[Primary hemangiosarcoma of the heart]

Primary cardiac sarcomas are malignant neoplasmas of mesenchymal cells. Angiosarcomas, unlike all other primary cardiac sarcomas, are typically found in the right atrium. We present the case of a 52-year-old patient in whom through echocardiography, computed tomography and angiography the precise diagnosis and extent of the tumor was revealed. Surgical treatment consisted of excision of the tumor with right atrium patch-plasty under cardiopulmonary bypass. Despite the successful operation the patient died 6 months later because of metastasis. Very early and precise diagnosis is essential to improve patient survival and prevent the development of metastases.

Aortic valve debridement by ultrasonic surgical aspirator in degenerative, aortic valve stenosis: follow-up with Doppler echocardiography

OBJECTIVE

Recently there has been an emphasis on reconstructing diseases native valves as an alternative to prosthetic valve replacement. Whereas; the surgical repair of aortic valve stenosis has been always problematic. This study was performed to estimate the clinical results after aortic valve debridement using ultrasonic energy.

METHODS

Between 1990-1994 26 patients underwent ultrasonic aortic valve decalcification. There were 15 females and 11 males, the age was in average 74 years. As a concomitant diagnosis 88% patients (23) had mostly mild, aortic valve insufficiency, 16 (61%) had coronary artery disease and 11 (42%) had mild mitral valve incompetence. All of the patients were operated with cardiopulmonary bypass using moderate hypothermia, cardioplegical arrest and topical cooling for myocardial protection. The calcifications were removed tangentially using Cavitron Ultrasonic Surgical Aspirator. (CUSA), CAVITRON, USA. Leaflet perforation and/or unsatisfactory valve closure have been indications for aortic valve replacement.

RESULTS

Two operative death (8%) have occurred and six patients have died in the further course (follow-up mean 17 months ranging from 4 to 61 months). Postoperative Doppler-Echocardiography results taken directly after surgery and then again 17 months later (n = 18) showed a decrease of peak and mean gradients across the aortic valve three and two times respectively (p < 0.001). 17 months after debridement we observed a mild rise in both gradients (by peak gradient p < 0.05). Directly postoperative, the aortic valve area increased doubly and decreased 17 months later slight, but it was still statistically significant in comparison with our preoperative data (p < 0.001). Follow-up echocardiography demonstrated late onset of moderate aortic valve insufficiency in 6 patients. The classification of New York Heart Association was improved in 13 (72%) survivors after 17 months.

CONCLUSIONS

Ultrasonic debridement of aortic valve stenosis allows precise and energy-controlled removal of calcium, increased doubly the valve area and decreased of peak and mean gradients statistically significant. The advantages of preserving the native aortic valve in elderly patients are relative good arguments; although a longer follow-up is necessary to establish this procedure.

Composite graft (Medtronic-Hall) replacement of the ascending aorta and aortic valve in aortic aneurysms: what is adequate follow-up?

Between 1987 and 1994, 39 patients underwent 41 replacements (2 reoperations) of the aortic valve and ascending aorta by composite grafts with mechanical valves. One patient had annuloaortic ectasia, one had a sinus of valsalva aneurysm, 13 patients had a Debakey type I acute dissection, 10 had a Debakey type II acute dissection including two Marfan patients, and 14 had atherosclerotic aneurysms. 6 patients (15%) died within a postoperative period of 30 days. The mean follow-up time was 40 months (1-82 months). Twenty-six patients were restudied by clinical examinations and computed tomography of the chest (CT). Two patients required emergency reoperation due to disruption of the proximal aortic anastomosis and right coronary anastomosis. Both patients had been diagnosed to have Marfan disease. Anastomotic dehiscence of composite grafts has a potentially high risk of lethal complications. In follow-up examination computed tomography was performed as a simple and accurate method to detect complications such as pseudoaneurysms, but up to now did not give the indications for reoperation. We suggest that complications may occur not only in the early postoperative period so that regular CT-scan control studies (every 6 to 12 months) should be performed in all patients who undergo composite graft replacement.

Efficacy of aprotinin in different doses and autologous blood transfusions in cardiac surgery

A study was undertaken to compare the two doses of aprotinin and the amount of autologous blood transfused in order to determine the optimal dose of this inhibitor for use in cardiac surgery. A total of 120 patients undergoing elective cardiac surgery from November 1990 to April 1992 took part in this randomized double-blind study. Two groups of 60 patients were treated. Patients in the high-dose group were given the dose of aprotinin recommended by the Hammersmith group (6 million kallikrein inactivator units), the other 60 (the low-dose group) received half the dose. Blood loss from thoracic drains in the postoperative period showed a statistically significant difference between the two groups between 6 and 12 h (a mean loss of 69 ml in the high-dose group versus 109.5 ml in the low dose, P = 0.003). The overall postoperative drainage losses were very similar (537.2 ml in the high-dose group versus 610.9 ml in the low dose). The blood and clotting markers did not differentiate between the high- and low-dose patients. In combination with autologous blood transfusions, a low dose of aprotinin appears as efficient in reducing postoperative blood loss as the high-dose regimen.