Leadless Pacemaker Infection Risk in Patients with Cardiac Implantable Electronic Device Infections: A Case Series and Literature Review

(1) Background: Leadless pacemakers (LPs) have been proposed as a reimplantation strategy in pacing-dependent patients undergoing cardiac implantable electronic device (CIED) extraction for infection. In this study, we analysed the risk of LP infection when this device is implanted before lead extraction. (2) Methods: This was a retrospective study including patients who underwent LP implantation between 2017 and 2022. Patients were divided in two groups according to whether LP was implanted following CIED extraction for infection (Group 1) or other indications (Group 2). The primary aim was to describe the risk of LP infection. (3) Results: We included in this study 49 patients with a median age of 81 [20-94] years, mostly males (36, 73%). In Group 1 patients, 17 cases (85%) showed systemic CIED infections, and 11 (55%) had positive lead cultures. Most Group 1 cases (n = 14, 70%) underwent one stage of LP implantation and CIED extraction. Mortality rate during follow-up was 20% (nine patients). Patients were followed up for a median of 927 [41-1925], days and no cases of definite or suspected LP infections were identified. (4) Conclusions: The risk of LP infection was extremely low. LP appears as a potential option for reimplantation in this setting and should be considered in pacing-dependent patients at a high risk of CIED infection recurrence.

A Novel Endosurgical Prosthesis to Treat Thoracoabdominal Aortic Aneurysm in Complex Anatomy or Emergency Settings

BACKGROUND

 Despite improvements in operative techniques, open thoracoabdominal aortic aneurysm (TAAA) repair is complex and characterized by high mortality and morbidity rate. Less invasive techniques have been developed since 2005 for the treatment of TAAA. Unfortunately, many of these devices require custom fabrication, resulting in delay of many weeks until treatment can be delivered but crucial in critical emergency cases. We present a novel hybrid endovascular and surgical prosthesis, which was tested on five pigs, with the aim of reducing the barrier issues of endovascular therapy in such particular cases.

METHODS

 The principal characteristic of the proposed hybrid endovascular prosthesis is to combine a proximal and distal stented zones and, in between, a classical surgical blood tied Dacron prosthesis. The device was tested in five pigs where feasibility of implantation and acute postoperative outcomes were evaluated, including bleeding, bowel ischemia, renal function, and peripheral blood perfusion.

RESULTS

 In all cases, following laparotomy, the endoprosthesis was successfully implanted under fluoroscopy and the surgical prosthesis zone could be easily detected by the radio-opaque markers. No major bleeding or cardiac events occurred throughout preparation and implantation. One hour after prosthesis implantation and surgical anastomoses of all vessels were completed, normal urine output was registered, and no acidosis was detected.

CONCLUSIONS

 This novel graft has shown ease of endoprosthesis and visceral vessels implantation without the need of thoracotomy or extracorporeal circulation and may be useful in an emergency setting or high risk and complex anatomy TAAA unsuitable for traditional endovascular aneurysm repair, or to avoid an excess waiting time for a "custom made" prosthesis. The great adaptability of this "hybrid" prosthesis in complex anatomy for the majority of TAAA could be important in high-risk patients and in some difficult situations, such as a high risk of imminent rupture.

Clinical outcome and hemodynamic performance of St. Jude Trifecta aortic prosthesis: short-term follow-up and risk factors analysis

BACKGROUND

We retrospectively analysed the short-term outcome of the third-generation St. Jude Trifecta aortic prosthesis.

METHODS

Between December 2014 and December 2017, 177 patients (mean age 75.1±6.8 years, 95 males, 82 females) underwent aortic valve replacement with a St. Jude Trifecta aortic prosthesis and were followed up to 27±9 months. Preoperatively 92 patients (52.0%) were in NYHA class III-IV, EuroSCORE II was 3.2%±2.1%.

RESULTS

Trifecta sizes implanted were 19 mm (n=46) (26%), 21 mm (n=69) (39%), 23 mm (n=46) (26%), 25 mm (n=16) (9%). Concomitant coronary artery bypass grafting was performed in 60 patients (34.0%). Operative mortality was 3.4% (1.7% for isolated aortic valve replacement versus 6.7% for combined aortic valve replacement and coronary artery bypass grafting) (P=0.084). The only independent predictor of mortality was the need for the mechanical ventilation greater than 24 hours (P=0.037); recently occurring myocardial infarction was risk factor for mortality at the univariate analysis only (P=0.013). Three-year survival was 84%±6%, freedom from cardiac death 98%±1%, freedom from prosthetic endocarditis 97%±1%. No thromboembolisms or structural valve degeneration were observed. Patient-prosthesis mismatch (PPM) was absent in 126 patients (71.2%), mild-to-moderate in 32 (18.1%), moderate in 19 (10.7%), severe in no any patient. Follow-up echocardiography showed an average mean and peak trans-aortic valve gradients reduction more than 70% in comparison with preoperative value (P<0.0001), and a significant regression of left ventricular hypertrophy (P<0.0001). Moderate PPM did not negatively affect survival. Concomitant severe coronary artery disease was found as an independent predictor of reduced survival (72%±12% versus 86%±6%) (P=0.015).

CONCLUSIONS

Trifecta aortic prosthesis seems to provide very favourable clinical outcome and hemodynamic performance. At three years, survival was negatively affected by severe coronary artery disease detected at the time of operation. During short-term follow-up, no early structural valve degeneration was been observed. Due to low incidence of PPM and low peak and mean trans-prosthetic aortic valve gradients, third generation Trifecta aortic prosthesis should be considered as one of the best options in the setting of the aortic valve replacement surgery. However, a long-term follow-up is mandatory to confirm the early promising data.

Influence of Body Mass Index on Outcomes of Patients Undergoing Surgery for Acute Aortic Dissection: A Propensity-Matched Analysis

To determine whether body mass index ≥30 kg/m² affects morbidity and mortality rates in patients undergoing surgery for type A acute aortic dissection, we conducted a retrospective study of 201 patients with type A dissection. Patients were divided into 2 groups according to body mass index (BMI): nonobese (BMI, <30 kg/m²; 158 patients) and obese (BMI, ≥30 kg/m²; 43 patients). Propensity score matching was used to reduce selection bias. The overall mortality rate was 19% (38/201 patients). The perioperative mortality rate was higher in the obese group, both in the overall cohort (33% vs 15%; P=0.01) and in the propensity-matched cohort (32% vs 12%; P=0.039). In the propensity-matched cohort, patients with obesity had higher rates of low cardiac output syndrome (26% vs 6%; P=0.045) and pulmonary complications (32% vs 9%; P=0.033) than those without obesity. The overall 5-year survival rates were 52.5% ± 7.8% in the obese group and 70.3% ± 4.4% in the nonobese group (P=0.036). In the propensity-matched cohort, the 5-year survival rates were 54.3% ± 8.9% in the obese group and 81.6% ± 6.8% in the nonobese group (P=0.018). Patients with obesity (BMI, ≥30 kg/m²) who underwent surgery for type A acute aortic dissection had higher operative mortality rates and an increased risk of low cardiac output syndrome, pulmonary complications, and other postoperative morbidities than did patients without obesity. Additional extensive studies are needed to confirm our findings.

Can Perceval sutureless valve reduce the rate of patient-prosthesis mismatch?†

OBJECTIVES

The aim of this study is to compare the theoretical incidence of patient-prosthesis mismatch (PPM) in patients undergoing a sutureless or a sutured aortic valve replacement using an exact statistical matching.

METHODS

Between May 2012 and March 2016, 65 patients with severe symptomatic aortic stenosis underwent a sutureless aortic valve replacement with the Perceval bioprosthesis in 2 centres. Moreover, 177 aortic valve replacements with conventional sutured bioprosthesis were performed between August 2003 and September 2015. Perceval and sutured patients were 1:1 exactly matched for sex and body surface area (BSA), resulting in 62 couples (sutureless: BSA 1.77 ± 0.16 m 2 , female 62.9% vs sutured: BSA 1.77 ± 0.15 m 2 , female 62.9%).

RESULTS

After matching, the indexed effective orifice area was 1.50 ± 0.18 cm 2 /m 2 and 0.81 ± 0.19 cm 2 /m 2 in the sutureless and the sutured group, respectively ( P  < 0.001). No PPM occurred in patients who received a Perceval bioprosthesis ( n  = 62). In the sutured group ( n  = 62), 38 patients (61.3%) developed a PPM, which was moderate in 41.9% ( n  = 26) and severe in 19.4% ( n  = 12) ( P  < 0.001).

CONCLUSIONS

The indexed effective orifice area of the sutureless group was significantly larger than in the sutured one. The incidence of PPM with the conventional sutured biprosthesis was 61.3%, while it decreases to 0% in the sutureless group. No PPM was reported in the sutureless valve group. Therefore, the Perceval sutureless valve provides larger effective orifice areas compared to the sutured conventional bioprosthesis and could be considered as a good option to reduce the risk of a PPM.

Cold crystalloid versus warm blood cardioplegia in patients undergoing aortic valve replacement

Background

Myocardial protection techniques during cardiac arrest have been extensively investigated in the clinical setting of coronary revascularization. Fewer studies have been carried out of patients affected by left ventricular hypertrophy, where the choice of type and temperature of cardioplegia remain controversial. We have retrospectively investigated myocardial injury and short-term outcome in patients undergoing aortic valve replacement plus or minus coronary artery bypass grafting with using cold crystalloid cardioplegia (CCC) or warm blood cardioplegia (WBC).

Methods

From January 2015 to October 2016, 191 consecutive patients underwent aortic valve replacement plus or minus coronary artery bypass grafting in normothermic cardiopulmonary bypass. Cardiac arrest was obtained with use of intermittent antegrade CCC group (n=32) or WBC group (n=159), according with the choice of the surgeon.

Results

As compared with WBC group, in CCC group creatine-kinase-MB (CK-MB), cardiac troponin I (cTnI), aspartate aminotransferase (AST) release, and their peak levels, were lower during each time points of evaluation, with the greater statistically significant difference at time 0 (P<0.05, for all comparisons). A time 0, CK-MB/CK ratio >10% was 5.9% in CCC group versus 7.8% in WBC group (P<0.0001). At time 0 CK-MB/CK ratio >10% in patients undergoing isolated aortic valve replacement was 6.0% in CCC group versus 8.0% in WBC group (P<0.01). No any difference was found in perioperative myocardial infarction (0% versus 3.8%), postoperative (PO) major complications (15.6% versus 16.4%), in-hospital mortality (3.1% versus 1.3%).

Conclusions

In aortic valve surgery a significant decrease of myocardial enzymes release is observed in favor of CCC, but this difference does not translate into different clinical outcome. However, this study suggests that in presence of cardiac surgical conditions associated with significant left ventricular hypertrophy, i.e., the aortic valve disease, a better myocardial protection can be achieved with the use of a cold rather than a warm cardioplegia. Therefore, CCC can be still safely used.

Mitral Valve Repair with a Semi-Rigid C-Band Annuloplasty Ring in Ischemic Mitral Regurgitation: Still a Viable Surgical Option?

BACKGROUND

Ischemic mitral valve regurgitation (IMR) develops in approximately 10% of patients after myocardial infarction. Surgical management of IMR is controversial, as many series have failed to demonstrate the superiority of mitral valve repair (MVRep) over mitral valve replacement (MVR) in IMR. Moreover, in the setting of MVRep, the choice of ring type is the subject of much debate. The study aim was to evaluate the results of MVRep in IMR with the use of a semi-rigid incomplete C-ring.

METHODS

Between January 2006 and May 2014, a total of 105 patients (79 males, 26 females; mean age 69 ± 8 years) underwent surgical MVRep using a semi-rigid incomplete ring (median size 30 mm) during coronary artery bypass grafting (CABG) to treat IMR. The patients' mean logistic EuroSCORE was 14 ± 12, and the preoperative left ventricular ejection fraction was 43 ± 11%. The mean duration of follow up was 48 ± 31 months, and was 100% complete.

RESULTS

In-hospital mortality was 6.6% (n = 7). The main predictor of in-hospital mortality was cardiopulmonary bypass time (p <0.05). Echocardiography performed at discharge showed moderate mitral regurgitation (MR) in only one patient, and significant reductions in left ventricular end-diastolic diameter (p <0.0001) and MR grade (p <0.0001). After seven years, freedom from all-cause death was 73 ± 9%, while freedoms from recurrence of MR grade ≥2 and NYHA class >II were 95 ± 3% and 89 ± 4%, respectively. Freedom from reintervention was 100%.

CONCLUSIONS

Despite the adverse prognosis of IMR, the present study demonstrated the effectiveness and durability of mitral valve repair with the use of a semi-rigid ring, as a concomitant procedure to CABG, showing good results in terms of recurrence of MR and event-free survival at mid-term follow up.

Single versus double antiplatelet therapy in patients undergoing coronary artery bypass grafting with coronary endarterectomy: mid-term results and clinical implications

Objectives

Coronary endarterectomy (CE) represents a useful adjunctive technique to coronary artery bypass grafting (CABG) in the presence of diffuse coronary artery disease. Nevertheless, the long-term patency of the graft remains unclear, and no standard anticoagulation and antiplatelet protocols exist for use after CE. The aim of this retrospective study was to evaluate and possibly to clarify the role of single (SAT) versus dual antiplatelet therapy (DAT) at mid-term follow-up.

Methods

Between January 2006 and December 2013, CE was performed in 90 patients (mean age 67 ± 8.2 years) who also underwent isolated CABG. After surgery, 20 patients received aspirin 100 mg daily (SAT group), and 52 patients received aspirin plus clopidogrel 75 mg daily (DAT group). Clopidogrel was discontinued in the DAT group 12 months after the operation.

Results

The overall in-hospital mortality rate was 2.7% (SAT 0% vs DAT 3.8%; P = ns). Perioperative myocardial infarction was 12.3% (SAT 15.0% vs DAT 11.5%; P = ns), and major bleeding requiring surgical re-exploration was 4.1% (SAT 10.0% vs DAT 1.9%; P = ns). Mean follow-up duration was 71.3 ± 32.7 months (median 79 months), and was 100% complete (5208/5208 pt-months). At 7 years of follow-up, freedom from cardiac death was 84 ± 9% in group SAT versus 85 ± 5% in group DAT (P = ns); freedom from new percutaneous coronary intervention was 93 ± 6% versus 100% (P = ns), and freedom from major adverse cardiac and cerebrovascular events was 73 ± 10% versus 75 ± 6% (P = ns).

Conclusions

In patients with diffuse coronary disease, CE is a safe and feasible technique with acceptable mid-term results. No differences were observed in terms of major clinical outcomes between patients treated with single versus dual antiplatelet therapy at least in a mid-term period of follow-up.

Long-Term Results of Aortic Root Surgery in Marfan Syndrome Patients: A Single-Center Experience

BACKGROUND AND AIM OF THE STUDY

The study aim was to compare long-term results of Marfan syndrome (MFS) patients affected by aortic root disease undergoing aortic root replacement with the Bentall or David operation.

METHODS

Since 1994, a total of 59 patients has been followed at the authors' Marfan Center, having undergone either a Bentall operation (Bentall group, n = 30) or a David operation (David group, n = 29).

RESULTS

No operative mortality was recorded. After 20 years (mean follow up 97 ± 82 months; range 1 to 369 months) no prosthesis-related major bleeding or thromboembolic events had been observed; the 20-year survival was 94 ± 6% in the Bentall group, and 100% in the David group (p = 0.32). Freedom from reintervention for aortic valve dysfunction was 100% in the Bentall group, and 75 ± 13% in the David group (p = 0.04). This inter-group difference became relevant after the first eight-year period of follow-up, and was mainly associated with a particular familiar genetic phenotype involving three out of four reoperated patients. Freedom from all-cause death, myocardial infarction, stroke, prosthetic valve-related complications, and reintervention on any aortic segment was 69 ± 12% in the Bentall group, and 67 ± 14% in the David group (p = 0.33).

CONCLUSIONS

The Bentall and David operations are both associated with satisfactory long-term results in MFS patients. The low rate of valve prosthesis-related complications suggested that the Bentall operation would continue to be a standard surgical treatment. The reimplantation technique, adopted for less-dilated aortas, provides satisfactory freedom from reoperation. Careful attention should be paid to the reimplantation technique in patients affected by a serious familiar genetic phenotype.

Bicuspid aortic root spared during ascending aorta surgery: an update of long-term results

BACKGROUND

Bicuspid aortic valve (BAV) aortopathy is well known in literature even if only few data exist regarding isolated supra-coronary aneurysm with normally functioning valve and root. Aim of this study is to clarify the long-term fate of bicuspid aortic root spared at the time of ascending aorta surgery.

METHODS

We identified forty-seven patients (mean age, 57±11 y; range, 35-81 y, 31 males) who were treated by means of supracoronary aortic replacement in presence of normally functioning BAV and not significantly enlarged sinues of Valsalva. Clinical follow-up (mean 93±50 months; range, 21-207) was 98.9% complete.

RESULTS

Freedom from cardiac death at 5- and 10-year was 95%±5% and 83%±16%. Three surviving patients required reoperation for the development of aortic insufficiency [2 cases treated by aortic valve replacement (AVR)] or for progression of aortic stenosis (AS) [1 case treated by transcatheter aortic valve implantation (TAVI)]. Freedom from new procedure on aortic valve was 100% and 94.4%±5.6% at 5- and 10-year. Composite event-free survival at 5- and 9-year was 82%±18% and 69%±30%.

CONCLUSIONS

Although in the setting of a BAV, aortic root integrity seems to remain stable during long term follow up with low rate of reoperation and occurrence of new adverse event.

Total Arch versus Hemiarch Replacement for Type A Acute Aortic Dissection: A Single-Center Experience

We retrospectively evaluated early and intermediate outcomes of aortic arch surgery in patients with type A acute aortic dissection (AAD), investigating the effect of arch surgery extension on postoperative results. From January 2006 through July 2013, 201 patients with type A AAD underwent urgent corrective surgery at our institution. Of the 92 patients chosen for this study, 59 underwent hemiarch replacement (hemiarch group), and 33 underwent total arch replacement (total arch group) in conjunction with ascending aorta replacement. The operative mortality rate was 22%. Total arch replacement was associated with a 33% risk of operative death, versus 15% for hemiarch (P=0.044). Multivariable analysis found these independent predictors of operative death: age (odds ratio [OR]=1.13/yr; 95% confidence interval [CI], 1.04-1.23; P=0.002), body mass index >30 kg/m² (OR=9.9; 95% CI, 1.28-19; P=0.028), postoperative low cardiac output (OR=10.6; 95% CI, 1.18-25; P=0.035), and total arch replacement (OR=8.8; 95% CI, 1.39-15; P=0.021) The mean overall 5-year survival rate was 59.3% ± 5.5%, and mean 5-year freedom from distal reintervention was 95.4% ± 3.2% (P=NS). In type A AAD, aortic arch surgery is still associated with high operative mortality rates; hemiarch replacement can be performed more safely than total arch replacement. Rates of distal aortic reoperation were not different between the 2 surgical strategies.

Valve Replacement with a Sutureless Aortic Prosthesis in a Patient with Concomitant Mitral Valve Disease and Severe Aortic Root Calcification

Aortic valve replacement with concomitant mitral valve surgery in the presence of severe aortic root calcification is technically difficult, with long cardiopulmonary bypass and aortic cross-clamp times. We performed sutureless aortic valve replacement and mitral valve annuloplasty in a 68-year-old man who had severe aortic stenosis and moderate-to-severe mitral regurgitation. Intraoperatively, we found severe calcification of the aortic root. We approached the aortic valve through a transverse aortotomy, performed in a higher position than usual, and we replaced the valve with a Sorin Perceval S sutureless prosthesis. In addition, we performed mitral annuloplasty with use of an open rigid ring. The aortic cross-clamp time was 63 minutes, and the cardiopulmonary bypass time was 83 minutes. No paravalvular leakage of the aortic prosthesis was detected 30 days postoperatively. Our case shows that the Perceval S sutureless bioprosthesis can be safely implanted in patients with aortic root calcification, even when mitral valve disease needs surgical correction.

A structural and (1)H NMR relaxometric study on novel layered carboxyalkylaminophosphonate nanocrystals with Gd(III) ions located in the framework

Novel Gd(III) carboxyalkylphosphonate nanocrystals were synthesized under mild hydrothermal conditions. Structural properties and (1)H NMR relaxometric behaviour in aqueous solution as a function of the magnetic field strength were investigated, aiming to evaluate the local chemical environment of the paramagnetic centres and their interaction and affinity with water molecules.

Mitral valve repair for the treatment of degenerative mitral valve disease with or without prosthetic ring annuloplasty: long-term outcomes

AIM

Aim of the study was to evaluate late outcomes of mitral valve repair with and without the use of prosthetic ring annuloplasty and standardized techniques for the treatment of degenerative mitral regurgitation (MR).

METHODS

Three hundred and five patients (mean age 62 ± 12 years) underwent mitral valve repair between January 1992 and February 2010 for degenerative MR. In the last five years, all repair techniques were performed routinely using prosthetic ring annuloplasty, with or without quadrangular or triangular resection of posterior leaflet and/or edge-to-edge technique. Mean follow-up (99% complete) was 78 ± 46 (2-220) months.

RESULTS

Operative mortality was 0.9% (3/305), 15-year actuarial survival 82% ± 4%. At 15 years freedom from cardiac death was 89% ± 3.7%, from reoperation 84% ± 5.8%, from endocarditis 100%. Independent predictors of all-causes mortality were advanced age at operation (P=0.0006) and mitral valve repair without reductive prosthetic annuloplasty (P=0.0019). Death for cardiac causes was significantly higher when reductive annuloplasty was performed without the use of prosthetic ring (P<0.01). Late progression to moderate or severe MR was observed in 23/299 patients (7.7%). Independent predictors of progression to moderate or severe MR was annuloplasty without the use of prosthetic ring (P=0.0053) and postoperative residual mild MR (P=0.0014). Reoperation was required in 13/299 patients (4.4%). At 10 years freedom from moderate or severe MR was 86% ± 6% and 92% ± 4% in patients with postoperative absent or trivial residual MR, respectively, as compared to 38% ± 15% in those with postoperative residual mild MR (P<0.0001), freedom from reoperation 94% ± 4% and 90% ± 14% vs. 56% ± 16% (P<0.0001).

CONCLUSION

Prosthetic annuloplasty in association with standardized techniques confers over 10 years survival advantage and better durability.

Surgical treatment of aortic valve regurgitation secondary to ascending aorta aneurysm: is adjunctive subcommissural annuloplasty necessary?

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.

Long-term outcomes after surgical ventricular restoration and coronary artery bypass grafting in patients with postinfarction left ventricular anterior aneurysm

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.

Long-term outcome of coronary artery bypass grafting in patients with left ventricular dysfunction

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.

Right ventricle mass in a woman discovered after preeclampsia

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.

Performance of a novel sternal synthesis device after median and faulty sternotomy: mechanical test and early clinical experience

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.

[Surgery for type A aortic dissection: long-term results and risk factor analysis]

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.

Influence of sternal size and inadvertent paramedian sternotomy on stability of the closure site: a clinical and mechanical study

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.

Thrombosis of the Left Anterior Descending Artery Due to Compression from Giant Pseudoaneurysm Late After a Bentall Operation

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.

Benefit of Partial Right-Bilateral Internal Thoracic Artery Harvesting in Patients at Risk of Sternal Wound Complications

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.

Free right internal thoracic artery in a "horseshoe" configuration: a new technical approach for "in situ" conduit lengthening

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.

Aortic root enlargement for aortic valve replacement in an achondroplastic dwarf

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.

Partial Right Internal Thoracic Artery Harvesting is Sufficient for Obtuse Marginal Branch Bypass Grafting

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.

Combination therapy for prevention of atrial fibrillation after coronary artery bypass surgery: a randomized trial of sotalol and magnesium

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.

Cardiac surgery in moderate to end-stage renal failure: analysis of risk factors

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.

Troponin I release after CABG surgery using two different strategies of myocardial protection and systemic perfusion

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.

Clinical evaluation of St Jude Medical Hemodynamic Plus versus standard aortic valve prostheses: The Italian multicenter, prospective, randomized study

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.

[Aortocoronary bypass in severe left ventricular dysfunction: 9 years of clinical experience and mid-term results]

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.

[Isolated aortic valve replacement with CarboMedics mechanical prosthesis: 9-year clinical experience and mid-term results]

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.

[Atrial septal aneurysm with cerebral ischemia: potential pathogenetic role of associated cerebral vascular malformation]

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.

[Bentall-DeBono intervention: 8 years of clinical experience]

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.

[Coronary heart surgery in women: the risk factors and short-term results]

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.