Addition of Intermittent Pneumatic Compression to Conventional Treatment Improves Volume Reduction Before Lymphatic Surgery for Lower Limb Lymphedema: A Pilot Study

This study assesses the impact of an advanced intermittent pneumatic compression device (IPC - Lympha Press® Optimal Plus) when added to Complete Decongestive Therapy (CDT) compared to CDT alone on volume reduction of limbs with lymphedema. The goal is to maximally reduce edema in preparation for microsurgery. Fifty subjects scheduled for Multiple Lymphatic-Venous Anastomosis (MLVA) were randomly (sequentially) assigned to experimental or control group: 25 (21 females and 4 males) in the experimental IPC group and 25 (20 females and 5 males) in the control group. The two groups were similar in age, sex distribution, and type of lymphedema. Results indicate the IPC group reported greater volume loss than the control group (p= 0.00137) comparing final vs. initial limb volume. The average percentage edema volume loss achieved with added IPC was two times greater (11.7%) than in the control group (5.0%). When differences in treatment duration were accounted for, the IPC group achieved consistently greater proportional volume loss (12.83% vs 6.30%) than conservative therapy alone. In our pilot study, IPC added to CDT resulted in greater proportional volume loss and provides better preparation for MLVA surgery.

[Assessment of agreement between anesthesiologists' location of anatomical landmarks]

OBJECTIVE

The main objective of this study was to evaluate agreement between anesthesiologists' location of specific anatomical landmarks in regional anesthesia.

MATERIAL AND METHODS

We administered an anonymous written questionnaire asking for the location of the T5 and T10 dermatomes, Tuffier's line (L3-L4 space), and the T7-T8 and C6-C7 spaces on an anatomical drawing. We asked about each anesthesiologist's number of years of experience and type of block most commonly performed and in what type of surgery, number of blocks performed per year, whether or not levels of sensory and motor blocks were assessed, and whether training had been received. Relative frequencies were then calculated. The relationships between years of experience and number of blocks performed and number of correct identifications of anatomical points were analyzed using the chi2 test.

RESULTS

We studied 100 doctors (66 residents and 24 staff anesthesiologists). The landmark for which agreement was highest was T10 (91.8%); agreement was lowest for T5 (38.1%). Forty-five percent of anesthesiologists performed between 100 and 250 neuraxial blocks per year. The most commonly performed procedure was a lumbar block (98% of the anesthesiologists). Level of sensory block was evaluated by 95% of the respondents and level of motor block by 83%. Response to heat and cold was used by 94.8%; the Bromage scale was used by 81%. The number of years of experience and the number of correctly located points appeared to be unrelated (P=.76). Nor was there a correlation between the number of blocks performed and number of correctly located points (P=.2).

CONCLUSIONS

T10 was the landmark correctly identified by the largest number of respondents; T5 was correctly identified by the fewest respondents, with answers differing by as much as 4 dermatomes.

Epidural Post-Operative Analgesia in Major Urologic Surgery: Our Experiences

Pulmonary, cardiovascular, gastrointestinal and urinary dysfunctions are among the physiologic outcomes of surgical lesions and stress, as well as metabolic, muscular and neuroendocrine disorders.

Our purpose is to prevent such complications in order to optimize the healing process and improve the patient's satisfaction through the application of a post-operative codified analgesia protocol allowing the combined use of local anaesthetics and morphine by both epidural bolus injection and elastomeric pump.

All the patients enrolled underwent the same anaesthetic program: the data processing emphasizes the satisfactory analgesic results of the treatment. More than 80% of the patients did not feel pain at awakening, up to 98.5% during the following hours; one patient only was still complaining 96 hours after surgery.

This excellent analgesic function results in an extremely low rate of severe post-operative complications, despite the fact that patients underwent radical and often prolonged surgery (31% was affected by severe systemic pathology).

We encountered a negligible and easy-to-treat complication rate secondary to the analgesic technique or to the infused drugs; the epidural analgesia proved effective in the healing process, with high satisfaction of clinicians and patients.

This represents for sure a fundamental alternative to the various methods described in literature.

Clinical actions of subarachnoid sevoflurane administration in vivo : a study in dogs

BACKGROUND

Halogenated ethers produce clinical effects at spinal sites. Nevertheless, in vitro and in vivo studies have not determined whether the immobilizing effect in the spinal cord is due to inhibition of nociceptive or motor transmission or both. Our goal was to characterize the clinical effects of direct spinal sevoflurane administration.

METHODS

Five adult beagle dogs completed the study. In a randomized and blinded manner each animal received placebo (saline 0.1 ml kg(-1)) and three concentrations of pure sevoflurane administered intrathecally (0.05, 0.075 and 0.1 ml kg(-1)) by means of a permanent spinal catheter. Sensory and motor block and state of consciousness were determined at baseline and at predetermined regular intervals until at least 2 h after total recovery.

RESULTS

None of the dogs presented a decrease in consciousness with either 0.05 or 0.075 ml kg(-1) of sevoflurane. Administration of 0.1 ml kg(-1) produced light sedation (2 on a four-point sedation scale) in three of the five dogs. A comparison of the duration of the sensory and motor blocks among the three sevoflurane dosages shows a significant dose-dependent increase that is greater in all cases than that for the saline solution.

CONCLUSIONS

Spinal administration of pure sevoflurane resulted in a dose-related and totally reversible motor and sensory regional block without any signs of clinical neurotoxicity or significant decrease in consciousness. Therefore the model allows us to comment on the analgesic effects at the spinal level in addition to the direct immobilizing effects of sevoflurane.

Minimally invasive thoracotomy for myocardial revascularisation. A study of 32 cases

BACKGROUND

This study aimed to evaluate the advantages offered by a myocardial revascularisation technique proposed by Kolessov in 1967: minimally invasive thoracotomy for myocardial revascularisation. The aim was to assess its short and medium-term benefits. During the course of the 1980s, the problems linked to extracorporeal circulation (ECC) and the contraindications for traditional myocardial revascularisation led to a renewed popularity of "beating heart" revascularisation techniques.

METHODS

The largest and most extensive series of patients in the literature undergoing myocardial revascularisation during left mini-thoracotomy was reported by Calafiore et al. In this study we report the series treated by our centre which, albeit involving only 32 cases, obtained good results in the short and medium term. This surgical procedure can only be applied to patients presenting monovasal obstructive coronary disease affecting the anterior interventricular artery (IVA) which must not present small calibre, calcified walls or a lateralised or intramyocardial anatomic position.

RESULTS

Invasive and non-invasive instrumental tests carried out to control the distal anastomoses of the left internal mammary artery (IMA) did not reveal angulations and/or stenosing tractions before the anastomosis of IMA to a significant extent also for treatment, when isolating IMA, able to obtain the longest possible length and the best mobility. No infection of surgical wounds was reported postoperatively, as sometimes occurs in median longitudinal sternotomy.

CONCLUSIONS

The 2-year follow-up showed the resolution of angina in 100% of the patients studied, as well as a satisfactory and rapid renewal of social relations.

Epoetin alpha in elective coronary and valve surgery in Jehovah's Witnesses patients. Experience in 45 patients

BACKGROUND

The religious beliefs of Jehovah's Witnesses who refuse homologous and autologous blood transfusion poses serious problems for surgeons when operating on patients requiring a mean transfusion requirement of =/>2 units of blood.

METHODS

After a number of encouraging studies in a randomised sample of patients 2-3 and after the treatment of some Jehovah's Witnesses 1, a group of 45 patients (23 females and 22 males) underwent elective heart surgery between June 1998 and December 2000. The patients, who were all Jehovah's Witnesses, received pre-treatment with epoetin alpha and ferrous sulphate. In the light of recent studies, it was also decided to repeat medullary preconditioning using the same intervals but with a higher dose. The patients underwent surgery involving myocardial revascularisation, mitral and/or aortic valve replacement, associated interventions, valvuloplasty and ascending aortic aneurysms. After obtaining informed and signed consent, the treatment protocol comprised the administration of 140 IU/kg epoetin alpha three times a week for 3 weeks associated with oral ferrous sulphate 3 times a day. Hematochemical levels (hemoglobin, free hemoglobin, hematocrit, ferritin, transferrin, haptoglobin, reticulocytes, iron levels) were monitored from admission to Day Hospital to discharge.

RESULTS

No patient in the study required blood transfusion.

CONCLUSIONS

The short, medium and long-term follow-up reconfirmed the substantial reliability of this drug linked to the absence of collateral effects.

Atherosclerotic aneurysm of the left main coronary artery. Case report and review of the literature

Coronary artery aneurysms involve the right coronary artery, the left anterior descending and the left circumflex coronary arteries in descending order of frequency; aneurysms involving the main left coronary artery are extremely rare. Atherosclerosis is the most common cause. Only eleven patients surgically treated with atherosclerotic left main coronary artery aneurysms are reported. We observed the twelfth case of atherosclerotic aneurysm of the left main coronary artery, successfully treated. In a 65-year-old man we found a large aneurysm originating at the distal segment of the left main coronary artery. A thromboendarterectomy was per-formed and was extended back into the left main and down the left anterior descending artery. An aneurysmorrhaphy and a three-vessel coronary artery bypass grafting were also performed. Three years later the patient was asymptomatic. Management of these cases is still controversial and based on anedoctal experience rather than controlled trials. Although surgery has been recommended to prevent complications, there are no available data comparing medical and surgical management. We feel that coronary bypasses should be performed in coronary artery aneurysm patients only when indicated by the severity of stenosis or progressive angina despite medical therapy. It is our opinion that anurysmorraphy should preserve native flow as much as possible.

Quadricuspid aortic valve, parossistyc supraventricular tachycardia and double right kidney: an uncommon association

Fourteen years after surgery for replacement of the aortic valve, an interesting case previously unreported was brought to our attention. The female patient came to our OP Dept for a routine follow-up: she had been found at surgery to have a quadricuspid aortic valve. Operation dated October 1985. At a careful appraisal of the world-wide literature, we noticed that such an association of pathologies had never been reported before: quadricuspid aortic valve, paroxystical supraventricular tachycardia and right double kidney with double renal pelvis and double proximal ureter. Other anomalies associated with the quadricuspid valve, available in the literature are: patent duct, subvalvular fixed aortic stenosis, ventricular septal defect, hypoplastic anterior mitral leaflet and pulmonary stenosis. The pathologic findings at autopsy of this congenital malformation vary between 0.008% and 0.033%; attention must be turned to the fact that the incidence can be underestimated if not expressly searched for. The first quadricuspid aortic valve was described in 1862 by Balington in an autoptic report and sixty other cases have been reported since. In rare cases this pathology has been diagnosed at angiography. At follow up our patient remains in SR with rare transitory episodes of supraventricular tachycardia.

Normothermic versus hypothermic perfusion during cardiopulmonary bypass. A randomized study on 132 patients

BACKGROUND

A prospective randomized trial to compare normothermic CPB with hypothermic CPB has been performed.

METHODS

132 patients undergoing CPB were randomized into two groups: group 1 underwent normothermic CPB and group 2 hypothermic CPB (between 26 and 30 degrees C).

RESULTS

Any significant difference was observed between the groups with regard to hospital mortality, blood transfusions, incidence of neurologic deficits and hematocrit, blood hemoglobin levels, platelet counts, plasma concentrations of glutamic-pyruvic transminase, glutamic-oxaloacetic transaminase, creatine kinase, valued at the 12th and 24th postoperative hour and at the 2nd, 3rd, and 4th postoperative day. A significant difference was observed between the groups with regard to tracheal extubation time, discharge time from the intensive care unit and inotropic drug infusion. The normothermic CPB patients group needed shorter time for tracheal extubation and discharge from the intensive care unit: this difference may be ascribed to a shorter inotropic drug infusion. Any increased surgical risks have been observed.

CONCLUSIONS

In conclusion, we think that normothermic CPB is favourable because it can reduce costs, it can improve the management of a cardiac surgery unit and it is more comfortable for patients.

Elective coronary and valve surgery without blood transfusion in patients treated with recombinant human erythropoietin (epoetin-alpha)

BACKGROUND

This study evaluates the real effectiveness of epoetin-alpha associated with ferrous sulphate, in reducing blood transfusion in patients undergoing elective open heart surgery not treated with autologous donation.

METHODS

Sixty patients had been divided into 2 groups: group A (30 patients) treated with 525 mg ferrous sulphate three time a day per os for 3 weeks; group B (30 patients) treated with epoetin-alpha 10,000 UI twice a week and 525 mg ferrous sulphate 3 times a day. Grouping of patients has been randomized. In both groups hemoglobin, hematocrit, reticulocytes, iron values, ferritine, transferrine, and serological values, have been evaluated sequentially before treatment, before surgery, day of operation, 1st, 2nd, 3rd, 7th postoperative days and at discharge.

RESULTS

In group A 86% patients needed blood transfusion (26 out of 30); in group B only 3% of patients needed blood transfusion (1 patient). One year follow up didn't show side effects related to epoetin-alpha.

CONCLUSIONS

This study confirms the real effectiveness of epoetin-alpha in reducing the postoperative need for homologous blood transfusion. No side effects due to epoetin-alpha treatment have been proved. The conclusion is drawn that epoetin-alpha can be used as an alternative to blood transfusion or in association with predeposit and in the treatment of basal anemia.

Thrombosis of mechanical valve prosthesis: thrombolysis vs surgical treatment. Report of two cases, personal experience and review of the literature

We report the cases of two patients, previously operated for mitral mechanical valve replacement who developed thrombosis of the prosthesis. The two patients were successfully treated with pharmacological thrombolysis with no recurrence. One patient developed late peripheral embolization most probably due to late mobilisation of a thrombotic fragment. Our experience with surgical management is reported (39 mitral and 5 aortic prosthetic thrombosis from 1982 to 1999 among 89 patients with prosthetic malfunction). Average time interval between surgery and thrombus formation is 26 months (max 204, min 1 month). Rate of mitral thrombosis is 3.9% and aortic 0.25%. Clinical presentation spreads from almost asymptomatic patients to critically ill patients with pulmonary oedema or frank cardiogenic shock. Temporary suspension of anticoagulant therapy (83% in our study group) to rule out minor surgery, appears to be the most frequent cause of thrombosis. Transthoracic or better transoesophageal echo-cardiography and Doppler are by far the most accurate diagnostic tools that can entirely replace angiographic assessment. Operative mortality was 64% in the prosthetic mitral thrombosis and 20% in the aortic one. Thrombolytic treatment may be affected by minor to relevant complications such as peripheral or central embolization but in our experience and according to the literature it seems much less hazardous than re-do surgery. Thrombolytic treatment is advocated for critical patients unless emergency institution of cardio pulmonary bypass is required and/or indicated. Re-do surgery remains indicated for all other cases of prosthetic malfunction.

Maullinia ectocarpii gen. et sp. nov. (Plasmodiophorea), an intracellular parasite in Ectocarpus siliculosus (Ectocarpales, Phaeophyceae) and other filamentous brown algae

An obligate intracellular parasite infecting Ectocarpus spp. and other filamentous marine brown algae is described. The pathogen forms an unwalled multinucleate syncytium (plasmodium) within the host cell cytoplasm and causes hypertrophy. Cruciform nuclear divisions occur during early development. Mature plasmodia become transformed into single sporangia, filling the host cell completely, and then cleave into several hundred spores. The spores are motile with two unequal, whiplash-type flagella inserted subapically and also show amoeboid movement. Upon settlement, cysts with chitinous walls are formed. Infection of host cells is accomplished by means of an adhesorium and a stachel apparatus penetrating the host cell wall, and injection of the cyst content into the host cell cytoplasm. The parasite is characterized by features specific for the plasmodiophorids and is described as a new genus and species, Maullinia ectocarpii.

Anaemia, osteogenesis imperfecta and valve diseases. The preoperative treatment with epoetin-alpha to increase haematocrit and haemoglobin levels in patients with high risk of perioperative bleeding

The case of a patient with Osteogenesis imperfecta is reported who underwent surgery for mitral valve replacement. Osteogenesis imperfecta is a hereditary disease of the connective tissue, associated with bone fragility, bluish colouring of the sclerae, loss of hearing and dental anomalies. Osteogenesis imperfecta is included in a group of hereditary pathologies with Ehlers-Danlos syndrome, Hurler syndrome, pseudoxanthoma elasticum and Marfan syndrome. In the literature there are few cases of patients with osteogenesis imperfecta operated for mitral valve disease secondary to such disease. The patient also has a positive family history and a severe anaemia: this was treated with epoetin-alpha and ferrous sulphate during the three weeks before surgery. The response to epoietin treatment was good while clinical outcome was poor due to rupture of the posterior ventricular wall in the 12th postoperative hour. The use of epoietin-alpha is discussed.

Left ventricular rupture after mitral valve replacement in a patient with osteogenesis imperfecta tarda

We describe the case of a patient with osteogenesis imperfecta tarda (Lobstein's syndrome) and mitral valve insufficiency. The course after mitral valve replacement was complicated by rupture of the left ventricular posterior wall, which caused massive bleeding and sudden death. The pathologic findings and the operative problems are discussed.

Aortic valve reconstruction associated to ascending aorta tubular graft replacement in aortic incompetence by annuloaortic ectasia

OBJECTIVE

Aortic valve incompetence associated with severe aortic ectasia is usually treated by aortic valve and ascending aorta replacement. In cases of isolated aortic ectasia or in Type A aortic dissection the valve is often normal and the incompetence is just due to annular dilatation. Such conditions lead to the application of various valve-sparing surgical techniques, as described by Senning et al., showing the advantages of preservation of the native valve, but the disadvantage of a high technical complexity and a high incidence of recidivation.

METHODS

We describe a valve-sparing surgical procedure, which has the advantage of a direct and simple approach together with satisfying mid-term results. After the aortic bulb has been fully transected, the excessive wall tissue is resected by two or three triangular excisions just above the valve commissures. Wall excision was indicated in those patients with an aortic diameter exceeding 65 mm at the sino-tubular junction. Tissue excision should not exert tension on to the coronary ostia or excessively reduce aortic diameter. Three external Teflon strips, overriding each other, are placed around the aortic bulb and are included in the direct suture of the edges of the triangular excisions. They are fixed by a running suture over the free border of the bulb. Aortic valve commissures are resuspended when needed. In this way, the aortic bulb, with a competent valve, is wrapped in a prosthetic and inextensible graft. The aortic continuity is then re-established with the interposition of a tubular dacron graft.

RESULTS

From April 1990 to December 1995, 21 patients (mean age 48 years, range 32-70) scheduled for surgery for aortic valve incompetence associated with annuloaortic ectasia were treated with this technique. In one patient the procedure failed to achieve a satisfying valve competence and the valve was replaced. In another case a prolapse of the non-coronary cusp required reoperation with aortic valve replacement, without further complications. At follow-up time (mean 42 months, range 18-78), all patients were well and healthy, with control echoes showing no residual valve incompetence and with invariate bulb diameters at every successive examination.

CONCLUSIONS

Our experience shows that this new valve-sparing approach allows safe and persistent correction of aortic valve incompetence and annuloaortic ectasia although longer term follow up is needed.

Stanford type A aortic dissection. A new surgical approach

We describe a new surgical technique adopted for the repair of Stanford type A aortic dissection. In order to minimize the risk of malperfusion caused by retrograde flow during cardiopulmonary bypass, we avoid femoral artery cannulation. On the hypothesis that it is best not to interfere with the hemodynamics of the dissection, we cannulate the dissected ascending aorta, in either the true or false lumen. We here report 2 cases of successful surgical treatment of Stanford type A aortic dissection. In both cases, the false lumen was cannulated under deep hypothermic circulatory arrest, without clamping the aorta. While the patient was cooling, a 10-mm GORE-TEX side arm was sutured to a Dacron graft prosthesis. Repair of the aortic arch was carried out 1st. The aortic cannula was inserted into the GORE-TEX side arm, the tubular prosthesis was cross-clamped, and cardiopulmonary bypass was reinstituted. After this, the aortic bulb was repaired as usual and the tubular prosthesis was sutured to the bulb. No postoperative cerebral complication occurred. Our experience must be confirmed by more cases and a longer follow up.

Subacute left ventricular free wall rupture complicating acute myocardial infarction. Successful surgical repair with a sutureless technique

The high mortality index related to surgical therapy with direct suture of rupture of left ventricular free wall following acute myocardial infarction, suggested we analyze and use alternative techniques. So we applied sutureless technique described by Padro to two patients. We used a Teflon patch fixed to the ventricular wall with a biocompatible synthetic glue, an ethyl-2-cyanoacrylate monomer, without any direct suturing of the infarcted myocardium. The two patients survived the operation and were discharged from the hospital 12 and 14 days after surgery. The sutureless technique allows, in our opinion, a more confident and safe aggressive attitude to subacute left ventricular free wall rupture.

The association between rhabdomyolysis and acute renal failure in patients undergoing cardiopulmonary bypass

OBJECTIVE

The authors describe 9 cases of rhabdomyolytic acute renal failure (ARF) as a complication of cardiopulmonary bypass.

EXPERIMENTAL DESIGN

Retrospective research between June 1992 and March 1994.

SETTING

Department of Cardiac Surgery.

PATIENTS

931 consecutive patients undergoing major cardiac surgery.

INTERVENTIONS

Patients affected by rhabdomyolytic ARF were treated with pharmacological therapy and/or plasmapheresis/continuous arteriovenous hemofiltration. In seven patients indirect cannulation of the femoral artery was used.

MEASURES

Incidence, risk factors of syndrome results obtained with pharmacological treatment, CAVH and plasmapheresis were evaluated. Statistical analysis was performed with ANOVA, Tukey Kramer test and chi2 test (p<0.05 as significant).

RESULTS

The syndrome occurred in 0.96% (9/931 patients) of the total cases; 11.3% (6/53 -p<0.0000) in patients undergoing a direct femoral artery cannulation for cardiopulmonary bypass and 9.5% (2/21, p<0.01) in patients in which the aortic balloon pump was used. Six patients develop acute anuric renal failure and underwent plasma exchange and hemodialysis (1 case) or CAVH (5 cases); 3 patients underwent early medical treatment and developed developed acute renal failure (ARF) with preserved diuresis. Early medical therapy appeared to prevent the evolution towards anuric ARF. The indirect cannulation of the femoral artery does not seem to produce a rhabdomyolytic ARF syndrome. In patients with direct femoral artery cannulation risk factors appear to be: arteriopathy (p<0.001), prolonged extra corporeal circulation (p<0.001), low cardiac output syndrome (p<0.001), continuous i.v. infusion of epinephrine (p<0.0001).

CONCLUSIONS

Rhabdomyolytic acute renal failure is a severe complication, early identification of patients ¿at risk¿ is most important. The preventive measures and the therapy adopted proved efficient.

Combined aortic valve replacement and left ventricular aneurysm plication in systemic lupus erythematosus

The case of a 37-year-old female patient is reported with systemic lupus erythematosus and severe renal function impairment, and associated aortic insufficiency, obstructive coronary disease and aneurysm of the left ventricular inferior free wall. Renal failure, hematologic disorder and the need for high-dose steroid therapy to control the autoimmune disease were considered the main surgical risks. Surgery included aortic valve replacement and plication of the ventricular aneurysm. The postoperative course was free of any major complications related to surgery or SLE disease.

[Protective efficacy of 3 anesthetic methods with reference to surgical stress in children]

Hormonal-metabolic stress responses have beyond doubt an effect on morbidity/mortality related to surgery. The present study med to determine which anaesthetic technique could afford the best protection in children, through analysis of the perioperative cortisol, prolactin and beta-endorphin plasma levels. Thirty-six young patients 3-10 years old, ASA I-II, scheduled for hypospadias or vesicoureteral reflux surgery of a duration > 60 min, were randomized into three groups (n = 12). Children of group I were given initially propofol and fentanyl then isoflurane 1%; group 2 received TIVA with propofol and fentanyl, group 3 received initially propofol then an epidural lumbar block with bupivacaine 0.25% (single shot) and continuous propofol i.v. infusion. Cortisol, prolactin and beta-endorphin levels increased significantly in group 1 only. No significant differences were observed between group 2 and 3. Early postoperative analgesia was better in group 3. These data suggest that TIVA and particularly epidural block could afford a better protection against the surgical stress in children submitted to subumbilical operations.

Rhabdomyolytic acute renal failure in cardiac surgery. A clinical case

OBJECTIVE

Authors describe 1 case of rhabdomyolytic acute renal failure as a complication of Cardiopulmonary bypass.

EXPERIMENTAL DESIGN

Case report.

SETTING

Department of Cardiac Surgery.

INTERVENTIONS

Patient affected by rhabdomyolytic acute renal failure was treated with pharmacological therapy, plasmapheresis and continuous arteriovenous hemofiltration (CAVH).

RESULTS

Anuric acute renal failure was diagnosed in 2nd post surgical day; serum myoglobin values was 16000 micrograms/l (normal values in non surgical patients < 88 micrograms/l), creatine phosphokinase serum values was 8790 UI/L (with Mb fraction < 8%). Patient underwent CAVH and two a day sessions of plasmapheresis; hematochemical and hemodynamic parameters improved progressively with resolution of acute renal failure and resumption of the diuresis on the 10th day. The CAVH was suspended on the 11th day and plasmapheresis on the 5th. Rhabdomyolytic syndrome should be correlated to the direct cannulation of the femoral artery for cardiopulmonary bypass and to prolonged time of extracorporeal circulation, with consequent leg ischemia/reperfusion induced injury which occurs during the extracorporeal circulation and continued during postoperative period; contributory causes should be the low cardiac output syndrome and alpha vasoconstrictor effect of high dose continuous intravenous administration of epinephrine.

CONCLUSIONS

Rhabdomyolytic acute renal failure is a severe complication of cardiopulmonary bypass; plasmapheresis and continuous arteriovenous hemofiltration seems to be suitable treatments.

[Predictive value of the shunt-to-infarct size ratio as a surgical risk factor in patients with decompensated post-ischemic interventricular septal rupture]

Postischemic septal rupture has always been evaluated, in respect of surgical indication, as regards the time lapse between infarct and rupture, interval between rupture and operation, extension of myocardial damage and general risk factors such as age, sex and associated pathologies. But in fact the surgeon is dealing with a two sided problem, the MI and the rupture, and thus surgical results depend upon both the residual ventricular function after MI and the consequences of volume overload on a damaged muscle. Surgical indication could not be based on a single criterion only. Extension of the MI alone is not fully predictive of operative mortality because, aside the reperfusion injury, the repair further jeopardizes viable myocardium and alters ventricular geometry; although the shunt appears unrelated to mortality it certainly interferes with operative outcome at least because of the time elapsed between rupture and repair. So far an index which could correlate the extension of myocardial damage and the entity of the shunt with each other was not available. Patients with septal rupture follow an emergency protocol and are often insufficiently investigated but every patients has a least one echo-Doppler evaluation or even a ventriculography while one or more ECGs are always available. With the presumption that the Qp/Qs is roughly indicative of the right ventricular volume overload and that ecg signs of myocardial infarct are always reliable, we have reviewed among our 24 patients with septal rupture those where a full ecg tracing and a quantitative Echo or angiographic evaluation of the shunt were available.(ABSTRACT TRUNCATED AT 250 WORDS)

Circumferential dissection of the ascending aorta with intimal intussusception. Case report and review of the literature

The present report describes an unusual case (apparently the 10th in the world literature) of a type-A aortic dissection with full circumferential detachment of the ascending aortic intima and intussusception thereof into the aortic arch and descending aorta, partly occluding the arch vessels. Computed tomographic scanning and 2-dimensional echocardiography failed to detect an intimal flap and a false lumen in the ascending aorta. Aortic dissection was visualized by aortography. The ascending aorta was surgically repaired and the aortic valve resuspended. The pertinent literature is reviewed.

The "fully no-touch" technique for the internal thoracic-coronary artery anastomosis

Extreme technical accuracy is crucial in coronary artery surgery. Although late graft patency depends mostly upon the patient's own biochemical status in chronic ischemic patients who have undergone elective surgery, graft disease is certainly promoted by an inaccurate technique or by careless arterial harvesting, which may cause both intimal lesions and anastomotic strictures. We describe a technique of internal thoracic-coronary artery anastomosis that fully prevents contact between vessels and surgical instruments. In order to enable the suturing of a fully dilated vessel, intracoronary papaverine is injected into the clamped aortic root while the heart is still beating and before systemic cooling begins. The suturing technique applies some microvascular principles, the chief being a high number of stitches incorporating the least amount of tissue, to avoid bulk.

[Doppler echocardiographic evaluation of functional parameters of mechanical and biological valve prostheses]

We studied and compared functional parameters in 314 valvular prostheses. The following parameters have been calculated: mean transvalvular gradients for aortic and mitral prostheses and functional area by Pht (pressure half time) for mitral prostheses. All patients with important depression in myocardial function, tachycardia or malfunctioning prostheses were excluded. 173 prostheses were in aortic position and 141 in mitral position. Mitral prostheses were: 31 biological and 110 mechanical. We subdivided mechanical prostheses in monoleaflet (Omnicarbon, Sorin-Carbocast and Allcarbon, Medtronic, Bjork-Shiley) and bileaflet (Sorin-Bicarbon, St. Jude). These three groups were compared: mean transvalvular gradients and area showed no differences. Aortic prostheses were: 33 biological and 140 mechanical; mechanical prostheses were subdivided in two groups: monoleaflet (Sorin Allcarbon e Carbocast, Bjork-Shiley, Medtronic, Omnicarbon) and bileaflet (Sorin-Bicarbon, St. Jude). Mean transvalvular gradients of these three groups were compared within each group for every size: bileaflet prostheses demonstrated inferior gradients than biological and monoleaflet for 19-21 and 23 sizes; in superior sizes there were no significant differences. Further analysis showed a significant correlation among gradients and body surface area in the 21 size prostheses (p = 0.004). Bileaflet prostheses in this subgroup showed less increase in mean gradient with surface area than mechanical and biological ones.

[The intramyocardial coronary artery and the muscular bridge. The physiopathological and surgical considerations in a clinical case]

Muscular bridging of the coronary artery affects both the vessel wall structure and the local blood flow. The vessel wall underneath the muscular bridge is usually thin and free from degenerative atherosclerotic changes. A coronary stenosis caused by a short muscular bridge is considered critical when greater than 75%, but these dynamic obstructions are often asymptomatic because of the diastolic coronary flow. A long intramyocardial course may instead affect blood flow before a critical stenosis has been reached. Spasm and late changes in diastolic compliance of the mural coronary artery play a definite role in the development of ischemia. The case of a young patient with a fully intramuscular left anterior descending artery and repeated episodes of effort spasm is presented, and etiology, features and surgical treatment are discussed.

[Serial Doppler echocardiography follow-up studies in the postoperative evaluation of severe pulmonary hypertension following surgery for mitral and mitral-aortic defects]

Between January 1987 and December 1991 26 patients with mitral and mitro-aortic disease and severe pulmonary hypertension (> or = 60 mmHg) were subjected to surgery. In 22 patients we have studied systolic pulmonary pressures by echocardiography-Doppler examination at 3-6 and 12 months from surgery. We noticed a decrease in pulmonary pressure values in all patients within 3 months from surgery (mean values pre-op 75 +/- 12.14; mean values post-op 42 +/- 11.26); within 6 months from surgery physiological values were reached in all patients (mean values 35 +/- 5.3). We have further divided patients in two subgroups: group A with pulmonary pressures superior or equal to 80 mmHg (mean values 90.00 +/- 17.32) and group B With pressure values between 60 and 79 mmHg (mean values 69.12 +/- 3.64). The first Doppler evaluation demonstrated a greater decrease in group B (mean values 37.8 +/- 6.5 versus 57 +/- 12.4); at the second control there was no statistically significant difference between the two groups (group A 36 +/- 5.48, group B 33.33 +/- 5.37). The only two operative deaths were caused by the pre-op cardiogenic shock. There has been no late mortality among survivors, 22 in NYHA Class I and 2 in NYHA Class II. Pulmonary hypertension decreases after surgery independently of the adopted procedure (replacement, repair or lysis).

Emergency surgical treatment for total left main coronary artery occlusion. A report of 2 cases

Treatment of total left main coronary artery occlusion is rarely reported (84 chronic and acute cases in the world literature), due to the high mortality rate from massive myocardial infarction. Acute occlusions have been treated with intracoronary streptokinase, with percutaneous transluminal coronary angioplasty, or with both. To date, there has been no report of successful surgical revascularization in an acute case. We present 2 cases of surgically treated patients who survived total left main coronary artery occlusion that appears to have been acute, or acutely evolving. Both patients had an 80% or greater stenosis of the right coronary artery, yet have remained in New York Heart Association functional class I or II postoperatively. We attribute this not only to the aggressive surgical approach, which enabled reperfusion to be achieved within 2 hours of total occlusion, but to the protective effect in these patients of right coronary-to-left anterior descending collaterals.

Surgical management of intracardiac myxomas. A 16-year experience

Twenty-six patients with an intracardiac myxoma underwent surgical resection at our institution from 1977 through 1992. Left atrial myxoma was diagnosed in 22 patients, left ventricular in 1, right atrial in 2, and right ventricular in 1. Six patients were asymptomatic; preoperative symptoms included dyspnea, arrhythmias, embolic episodes, and syncope. The diagnosis was established with transthoracic echocardiography in all cases but one. Surgery was performed in all cases with the aid of cardiopulmonary bypass with moderate hypothermia and cold crystalloid cardioplegia. One patient with a left ventricular myxoma died in a comatose state during the immediate postoperative period. Long-term clinical and echocardiographic evaluation was performed in 19 patients; results were excellent (all the patients were in New York Heart Association functional class I or II), and no recurrences were documented. The clinical characteristics, diagnostic methods, and surgical approach are presented and discussed.

Ten years of surgery of aortic dissections and aneurysms. Clinical experience and original contributions

From January '82 to April '91, 117 patients with aortic disease were operated upon at our University Hospital in Genoa, Italy. Thirty-seven had arch dissections or aneurysms; 66 had acute aortic dissection type A and 14 had aortic dissections or aneurysms type B, acute and chronic. Patients with arch or type B aortic pathology but without surgical indication and cases of post-traumatic aortic transections are not included. There were 84 male and 33 female patients with a mean age of 52 (6 min and 74 max). In the acute patients, the mean interval between clinical onset and surgery was 34 hours (6 min-72 max). All patients with primary arch disease had surgical repair with the aid of deep hypothermia and circulatory arrest (17-96 min). Type A dissections were treated with standard CPBP at 28 degrees C. Surgical techniques included direct suture of intimal tear alone, direct suturing of the two aortic stumps; interposition of Dacron tubular prosthesis; Bentall repair; separated valve and aortic replacement; an original aortic bulb aortoplasty with valve repair; arch replacement with resuturing of one or more aortic trunks. Human fibrin glue (Tissucol) was employed either as haemostatic agent, widely spread over the suture lines or as tissue adhesion agent between dissected aortic layers. Human fibrin glue is adopted because it gathers high glueing capacity and maintenance of the elastic property of the vessel wall. Hospital mortality (30 days) has been 25% in ascending aortic dissections (16/66 patients) and 50% in patients with arch disease (18/37 patients) who needed circulatory arrest. Late mortality 5/83 (6%). Reoperations for aortic valve insufficiency or re-dissection have been 7 (8.4%). Early diagnosis (increasing reliability of 2D-Echo and CT scans), aggressive surgery, meticulous myocardial and cerebral protection and introduction in clinical use of biological glues seem to be the milestones of present and further improvements in surgical results.

Arterial shunt with pump infusion line for the treatment of chronic thoracic aortic aneurysms: the "modified shunt of Gott"

Dissection of the aneurysm is the most dangerous step during graft replacement of the descending thoracic aorta. Sudden hemorrhage may follow wall rupture or disruption of major collaterals before the aorta can be clamped. A simple modification of the classic Gott is illustrated, which makes the shunt work also as a partial bypass if needed, with rapid reinfusion of blood losses. Nineteen of 25 patients requiring resection of descending aortic aneurysms from 1982 to 1990 were treated with this method with no mortality.

[Acute surgically-treated complications of myocardial infarct. Clinical experience and discussion of surgical indications]

Post-infarction free-wall, papillary muscle and septal myocardium rupture yields a lowering mortality, not only due to the improved surgical technique but also to a more careful selection of surgical candidates. The value of pericardial decompression in cases of free-wall rupture is discussed. Echocardiographic evidence of blood in the pericardium after a myocardial infarction is not a direct indication for a diagnostic sampling, decompression or surgery. Pericardiocentesis is not a risk-free procedure and should be limited to patients with life-threatening acute tamponade. Clinical results of 34 patients operated upon for myocardial rupture, regardless of adopted technique or timing of surgery, confirm that the decision about a patient's operability should follow a careful evaluation of the following risk factors in this order: infarct size, age, cardiogenic shock, multiorgan failure, rupture site, cardiac failure and associated diseases.

Coronary occlusion secondary to blunt chest trauma: a first attempt at balloon angioplasty

There have been only 58 angiographically documented reports of transmural myocardial infarction due to closed-chest trauma. None of these cases has been treated by percutaneous transluminal coronary angioplasty. We report the case of a 40-year-old man who developed an anterior-wall myocardial infarction secondary to blunt chest trauma suffered in an automobile accident. Angiographic study performed 2 months after the injury revealed an isolated total obstruction of the left anterior descending coronary artery. The patient was judged a good candidate for balloon angioplasty, but total reocclusion occurred within 24 hours of the procedure and a 2nd attempt did not restore patency. Surgical revascularization was performed a week later. A year after his injury, the patient remains asymptomatic and is back at work. Despite the failure of percutaneous transluminal coronary angioplasty in its 1st application to coronary artery repair after blunt chest trauma, we believe it to be the treatment of choice in young patients and in single-vessel disease.

[Antibiotic prophylaxis with cefoxitin in abdominal surgery (remarks on 50 cases)]

The authors, after stating the results of their clinical experience on 50 patients subjected to antibiotic prophylaxis with cefoxitin on the occasion of surgical operations on abdomen, compare the results of the antibiotic prophylaxis after a short time with those of the prophylaxis-therapy after an average time.

[Intra-abdominal foreign bodies following laparotomy interventions: report of a case]

The authors report their own observation of a case of post-laparotomic endoabdominal foreign body, which for a long period had remained asymptomatic. Starting from the clinical case, they effect a short study of such iatrogenic pathology, and state the diagnostic and therapeutic criteria thereabout. They subsequently dissertate on the possible preventing means.

Rational indications for sphincterotomy through intraoperative cholangiomanometry

The loss of function of Oddi's sphincter due to sclerosis secondary to a lithiasic or alithiasic phlogosis, is the only rational indication for sphincterotomy. An operative test of the Oddi sphincter function is proposed, based on an original manometric procedure. This method, employed on 567 patients undergoing biliary surgery, allowed demonstration of a loss of function of Oddi's sphincter in 53 patients (9.4%), in whom a sphincterotomy was performed.

[Postoperative functional evaluation and pharmacological study of Oddi's sphincter by means of cholangiomanometry using a Kehr tube]

The Authors report their experience of postoperative cholangiomanometry carried out through a T-tube on 19 patients; in 13 of such patients the Oddi's sphincter was intact, while 6 of them underwent sphincterectomy. In 8 patient's a manometric study of the duodenum was associated. They performed both variable flow and pressure and constant flow manometry and their results show that such examination is a reliable test both for the functional evaluation of the surgical procedure, and for the study of the action of various drugs on Oddi's sphincter function and its correlation with duodenal motility.

[Surgery of biliary lithiasis. I. Physiopathology and diagnosis]

Experimental studies and clinical observations are referred to in stressing the frequent correlation between duodenal, biliary and pancreatic disturbances, and the importance of the role of spontaneous or iatrogenic impairment of Oddi's sphincter in the origin of this pathology. These physiopathological concepts are regarded as fundamental in the correct surgical management of cholelithiasis. A pre- and postoperative diagnostic protocol designed to investigate the anatomofunctional aspects of the duodenum and pancreas as well as bile duct morphology and Oddi sphincter function is described. Its employment enabled 633 cases to be divided six well-defined groups for diversified treatment.