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ABSTRACT: Optimal strategy (staged or combined) for the treatment of patients with concurrent severe carotid and cardiac disease is still controversial. Moreover, carotid artery stenting (CAS), has become a valid alternative to carotid endarterectomy (CEA) and has been proposed for the treatment of cardiac patients. The authors report the preliminary results of a new therapeutic strategy consisting in combined CAS and cardiac surgery.
An initial series of 22 patients underwent combined CAS and cardiac surgery in the same operating room and under general anesthesia. All filter-protected CAS procedures were performed under only heparin and aspirin. A cervical approach (3-cm cervicotomy) was used in patients with documented vessel tortuosity or severe aorto-iliac occlusive arteriopathy. In all the other cases a femoral access was used. A double antiplatelet regimen was initiated in the early postoperative period, once major bleedings were excluded.
Among the 22 patients who underwent this combined procedure, no deaths, no myocardial infarctions and one controlateral stroke (overall complication rate: 4.5%) were observed. This stroke was observed after transcervical CAS, coronary artery bypass and mitral valve replacement. No major postoperative bleedings nor stent thrombosis were observed.
Combined carotid stenting and cardiac surgery, performed in the same operating room under only heparin and aspirin, seems a safe and effective strategy for the treatment of patients with concomitant carotid and cardiac disease.
The Journal of cardiovascular surgery 03/2009; 50(1):49-54. · 1.56 Impact Factor
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ABSTRACT: Aim of this study was to evaluate the factors influencing immediate and long-term results in patients undergoing aortic root replacement with a composite graft.
Between January 1989 and February 1999, 105 patients (83 males, 22 females) who underwent Bentall technique were studied. Preoperative diagnosis was annulo-aortic ectasia in 54, aortic dissection in 27, atherosclerotic aneurysm in 21, and aortitis in 3 cases. Seventeen patients were affected by Marfan's syndrome. All cases, elective, urgent, and emergency were included. Button technique was performed and the associated surgical procedures were coronary artery bypass grafting in 21, total aortic arch replacement in 15, proximal hemi arch in 5, and mitral valve replacement in 5 cases.
The overall hospital mortality rate was 7.6% (n=8). Univariate analysis using chi(2) and/or two-sample "t"-test showed that dissection, aortitis, aneurysm rupture into-pleura or pericardium, emergency status, redo, prolonged pump times and circulatory arrest, were predictors influencing in-hospital mortality. Coagulopathy, low cardiac output, stroke, perioperative myocardial infarction, surgical bleeding leading to reoperation, were significantly related to in-hospital mortality (by correlation analysis). A multivariate analysis showed that, emergency status (p=0.027), aortic dissection (p=0.029), perioperative myocardial infarction (p=0.0021), reoperation for bleeding (p=0.0023), and pump time >180 min (p=0.011), were significant. The actuarial survival rate at 10 years follow-up was 84.7%. There were 8 late deaths. The Kaplan-Meier showed significant differences when considering dissection vs non-dissection (p=0.018), but did not reach significance in Marfan vs non-Marfan groups (p=0.83). NYHA class IV (p=0.052), previous cardiac surgery procedure (p=0.041), concomitant CABG (p=0.021), total aortic arch reconstruction (p=0.001), and mitral valve replacement (p=0.016), were identified as significant by Log Rank test.
The Bentall procedure for aortic root replacement is safe and durable; in hospital mortality in elective status it was 1.28%; early and long-term mortality higher in patients with acute dissection. Six late deaths were procedures related. Sixty-six patients (76.4%) were in NYHA I class at follow-up. The incidence of late outcomes, thromboembolism (1.03%), graft infection (2.06%), pseudoaneurysm (0%), reoperation in ascending aorta or aortic valve (3.1%), operations on the remaining aorta (6.7%), and hemorrhage due to anticoagulant therapy (1.03%), are very low.
The Journal of cardiovascular surgery 07/2002; 43(3):337-43. · 1.56 Impact Factor
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ABSTRACT: We herein describe a safe and reproducible technique for left atrial volume reduction in patients with a giant left atrium. In a 56-year-old patient undergoing redo mitral valve replacement, the left atrium measured 18 x 20 x 17 cm occupying the middle-lower segment of the right hemithorax with compression of the adjacent organs. The left atrial volume was reduced by triangular resections of the atrial wall and the mitral valve was replaced using a mechanical prosthesis. The postoperative course was uneventful and the left atrial diameter was 11.2 cm at the latest control.
European Journal of Cardio-Thoracic Surgery 09/2001; 20(2):412-4. · 2.55 Impact Factor
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ABSTRACT: Acute type A aortic dissection is a surgical emergency still associated with high postoperative complications. The aim of this study was to investigate factors for hospital mortality and neurologic deficit in patients undergoing emergency operation for acute type A aortic dissection.
Eighty-five consecutive patients (age range, 20 to 82 years) operated on for acute type A aortic dissection over a 6-year period were evaluated. Univariate and stepwise multiple logistic regression analyses were conducted among 32 perioperative variables.
All patients underwent surgical procedures under deep hypothermic circulatory arrest. Antegrade or retrograde cerebral perfusion was used in 23 patients (27.1%) and 18 patients (21.2%), respectively. Forty-three patients underwent arch/hemiarch replacement and the ascending aorta was replaced in 42 patients. Overall mortality rate was 25.9% (22 of 85 patients). Multiple logistic regression analysis showed that lack of cerebral perfusion (p = 0.021) and postoperative renal failure (p = 0.006) were the best predictors for hospital death. Twenty-one patients (24.7%) experienced neurologic accidents. The risk factor for postoperative neurologic complication was lack of cerebral perfusion (p = 0.013). Hospital mortality was 13% (3 of 23 patients) and 16.7% (3 of 18 patients) in the antegrade and retrograde cerebral perfusion groups (p > 0.05) and neurologic deficit was 13% (3 of 23 patients) and 11.1% (2 of 18 patients), respectively (p > 0.05).
Hospital mortality and neurologic complications in patients undergoing emergent operation for acute type A aortic dissection were reduced when cerebral perfusion was used with deep hypothermic circulatory arrest.
The Annals of Thoracic Surgery 02/2001; 71(1):33-8. · 3.74 Impact Factor
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ABSTRACT: We report the diagnosis of mammary artery graft dysfunction by high-resolution transthoracic Doppler and venous adenosine infusion. The patient was treated by percutaneous balloon angioplasty, with optimal angiographic results. Coronary flow reserve in the distal left anterior descending artery was abnormal before angioplasty, and recovered soon after the procedure. The utility of this new non-invasive technique in the diagnosis of flow-limiting stenoses and follow-up of coronary angioplasty is described.
Italian heart journal: official journal of the Italian Federation of Cardiology 10/2000; 1(9):636-9.
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ABSTRACT: Sternal wound infections (SWIs) can be subdivided into two types, superficial or deep, that require different treatments. The clinical diagnosis of superficial SWI is normally easy to perform, whereas the involvement of deep tissues is frequently difficult to detect. Therefore, there is a need for an imaging study that permits the assessment of SWIs and is able to distinguish between superficial and deep SWI. The present work was a prospective study aiming to evaluate the role of technetium-99m hexamethylpropylene amine oxime (99mTc-HMPAO) labelled leucocyte scan in SWI management. Twenty-eight patients with suspected SWIs were included in the study. On the basis of clinical examination they were subdivided into three groups: patients with signs of superficial SWI (group 1), patients with signs of superficial SWI and suspected deep infection (group 2) and patients with suspected deep SWI without superficial involvement (group 3). Ten patients previously submitted to median sternotomy, but without suspected SWI, were also included in the study as a control group (group 4). All patients with suspected SWI had bacteriological examinations of wound secretion, if present. In addition 99mTc-HMPAO labelled leucocyte scan was performed in all patients. The patients of groups 1, 2 and 3 were treated on the basis of the clinical signs and microbiological findings, independently of the scintigraphic results. The patients of group 4 did not receive treatment. The final assessment of infection was based on histological and microbiological findings or on long-term clinical follow-up. Sensitivity, specificity, accuracy and positive and negative predictive values for scintigraphic and non-scintigraphic results were calculated. In the diagnosis of superficial and deep SWI, clinical and microbiological examination (combined) yielded, respectively, a sensitivity of 68.7% and 100%, a specificity of 77.3% and 80.8%, an accuracy of 73.7% and 86.8%, a positive predictive value of 68.7% and 70.6% and a negative predictive value of 77.3% and 100%. The scintigraphic results obtained in superficial SWI yielded a sensitivity of 56.2%, a specificity of 90.9%, an accuracy of 76.3%, a positive predictive value of 81.8% and a negative predictive value of 74.1%, while, by contrast, in deep SWI all of these values were 100%. Therefore, one can conclude that 99mTc-HMPAO labelled leucocyte scan permits accurate diagnosis of deep SWI, solving the main clinical problem in this field. In the present study the categorisation of patients without taking into account 99mTc-HMPAO labelled leucocyte planar scan findings caused a non-negligible number of cases of superficial SWI to be treated as though they were deep SWI. This "overestimation" led to unnecessary surgery, increased and prolonged use of antibiotics with more (higher) toxicity and additional expense.
European Journal of Nuclear Medicine 07/2000; 27(6):660-7.
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ABSTRACT: In order to predict tissue viability in infarcted myocardial areas, changes induced by nitroglycerine infusion on Sestamibi myocardial uptake were evaluated in 37 patients with previously confirmed myocardial infarction undergoing coronary artery bypass grafting, and compared with echocardiographic and perfusional changes occurring after the operation. The improvement of Sestamibi uptake after nitroglycerine correctly classified 24/26 (92%) patients showing postoperative improvement of wall motion in the infarcted area, whereas 24/31 (77%) patients with nitroglycerine-induced increase in Sestamibi uptake had improved wall motion after operation. The presence of collateral flow to the infarcted area was associated with a significantly (P < 0.01) higher increase in Sestamibi uptake both during nitroglycerine infusion and postoperatively. An increase in wall motion score after operation was associated with a significantly higher (P < 0.05) increase in Sestamibi uptake score during nitroglycerine infusion. Thus, the results of this study suggest that Sestamibi perfusional myocardial scintigraphy during nitroglycerine infusion is capable of assessing viable but chronically hypoperfused myocardium and predicting postoperative wall motion and perfusional improvement, to yield the best results in patients with evidence of collateral circulation that supplies the infarcted area.
Cardiovascular Surgery 05/1998; 6(2):149-55.
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K Iwashiro,
A Criniti, R Sinatra,
A A Dawodu,
G d'Amati,
F Monti,
L Pannarale,
P Bernucci,
G L Brancaccio,
A Vetuschi,
E Gaudio,
P Gallo,
P E Puddu
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ABSTRACT: We aimed at investigating contractile changes after hypoxia-reoxygenation and dobutamine challenge in superfused human atrial pectinate muscle to see whether high versus low stimulation rate during hypoxia might account for outcome differences compatible with the definition of an in vitro model of myocardial stunning and whether pretreatment with the dihydropyridine Ca2+ entry blocker felodipine might afford protection.
Human right atrial trabeculae obtained from adult patients were superfused in an organ bath with oxygenated (O2 content 16 ml/l) and modified (NaHCO3 25.7 mmol/l) Tyrode's solution at 37 degrees C. Dobutamine (1 nmol/l to 10 micromol/l) was superfused in 10 oxygenated preparations to select the optimal drug concentration to be used in another 22 which were randomized. Group (A) consisted of time-related controls (Tyrodes's solution for 225 min at cycle length (CL) 1600 ms and no dobutamine). There were two test groups, respectively: (B) low (1600 ms CL) and (C) high (400 ms CL) stimulation rate. After 60 min of stabilization, in groups B and C, hypoxic superfusion (O2 content 5 ml/l) lasted 60 min, then reoxygenation (60 min) and dobutamine challenge (1 micromol/l, 15 min) were performed. Analysis of variance for repeated measures with the Greenhouse-Geisser correction, and a repeated measures model with structured covariance (preparation mass, length, width and time-varying time to peak tension) matrices were used whereby grouping (G), time (T) and G x T interaction were weighted. Force-frequency relationship and post-pausal potentiation were studied after each phase. Electrophysiology, histomorphometry and electron microscopy were carried out (n=6). Felodipine (0.1 micromol/l, n=5) pretreatment (15 min before hypoxia) was given in parallel experiments.
Time-related controls showed approximately 10% per hour decrease of developed tension and the Paradise test provided approximately 80% of control values. In test groups (as compared to baseline values) contractility was decreased approximately 65% after hypoxia-reoxygenation and it increased approximately 25% after dobutamine (G, 0.0065<P<0.0155; T, P=0.00005; G x T, P=0.00005). High stimulation rate during hypoxia worsened hypoxia-reoxygenation contractile changes, whereas reversibility after dobutamine was less. In both B and C groups during hypoxia, contractility decreased quite rapidly, although by 10 min or so a plateau (approximately 50%) was reached in group B, whereas in group C contractility decreased to <20%. None of the covariates contributed significantly to predict the dependent variables investigated. Force-frequency relationship and post-pausal potentiation were repeatable, paralleled overall changes due to hypoxia, reoxygenation and dobutamine challenge and were useful to discriminate Ca2+-related diastolic processes thus helping index myocardial contractile reserve. Force-frequency relationship was negative at high stimulation rates, concomitant to an abrupt change of shape and duration of action potential with little time for Ca2+-related Ca2+ release and ensuing systolic processes. Felodipine pretreatment enabled an unblunted response to dobutamine. Histomorphometry showed an unexpected 'fibrotic core'. At electron microscopy, subendocardial and deep part of the same pectinate muscles showed identical degrees of degenerative lesions. Superfused samples showed, unexpectedly, less anoxic lesions than preparations fixed within 15 min from surgical explant, although lesions were higher than in samples fixed immediately after explant.
This might be a relevant model, whereby pharmacological or physical interventions are tested. Native human atrial trabeculae might be used without dissection and/or preservatives. If high stimulation rate during hypoxia is used the power of hypothesis testing is maximized. Future studies with this material will be easier and comparatively smaller series might be investigated. Felo
International Journal of Cardiology 11/1997; 62(2):107-32. · 7.08 Impact Factor
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ABSTRACT: The aim of the present study was to evaluate early and late results of two different surgical techniques for left ventricular aneurysms repair. The conventional aneurysmectomy and direct closure of the ventricular wall and the endoventricular patch plasty.
We retrospectively reviewed 118 patients operated on for postinfarction left ventricular aneurysm from 1981 to 1994. Eighty-seven patients (Group A) were operated upon between 1981 and 1991 with the conventional technique and 31 patients (Group B) between 1992 and 1994 with the endoventricular patch plasty technique. Preoperative clinical, hemodynamic and echocardiographic evaluation with operative procedures and early postoperative results of all patients are reported. We also analyzed results of late clinical and echocardiographic controls of 34 patients of Group A and all patients of Group B after a mean follow-up of 42 and 28 months, respectively.
Mean number of by-pass grafts was 1.9 in Group A and 2.6 in Group B (P = 0.01). The left anterior descending coronary artery was revascularized in 27 patients of Group A (34.6%) and 26 of Group B (89.7%) (P < 0.001); the left internal mammary artery was used in seven patients of Group A (8.9%) and 24 of Group B (82.8%) (P < 0.001). Hospital mortality in Group A was 10.3% (9/87), in Group B there was no hospital mortality (P > 0.05). Thirty-two patients of Group A (36.8%) and 3 of Group B (9.7%) suffered of low cardiac output syndrome (P = 0.01). At late control, improvements observed in NYHA and CCS classes, left ventricular ejection fraction (all P < 0.001 in both groups versus preoperative values) and left ventricular end-diastolic diameter (P > 0.05 in Group A and P < 0.001 in Group B) proved to be statistically higher in patients of Group B.
Endoventricular patch plasty associated with a complete myocardial revascularization, in particular of the anterior descending coronary, and a larger use of the internal mammary artery, permits, by means of reconstruction of the left ventricular geometry, a better outcome for patients undergoing left ventricular aneurysmectomy.
European Journal of Cardio-Thoracic Surgery 08/1997; 12(2):291-7. · 2.55 Impact Factor
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Journal of Interventional Cardiology 01/1996; 8(6 Suppl):841-4. · 1.18 Impact Factor
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ABSTRACT: During the past decade, a variety of innovative procedures and devices for non-pharmacological treatment of tachyarrhythmias have been proposed. Recent improvements in the implantable cardioverter/defibrillators and transcatheter ablative techniques have resulted in a revolution of the therapeutic approach in ventricular and supraventricular tachyarrhythmias, respectively, providing a valuable alternative to conventional antiarrhythmic surgery. Indeed, the selection criteria for surgery for tachyarrhythmias have been revised, and this therapeutic option is considered appropriate only for selected patients with postinfarction ventricular tachycardia. Ther implantable cardioverter/defibrillator has proved effective in conversion of life-threatening tachyarrhythmias, leading a dramatic decrease in the incidence of sudden death in high risk subjects. Thus, with further refinements, a wide use of this therapeutic modality can be anticipated. Transcatheter ablation has become the first-line option in the most common forms of supraventricular tachycardias, such as accessory pathway-mediated tachycardia and AV nodal reentry. More recently, encouraging results of this technique in common atrial flutter and ectopic atrial tachycardia have been reported, although confirmation with larger series and longer follow-up is needed. In general, results of catheter ablation in ventricular tachycardia have been disappointing, with the exception of bundle branch reentry and idiopathic ventricular tachycardia, in which a high success rate is reported. An increasingly important role of these therapeutic modalities is expected. In the meanwhile, due to their evolutional character and the specific competence required for their use, such procedures should be performed exclusively in well trained centers.
Cardiologia (Rome, Italy) 01/1994; 38(12 Suppl 1):397-408.
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The American Journal of Cardiology 09/1992; 70(4):553-4. · 3.37 Impact Factor
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ABSTRACT: Successful transcatheter ablation of an accessory pathway in 2 patients with life-threatening tachyarrhythmias is reported. In both cases, electrophysiological evaluation documented the posterior septal location of the anomalous atrioventricular connection. Radiofrequency current energy was delivered just below the coronary sinus orifice, and resulted in disappearance of preexcitation. During the follow-up, both patients remained free from tachyarrhythmias on no medication, and serial electrocardiographic recordings confirmed the persistent absence of preexcitation. It is concluded that ablation of accessory pathways can be accomplished easily and without risk by means of the radiofrequency catheter technique. This therapeutic modality requires a short hospitalization and can be recommended as the first option in patients with the Wolff-Parkinson-White syndrome.
Cardiologia (Rome, Italy) 05/1992; 37(4):291-6.
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ABSTRACT: The introduction of transcatheter ablation techniques has opened a new era of the management of tachyarrhythmias. The rationale of these therapeutic procedures lies in the induction of an irreversible and limited damage to cardiac tissue involved in arrhythmias. In its original form, the technique involves the delivery of high energy DC discharges (fulguration) to the target area through a temporary catheter electrode. A primary drawback of fulguration, when used for ablation of AV node-His bundle, is the induction of a pacemaker-dependent state; the barotraumatic effect that results from high energy impulses constitutes the major limitation in the case of ablation of accessory pathways or arrhythmogenic areas. Recently, the efficiency of the procedure has been substantially improved by the use of low-power, high-frequency alternating current (radiofrequency), that allows to deliver graded amounts of disrupting energy to selected areas while avoiding undesirable biophysical effects to the surrounding tissue. Remarkable results, with a success rate close to 100%, are reported with radiofrequency ablation of AV node reentry tachycardia, as well as reciprocating tachycardia associated with the preexcitation syndrome, so that this technique can be considered the procedure of choice for both categories of patients. Catheter modification of AV conduction provides a therapeutic tool for treating atrial tachyarrhythmias with rapid ventricular responses. In such cases, however, the risk of AV block with the need for pacemaker implantation must be taken into account. Results of catheter ablation of ventricular tachycardia have been inconstant and generally disappointing, except for ventricular tachycardias due to reentry in the His-Purkinje system, for which a high success rate is reported. Experience with radiofrequency ablation in ventricular tachycardia is very limited, but localization of a critical segment of reentry could improve the efficiency of this technique.
Cardiologia (Rome, Italy) 01/1992; 36(12 Suppl 1):469-84.
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ABSTRACT: From January 1981 to January 1991, 40 patients underwent operation for acute ascending aorta dissection (AAD, 14 patients), chronic ascending aorta dissection (CAD, 9 patients) or aortic ectasia (AE, 17 patients), with simultaneous aortic valve replacement in 30 cases (75%). Average age was 54 years with a 3:1 M/F ratio. In 20 cases (50%) a composite graft bearing a mechanical bileaflet valve was inserted with coronary artery reattachment (Bentall operation). In 16 cases (40%) the ascending aorta was replaced by a woven dacron graft alone (7 cases) or associated with aortic valve substitution (7 cases) or resuspension (2 cases). In 1 case (2.5%) a sutureless ring graft replacement of ascending aorta was carried out and 3 patients (7.5%) underwent aortoplasty with aortic valve substitution. Postoperative mortality rate was 21% for AAD group, 11% for CAD group and 6% for AE group. Non-fatal postoperative complications developed in 36% of AAD patients and in 78% and 29% of CAD and AE patients respectively. These complications occurred in 45% of patients who underwent Bentall operation, in 44% of those who underwent ascending aorta replacement associated with aortic substitution or resuspension, and in 14% of those operated of simple ascending aorta replacement. Average follow-up was 41.6 months (range 1.7-107.4 months). During this period 5 deaths occurred for a long-term mortality rate of 14.2%. Out of 30 survivors 21 (70%) underwent CT-study to evaluate the natural course of the false channel and the risk of redissection or late aneurysm formation.(ABSTRACT TRUNCATED AT 250 WORDS)
Cardiologia (Rome, Italy) 07/1991; 36(6):469-76.
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ABSTRACT: Expanded polytetrafluoroethylene (e-PTFE) sutures have been used with increasing frequency to replace chordae tendineae in mitral valves prolapsing because of myxoid change. A case is reported where fibrosis and calcification of the endocardial overgrowth covering the synthetic chordae led to severe mitral regurgitation 7 years after plastic repair and required mechanical prosthetic valve implantation.
Cardiovascular Pathology 10(2):87-9. · 2.07 Impact Factor
