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European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 03/2013; · 2.40 Impact Factor
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Roberto Lorusso,
Sandro Gelsomino,
Enrico Vizzardi,
Antonio D'Aloia, Giuseppe De Cicco,
Fabiana Lucà,
Orlando Parise,
Gian Franco Gensini,
Pierluigi Stefàno,
Ugolino Livi, [......],
Francesco Nicolini,
Tiziano Gherli,
Valentino Borghetti,
Alessandro Pardini,
Philippe-Primo Caimmi,
Ezio Micalizzi,
Carlo Fino,
Paolo Ferrazzi,
Michele Di Mauro,
Antonio Maria Calafiore
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ABSTRACT: OBJECTIVE: It is uncertain whether mitral valve replacement is really inferior to mitral valve repair for the treatment of chronic ischemic mitral regurgitation. This multicenter study aimed at providing a contribution to this issue. METHODS: Of 1006 patients with chronic ischemic mitral regurgitation and impaired left ventricular function (ejection fraction < 40%) operated on at 13 Italian institutions between 1996 and 2011, 298 (29.6%) underwent mitral valve replacement whereas 708 (70.4%) received mitral valve repair. Propensity scores were calculated by a nonparsimonious multivariable logistic regression, and 244 pairs of patients were matched successfully using calipers of width 0.2 standard deviation of the logit of the propensity scores. The postmatching median standardized difference was 0.024 (range, 0-0.037) and in none of the covariates did it exceed 10%. RESULTS: Early deaths were 3.3% (n = 8) in mitral valve repair versus 5.3% (n = 13) in mitral valve replacement (P = .32). Eight-year survival was 81.6% ± 2.8% and 79.6% ± 4.8% (P = .42), respectively. Actual freedom from all-cause reoperation and valve-related reoperation were 64.3% ± 4.3% versus 80% ± 4.1%, and 71.3% ± 3.5% versus 85.5% ± 3.9 in mitral valve repair and mitral valve replacement, respectively (P < .001). Actual freedom from all valve-related complications was 68.3% ± 3.1% versus 69.9% ± 3.3% in mitral valve repair and mitral valve replacement, respectively (P = .78). Left ventricular function did not improved significantly, and it was comparable in the 2 groups postoperatively (36.9% vs 38.5%, P = .66). At competing regression analysis, mitral valve repair was a strong predictor of reoperation (hazard ratio, 2.84; P < .001). CONCLUSIONS: Mitral valve replacement is a suitable option for patients with chronic ischemic mitral regurgitation and impaired left ventricular function. It provides better results in terms of freedom from reoperation with comparable valve-related complication rates.
The Journal of thoracic and cardiovascular surgery 11/2012; · 3.41 Impact Factor
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ABSTRACT: OBJECTIVES: Barlow disease represents a surgical challenge for mitral valve repair (MR) in the presence of mitral insufficiency (MI) with multiple regurgitant jets. We hereby present our mid-term experience using a modified edge-to-edge technique to address this peculiar MI. METHODS: From March 2003 till December 2010, 25 consecutive patients (mean age 54±7years, 14 males) affected by severe Barlow disease with multiple regurgitant jets were submitted to MR. Preoperative transesophageal echo (TEE) in all the cases showed at least 2 regurgitant jets, involving one or both leaflets in more than one segment. In all the patients, a triple orifice valve (TOV) repair with annuloplasty was performed. Intra-operative TEE and postoperative transthoracic echocardiography (TTE) were carried out to evaluate results of the TOV repair. RESULTS: There was no in-hospital death and one late death (non-cardiac related). At intra-operative TEE, the three orifices showed a mean total valve area of 2.9±0.1cm(2) (range 2.5-3.3cm(2)) with no residual regurgitation (2 cases of trivial MI) and no sign of valve stenosis (mean transvalvular gradient 4.6±1.5mmHg). At follow up (mean 38±22months), TTE showed favourable MR and no recurrence of significant MI (6 cases of trivial and 1 of mild MI). Stress TTE was performed in 5 cases showing persistent effective valve function (2 cases of trivial MI at peak exercise). All the patients showed significant NYHA functional class improvement. CONCLUSIONS: This report indicates that the TOV technique is effective in correcting complex Barlow mitral valves with multiple jets. Further studies are required to confirm long-term applicability and durability in more numerous clinical cases.
International journal of cardiology 07/2012; · 7.08 Impact Factor
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Roberto Lorusso,
Sandro Gelsomino,
Fabiana Lucà, Giuseppe De Cicco,
Giuseppe Billè,
Rocco Carella,
Emmanuel Villa,
Emanuel Villa,
Gianni Troise,
Mario Viganò, [......],
Claudio Russo,
Aldo Cannata,
Roberto Trevisan,
Ugolino Livi,
Roberto Scrofani,
Carlo Antona,
Andrea Sala,
Gian Franco Gensini,
Jos Maessen,
Andrea Giustina
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ABSTRACT: The present study was aimed at determining the impact of type 2 diabetes mellitus (DM) on postoperative bioprosthetic structural valve degeneration.
Twelve Italian centers participated in the study. Patient data refer to bioprosthetic implantations performed from November 1988 to December 2009, which resulted in 6184 patients (mean age 71.3±5.4 years, 60.1% male) being enrolled. Of these patients, 1731 (27.9%) had type 2 DM. The propensity score-matching algorithm successfully matched 1113 patients with type 2 DM with the same number of no-DM patients. The postmatching standard differences were less than 0.1 for each of the covariates, and 64.2% of DM patients were matched. The early (30 days) mortality rate was 7.8% (n=87) versus 2.9% (n=33) in patients with or without type 2 DM (P<0.001), respectively. Seven-year freedom from valve deterioration was significantly lower in patients with DM (73.2% [95% confidence interval, 61.6-85.5] versus 95.4% [95% confidence interval, 83.9-100], P<0.001). In Cox regression models with robust SEs that accounted for the clustering of matched pairs, DM was the strongest predictor of structural valve degeneration (hazard ratio 2.39 [95% confidence interval 2.28-3.52]). When we allowed for interaction between type 2 DM and other key risk factors, DM remained a significant predictor beyond any potentially associated variable.
Patients with type 2 DM undergoing bioprosthetic valve implantation are at high risk of early and long-term mortality, as well as of structural valve degeneration.
Circulation 12/2011; 125(4):604-14. · 14.74 Impact Factor
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ABSTRACT: Refractory vascular spasm (RVS) concomitantly involving the entire coronary artery system and grafted conduits after coronary artery bypass grafting (CABG) surgery is a rare, but dreadful event. No consensus exists in terms of appropriate management.
Between 1986 and 2009, 5,762 patients underwent isolated CABG at our institution, and 7 patients experienced RVS involving the coronary arteries and implanted conduits. Mean age was 65.6 years and 3 were female. All patients received from 3 to 5 distal anastomoses, including use of the left internal mammary artery. During the same time period, 18 patients experienced perioperative vasospasm of a single coronary artery or of a grafted conduit.
All diffuse RVS events occurred between 3 and 8 hours after surgery. All patients had diffuse ischemic-like electrocardiographic changes, and 5 patients rapidly developed cardiogenic shock in the intensive care unit. Angiography was quickly performed in all patients and showed diffuse RVS involving either the native coronary arteries or the anastomosed arterial and venous conduits. The first 5 patients of this series died in the catheterization lab due to rapidly evolving refractory cardiogenic shock and unresponsive cardiac arrest, despite intraaortic counterpulsation and aggressive pharmacologic interventions (selective vasodilators and systemic inotropes). In the last 2 patients, extracorporeal membrane oxygenation was quickly instituted (1 in the catheterization lab, 1 in the operating room) and RVS could be successfully managed with complete resolution of ongoing vasospasm. In the single vascular spasm, there was only 1 death for refractory cardiac arrest, whereas all the other patients were successfully treated with direct infusion of vasodilators.
Diffuse RVS after CABG is a rare but lethal condition. Our experience, although limited, indicates that in such cases an aggressive treatment, that is, prompt extracorporeal membrane oxygenation institution and controlled cardiocirculatory assistance, represents the preferred solution to face such a dramatic event and may save patient lives.
The Annals of thoracic surgery 12/2011; 93(2):545-51. · 3.74 Impact Factor
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ABSTRACT: Lung erosion represents a dreadful complication in patients affected by thoracic aortic aneurysms. Intraoperative occurrence of severe bleeding and extensive air leakage from the pulmonary erosion is usually quite particularly dangerous and challenging because of fragile lung tissue to be repaired, hypo-coagulative state, and the need for full mechanical ventilation. We report the case of a patient who had uncontrollable pulmonary bleeding and marked air leakage from an aortic aneurysm-induced lung erosion and laceration, which were effectively treated with a hemostatic patch (Tachosil, Nycomed, Linz, Austria) after unsuccessful conventional surgical approaches.
The Annals of thoracic surgery 03/2011; 91(3):917-9. · 3.74 Impact Factor
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Sandro Gelsomino,
Roberto Lorusso,
Ugolino Livi,
Stefano Romagnoli,
Salvatore Mario Romano,
Rocco Carella,
Fabiana Lucà,
Giuseppe Billè,
Francesco Matteucci,
Attilio Renzulli,
Gil Bolotin, Giuseppe De Cicco,
Pierluigi Stefàno,
Jos Maessen,
Gian Franco Gensini
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ABSTRACT: The study was aimed to determine the measurement accuracy of The CDI™ blood parameter monitoring system 500 (Terumo Cardiovascular Systems Corporation, Ann Arbor MI) in the real-time continuous measurement of arterial blood gases under different cardiocirculatory stress conditions
Inotropic stimulation (Dobutamine 2.5 and 5 μg/kg/min), vasoconstriction (Arginine-vasopressin 4, 8 and 16 IU/h), hemorrhage (-10%, -20%, -35%, and -50% of the theoretical volemia), and volume resuscitation were induced in ten swine (57.4 ± 10.7 Kg).Intermittent blood gas assessments were carried out using a routine gas analyzer at any experimental phase and compared with values obtained at the same time settings during continuous monitoring with CDI™ 500 system. The Bland-Altman analysis was employed.
Bias and precision for pO2 were - 0.06 kPa and 0.22 kPa, respectively (r2 = 0.96); pCO2 - 0.02 kPa and 0.15 kPa, respectively; pH -0.001 and 0.01 units, respectively ( r2 = 0.96). The analysis showed very good agreement for SO2 (bias 0.04,precision 0.33, r2 = 0.95), Base excess (bias 0.04,precision 0.28, r2 = 0.98), HCO3 (bias 0.05,precision 0.62, r2 = 0.92),hemoglobin (bias 0.02,precision 0.23, r2 = 0.96) and K+ (bias 0.02, precision 0.27, r2 = 0.93). The sensor was reliable throughout the experiment during hemodynamic variations.
Continuous blood gas analysis with the CDI™ 500 system was reliable and it might represent a new useful tool to accurately and timely monitor gas exchange in critically ill patients. Nonetheless, our findings need to be confirmed by larger studies to prove its reliability in the clinical setting.
BMC Anesthesiology 01/2011; 11(1):1.
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ABSTRACT: Alpha1-antitrypsin deficiency (A1ATD) is usually linked to chronic lung dysfunction and chronic liver disease. Recent evidence have shown involvement also of the cardiovascular system. Indeed, dissection of the thoracic aorta or of the coronary arteries, and intra-cerebral aneurysms has been shown to represent concomitant vascular adverse events and apparently related to the impaired vascular wall integrity, strictly related to the elastase levels which are usually modulated by the A1AT. The case herein reported describes a patient affected by A1ATD associated with a large pseudoaneurysm of the left ventricle without any known predisposing factors to pseudoaneurysm development (coronary artery disease, acute myocardial infarction, taruma and myocarditis) indicating that the connective tissue impairment documented in A1ATD may also affect the myocardial structure, ultimately leading to weakened wall integrity, sudden rupture and pseudoaneurysm formation successfully managed by a surgical approach.
International journal of cardiology 03/2010; 145(2):384-6. · 7.08 Impact Factor
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ABSTRACT: Aortic regurgitation (AR) and first-degree atrioventricular heart block (FDAVB) are encountered in ankylosing spondylitis (AS). This rheumatological disease also presents in 90% of the cases an immunogenetic marker that is Human Leucocyte Antigen-B27 (HLA-B27). In this report we describe a case of a patient presenting with AR, FDAVB, aneurysm and thinning of the ascending aortic wall, aneurysm of the sinuses of Valsalva and inferior myocardial infarction-like electrocardiographic pattern with unknown cardiac AS and absence of other AS-related systemic manifestations.
International journal of cardiology 06/2009; 137(3):e61-2. · 7.08 Impact Factor
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The Journal of thoracic and cardiovascular surgery 03/2009; 137(2):499-500. · 3.41 Impact Factor
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ABSTRACT: We hypothesized that a preoperative symmetric pattern with anterior mitral leaflet (AML) tethering predominance is related to lack of LVRR after restrictive annuloplasty.
In 300 patients with surgical annuloplasty for chronic ischemic mitral regurgitation the AML and posterior mitral leaflet (PML) tethering angles were quantified and patients were divided on the basis of the preoperative anterior/posterior tethering angle ratio: there were 144 patients with symmetric (Group 1) and 156 with asymmetric (Group 2) preoperative tethering pattern patients underwent echocardiography preoperatively, at discharge and at follow-up appointments (6 months [IQR 5-8 months]; late, 48 months [15-63 months]). Reverse remodeling was defined as a reduction in left ventricular end systolic volume index >15%.
LVRR was higher in the asymmetric group at discharge (69.2% vs. 9.7%, p<0.001), early (70.55% vs. 10.45%, p<0.001 and late follow up (81.4% vs. 4.8%, p<0.001). At multivariable regression analysis corrected by significant key factors of LVRR, symmetric leaflet tethering (OR, 4.8 [95% CI 2.9-5.6], p<0.001), anterior tethering angle alpha'<39.5 degrees (OR, 5.0 [95% CI 2.0-6.6], p<0.001), coaptation height<11 mm (OR, 2.5 [95% CI 1.1-3.3], p=0.006) and coaptation length > or =8 mm at the end of procedure (OR, 2.0 [CI 0.8-3.0], p=0.01) were independent predictors of LVRR. Compared with patients with asymmetric pattern (adjusted OR 0.2 [95% CI 0.03-1.6), those with symmetric pattern had >4-fold odds for lack of LVRR.
The preoperative symmetric pattern with AML prevalence was strongly associated with lack of reverse remodeling after annuloplasty. An accurate echocardiographic evaluation of the tethering mechanisms should be incorporated into clinical risk assessment and prediction models.
International journal of cardiology 01/2009; 141(2):182-91. · 7.08 Impact Factor
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Roberto Lorusso,
Domenico Corradi,
Roberta Maestri,
Silvia Bosio,
Alessandra Curulli,
Cesare Beghi,
Piersilvio Gerometta,
Claudio Russo,
Sandro Gelsomino,
Antonella Moreo, Giuseppe De Cicco,
Giuseppe Rosano,
Maurizio Volterrani
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ABSTRACT: The aim of our study was to examine the effects of statin therapy (atorvastatin) on post-implant structural changes of bovine pericardial tissue in a subcutaneous animal model.
Sixty male C57BL/6 mice underwent subcutaneous dorsal implantation of bovine pericardial fragments. Animals were randomized to treatment with atorvastatin (50 mg/kg) (statin group - SG) or to vehicle (control group - CG). After 1.5 months, all fragments were explanted and submitted to histopathological assessment (semi-quantitative analysis) to elucidate extent of inflammatory infiltrate, signs of tissue injury, or presence of microcalcification. Calcium determination of the implanted pericardial tissue was also performed by inductively coupled plasma mass spectrometry (ICP-MS) assessment. ICP-MS analysis showed that pericardial fragments in SG had significantly (p<0.01) less calcium content than CG (625+/-142 vs. 962+/-590 microg/g, respectively). Light microscopy showed marked inflammatory infiltrates and tissue injury of pericardial specimens in CG animals, whereas SG animals maintained a better preserved original pericardial structure.
Our findings indicate that atorvastatin significantly attenuates the post-implant structural degeneration of artificial valve bovine pericardial tissue in a subcutaneous animal model. Further observations are mandatory to assess the effects of statins on the implanted bioprosthetic valve tissue in the blood circulation.
International journal of cardiology 01/2009; 141(1):68-74. · 7.08 Impact Factor
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ABSTRACT: Infective endocarditis in pregnancy has a low incidence, often being associated with a previous history of rheumatic or congenital heart disease. In most reports the disease tends to run a subacute course and to appear more frequently in the third trimester of pregnancy. We present the case of a 36-year-old woman with large vegetations on the mitral valve due to infective endocarditis detected at the 32(nd) week of her first pregnancy. The difficulties in selecting the appropriate management strategy, particularly optimal time and mode of delivery, optimal time and type of valve surgery, are emphasized.
Cases Journal 01/2009; 2:6537.
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ABSTRACT: Appropriate sternotomy and sternal closure are the most important factors in mechanical stability of the sternum and prevention of several postoperative complications. Easy techniques for identifying the sternal midline to facilitate opening and for obtaining reinforced closure are described. These techniques require minimal additional time. They are particularly indicated in patients at risk of sternotomy-related complications, and helpful to young surgeons in training.
Asian cardiovascular & thoracic annals 11/2008; 16(5):414-5.
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ABSTRACT: Emergency surgery for acute vein graft perforation and balloon entrapment during percutaneous angioplasty is reported here. Prompt extracorporeal circulation through peripheral cannulation enabled the control of systemic perfusion despite cardiac arrest. Vein graft repair was achieved by an autologous pericardial patch. Appropriate and tailored mechanical circulatory support allowed successful extracorporeal circulation withdrawal, limited intraoperative cardiac damage, and postoperative controlled recovery of ventricular function with ultimate favorable outcome.
The Annals of thoracic surgery 10/2008; 86(3):1002-4. · 3.74 Impact Factor
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European Journal of Cardio-Thoracic Surgery 09/2008; · 2.55 Impact Factor
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ABSTRACT: We investigated leaflet and subvalvular configurations to identify mechanisms leading to recurrent mitral regurgitation after combined undersized mitral annuloplasty and coronary artery bypass and to preoperatively recognize patients who are unlikely to benefit from this approach.
Among 261 subjects with chronic ischemic mitral regurgitation undergoing undersized annuloplasty and coronary bypass surgery at one institution between September 2001 and September 2007, 31 were excluded: 4 had intraoperative annuloplasty failure, 12 showed residual regurgitation, and 15 had incomplete echocardiograms available. The study population consisted of 230 patients who were divided into 2 groups: patients without (group 1, n = 176) or with (group 2, n = 54) late recurrent mitral regurgitation. Fifty healthy subjects were used as control subjects. Serial echocardiographic analysis was performed preoperatively, at discharge, and at follow-up appointments (early: median, 6 months [interquartile range, 5-6 months; late: median, 33 months [interquartile range, 17-51 months]).
Subjects with late regurgitation had preoperatively more symmetric tethering (P < .001), more accentuated anterior mitral leaflet tethering (P < .001), and more restricted anterior leaflet excursion (P = .003) than patients in group 1. Postoperatively, tethering of the posterior leaflet increased (P < .001) and was predominant in both groups, whereas tethering of the anterior leaflet was reduced at discharge (P = .01 and P = .03, respectively), remaining constant afterward. Multivariable analysis showed an anterior tethering angle of 39.5 degrees or greater (P < .001), an anterior/posterior tethering angle ratio of 0.76 or greater (P < .001), an anterior leaflet excursion angle of 35 degrees or less (P = .001), and a coaptation height of 11 mm or greater (P = .04) to be predictors of recurrent mitral regurgitation.
Preoperative symmetric tethering with anterior mitral leaflet predominance was strongly associated with recurrence of mitral regurgitation. Measures of leaflet tethering resulted in fundamental findings to identify ischemic patients who can really benefit from restrictive annuloplasty. Further larger studies are necessary to confirm our results.
The Journal of thoracic and cardiovascular surgery 08/2008; 136(2):507-18. · 3.41 Impact Factor
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ABSTRACT: The aim of the study was to evaluate the effects of phosphorylcholine coating (PC) on intra-operative extracorporeal circulation (ECC) management and perioperative outcome. One hundred and twenty consecutive cardiac surgery patients were enrolled for the study. Patients were randomly assigned to ECC with PC circuits (60 patients) or to corresponding non-coated circuits (60 patients). Trans-oxygenator pressure drop, blood flows, flow resistances and ECC parameters were recorded at surgery before ECC institution and every 10 min thereafter until ECC discontinuation. Postoperative variables (hematological parameters, drainage blood loss, mechanical ventilation time, incidence of atrial fibrillation, use of blood products) were also assessed and compared between groups. No differences were found between the two groups in terms of demographics, operative, and hematological profiles. PC showed, at equal pump flows, to significantly (P<0.01) attenuate pressure drop across oxygenators and to reduce oxygenator inlet pressures during ECC. Postoperatively, PC showed to remarkably reduce platelet consumption. Coating showed also to reduce postoperative blood loss, although the difference did not reach statistical significance. No differences between the two groups were found in terms of additional perioperative effects. The use of PC in low-risk elective cardiac surgery patients enhances ECC management, by means of a less restrictive trans-oxygenator blood flow.
Interactive cardiovascular and thoracic surgery 08/2008; 8(1):7-11.
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Journal of cardiothoracic and vascular anesthesia 05/2008; 23(2):251-2. · 1.06 Impact Factor
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ABSTRACT: No data exist in the English-language literature about patients with Barlow disease associated to Steinert syndrome and little is known about the employment of hypothermic cardiopulmonary bypass (CPB) and hyperkalemic cardioplegia in these patients. We present our experience with six patients affected by myxomatous degeneration associated to Steinert disease undergoing complex mitral valve repair. In all patients we employed mild hypothermic CPB (31 degrees C) and myocardial protection was achieved, in the entire cohort, by the use of blood hyperkalemic cold cardioplegia. The postoperative course was uneventful in all patients and neither shivering nor generalized muscle contraction were observed. Furthermore, all patients have remained well on an outpatient basis. Hypothermic CPB and hyperkalemic cardioplegia can be safely employed in patients with Steinert syndrome requiring complex cardiac surgery. Further large studies are necessary to confirm our findings.
Interactive cardiovascular and thoracic surgery 05/2008; 7(2):222-6.
