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Mve Mvondo C, Nardi P, Bassano C, Bertoldo F, Grego S, D'Auria F, Scafuri A, Chiariello L. Surgical treatment of aortic valve regurgitation secondary to ascending aorta aneurysm: is adjunctive subcommissural annuloplasty necessary? Ann Thorac Surg 2012; 95:586-92. [PMID: 23261112 DOI: 10.1016/j.athoracsur.2012.09.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Revised: 09/13/2012] [Accepted: 09/20/2012] [Indexed: 11/16/2022]
Abstract
BACKGROUND Subcommissural aortic annuloplasty (SCA) has been recommended for treatment of functional aortic regurgitation (AR), but its association with sinotubular junction adjustment is still controversial. METHODS Sixty patients with moderate or severe functional AR secondary to proximal ascending aorta aneurysm operated on between May 2004 and December 2010 were reviewed. Forty patients underwent SCA and ascending aorta repair (SCA group; mean age, 65 ± 9 years) and 20 underwent ascending aorta repair alone (non-SCA group; mean age, 69 ± 8 years). Preoperative AR grades were comparable between groups (p = 0.9). Echocardiographic data at discharge and during follow-up (SCA group, 41 ± 13 months; non-SCA group, 46 ± 13 months) were analyzed. RESULTS Improvement of mean AR grade was better in the SCA group than in the non-SCA group at discharge (0.78 ± 0.9 vs 1.8 ± 0.1/4+, p = 0.0001) and at follow-up (0.44 ± 0.8 vs 2.4 ± 0.7/4+, p = 0.0001). Cox-regression analysis (odds ratio [95% confidence interval]) identified a higher residual AR at discharge (0.14 [0.012-0.37], p = 0.02) and the surgical technique, SCA or not (0.5 [0.03-0.899], p = 0.04), as predictors of more than grade 2/4+ AR at follow-up. Five-year freedom from more than grade 2/4+ AR was 94.4% ± 5.4% vs 58% ± 16% in SCA vs non-SCA (p = 0.02), respectively, and the survival rate was 95% ± 5% vs 89% ± 7.5% (p = 0.7). No valve stenosis was observed in the SCA group. CONCLUSIONS SCA is effective for treatment of functional AR, providing stable results even for significant AR. Our results suggest that it should be possibly associated to sinotubular junction adjustment. SCA seems to not impair normal aortic valve opening.
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Nardi P, Scafuri A, Pellegrino A, D'Auria F, Polisca P, Zeitani J, Chiariello L, Mvondo C. Left Atrial Radiofrequency Ablation Associated with Valve Surgery: Midterm Outcomes. Thorac Cardiovasc Surg 2012; 61:392-7. [DOI: 10.1055/s-0032-1322606] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Nardi P, Pellegrino A, Scafuri A, Olevano C, Bassano C, Zeitani J, Chiariello L. Survival and Durability of Mitral Valve Repair Surgery for Degenerative Mitral Valve Disease. J Card Surg 2011; 26:360-6. [DOI: 10.1111/j.1540-8191.2011.01275.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Nardi P, Pellegrino A, Scafuri A, Bellos K, De Propris S, Polisca P, Chiariello L. Permanent pacemaker implantation after isolated aortic valve replacement: incidence, risk factors and surgical technical aspects. J Cardiovasc Med (Hagerstown) 2010; 11:14-9. [DOI: 10.2459/jcm.0b013e32832f9fde] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Nardi P, Pellegrino A, Scafuri A, Binaco I, Polisca P, Iorio F, Versaci F, Chiariello L. Long-term outcomes after surgical ventricular restoration and coronary artery bypass grafting in patients with postinfarction left ventricular anterior aneurysm. J Cardiovasc Med (Hagerstown) 2009; 11:96-102. [PMID: 19952949 DOI: 10.2459/jcm.0b013e32832f9fc1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Surgical ventricular restoration (SVR) for postinfarction left ventricular anterior aneurysm improves left ventricular function. The aim of this study was to evaluate whether concomitant multivessel coronary artery disease (MVCAD) can affect long-term outcome. Thus, long-term results of SVR associated with multiple coronary artery bypass grafting (CABG) for MVCAD (group 1) were compared with SVR with or without CABG to left anterior descending artery and/or its diagonal branch for single-vessel coronary artery disease (group 2). METHODS Data from 104 consecutive patients (age 64 +/- 8 years) with left ventricular anterior aneurysm, subjected to SVR from January 1994 to December 2004 and divided into group 1 (n = 79) and group 2 (n = 25), were analyzed. RESULTS In group 1 vs. group 2, number of grafts/patient (2.7 +/- 0.9 vs. 0.6 +/- 0.6, P < 0.0001) was higher, cardiopulmonary bypass (109 +/- 30 vs. 65 +/- 28 min, P < 0.0001) and aortic cross-clamp times (65 +/- 18 vs. 44 +/- 23 min, P < 0.0001) were longer, resected aneurysmatic area (12 +/- 8 vs. 17 +/- 11 cm2, P < 0.05) was smaller. Operative mortality was 3.7 vs. 4% (P = not significant). At 12 years, survival (85 +/- 5 vs. 80 +/- 16%) and freedom from cardiac events (70 +/- 7 vs. 75 +/- 16%) were not statistically different in both groups. Follow-up echocardiography showed significant left ventricular ejection fraction improvement in group 1 (0.45 +/- 0.07 vs. 0.34 +/- 0.10 preoperatively, P < 0.0001) and group 2 (0.47 +/- 0.09 vs. 0.36 +/- 0.12, P = 0.001). Independent predictors of late death were preoperative history of ventricular arrhythmias (P < 0.001) and hypo/akinesia of proximal myocardial anterior wall (P < 0.05). CONCLUSION Late survival and freedom from cardiac events are excellent after SVR, also when concomitant MVCAD requires complete revascularization. Ventricular arrhythmias and impaired left ventricular anterior wall function are predictors of worse outcome.
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Nardi P, Pellegrino A, Scafuri A, Colella D, Bassano C, Polisca P, Chiariello L. Long-term outcome of coronary artery bypass grafting in patients with left ventricular dysfunction. Ann Thorac Surg 2009; 87:1401-7. [PMID: 19379873 DOI: 10.1016/j.athoracsur.2009.02.062] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2008] [Revised: 02/19/2009] [Accepted: 02/20/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND Coronary artery bypass grafting (CABG) is a well-accepted therapeutic strategy for patients with multivessel coronary artery disease and left ventricular dysfunction. The aim of the study was to evaluate long-term results after CABG in patients with preoperative left ventricular ejection fraction (LVEF) of 0.35 or less. METHODS Data from 302 consecutive patients (mean age, 62 +/- 8.7 years) with LVEF of 0.35 or less who had undergone CABG were analyzed. Epinephrine and enoximone with or without norepinephrine were used to increase cardiac index. Intra-aortic balloon pump or left ventricular assist devices, or both, were used in case of postoperative low output syndrome. RESULTS Complete revascularization was achieved in 298 of 302 patients (98.7%); internal thoracic artery was used in 294 (97.4%). Operative mortality was 5.3%; independent predictors of operative mortality were emergency CABG (p = 0.005), history of ventricular arrhythmias (p = 0.007), and previous anterior myocardial infarction (p = 0.05). At follow-up, all-cause mortality was 30.8%, and 10-year survival was 63% +/- 4%; independent predictors of late all-cause mortality were history of ventricular arrhythmias (p < 0.0001), chronic renal dysfunction (p = 0.0004), and diabetes mellitus (p = 0.04). Cardiac death was 20.4%, and 10-year freedom from cardiac death was 73% +/- 3.3%; independent predictors of cardiac death were history of ventricular arrhythmias (p = 0.004), chronic renal dysfunction (p = 0.03), and more than one previous anterior myocardial infarction (p = 0.004). At 80 +/- 44 months of follow-up, echocardiography showed significant LVEF improvement (0.43 +/- 0.09 versus 0.28 +/- 0.06, p < 0.0001). Ten-year freedom from myocardial infarction was 87% +/- 3%. CONCLUSIONS Excellent long-term results after CABG can be expected for patients with LVEF of 0.35 or less. Complete revascularization and internal thoracic artery grafting are associated with high freedom from myocardial infarction. Careful treatment of arrhythmias, diabetes, and renal dysfunction is necessary to improve long-term survival.
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Scafuri A, Bellos K, Nardi P, Chiariello L. Right ventricle mass in a woman discovered after preeclampsia. Interact Cardiovasc Thorac Surg 2009; 8:699-700. [PMID: 19279054 DOI: 10.1510/icvts.2008.199331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Cardiac masses are discovered occasionally. They are represented by thrombi, vegetations and tumors, primary or metastatic. The most frequent cardiac tumor is myxoma. The coincidence of pregnancy and a primary cardiac tumor is extremely rare. Only a few case reports of heart tumors during pregnancy are presented in the literature. The case of a young woman with the initial echocardiographic diagnosis of right ventricle mass is reported.
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Zeitani J, Penta de Peppo A, Bianco A, Nanni F, Scafuri A, Bertoldo F, Salvati A, Nardella S, Chiariello L. Performance of a novel sternal synthesis device after median and faulty sternotomy: mechanical test and early clinical experience. Ann Thorac Surg 2008; 85:287-93. [PMID: 18154824 DOI: 10.1016/j.athoracsur.2007.08.036] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2007] [Revised: 08/11/2007] [Accepted: 08/14/2007] [Indexed: 11/17/2022]
Abstract
BACKGROUND Reinforcement of chest closure may be required in patients with multiple risk factors of wound dehiscence. Performance of a light, size-adaptable closure reinforcement device (DSS: Sternal Synthesis Device; Mikai SpA, Vicenza, Italy) is presented. METHODS A longitudinal median or paramedian incision was performed in artificial sternal models: closure was accomplished with simple interrupted steel wires or reinforced with the DSS. Forces required for separation of the rewired sternal halves during a monotonic tensile test were analyzed. A high velocity traction cycles test was also adopted to simulate the impact of coughing. RESULTS After median incision, ultimate load values inducing break of the sternum models were 580 +/- 35 N (Newton) in controls; failure of the test occurred at 1,200 +/- 47 N in the reinforced group (p = 0.0002). More lateral displacement of sternal halves at increasing forces was observed in controls (p = 0.0001). After paramedian incision, ultimate load values inducing break of the constructs were lower in controls (220 +/- 20 N vs 500 +/- 25 N, p = 0.001), which also showed more lateral displacement of sternal halves than the reinforced group (p = 0.002). At the high velocity traction cycles test, the number of cycles required to break the models was lower in controls (2,250 +/- 35 vs 3,855 +/- 48 cycles, p = 0.0001). Preliminary clinical experience in 45 patients showed ease of implantation and low risk of complications. CONCLUSIONS The proposed sternal reinforcement device provides substantial sternal support at electromechanical testing after median and faulty sternotomy and may hopefully prevent sternal wires migration and bone fractures in high risk patients.
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Versaci F, Del Giudice C, Scafuri A, Zeitani J, Gandini R, Nardi P, Salvati A, Pampana E, Sebastiano F, Romagnoli A, Simonetti G, Chiariello L. Sequential Hybrid Carotid and Coronary Artery Revascularization: Immediate and Mid-Term Results. Ann Thorac Surg 2007; 84:1508-13; discussion 1513-4. [DOI: 10.1016/j.athoracsur.2007.05.048] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2007] [Revised: 05/18/2007] [Accepted: 05/21/2007] [Indexed: 11/16/2022]
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Nardi P, Scafuri A, Pellegrino A, Bassano C, Zeitani J, Bertoldo F, Penta de Peppo A, Chiariello L. [Surgery for type A aortic dissection: long-term results and risk factor analysis]. GIORNALE ITALIANO DI CARDIOLOGIA (2006) 2007; 8:580-585. [PMID: 17972428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
BACKGROUND Identification of risk factors may help prevent mortality and recurrence after surgical treatment of type A aortic dissection. METHODS From January 1995 to March 2006, 100 consecutive patients (82 men, 18 women, mean age 58 +/- 12 years) with type A acute aortic dissection were submitted to replacement of ascending aorta (n = 62), arch (n = 27), or the aortic root (n = 11, 9 with the Bentall operation and 2 with the David aortic valve reimplantation). Patients were followed up for 48 +/- 33 months (range 1-120 months). RESULTS Operative mortality was 18% for aortic root replacement, 24% for ascending aorta replacement, 26% for arch replacement, respectively (p = NS). Independent risk factors for operative mortality were: acute (p = 0.001) and chronic renal dysfunction (p = 0.02), advanced patient age (61 +/- 13 vs 56 +/- 13 years, p = 0.02), prolonged bypass time (p = 0.01). Antegrade cerebral perfusion and moderate hypothermia during arch replacement was associated with better results than deep hypothermia (mortality 0/12 vs 7/15 patients, p = 0.008). Eight-year survival and freedom from cardiovascular events were 74 +/- 7.5% and 70 +/- 7.4%, respectively. Independent risk factor for late death was left ventricular ejection fraction < 0.50 (p = 0.02). Five out of 67 patients (7.5%) submitted to replacement of the ascending aorta with a tubular graft, who presented a dilated aortic root diameter (47 +/- 3.4 vs 40.4 +/- 4.9 mm, p = 0.004), were reoperated for proximal progression of the disease into the native aortic root (dilation n = 3, dissection n = 2) after 33 +/- 20 months (range 2-58 months). Proximal aorta reoperation was associated with markedly reduced 8-year survival (52 +/- 23 vs 82 +/- 7%, p = 0.017). CONCLUSIONS Surgery for acute aortic dissection represents an emergency treatment with satisfactory long-term results. Survival is affected by renal dysfunction at presentation, which should be aggressively treated, and by progression of the disease requiring reoperation; a dilated diameter of the aortic root should therefore indicate root replacement at the time of first operation.
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Zeitani J, Penta de Peppo A, Moscarelli M, Guerrieri Wolf L, Scafuri A, Nardi P, Nanni F, Di Marzio E, De Vico P, Chiariello L. Influence of sternal size and inadvertent paramedian sternotomy on stability of the closure site: a clinical and mechanical study. J Thorac Cardiovasc Surg 2006; 132:38-42. [PMID: 16798300 DOI: 10.1016/j.jtcvs.2006.03.015] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2005] [Revised: 02/16/2006] [Accepted: 03/08/2006] [Indexed: 01/28/2023]
Abstract
BACKGROUND The influence of sternal size and of inadvertent paramedian sternotomy on stability of the closure site is not well defined. METHODS Data on 171 consecutive patients undergoing cardiac surgery through a midline sternotomy were prospectively collected. Intraoperative measurements of sternal dimension included thickness and width at the manubrium, the third and fifth intercostal spaces; paramedian sternotomy was defined as width of one side of the sternum equaling 75% or more of the entire width, at any of the three levels. The chest was closed with simple peristernal steel wires and inspected to detect deep wound infection and/or instability for 3 postoperative months. The sternal factors and several patient/surgery-related factors were included in a multivariate analysis model to identify factors affecting stability. An electromechanical traction test was conducted on 6 rewired sternal models after midline or paramedian sternotomy and separation data were analyzed. RESULTS Chest instability was detected in 12 (7%) patients and wound infection in 2 (1.2%). Patient weight (P = .03), depressed left ventricular function (P = .04), sternum thickness (indexed to body weight, P = .03), and paramedian sternotomy (P = .0001) were risk factors of postoperative instability; paramedian sternotomy was the only independent predictor (P = .001). The electromechanical test showed more lateral displacement of the two rewired sternal halves after paramedian than midline sternotomy (P = .002); accordingly, load at fracture point was lower after paramedian sternotomy (220 +/- 20 N vs 545 +/- 25 N, P = 0.001). CONCLUSIONS Inadvertent paramedian sternomoty strongly affects postoperative chest wound stability independently from sternal size, requiring prompt reinforcement of chest closure.
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Zeitani J, Scafuri A, de Peppo AP, Gaspardone A, Polisca P, Di Marzio E, Sgrò S, De Vico P, Chiariello L. Thrombosis of the Left Anterior Descending Artery Due to Compression from Giant Pseudoaneurysm Late After a Bentall Operation. J Card Surg 2006; 21:195-7. [PMID: 16492287 DOI: 10.1111/j.1540-8191.2006.00206.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND A postoperative pseudoaneurysm may develop and gradually expand in the mediastinal space even late following Bentall operation for aortic root replacement, particularly in patients with dissection of the aorta. METHODS A very large (148 mm) pseudoaneurysm originating of the right coronary ostium suture line was observed in a patient admitted with unstable angina 6 years after Bentall procedure for type A aortic dissection. Angiograms showed reduced flow in the right coronary and thrombotic subocclusion of the left anterior descending (LAD) coronary artery due to extrinsic compression from the expanding mediastinal mass. RESULTS Reoperation was performed during femoro-femoral cardiopulmonary bypass and brief period of circulatory arrest to clamp the tubular graft. After closure of the detected right coronary ostium in the tubular graft double bypass, grafting to the right coronary and LAD arteries was required. Postoperative course was uneventful. CONCLUSIONS Close long-term follow-up after a Bentall procedure is required to minimize the risk of developing a large pseudoaneurysmal mass, in particular, after dissection of the aorta.
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Zeitani J, Penta de Peppo A, De Paulis R, Nardi P, Scafuri A, Nardella S, Chiariello L. Benefit of Partial Right-Bilateral Internal Thoracic Artery Harvesting in Patients at Risk of Sternal Wound Complications. Ann Thorac Surg 2006; 81:139-43. [PMID: 16368351 DOI: 10.1016/j.athoracsur.2005.06.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2005] [Revised: 06/03/2005] [Accepted: 06/08/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Excellent long-term patency of the internal thoracic artery (ITA) graft promotes use of bilateral ITA bypass grafting; sternal devascularization, however, increases the risk of wound complications. We hypothesized that restricting right ITA (RITA) harvesting to a short proximal skeletonized segment (3 to 5 cm) would result in adequate residual blood supply to reduce that risk. METHODS Seventy-eight patients with numerous risk factors for wound complications underwent composite double ITA grafting, utilizing the RITA segment anastomosed to the left skeletonized ITA and to the obtuse marginal branch in Y fashion. Blood flow in the distal RITA was assessed by parasternal transthoracic Doppler ultrasonography. Comparisons were made with prospectively collected data of patients undergoing pedicled single (n = 160) or skeletonized bilateral ITA grafting (n = 143) during the same period. RESULTS Incidence of obesity, chronic obstructive pulmonary disease, diabetes, and peripheral vascular disease was higher in study patients. Postoperative Doppler ultrasonography detected reversed systolic dominant flow pattern. Wound complications occurred in 2 of 78 (2.6%) patients, compared with 14 of 143 (9.8%) after bilateral ITA (p = 0.04) and 8 of 160 (5%) after single ITA grafting (p = ns). Technique of bilateral ITA harvesting (partial right versus full length; odds ratio, 0.2; confidence interval: 0.04 to 0.9) and diabetes mellitus (odds ratio, 2.7; 95% confidence interval: 1.1 to 6.3) were independent predictors of wound complications in the entire series. CONCLUSIONS Substantial residual blood supply is detectable after partial RITA harvesting and may prevent wound complications in high-risk patients.
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Zeitani J, Penta de Peppo A, Scafuri A, Versaci F, Chiariello L. Free right internal thoracic artery in a "horseshoe" configuration: a new technical approach for "in situ" conduit lengthening. J Card Surg 2005; 20:583-4; discussion 585. [PMID: 16309418 DOI: 10.1111/j.1540-8191.2005.00128.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Severe chronic obstructive pulmonary disease with large lung volumes may prevent both the "in situ" internal thoracic arteries to reach coronary anastomoses sites. We present a method to revascularize the left antero-lateral myocardial wall using the right internal thoracic artery as a "free graft" anastomosed side to end to the "in situ" left internal thoracic artery, in a "horseshoe" fashion. The two ends of the "free graft" were anastomosed to the left anterior descending coronary artery and the second obtuse marginal branch, respectively. This method was successfully used in a 74-year-old patient with severe chronic obstructive pulmonary disease.
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Scafuri A, Moscarelli M, Guerrieri Wolf L, Del Giudice C, Nardi P, Chiariello L. Aortic root enlargement for aortic valve replacement in an achondroplastic dwarf. Tex Heart Inst J 2005; 32:442-4. [PMID: 16392240 PMCID: PMC1336731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
We present a case of aortic valve replacement combined with aortic root enlargement, performed on an achondroplastic dwarf with severe calcific aortic stenosis. There are no data about the incidence of valvular diseases in achondroplastic patients. To our knowledge, this is the 1st time that an aortic valve replacement associated with an aortic root enlarging procedure has been performed in this kind of patient. The aim of this report is to show that achondroplasia, in and of itself, is not a contraindication to aortic valve replacement.
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Zeitani J, Penta de Peppo A, De Paulis R, Nardi P, Scafuri A, Versaci F, Chiariello L. Partial Right Internal Thoracic Artery Harvesting is Sufficient for Obtuse Marginal Branch Bypass Grafting. Ann Thorac Surg 2005; 79:361-2. [PMID: 15620988 DOI: 10.1016/j.athoracsur.2003.09.095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/22/2003] [Indexed: 10/26/2022]
Abstract
My colleagues and I present a method for revascularizing the left anterolateral myocardial wall by using an in situ left internal thoracic artery to left anterior descending coronary artery system and a short proximal segment (3 to 5 cm) of the right internal thoracic artery in Y fashion anastomosed to the in situ left internal thoracic artery to revascularize the obtuse marginal branches. With this technique the left ventricular anterolateral wall can be revascularized with both internal thoracic arteries, leaving a consistent residual blood supply to the right hemisternum.
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Forlani S, Moscarelli M, Scafuri A, Pellegrino A, Chiariello L. Combination therapy for prevention of atrial fibrillation after coronary artery bypass surgery: a randomized trial of sotalol and magnesium. ACTA ACUST UNITED AC 2004; 7:168-71. [PMID: 14618045 DOI: 10.1023/a:1027423802701] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Atrial Fibrillation (AF) is a common complication of coronary artery bypass surgery reported to occur in 20-40% of patients. Sotalol alone and magnesium alone have been shown to decrease the incidence of AF. The aim of this study was to evaluate the efficacy of these two agents, alone or in combination, to reduce postoperative AF. METHODS Two hundreds and seven consecutive coronary artery bypass patients were randomized to receive sotalol alone (80 mg two times daily for five days starting from the morning of the first postoperative day), magnesium alone (1.5 g daily for six days starting in the operating room just before cardiopulmonary bypass), both pharmacological agents at the same dosages or no antiarrhythmic agents (Control group). Patients with an ejection fraction <40% were excluded. RESULTS The incidence of postoperative AF was 11.8% (6/51) in the sotalol group, 14.8% (8/54) in the magnesium group, 1.9% (1/52) in sotalol+magnesium group and 38% (19/50) in the control group. The differences were significant between the control group and the other three groups (sotalol, magnesium and sotalol + magnesium groups: p = 0.002, p = 0.007 and p < 0.0001 respectively), and between the sotalol + magnesium group and single drug groups (sotalol and magnesium groups: p = 0.04 and p = 0.01, respectively. CONCLUSION The incidence of AF after coronary surgery was significantly reduced by the administration of sotalol alone and magnesium alone. The incidence of postoperative AF was further reduced by combining the two pharmacological agents.
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Penta de Peppo A, Nardi P, De Paulis R, Pellegrino A, Forlani S, Scafuri A, Chiariello L. Cardiac surgery in moderate to end-stage renal failure: analysis of risk factors. Ann Thorac Surg 2002; 74:378-83. [PMID: 12173816 DOI: 10.1016/s0003-4975(02)03711-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND The incremental surgical risk caused by different categories of renal failure is not well defined. METHODS Data from 159 patients with moderate to end-stage renal dysfunction, who had consecutive operations using cardiopulmonary bypass, were included in a multivariate analysis of morbidity and survival. Ninety-nine patients had preoperative serum creatinine levels (PSCL) of 1.9 to 2.5 mg/dL (moderate), 36 had PSCL higher than 2.5 mg/dL and were not dialysis dependent (severe), and 24 required chronic dialysis (end-stage dysfunction). RESULTS Operative mortality was 4% with moderate dysfunction and compared favorably with 16.7% in severe and 8% in end-stage dysfunction (p < 0.05). Independent predictors of death were severe non-dialysis-dependent renal dysfunction (p < 0.05), diabetes (p < 0.05), and cardiopulmonary bypass time (p < 0.01). Severe renal dysfunction (p < 0.01) and diabetes (p < 0.01) also predicted pulmonary and neurologic morbidity. Freedom from late death at 4 years was 82% +/- 5% with moderate, 49% +/- 10% with severe, and 60% +/- 10% with end-stage dysfunction (p < 0.01). Time to late death was adversely affected by severe (p < 0.05) and end-stage dysfunction (p < 0.01). Persistent improvement of symptoms was observed in all subgroups. CONCLUSIONS Satisfactory early and late surgical outcomes may be expected in patients with moderate renal failure, but outcomes are often poor with severe non-dialysis-dependent and end-stage renal dysfunction.
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De Paulis R, Penta De Peppo A, Colagrande L, Nardi P, Tomai F, Forlani S, Scafuri A, Piciché M, Chiariello L. Troponin I release after CABG surgery using two different strategies of myocardial protection and systemic perfusion. THE JOURNAL OF CARDIOVASCULAR SURGERY 2002; 43:153-9. [PMID: 11887047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
BACKGROUND Controversies still exist over the optimal temperature for blood cardioplegia and systemic perfusion. This study investigates the effect of temperature of blood cardioplegia and systemic perfusion on the release of troponin I and other biochemical markers. METHODS One hundred and fifty-four consecutive patients were randomly assigned to one of two cardioplegic and systemic perfusion strategies of cold blood cardioplegia with moderate systemic hypothermia (27 degrees C) or tepid blood cardioplegia with mild systemic hypothermia (33 degrees C). Cardiac troponin I and other biochemical markers were measured at baseline, at the end of surgery, at 12 hours and daily thereafter. A two-way ANCOVA for repeated measure was performed to test the effect of cardioplegia on enzyme release independently of variables that were different between the two groups. RESULTS The time course of dismission of troponin I, creatine kinase MB, and lactate dehydrogenase were significantly lower with tepid blood cardioplegia and mild systemic perfusion independently of the number of distal anastomoses, CPB time, cross clamp time or total volume of cardioplegia. There were no differences between the two groups in the release of total creatine kinase, aspartate transaminase and alanine transferase. CONCLUSIONS Both strategies of myocardial protection and systemic perfusion guarantee subclinical minor myocardial damage. The strategy of tepid whole blood cardioplegia and mild systemic hypothermia seems to preserve myocardium better than whole blood cold cardioplegia.
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Vitale N, Caldarera I, Muneretto C, Sinatra R, Scafuri A, Di Rosa E, Contini A, Tedesco N, Pierangeli A, Abbate M, Gherli T, Casarotto D, Di Summa M, Marino B, Chiariello L, de Luca L. Clinical evaluation of St Jude Medical Hemodynamic Plus versus standard aortic valve prostheses: The Italian multicenter, prospective, randomized study. J Thorac Cardiovasc Surg 2001; 122:691-8. [PMID: 11581600 DOI: 10.1067/mtc.2001.116205] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Hemodynamic and clinical performances of 21-mm and 23-mm St Jude Medical Hemodynamic Plus aortic valves (St Jude Medical, Inc, St Paul, Minn) were compared with those of 21-mm and 23-mm St Jude Medical standard cuff aortic valves in the first such multicenter, prospective, randomized study. Hemodynamic Plus valves are mechanical, bileaflet prostheses suitable for the small aortic anulus. METHODS Patients with 21-mm and 23-mm anulus diameters were randomized to receive either a Hemodynamic Plus or a standard cuff valve. Postoperatively and at 6 months after the operation, patients underwent 2-dimensional Doppler echocardiography. Ejection fraction, cardiac output, peak gradient, mean gradient, effective orifice area, effective area index, and performance index were calculated. Postoperative and 6-month echocardiographic measurements and their variations across observation times were analyzed statistically. RESULTS Of the 140 patients enrolled, 5 died at operation and 1 died of aortic dissection during the follow-up period. Eight patients were lost to follow-up. A total of 125 patients completed the study. In 1 patient a sewing cuff escaped intraoperatively. At 6 months the 21-mm and 23-mm Hemodynamic Plus valves showed significantly lower peak gradients and mean gradients than those of the 21-mm and 23-mm standard cuff valves. The 21-mm Hemodynamic Plus valves had gradients similar to those of the 23-mm Hemodynamic Plus valves. The effective orifice area did not differ significantly between the Hemodynamic Plus and standard cuff valves at either measurement. No valve mismatch was found in the 4 groups of patients. A more enhanced decrease of peak gradients and mean gradients and a more enhanced increase of effective orifice areas, effective area indices, and performance indices were found across observation times for patients with Hemodynamic Plus valves compared with those with standard cuff valves. CONCLUSIONS Clinical hemodynamic performances of 21-mm and 23-mm St Jude Medical Hemodynamic Plus valves correspond closely with those of standard cuff valves, and gradients are substantially better than those of standard cuff valves of the same diameter. Therefore, use of this valve may minimize the need for aortic anulus enlargement. Early follow-up results with the Hemodynamic Plus valves were excellent, although more time is required to confirm this outcome.
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Nardi P, De Paulis R, Penta de Peppo A, Forlani S, Tomai F, Scafuri A, Pellegrino A, Polisca P, Chiariello L. [Aortocoronary bypass in severe left ventricular dysfunction: 9 years of clinical experience and mid-term results]. ITALIAN HEART JOURNAL. SUPPLEMENT : OFFICIAL JOURNAL OF THE ITALIAN FEDERATION OF CARDIOLOGY 2001; 2:894-9. [PMID: 11582722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
BACKGROUND Compared with medical therapy alone, coronary artery bypass surgery improves survival in patients with coronary disease and left ventricular dysfunction. Many of these patients have a hibernating myocardium secondary to chronic ischemia with the potential for improvement in left ventricular function and heart failure symptoms following revascularization therapy. Cardiac transplantation remains the treatment of choice for patients with severe congestive heart failure. METHODS From January 1992 to June 2000, 351 consecutive patients (318 men, 33 women, mean age 62.8 +/- 8.9 years) with a left ventricular ejection fraction (EF) < or = 35% and with multivessel coronary artery disease underwent isolated coronary artery bypass grafting. Preoperatively 226 patients were in CCS class III-IV and 113 in NYHA class III-IV. The mean number of grafts was 3.4 +/- 0.8/patient and complete revascularization was achieved in 98.6% of cases. The internal mammary artery was used in 341 patients (97.2%) and in 328 (96%) as a graft for the left anterior descending artery. Follow-up was obtained in 97% of the patients and on average lasted 42 +/- 28 months. RESULTS The hospital mortality was 5.9%. At multivariate analysis urgent operation (p < 0.01) and a lower EF (25.9% in deaths vs 29.1%, p < 0.05) were predictors of an increased operative mortality. EF (assessed postoperatively at transthoracic echocardiography in survivors) improved from 28.9 +/- 5.7 to 34.4 +/- 7.7% (p < 0.0001). At 1, 3, 5, 7, and 9 years respectively, the all-cause survival was 93 +/- 1.5, 85 +/- 2.2, 77 +/- 3.1, 69 +/- 4.9, and 60 +/- 7.3% and the freedom from cardiac death was 94 +/- 1.4, 89 +/- 1.9, 88 +/- 2, 80 +/- 4.7, and 76 +/- 5.7% with an improvement in the anginal and congestive heart failure status (p < 0.0001). CONCLUSIONS In patients with coronary artery disease and severe left ventricular dysfunction, after evaluation of the clinical presentation, of the usefulness of vessels as grafts and of the presence of myocardial viability, 1) coronary artery bypass grafting can be performed with a low mortality and a good mid-term survival, 2) improvement in left ventricular function can be documented after coronary bypass surgery, 3) the internal mammary artery can be safely used as a graft, 4) the quality of life is improved as demonstrated by the improvement in the anginal and congestive heart failure status.
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Scafuri A, Nardi P, De Paulis R, Buratta MM, Forlani S, Bertoldo F, Chiariello L. [Isolated aortic valve replacement with CarboMedics mechanical prosthesis: 9-year clinical experience and mid-term results]. ITALIAN HEART JOURNAL. SUPPLEMENT : OFFICIAL JOURNAL OF THE ITALIAN FEDERATION OF CARDIOLOGY 2001; 2:783-7. [PMID: 11508297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
BACKGROUND Appraisal of the medium-term results of isolated aortic valve replacement with a CarboMedics mechanical prosthesis. METHODS We assessed the clinical data of 195 consecutive patients (mean age 59.7+/-10.9 years) operated on between January 1992 and June 2000. Valve disease consisted of aortic stenosis regurgitation in 94 patients (48.2%), isolated aortic failure in 57 (29.2%) and isolated stenosis in 44 (22.6%). One hundred and four patients were in NYHA functional class III and 25 in NYHA functional class IV Follow-up was by telephone interview to 100% of the patients (average follow-up 39+/-20 months). RESULTS The operative mortality was 3.6% (5% in the period January 1992-December 1995, 1.3% in the period January 1996-June 2000). Sixteen deaths occurred in the long term. Thus, the actuarial survivals at 36 and 72 months were 92+/-7% and 82+/-16% respectively. In the group of survivors, 139 patients (81%) were in NYHA class 1,26 (15%) in NYHA class II, and 7 (4%) in NYHA class III. The freedom from embolic events was 96+/-3.7% and that from hemorrhagic events was 90+/-9.4%. All the events occurred during the first 36 months; none of the patients developed infections or periprosthetic leaks. CONCLUSIONS At the medium term, the CarboMedics mechanical valve prosthesis appears to be reliable, with an actuarial survival, quality of life and incidence of morbidity comparable to those reported for other types of second-generation mechanical prostheses.
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Nardi P, Scafuri A, Bertoldo F, el Fakhri F, De Matteis GM, Forlani S, Chiariello L. [Atrial septal aneurysm with cerebral ischemia: potential pathogenetic role of associated cerebral vascular malformation]. ITALIAN HEART JOURNAL. SUPPLEMENT : OFFICIAL JOURNAL OF THE ITALIAN FEDERATION OF CARDIOLOGY 2000; 1:1059-62. [PMID: 10993016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Atrial septal aneurysm can be associated with other cardiovascular diseases such as atrial septal defect, patent ductus arteriosus, pulmonary hypertension and cerebrovascular events (transient ischemic attack or stroke). The introduction of transthoracic and more recently transesophageal echocardiography allowed for a more frequent observation of this pathology and also suggested that atrial septal aneurysm is a risk factor for cerebral ischemia. However, the pathophysiological pathway is still unclear. In January 1997 a 33-year-old man was admitted to our hospital because of atrial septal aneurysm and a previous cerebrovascular event. Magnetic resonance imaging revealed a cerebrovascular malformation and transesophageal echocardiography confirmed the presence of atrial septal aneurysm. We hypothesize that a common etiopathogenetic pathway may cause both the cardiac and cerebrovascular anomaly and that the latter may be responsible alone for cerebral ischemic events; thus in the presence of an atrial septal aneurysm associated with a cerebrovascular malformation, a conservative medical approach may be the treatment of choice.
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Scafuri A, Nardi P, Forlani S, Bassano C, Pierri MD, Pellegrino A, Polisca P, Tomai F, De Matteis GM, Chiariello L. [Bentall-DeBono intervention: 8 years of clinical experience]. ITALIAN HEART JOURNAL. SUPPLEMENT : OFFICIAL JOURNAL OF THE ITALIAN FEDERATION OF CARDIOLOGY 2000; 1:783-9. [PMID: 11204011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
BACKGROUND Annulo-aortic ectasia is a dilation of the aortic root with the involvement of the Valsalva sinuses. In 1968 Bentall and DeBono proposed to replace the aortic valve, the Valsalva sinuses and the ascending aorta with a composite tube graft containing aortic valve prosthesis. Consequently coronary ostia had to be reimplanted on the prosthetic tube. Recently the use of new materials has resulted in a more acceptable operative risk, and postoperative bleeding and late mortality have been reduced. METHODS From January 1991 to December 1998, 44 out of 241 patients were operated on with the Bentall-DeBono procedure, affected by dissecting or expansive aneurysm of the ascending aorta. Of the 44 patients (35 males, 9 females, mean age 53.7 years), 3 presented with acute aortic dissection, 5 were asymptomatic, 10 were in NYHA functional class II, 14 in class III, 9 in class IV, and 2 in CCS class 4; 1 patient had dysphonia; 37 patients presented with isolated aortic regurgitation, and 7 associated aortic valvular stenosis. The diagnosis of acute dissection was made by transesophageal echocardiography and that of expansive aneurysm by thorax helical computed tomographic scanning and/or magnetic resonance imaging and cardiac catheterization. Follow-up was obtained in 100% of the patients for an average of 23 +/- 20.9 months (range 4-79 months). RESULTS Four patients (9%) died; in 4 patients (9%) postoperative bleeding needed reoperation, in 5 (11.4%) a permanent pacemaker for atrioventricular block was implanted, and 1 patient (2.3%) had transient hemiparesis. At univariate analysis predictive factors for operative risk were NYHA functional class IV (p < 0.005) and atherosclerotic etiology (p < 0.05). At follow-up 7 late deaths occurred for an actuarial survival at 24 months of 75 +/- 9%. Causes were sudden death in 3 patients, cardiac failure in 3 and stroke in 1 patient; 31 surviving patients (94%) were in NYHA functional class I and 2 patients in class II (6%). CONCLUSIONS The Bentall-DeBono procedure involves moderate risk with good results; clinical presentation and associated valvular pathology influence early and mid-term results.
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Nardi P, Pellegrino A, De Paulis R, Scafuri A, Versaci F, Polisca P, el-Fakhri F, Chiariello L. [Coronary heart surgery in women: the risk factors and short-term results]. ITALIAN HEART JOURNAL. SUPPLEMENT : OFFICIAL JOURNAL OF THE ITALIAN FEDERATION OF CARDIOLOGY 2000; 1:537-42. [PMID: 10832141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
BACKGROUND Coronary artery bypass grafting is reported to have a higher (2-3 times) mortality in women than in men, most likely due to older age, higher incidence of hypertension, diabetes mellitus, hypercholesterolemia, obesity, angina and preoperative myocardial infarction, smaller diameter of coronary arteries, and smaller body surface area. METHODS From January 1992 to December 1997, 347 female and 2098 male patients were submitted to isolated coronary artery bypass grafting. For both groups were considered: a) clinical presentation (age, height, weight, body surface area, NYHA and CCS functional classes, incidence of preoperative myocardial infarction); b) risk factors for cardiovascular diseases (diabetes mellitus, smoking habit, dyslipidemia, hypertension, familiarity); c) concomitant diseases (obesity, chronic obstructive pulmonary disease, peripheral vascular disease, thyroid dysfunction); d) hemodynamic and anatomical data (extent of coronary artery disease, diameter of coronary arteries, left ventricular function); e) surgical procedure (number and type of grafts used, urgent procedures, incidence of redo procedures). Early (up to 30 days after surgery) results were evaluated in terms of complications and mortality. RESULTS On admission, women were older than men (p = 0.0001), were shorter (p < 0.0001), weighed less (p < 0.0001), and had a smaller body surface area (p < 0.0001); they had more severe angina (p = 0.002), diabetes mellitus (p = 0.002), hypercholesterolemia (p = 0.003), thyroid dysfunction (p < 0.0001), their coronary arteries were smaller (left anterior descending artery, p = 0.05; obtuse marginal branch, p = 0.008; diagonal branch, p = 0.01), and had less grafts implanted at surgery (p = 0.02). There was no difference between women and men in the use of the internal thoracic artery. Women did not have a higher mortality than men (4.6 vs 3.2%). Uni- and multivariate analysis did not show extraoperative risk factors for women; for men older age (p = 0.005) and poor left ventricular function (p = 0.01) were independent predictive factors of operative mortality. CONCLUSIONS In spite of what is suggested by the literature, coronary artery bypass grafting does not have a significant higher operative risk for women than men, probably due to surgical technique refinements and extensive use of the internal thoracic artery.
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