical aggression on the arterial vessels. However, the extensive anatomical lesions shown up by lymphography are not reflected in evident clinical signs; whenever oedema or lymphorrhoea of the surgical wounds are observed, these symptoms are always of slight importance and easily and quickly resolved. At long-term follow-up, no clinical evidence of impairment ot the venous and lymphatic venous return circulation was ever encountered. For prophylactic purposes the lymphatic structure encountered during the operation should be carefully ligated to counteract another dangerous complication: infection.

[Surgical treatment of massive pulmonary embolism. Personal cases]. / Il trattamento chirurgico dell'embolia polmonare massiva. Casistica personale.

5 cases of pulmonary embolism are reported. 3 of these were subjected to pulmonary embolectomy with complete success; repeated controls bear witness to the good long-term cardiorespiratory condition. Two patients died, one following angiography, the other at anaesthetic induction; this fact shows the desirability of submitting patients to partial support extracorporeal circulation prior to angiography and, in any cases, before submitting them to anaesthesia. This surgical success obtained in treatment of the three cases shows that embolectomy continues to play a decisive role.

[Intestinal complications during a course of vascular reconstructive surgery. Case reports]. / Le complicanze intestinali in corso di chirurgia vascolare ricostruttiva. Contributo casistico

Twenty-one cases of gastro-enteric complications during aorto-iliac-femoral reconstructive surgery carried out from 1965 to 1973 in the Department of Surgery of University in Milan are studied. Causes, frequence, clinical data and medical and surgical procedures are discussed.