[Comparison between propofol and isoflurane in patients undergoing aorto-coronary bypass. Effect on systemic and coronary circulation]

The Authors report their experience with the use of two different anaesthetic techniques (propofol-fentanil versus isoflurane-fentanyl) for induction and maintenance of anaesthesia in patients undergoing coronary artery surgery. Haemodynamic data (regarding systemic and coronary circulation) showed an almost similar pattern of change after induction, intubation, skin incision and sterotomy, except for a greater decrease of systemic vascular resistances after induction in patients who received propofol. Cardiac output decreased more in the isoflurane group while changes in coronary sinus flow were equal in the two groups.

[Emergency surgery of acute coronary insufficiency]

In our centre, during the last five years, emergency operations (within 6 hours) and urgent operations (within 72 hours) have represented 1/4 of all coronary surgery. 295 patients (pts) have been operated on since 1972: of these, 279 with simple revascularization, 5 with combined major surgery, and 11 as a consequence of mechanical complications of acute myocardial infarction. These last were all in cardiogenic shock: the overall 30-day mortality rate was 5.4% (3.6% in those pts with simple revascularization, 20% in those with combined major surgery, and 45.4% in pts with cardiogenic shock). In the subgroup with simple revascularization, the incidence of non fatal perioperative acute myocardial infarction (AMI) was 4.7% in 253 pts with unstable angina, 52.2% in 23 pts with abrupt closure during coronary angioplasty, and obviously 100% in 3 pts surgically treated during evolving AMI. We were able to identify in the univariate analysis as the only 30-day risk mortality factors: 1) a reduced ejection fraction (< 30%) and 2) the combination with endarterectomy. Other factors (female sex, age > 70, severity of angina, diffuse coronary artery disease and more than 3 by pass grafts) have shown a tendency to increase the mortality rate without statistical significance. No deaths occurred in pts revascularized in emergency situations due to coronary angioplasty complications. In recent years emergency and urgent coronary surgical operations have been increasing, with an increase in pts with higher risk factors. In pts with simple revascularization, 30-day mortality and incidence of myocardial infarction are similar to those of elective surgery. In pts with abrupt closure as a consequence of coronary angioplasty the mortality rate seems very low, while the incidence of infarction remains extremely high. These observations have allowed the development of an integrated protocol of intervention in acute unstable coronary syndromes.

Cor triatriatum. Clinical presentation and operative results

From November 1973 to January 1988, 15 patients with cor triatriatum underwent surgical correction at the Department of Cardiac Surgery, Ospedali Riuniti, Bergamo, Italy. Their ages ranged from 15 days to 48 years. Eight patients (53%) were younger than age 1 year. Evidence of congestive heart failure was present in five infants, whereas three infants, three children, and two adults initially had signs of pulmonary venous obstruction, and two children had a heart murmur only. Five patients had cor triatriatum alone; in ten cases there also was an atrial septal defect. Associated anomalies in four patients included left superior vena cava, ventricular septal defect and left superior vena cava, partial anomalous pulmonary venous connection, and bilateral partial anomalous pulmonary venous connection. Cor triatriatum was repaired with the aid of cardiopulmonary bypass in all patients. Excision of the membrane was accomplished with a right atrial approach in 13 patients and a left atriotomy in one patient. Both atria were opened in one case. All associated anomalies were simultaneously corrected. Three patients (20%) died early after operation. Among the 12 survivors, no late events have occurred, and all of them are presently in New York Heart Association functional class I. A recent echocardiogram shows absence of residual obstruction or shunt and good development of the left cardiac chambers.

[Pseudoaneurysm of the left ventricle. Description of a clinical case]

The paper describes a case of pseudoaneurysm of the left ventricle following an earlier operation to close a post-infarction interventricular defect. The nosological entity is described paying particular attention to preoperative functional tests and intraoperative anesthesiological procedures. The careful monitoring of refilling pressure and cardiac load represents an essential for the correct infusion of drugs and optimal volemic refilling.

[Role of creatine phosphate in myocardial protection in heart surgery]

The Authors report their experience with the use of Creatine Phosphate (CP) in cardiac surgery. Forty patients undergoing mitral valve replacement are randomly divided into two groups: the former is treated with plain cardioplegia, the latter with CP-enriched cardioplegia at a concentration of 10 mmol/l. A sample of papillary muscle, obtained from the removed valve, is studied by means of spectrophotometric analysis in order to assess the enzyme activities and the intermediate metabolites of the different biochemical pathways of the myocardial cell. Our results suggest a possible interaction of exogenous CP with the cellular metabolism: all the mechanisms involved with the production of energy seem to be shifted towards a better preservation of the available pool of high-energy compounds.

Two-stage correction for tetralogy of Fallot

The policy for surgical treatment of tetralogy of Fallot in younger patients is still controversial. Our overall 14-year experience has been reviewed with regard to the factors influencing mortality for both shunts and corrective procedures. An attempt has been made to evaluate our current expected cumulative mortality for two-stage correction in patients under 2 years of age. From November, 1966 through April, 1983, 440 shunts and 647 total corrections were performed. Patients under 2 years of age, and those with unfavorable anatomy and/or physiology, generally underwent two-stage correction. Early correction was occasionally performed in this age group on patients with very favorable anatomy, or in case of early shunt failure. Retrospective standard statistical analysis was carried out in order to evaluate the influences of the year of operation, age, and operative technique on mortality. The overall early mortality of shunt procedures was 5.7% (11.4% below and 3.5% over 6 months of age). Since 1978 it has dropped to 2.8% (4.2% below and 2.1% over 6 months). The Waterston shunt had a higher (7%) operative mortality than the Blalock (3%) or Goretex (2.6%) shunts. The overall early mortality of total corrections was 15.1% (25.2% below and 13.5% over 2 years of age). It has dropped to 6.9% since 1978 (29.9% below and 6.2% over 2 years).(ABSTRACT TRUNCATED AT 250 WORDS)

Beam pattern (diffraction) correction for ultrasonic attenuation measurement

The measurement of tissue attenuation from pulse-echo data has been widely investigated. This paper examines correction of the measurements for the effect of the transducer beam. Computer and experimental studies are performed on a number of reflectors including smooth and rough planes, ideal point scatterers, T.M. material and liver and spleen tissue. It is shown that the corrections obtained from T.M. phantom material differ from those obtained using in vivo tissue as the reflector and corrections for liver and spleen differ markedly. Comment is made on the possibility of using "beam correction" itself as a tissue characterization parameter.

Waterston anastomosis for initial palliation of tetralogy of Fallot

Two hundred twenty-seven patients (median age 5.4 months) in whom a Waterston anastomosis was done for initial palliation of tetralogy of Fallot between 1966 and 1979 were studied. Twelve patients died in the hospital (5.3%; 70% confidence limits, 3.8% to 7.3%). Young age, low weight, and poor clinical condition did not appear to be incremental risk factors, whereas a too large or a too small shunt was largely responsible for the hospital mortality and morbidity. Follow-up information was available in all the 215 patients discharged from the hospital. At the last follow-up visit, before any further surgical procedure, 74% of the patients were clinically in good condition. By actuarial methods, 97.7% of hospital survivors were alive and 95.8% were event-free at and beyond 3 years postoperatively. Eighty-six patients have been catheterized in preparation for secondary repair (mean interval between Waterston shunt and catheterization, 2.9 +/- 1.38 years). One patient developed pulmonary vascular disease, four acquired pulmonary atresia, and 14 had a severe kinking of the right pulmonary artery at the site of the anastomosis.

Surgical repair of persistent truncus arteriosus in infancy

Fourteen patients younger than two years of age with persistent truncus arteriosus underwent primary repair. Twelve of them were less than 1 year and 4 less than 3 months of age. Intractable heart failure was the indication for surgery in all patients but one who had increased pulmonary vascular resistance. There were 5 hospital and 2 late deaths. Six out of the 7 survivors (median follow-up: 29 months) were symptom-free. The remaining infant who preoperatively had significant truncal valve regurgitation was doing fairly well 2 1/2 years after repair. Our experience suggests that, although the mortality remains high, primary repair for infants with persistent truncus arteriosus is feasible and offers better overall results than does pulmonary artery banding followed by later intracardiac repair. We advise primary repair for all infants with intractable heart failure or increasing pulmonary vascular resistance with or without truncal valve regurgitation. Elective repair is recommended before the age of 2 years to minimize the risk of pulmonary vascular disease.

Repair of tetralogy of Fallot after Waterston anastomosis

Sixty-three corrective operations have been performed in patients with Tetralogy of Fallot and a previously constructed Waterston shunt. The patients were from 1.4 to 8 years of age (median 4.3 years), and the mean interval between the Waterston shunt and the repair was 39.3 +/- 16.05 months. Three patients developed pulmonary atresia and six required a second anastomosis prior to intracardiac repair. Kinking and stenosis of the right pulmonary artery at the site of the Waterston anastomosis occurred in 12 (19 percent; 70 percent confidence limits 14 to 26 percent) patients who required patch enlargement of the right pulmonary artery at repair. Seven (11 percent; 70 percent confidence limits 7 to 17 percent) patients died in the hospital and three (5 percent; 70 percent confidence limits 2 to 11 percent) during the period of late follow-up. None of the early or late deaths was specifically related to the presence of the previously performed Waterston anastomosis.

Transposition of the great arteries. Successful Senning's operation in 35 consecutive patients

Mustard's operation for TGA (transposition of the great arteries) has been obstructive complications. In order to try to avoid these complications, we used Senning's operation for TGA. Our experience in 35 consecutive cases is reported. There were no operative or late deaths. Four patients had a PDA; three had a significant VSD with subpulmonary stenosis in two. Previous atrial septectomy and persistent LSVC did not represent contraindications to this procedure. The postoperative course has been smooth and uneventful in all patients. Follow-up periods of one to twenty months demonstrated sinus rhythm in all patients and there were no significant gradients between the venae cavae and the new systemic atrium in 12 reinvestigated patients. On the basis of these results, Senning's operation is recommended as a valid alternative to Mustard's operation.