Comparison of minimally invasive versus conventional thoracic aortic operations: Early and midterm results in a series of 624 patients

OBJECTIVE

Despite minimally invasive techniques having gained wider application in cardiac surgery, current evidence on minithoracic aortic surgery is still limited. The aim of this study was to compare early and midterm outcomes of patients undergoing operations of the proximal thoracic aorta through ministernotomy (MS) versus full sternotomy (FS).

METHODS

Data from 624 consecutive patients who underwent proximal aortic repair through MS (n = 214, 34.3%) and FS (n = 410, 65.7%) at two aortic centers were analyzed. Treatment selection bias was addressed using propensity score matching (MS vs. FS). After matching, two well-balanced groups of 202 patients each were created.

RESULTS

Median cardiopulmonary bypass and cross-clamp times were 88 and 68 min, respectively, with no difference between groups. Overall, 30-day mortality was 1% (n = 2) in MS and 0.5% (n = 1) in FS (p = .6). No difference was found in the rates of stroke (MS n = 5, 2.5%; FS n = 5, 2.5%), dialysis (MS n = 1, 0.5%; FS n = 4, 2%), bleeding (MS n = 7, 3.5%; FS n = 7, 3.5%), and blood transfusions (MS n = 67, 33.3%; FS n = 57, 28.4%). Patients receiving MS showed a lower incidence of respiratory insufficiency compared with FS (0% vs. 2.5%, p = .04). Intensive care unit and hospital stays were similar between groups. Two-year survival rate was 97.2% in MS and 96.5% in FS (p = .9).

CONCLUSIONS

Mini proximal aortic operations can be performed successfully without compromising the proven efficacy and safety of conventional access. In selected patients, MS was associated with very low mortality and morbidity rates. Additionally, MS demonstrated superior clinical outcomes as regards respiratory adverse events, when compared with FS.

A threatening meteor for cardiac surgeons: anomalous Left Main Coronary Origin in Type-A Aortic Dissection

We present the case of a type A aortic dissection originating from the right coronary ostium and an intraoperative diagnosis of the entire coronary artery system originating from a single right-sided coronary ostium.

C13 COMPARISON OF MINIMALLY INVASIVE VERSUS CONVENTIONAL THORACIC AORTIC OPERATIONS: EARLY AND MID–TERM RESULTS IN A SERIES OF 624 PATIENTS

Objective

Despite minimally invasive techniques have gained wider clinical application in cardiac surgery, current evidence on mini thoracic aortic surgery is still limited. The aim of this study was to compare early and mid–term outcomes of patients undergoing proximal thoracic aortic interventions through mini–sternotomy (MS) versus full sternotomy (FS).

Methods

Data from 624 consecutive patients undergoing proximal aortic operations through MS (n = 214, 34.3%) and FS (n = 410, 65.7%) at 2 aortic centers, were analysed. Patients with prior cardiac operations and active endocarditis, and those who underwent emergency operation and combined procedures were excluded. Treatment selection bias was addressed by the use of propensity score matching (MS vs FS). After matching, 2 well–balanced groups of 202 patients each were created. Surgical procedures involved aortic valve replacement/repair and ascending aorta replacement in 190 patients (47%), aortic root replacement in 110 patients (27.2%) and isolated ascending aorta replacement in 104 patients (25.7%).

Results

The median cardiopulmonary bypass and cross clamp times were 88 and 68 minutes, respectively, with no difference between groups. Overall 30–day mortality was 0.7%, being 1% (n = 2) in patients underwent MS and 0.5% (n = 1) in those underwent FS (p = 0.6). No difference was found in the rates of stroke (MS n = 5, 2.5%; FS n = 5, 2.5%), dialysis (MS n = 1, 0.5%; FS n = 4,2%), bleeding (MS n = 7, 3.5%; FS n = 7, 3.5%), and blood transfusions (MS n = 67, 33.3%; FS n = 57, 28.4%) (Table 1). Patients receiving MS were associated with a lower incidence of respiratory insufficiency compared with those receiving FS (0% vs. 2.5%, p = 0.03). The median intensive care unit length of stay was 24 and 25 hours in MS and FS group, respectively (p = 0.3), and in–hospital stay was 7 days both in MS and FS group (p = 0.9). Three–year survival rate was 96.6% in patients receiving MS and 95.7% in those receiving FS (p = 0.9).

Conclusions

Our findings showed that mini proximal aortic operations can be performed successfully without compromising the proven efficacy and safety of conventional access. In selected patients, MS was associated with very low mortality and morbidity rates. Additionally, MS demonstrated superior clinical outcomes as regards respiratory adverse events, when compared with FS.

Active infective endocarditis: Clinical characteristics and factors related to hospital mortality

BACKGROUND

Little information exists on the clinical characteristics and factors related to hospital mortality in patients with active infective endocarditis referred for surgery.

METHODS

Between January 1, 2003 and December 31, 2006, 86 patients (56 males, 30 females, mean age 59.2 years) with active infective endocarditis were referred to our Department (2.8% of overall hospitalizations). The relation of several clinical, laboratory and echocardiographic findings at admission with hospital mortality was evaluated.

RESULTS

A native valve (NVE) was involved in 50/86; the other 30 had a prosthetic valve endocarditis (PVE). Six had pacemaker endocarditis. The aortic valve was involved more frequently than the mitral valve, both in NVE and PVE. The tricuspid valve was involved in four drug addicts; 51% of patients were in NYHA class III-IV. Staphylococci and streptococci were isolated in 69% of patients (39% vs 30%). Blood cultures were negative in 24%. Overall hospital mortality has been 11.6%. Two patients died before surgery, eight in the perioperative period. Hospital mortality was closely related to age, clinical and laboratory evidence of advanced septic condition (temperature > 38°C, leukocytosis and creatinine > 2.0 mg/dL) and hemodynamic impairment.

CONCLUSIONS

Active infective endocarditis is a significant cause of referral to heart surgery departments and hospital mortality is still > 10%. Clinical and laboratory parameters easily available at admission suggest that severe sepsis and/or hemodynamic impairment may be helpful in predicting the clinical outcome in this group of high risk patients.

Left ventricular outflow tract false aneurysm late after aortic valve replacement

We describe an unusual case of left ventricular outflow tract (LVOT) pseudoaneurysm late after aortic valve replacement. A 77-year-old man, who had undergone aortic valve replacement with mechanical prosthesis 7 years ago, presented, asymptomatic, with a transesophageal echocardiography (TTE) diagnosis of a large cavitary mass arising behind the aortic wall. The orifice of the pseudoaneurysm was successfully surgically closed and the aortic root reconstructed with cryopreserved homograft.

An unusual case of cardiac tamponade

A case of a 67-year-old woman with cardiac tamponade caused by toothpick ingestion is presented. At clinical presentation, it mimicked postinfarction ventricular free wall rupture and the diagnosis was not made until the operation. Ingested toothpicks have often been reported as a cause of intestinal injuries, but in this rare case the toothpick migrated into the pericardium and caused laceration of the right coronary artery.

Intramural hematoma of the aorta: diagnosis and treatment

OBJECTIVE

Increasing use of modern high-resolution imaging techniques yields to describe very early stages of aortic pathology which, if left untreated, may lead to overt aortic dissection. One typical example is aortic intramural hematoma (IMH) with a limited number of cases described in the literature and uncertainties still existing about the most appropriate treatment. Purpose of our study is to report our experience in the evaluation and treatment of IMHs.

METHODS

From 1991 to 1999 175 patients were conveyed to our centre for aortic dissection; in nine of them diagnosis of acute IMH was performed.

RESULTS

Diagnosis was obtained by means of conventional CT scan of the chest. All the patients underwent surgery, one patient died (11%). At the follow-up (mean 31 months) eight patients were alive and well and did not require any other cardiac surgery.

CONCLUSIONS

The possibility to progress to overt aortic dissection may explain the need to an early diagnosis in the treatment of acute IMHs. Immediate surgical treatment is, in our experience, the preferred therapeutic option.

Effect of 5-HT4 receptor stimulation on the pacemaker current I(f) in human isolated atrial myocytes

OBJECTIVE

5-HT4 receptors are present in human atrial cells and their stimulation has been implicated in the genesis of atrial arrhythmias including atrial fibrillation. An I(f)-like current has been recorded in human atrial myocytes, where it is modulated by beta-adrenergic stimulation. In the present study, we investigated the effect of serotonin (5-hydroxytryptamine, 5-HT) on I(f) electrophysiological properties, in order to get an insight into the possible contribution of I(f) to the arrhythmogenic action of 5-HT in human atria.

METHODS

Human atrial myocytes were isolated by enzymatic digestion from samples of atrial appendage of patients undergoing coeffective cardiac surgery. Patch-clamped cells were superfused with a modified Tyrode's solution in order to amplify I(f) and reduce overlapping currents.

RESULTS AND CONCLUSIONS

A time-dependent, cesium-sensitive increasing inward current, that we had previously described having the electrophysiological properties of the pacemaker current I(f), was elicited by negative steps (-60 to -130 mV) from a holding potential of -40 mV. Boltzmann fit of control activation curves gave a midpoint (V1/2) of -88.9 +/- 2.6 mV (n = 14). 5-HT (1 microM) consistently caused a positive shift of V1/2 of 11.0 +/- 2.0 mV (n = 8, p < 0.001) of the activation curve toward less negative potentials, thus increasing the amount of current activated by clamp steps near the physiological maximum diastolic potential of these cells. The effect was dose-dependent, the EC50 being 0.14 microM. Maximum current amplitude was not changed by 5-HT. 5-HT did not increase I(f) amplitude when the current was maximally activated by cAMP perfused into the cell. The selective 5-HT4 antagonists, DAU 6285 (10 microM) and GR 125487 (1 microM), completely prevented the effect of 5-HT on I(f). The shift of V1/2 caused by 1 microM 5-HT in the presence of DAU 6285 or GR 125487 was 0.3 +/- 1 mV (n = 6) and 1.0 +/- 0.6 mV (n = 5), respectively (p < 0.01 versus 5-HT alone). The effect of 5-HT4 receptor blockade was specific, since neither DAU 6285 nor GR 125487 prevented the effect of 1 microM isoprenaline on I(f). Thus, 5-HT4 stimulation increases I(f) in human atrial myocytes; this effect may contribute to the arrhythmogenic action of 5-HT in human atrium.

[Mitral valve replacement with the Björk-Shiley monostrut prosthesis: a 4-year clinical experience]

Mitral valve replacement with Björk-Shiley monostrut prostheses was performed in 142 patients, aged 18 to 73 (mean age: 53.8). A group of 101 patients underwent isolated mitral replacement (group A), while both mitral and aortic (in one case tricuspid) valves were replaced in 41 (group B). In 19 of group A patients and in 9 of group B patients a tricuspid annuloplasty was added. Hospital mortality was one case in each group (group A: 1%; group B:2.4%). The cause of death was low output in both cases (i.e. not valve-related). Late mortality occurred in 4 cases (4%) in group A, and in 3 cases (7.3%) in group B (follow-up: 6 to 58 months; mean follow-up: 24 months). Actuarial survival was 93.79% in group A and 89.94% in group B one year after surgery; it was 93.79% in group A and 81.76% in group B after 3 years. All deaths from undetermined causes, as well as any new unexplained neurological deficit or peripheral emboli, were considered to be valve-related: 84.18% of group A patients, as well as 67.90% of group B, were event free after 3 year (actuarial). most valve-related events occurred in the first year after surgery. We observed thromboembolism in 3 cases for each group: one patient in group B had pannus formation over the prosthetic annulus; prosthetic valve endocarditis in 1 case of group A and 2 of group B; significant hemorrhage due to anticoagulant therapy in 1 (group A); one patient in each group died suddenly, 4 and 7 months postoperatively. One group A patient and 2 group B patients were reoperated: a new valve prosthesis was implanted in two patients. Mean transvalvular gradient, as determined by echocardiography, was 3.8 +/- 2.3 (SD) mmHg in the case of isolated mitral replacement. In conclusion, we believe these results are highly encouraging, especially in the isolated mitral replacement group. Björk-Shiley monostrut prosthesis has been demonstrated to be a reliable valve substitute, with an acceptable incidence of complications. No Björk-Shiley monostrut prosthesis structural deterioration was seen, and its hemodynamic behaviour may be considered satisfactory.

[Compliance problems in the oral anticoagulant treatment of patients wearing heart valve prostheses]

The need for and the efficacy of oral anticoagulation in patients who have undergone prosthetic valve replacement is widely demonstrated. The aim of this study is to assess how dicumarolic treatment is understood and actually accomplished by patients. A 30-question form was sent to 292 patients discharged following valve replacement, 5 to 45 months (mean: 19 months) after surgery. All of the 220 patients who submitted their answers, were effectively on oral anticoagulants. More than 95% of them knew exactly the suggested optimal prothrombin activity range. About one fifth of the patients has laboratory tests performed weekly, and nearly one half does so every 10-15 days. One fourth of the patients does not consult a physician for decision making about drug dosage. Difficulties in maintaining anticoagulation in the desired range, occurring at least once every month, are reported by 18.6% of patients. Haemorrhage was never experienced by 83.18%; in one single case thromboembolism was apparent. A few patients (2.27%) think of oral anticoagulation as a "difficult" treatment. We conclude that complete information is needed, about the aim, the modality, and the potential hazard of oral anticoagulation, so that a better understanding of the treatment and an improved cooperation between physicians and patients can result in benefits, in terms of the safety and efficacy of life-long antithrombotic therapy.

Gene interaction in the phenotypic expression of mental diseases

A genealogical analysis is carried out on the pedigrees of 10 twin pairs with two or more psychoses. The probands' symptoms reveal some peculiar aspects, i.e., an atypical phenomenology possibly due to the interference of more pathological genes. Schizophrenia, depression, epilepsy, and obsessive neurosis, are found in the pedigrees in different combinations. The study of these pedigrees would lead to the conclusion that interaction of more than one psychosis gives rise to atypical forms as a result of an attempt to establish a state of balance between opposing dynamic actions, as in reversible chemical reactions. Probands' symptoms are less severe and with an often more favourable prognosis. Epilepsy tends to become independent and the major psychoses seem to be epistatic on it. As for obsessive-compulsive neurosis, probands may progress into schizophrenia or depression if one of these psychoses is present in the pedigree, or may represent the neurotic form of the major disease.

The ergon-chronon system in schizophrenia. A twin study

Ten (eight MM and two FF) MZ twin pairs, with one or both schizophrenic members, have been examined. The disease was concordant in four pairs, discordant in one pair, and partly concordant in five pairs.

The time of onset was simultaneous in five pairs, but showed differences of three years in two pairs, and of one-two years in two more pairs. Concordance in the time of onset was not related to severity of the disease.