Transmyocardial laser revascularization. Personal experience

BACKGROUND

Indirect revascularization is a therapeutic approach in case of severe angina not suitable for percutaneous or surgical revascularization. Transmyocardial revascularization (TMR) is one of the techniques used for indirect revascularization and it allows to create transmyocardial channels by a laser energy bundle delivered on left ventricular epicardial surface. Benefits of the procedure are related mainly to the angiogenesis caused by inflammation and secondly to the destruction of the nervous fibers of the heart.

PATIENTS AND METHOD

From September 1996 up to July 1997, 14 patients (9 males - 66.7%, mean age 64.8±7.9 years) underwent TMR. All patients referred angina at rest; Canadian Angina Class was IV in 7 patients (58.3%), III in 5 (41.7%). Before the enrollment, coronarography was routinely performed to find out the feasibility of Coronary Artery Bypass Graft (CABG): 13 patients (91,6%) had coronary arteries lesions not suitable for direct revascularization; this condition was limited only to postero-lateral area in one patient submitted to combined TMR + CABG procedures.

RESULTS

Mean discharge time was 3,2±1,3 days after surgery. All patients were discharged in good clinical conditions. Perfusion thallium scintigraphy was performed in 7 patients at a mean follow-up of 4±2 months, showing in all but one an improvement of perfusion defects. Moreover an exercise treadmill improvement was observed in the same patients and all of them are in good clinical conditions, with significantly reduced use of active drugs. CONCLUSION; Our experience confirms that TMR is a safe and feasible procedure and it offers a therapeutic solution in case of untreatable angina. Moreover, it could be a hybrid approach for patients undergoing CABGs in case of absence of vessels suitable for surgical approach in limited areas of the heart.

A simple method to correct aortic tube graft kinking without cardiopulmonary by-pass and aortic clamping

A method for correcting the tube kinking after ascending aortic replacement for acute dissection is described. Its main advantage is the no need for cardiopulmonary by-pass (CPB) and aortic clamping to solve the problem.

Bovine pericardial bioprosthesis in mitral position. A ten-year follow-up

BACKGROUND

The pericardial bovine prosthesis Pericarbon should offer some advantages in comparison with the former generations, because its development is focused on solving previous problems and resulted in the variation of the pericardial fixation method, of valve structure and of stent coating. This hypothesis was evaluated through a retrospective follow-up.

METHODS

Between 1985 and 1989, 78 Pericarbon prostheses O 29 were implanted in mitral position by the same surgeon. All patients received warfarin for the first three months to maintain an International Normalized Ratio between 2.5 and 3.5; after which they received antiaggregant therapy indefinitely. With an average follow-up period of 7.34 years for a total of 573 patient-years, we evaluated perioperative and late mortality, late morbidity (thromboembolic and haemorrhagic events, reoperations, primary tissue failures, endocarditic events) and patient clinical conditions.

RESULTS

Perioperative mortality was 1.28% (1/78), late mortality was 11.6% (9/77) with 5 valve-related deaths. 5-year survival was 93% and 10-year survival 97%. Fifteen patients required reoperation for prosthetic replacement, fourteen for primary tissue failure. There were ten minor thromboembolic events, one major event, one haemorrhage and one prosthetic endocarditis (the last two with patient exitus). After 10 years (75% of patients were in New York Heart Association class I-II.

CONCLUSIONS

Besides the known better haemodynamic performance, Pericarbon bioprosthesis seems to present a survival and redofreedom curve comparable to the best porcine prosthesis, with less incidence of endocarditis, thromboembolic events and prosthesis leakage.

Patent ductus arteriosus. Follow-up of 677 operated cases 40 years later

BACKGROUND

This review is about the patency of ductus arteriosus (PDA), with particular care concerning diagnosis, surgical techniques, survival and postoperative pregnancy in operated females.

METHODS

a) Sperimental study: the research has been conducted retrospectively and the follow-up is 40 years. b)

ENVIRONMENT

all the patients were operated on in the Division of Cardiac Surgery, University of Turin (public structure) and in the Italian Institution of Cardiac Surgery (private structure). c)

PATIENTS

from 1958 to 1987, 677 patients were operated on: mean age was 11.5 +/- 8.7 years. A complete follow-up was made on 487 patients (72%). d) Technique of operation: left lateral thoracotomy was often performed; in younger children, however, the tying of PDA was frequently made within the pericardium by left anterior thoracotomy in the third intercostal space. In uncomplicated situations, PDA was tied more frequently than divided, by two purse string stitches and one or two transfixed ligatures. e)

SURVEY

overall early and late mortality, the clinical conditions of all patients, pregnancies and preor postoperative miscarriages of operated women were examined.

RESULTS

From 1958 to 1967 overall early mortality was 5%; during the following years, there was no hospital mortality. The recurrence of PDA occurred only in 4 patients. 72% of the operated females became pregnant.

CONCLUSION

Life expectancy is normal after surgical closure of an uncomplicated PDA in infancy or in childhood but premature death may not always be avoided operating on adults with long-standing chronic congestive heart failure. At least, postoperative pregnancy is not a risk factor for the mother and PDA seems not to be correlated to foetal transmission.

Bjork-Shiley convexo-concave valve: is a prophylactic re-replacement justified?

BACKGROUND

The Bjork-Shiley convexo-concave (BS-CC) heart valves represent the improved model of the standard valve first introduced with a different design of the disc valve to ameliorate hemodynamic performances and reduce thromboembolic complications. About 86,000 BS-CC were implanted during 1979-1986 and of them a small number developed an intrinsic dysfunction resulting in sudden death.

METHODS

From 1979 to 1986 we implanted in 117 patients (48 males, 69 females, mean age 46.35+/-12.47, range 8-65 years) 125 BS-CC. In 38.5% (45/117) of the cases heart valve replacement represented the second cardiac procedure after a previous closed heart digital commissurotomy. The mean size of the implanted prosthesis was 25.6+/-2.8 for aortic valve and 29.5+/-1.2 for mitral valve.

RESULTS

Hospital mortality was 4.27% (5/117) and survival rate at 10 years is 71.4% and at 17 years 54.7% (Kaplan-Meier). At follow-up causes of death proved valve related in most of the patients but with no evidence of valve fracture. We had 1 case of sudden death in patients at high risk (largest size, aortic position) and 30 cases of death by unknown causes but they did not have an autopsy to confirm the cause of death.

CONCLUSIONS

We conclude that in our population with BS-CC at the moment there is no indication for prophylactic replacement because of the higher risks of a reoperation (third or fourth in the 35.4% of our patients) than a strut fracture. Nevertheless we believe an autopsy mandatory in all these patients at risk, when sudden death occurs.

Left atrial approach to big myxoma with angiographically visible neovascularity. Report of one case

In this article, we report a 65-year-old man with a large atrial myxoma arising from the posterior wall and from the base of the right inferior pulmonary vein. The big neoplastic mass showed a large implant site. A rare atrial myxoma neovascularity arising from the atrial circumflex artery was very clearly visualized by selective coronary arteriography. The surgical approach used to resect this tumor was an isolated left atriotomy that provided excellent exposure and safe excision.

Surgical treatment of massive pulmonary embolism. A case report

Pulmonary embolism is a serious complication following trauma and bed rest and it represents a challenge in the prompt diagnosis and medical or surgical therapy. We present a surgically treated patient with a massive pulmonary embolism (more than 50% of the vascular pulmonary bed) which occurred after an inferior leg trauma which required a prolonged bed immobilization. We believe surgical intervention is the treatment of choice in patients with massive pulmonary embolism who do not respond to fibrinolytic therapy. Moreover prompt surgical embolectomy is mandatory to have more chances to save the patient's life.

The seagull wing self retaining prosthesis in the surgical treatment of pectus excavatum

BACKGROUND

Between June 1958 and June 1996 we operated many patients affected by pectus excavatum with an original surgical technique. In this study we evaluated the durability of the results.

METHODS

EXPERIMENTAL DESIGN

Retrospective study with a mean follow-up time of 15.8 years/pt, and 60% complete.

SETTING

private and institutional practice.

PATIENTS OR PARTICIPANTS

357 patients (253 males and 104 females, mean age = 18.2+/-5.1 years) affected by pectus excavatum. The grade of PE (Chin classification) was I in 76 patients, II in 165 and III in the remaining 116. Most of the patients required operation for aesthetic reasons only (339 patients; 95%).

INTERVENTION

the surgical technique consisted of a double transversal sternotomy at the level of the lowest and highest part of the depression associated with a longitudinal sternotomy. A wedge resection of the ribs was then performed and the sternum was fixed using an original stainless steel strut prosthesis moulded into a seagull wing. The strut was removed 12 months postimplantation.

RESULTS

There were no operative deaths. Four patients (1.2%) had sternal wound infection, which was successfully treated. From the aesthetic point of view, the postoperative results were excellent in 262 patients (73.4%), good in 82 (22.9%) and poor in 13 (3.6%). All subjective symptoms, when present, disappeared after surgery.

CONCLUSIONS

The seagull wing prosthesis appears to be safe, easy to implant and to remove, and comfortable for the patient. This technique has shown good long-term results independently of type of deformity and patient age.

Twelve-year follow up with the Sorin Pericarbon bioprosthesis in the mitral position

BACKGROUND AND AIMS OF THE STUDY

The aim of this study was to evaluate the long-term follow up of the Pericarbon pericardial bioprosthesis implanted in the mitral position.

METHODS

Between January 1985 and January 1991, 78 patients (26 males, 52 females; mean age 56.9 +/- 7.8 years) underwent isolated mitral valve replacement with a Pericarbon valve. All bioprostheses were size 29 mm and implanted by the same surgeon.

RESULTS

Total follow up was 663.2 pt-years and it was 97% complete. Early mortality was 1.3% (1/78); two minor cerebral embolisms were observed as early complications. At 12 years the overall survival rate was 85.0 +/- and valve-related survival 93.1 +/- 3.0%; freedom from embolic events was 83.0 +/- 4.5% and from endocarditis 98.7 +/- 1.3%. Freedom from primary tissue failure was 56.8 +/- 6.6%; it was 86.3 +/- 7.5% in patients aged > 60 years and 36.8 +/- 8.2% in younger patients. There were 27 reoperations, 26 for primary tissue failure, one for endocarditis. Comparison between basal and follow up echocardiographic studies showed a significant stenotic deterioration of the bioprosthesis and a negligible incidence of regurgitation. Morphological findings of explanted bioprostheses were characterized by stenotic and diffuse microcalcification, but no tissue tear was observed.

CONCLUSIONS

These results confirm that the Pericarbon bioprosthesis is structurally safe and free from the fatigue problems which afflicted the first and second generation of pericardial valves. As with other tissue valves, the rate of calcification is age-dependent, suggesting preferential use of the Pericarbon prosthesis in elderly people.

[Correlation between malfunction of a bioprosthesis and deformation of a valve stent. Comparison of three different vale models]

BACKGROUND

Stent deformation seems to be effective in the long term performances of bioprostheses.

METHODS

The Inward Banding Angle (IBA) of three different models of bioprostheses explanted during the period 1991-1992 at our Division of Cardiac Surgery in 45 different patients (26 males; 9 females; mean age 59.71 +/- 10.74, range 26-75) has been measured. Explanted valves were as follow: Hancock, (H = 13); Carpentier-Edwards (C = 14) e Xenomedica (X = 18). Primary tissue failure was the most common cause of re-operation (n = 30; 66.7%) but also endocarditis (n = 6; 13.3%) and paraprothetic leak (n = 10; 22.2%). A semi-quantitative score (0-4) was used to assess calcifications (1.51 +/- 1.56); tears (0.41 +/- 0.98); vegetation's (0.51 +/- 0.99) and fibrosis (2.7 +/- 1.27). The mean follow-up was 7.77 +/- 3.79 years (range 1.5 +/- 16 years). The mean IBA evaluated after explantation was 3.34 +/- 2.29 degrees.

RESULTS

Statistical analysis showed a significance in term of IBA in the Hancock group vs Carpentier (P < 0.02); a less duration in the Xenomedica group vs H and C (p < 0.001) and an increased susceptibility to vegetation's and fibrosis in the Xvs C (p < 0.01) and H (p < 0.05) respectively. A suggestive correlation between IBA and time and between IBA and diameter was found but no statistical significance was observed.

CONCLUSIONS

In conclusions, it is suggested that all materials tends to deform during time and a possible explanation of stent deformation can be the different material used in the stent fabrication. Moreover, mechanical stress and compression around the ring can be another mechanism of creep.

Atrial septal defect and pregnancy: a retrospective analysis of obstetrical outcome before and after surgical correction

STUDY OBJECTIVES

To describe the obstetrical outcome and long-term cardiac follow-up of a group of patients who had surgery for atrial septal defect repair before pregnancy and a group who underwent pregnancy before surgical correction.

DESIGN

Retrospective.

SETTING

Public Institution.

PATIENTS

Eighty women (mean age 20.15 +/- 4.5 years) complaining of atrial septal defect, 60 of which had surgical correction before pregnancy and subsequently had 115 pregnancies, and 20 of which underwent pregnancy before the correction of cardiac defect and subsequently had 48 pregnancies.

INTERVENTIONS

Surgical correction of atrial septal defect: 49 by open heart technique (13 with cardiopulmonary bypass, 36 with light hypothermic circulatory arrest), 11 by closed heart techniques.

RESULTS

Patients who underwent pregnancy before surgery had an increased incidence of miscarriage, pre-term delivery and cardiac symptoms during pregnancy. Patients operated before pregnancy required more frequently cesarean section and pharmacological therapy. The frequency of stillbirths, malformations in the offspring and long-term cardiac complications were similar in both groups.

CONCLUSIONS

Surgical correction of atrial septal defect before pregnancy is recommended even in case of apparently well compensated hemodinamic situation for the low rate of surgical complications in spite of the higher incidence of obstetrical problems in case of medical therapy alone.

Ventricular septal rupture after a myocardial infarction: clinical features and long term survival

BACKGROUND

Ventricular septal defect (VSD) represents a serious complication after acute myocardial infarction (AMI) with an incidence of 1-2%. Surgical treatment is often mandatory in the early period after AMI because of the worsening of the hemodynamic and clinical conditions.

METHODS

We reviewed 34 patients complicating AMI who underwent surgical treatment at our Institution from January 1988 to December 1994 (23 males, 11 females, mean age 64.2+/-7.96, range 45-78). The localization of the AMI was anterior in 47.05% but inferior in 52.95% of the patients (p=NS). The mean time between AMI and VSD was 5.24+/-9.31 days. The preoperative NYHA functional class was III-IV in 93% of the patients. QP/QS ratio was 2.7+/-0.65 and the diameter of VSD ranged from 1 to 8 (mean 2.5+/-0.35). In 26 patients (76.4%) an intraortic balloon pump (IABP) was inserted before surgery. Surgical treatment was done after 10+/-17.7 days after VSD appearance through a left ventriculotomy. Ten patients received a concomitant myocardial revascularization.

RESULTS

Overall surgical mortality was significantly higher (p<0.05) in patients operated on in the early period after AMI (1+/-1.4 days) and with VSD complicating an inferior AMI. A complete follow-up was possible in all the survivors with a cumulative FU of 1453 month/patients. Two patients received a redo procedure after 30 and 40 days after the first correction because of a residual shunt. We observed 3 late deaths for re-AMI and one for complications after bronchial pneumonia. The actuarial survival rate is 70% at 1 year, 68% at 2 years and 65% at 7 years. NYHA functional class after operation is 1-11 in 91% of the patients.

CONCLUSIONS

The major determinant of hospital survival in VSD after AMI in our patient population was the anatomical localization and the early timing of the operation. We believe that a prompt diagnosis and immediate cardiac support (IABP or ventricular assist device) is recommended to obtain a hemodynamic stabilization and to achieve the shaping of stronger cicatricial tissue before surgery. Nevertheless surgical repair of VSD is mandatory when clinical and hemodynamic condition becomes unacceptable. The results in the long term assessment are very satisfying.

Williams-Beuren syndrome. Long-term results of surgical treatments in six patients

To settle long-term outcome after surgery for supravalvular aortic stenosis in the Williams-Beuren syndrome, we reviewed the records of 6 patients who had repair of the localized form (n = 5) or diffuse form (n = 1) at our Institution from 1965 to 1971. Four patients were females and 2 males, ages at operation ranged from 9 to 16 years (mean = 13 +/- 2.37 years). In all the patients was present the typical elfin facies with mental retardation and reduced I.Q. Preoperative omeral pressure was different between left and right arm (89 +/- 7/67 +/- 8 vs 105 +/- 8/77 +/- 4). Chest X-ray showed and enlargement of the cardia silhouette in all the patients. Cardiac catheterization, performed in all the patients, allowed diagnosis of supravalvular aortic stenosis and, in one case of subaortic stenosis associated. Intraoperatively a coronary tree enlargement was found in all cases with particular involvement of the right coronary in two patients. The mean diameter of the ascending aorta was 5.67 +/- 1.97 mm but the smallest (3 mm) was in the diffuse group. In group with localized stenosis the aortic root was enlarged with a teardrop patch in Dacron (n = 4) or a simple transverse suture after a longitudinal incision (n = 1). A pantaloon-shaped patch was necessary in the diffuse form case. There were no operative deaths and all the patients were discharged from the hospital after 2 weeks. A clinical follow-up was possible in all the patients (10%) extended from 25 to 30 years (mean = 27.7 +/- 2.19 years); there were no late deaths and at presents time the mean age of the patient is 40 +/- 3 years. All patients were in functional class I or II. There was no significant difference between patients with a teardrop-shaped or pantaloon-shaped patch in terms of late gradient, survival, or aortic insufficiency studied by Echocardiography and color-Doppler. Of six patients two are living with parents or relatives but four are in a farm-college for disable people working and having some responsibility. We conclude that surgery for the correction of supravalvular aortic stenosis in Williams-Beuren syndrome is mandatory and both the procedures with patch techniques provide excellent long-term results of gradients and aortic valve competence. Moreover the patients after the operation can have a normal activity with a satisfactory style and expectation of life.

[Transeptal access to the mitral valve. Long-term results]

Optimal mitral valve repair or replacement requires an excellent exposure. We used a transeptal approach since 1975 at our Institution to obtain adequate exposure of mitral valve in 135 patients (48 males, 87 females, mean age 47.4 +/- 11.8, range 12-68). A mechanical valve (Bjork = 120; Sorin = 15) was implanted in mitral position. Associated procedures were performed in the 66% of the patients and most of them were tricuspid repair. About half of the patients were at the second or third cardiac operation after a previous closed heart mitral commissurotomy 15.15 +/- 5.6 years before. Exposure was excellent in the 95% of the cases. Hospital mortality was 12.6% and significantly major in patients at redo operation. Three patients with a concomitant aortic valve replacement required a definitive pace-marker implantation. A complete follow-up was possible in all patients who survived at operation. Actuarial survival rate at 10 years in 83% and at 20 years is 70%. Freedom from all events valve related at 10 years is 86% and at 20 years is 74%. None of the patients at echocardiographic follow-up revealed complications related to the transeptal approach to the mitral valve. In conclusion we suggest the use of transeptal approach to the mitral valve in case of redo-operations, concomitant tricuspid repair, small left atrium and in case of mitral valve repair because of the good exposure and the less inherent complications.

Heart valve replacement with CarboMedics bileaflet prosthesis: surgical results and clinical evaluation. A medium term follow-up

From March 1990 to July 1991, 110 patients (44 males, 66 females; mean age 54.44 +/- 8.8 years) underwent hearth valve replacement with a CarboMedics bileaflet prosthesis (CarboMedics Inc, Texas, USA). Preoperative pathophysiologic conditions were: aortic stenosis in 32 patients, aortic regurgitation in 22 patients; mitral stenosis in 27 patients and mitral regurgitation in 14 patients. Mitroaortic disease was present in 14 patients but 1 had triple valve disease. NYHA class was III or IV in 91 patients (83%). Operative mortality rate was 0.91% (1 patients). Actuarial survival rate is 95% at 58 months. Actuarial freedom from thromboembolic events in 95% at 58 months. Actuarial freedom from hemorrhage is 100%. Endocarditis befell in 2 patients; actuarial freedom from this complication at 58 months is 95%. Actuarial freedom from reoperation in 99%. We conclude that the low incidence of valve related events and the low mortality supports the use of the bileaflet valve CarboMedics.

Repair of femoral pseudoaneurysm after cardiac catheterization: utility of extraperitoneal iliac control

Femoral artery lesions may occur after cardiac catheterization or percutaneous transluminal coronary angioplasty (PTCA). The incidence of pseudoaneurysm following transfemoral catheterization ranges from 0.21 to 6.25%. Among 3162 cardiac catheterization procedures thirteen (0.41%) patients presented a femoral pseudoaneurysm requiring surgical repair. The Authors reported their technical consideration about the utility of extraperitoneal iliac control during surgical repair of femoral artery pseudoaneurysm due to cardiac catheterization.

A rare complication of mitral valve replacement: sudden cardiac death for immobilization of disc valve by an unraveled suture

Disc immobilization caused by an unraveled suture in a mitral valve prosthesis represents a rare extrinsic complication in heart valve replacement. We report a case of a 54-year-old white male who underwent mitral valve replacement because of a severe mitral regurgitation. A Björk-Shiley tilting disc was implanted with interrupted "U" shaped 3/0 silk sutures. There were no complications and the patient was discharged in the 10th postoperative day. Twenty days after surgery the patient died for acute pulmonary edema. Autopsy revealed an unraveled suture producing interference with the tilting disc as a cause of disc prosthesis immobilization in closed position. The possible explication of this rare complication is the combination between unraveled suture and the pleating held by Teflon sewing ring after restoring heart function. A flaccid heart can produce an overestimation of the annulus size and the valve ring can bring an anomalous interference with the valve mechanism. In conclusion disc immobilization by an unraveled suture is a complication that can occur very rarely but an accurate prevention must be warrant particularly with a tilting disc more than a beleaflet prosthesis.

Correction of pectus excavatum with a self-retaining seagull wing prosthesis. Long-term follow-up

Between June 1958 and December 1991, 315 patients (217 male and 98 female, mean age = 17.8 +/- 5.5 years) affected by pectus excavatum (PE) were surgically treated. Most of the patients required operation for aesthetic reasons only (299 patients; 95 percent). The grade of PE (Chin classification) was I in 72 patients, II in 152, and III in the remaining 91. The surgical technique consisted of a double transversal sternotomy at the level of the lowest and highest part of the depression associated with a longitudinal sternotomy. A wedge resection of the ribs was then performed and the sternum was fixed using a stainless steel strut molded into a seagull wing prosthesis. The strut was removed 12 months postoperatively. There were no operative mortalities. Four patients had sternal wound infection that was successfully treated. The mean follow-up was 15.8 years per patient and was 60 percent complete. From the aesthetic point of view, the postoperative results were excellent in 246 patients (78 percent), good in 57 (18 percent), and poor in 12 (4 percent). All subjective symptoms, when present, disappeared after surgery. The seagull wing prosthesis appears to be safe, easy to implant and to remove, and comfortable for the patient. This technique has shown good long-term results independently of type of deformity and patient age.

[Esthetic suture of the lower limbs after a saphenous vein graft in cardiac surgery. Polydioxanone vs Vicryl]

The vena saphena magna is widely used as a passage during myocardial revascularisation surgery (CABG). The preparation of the vein involves a long incision on the thigh and leg which is routinely closed using a continuous suture thread in Vicryl of the subcutis and continuous intradermal suture of the cutis. The authors retrospectively evaluated the functional and esthetic results of intradermal suture performed using two different types of reabsorbable thread: PDS II and Vicryl. A total of 178 patients underwent CABG surgery at the Heart Surgery Division of Tor Vergata University of Rome during the period January-September 1992. Mean age was 63 year +/- 7 (SD), 140 were males and 38 females. PDS II 3/0 was used for intradermal suture in 88 patients, whereas Vicryl 3/0 was used in 90. There were no significant differences between the two groups with regard to age, sex, number of grafts, associated pathologies or wound length. After 1-9 months (mean 5.6 months) the surgical wound on the saphenectomized limb was evaluated. It was found that compared to Vicryl the use of PDS II presented a higher incidence of keloids (p > 0.05). This was probably due to the greater reaction provoked in the dermis by the monofilament compared to twisted thread. The authors conclude that the use of a reabsorbable twisted thread, such as Vicryl or Vicryl Rapid, is preferable owing to the higher rate of compliance and lower incidence of complications.

Kinking of internal carotid artery: is it a risk factor for cerebro-vascular damage in patients undergoing cardiac surgery?

The incidence of carotid artery kinking is reported from 4% to 25% in different studies. During cardiopulmonary by-pass (CPB) in cardiac surgery the hemodynamic effects related to the kinking could produce hypoperfusion especially if associated with atherosclerotic lesions of the carotid arteries. We report our experience of 653 patients (538 males, 115 females, mean age 58.3 years) studied by coronaroangiography and internal carotid artery duplex scanning during the period January 1991-December 1992. Thirty-seven patients (22 males, 15 females, mean age 64.9 years), revealed anomalies of the internal carotid artery classificated as tortuosity (9 patients; 24.4%), and kinking (28 patients; 75.6%). All but 4 patients underwent cardiac surgery isolated or associated with carotid thrombo-endarterectomy (TEA) with Dacron patch arterioplasty. Three patients died (8.1%), one of them from cerebrovascular accident. He was a patient who had thromboembolism from the ascending aorta but without associated atherosclerotic lesions of carotid arteries. Asymptomatic isolated internal carotid artery kinking does not seem to be a risk factor for neurological complications during CPB. If carotid kinking is symptomatic and associated with atherosclerotic plaque producing internal carotid artery stenosis greater than 75%, we strongly suggest surgical treatment before cardiac operation.

[The long-term results in multiple procedures on the heart valves]

In the period 1972-1988, 209 patients (81 males, 128 females, mean age 42.4 +/- 11.9, range 20-71 years) underwent surgery for multiple valve repair (MVR) at the Italian Institution of Cardiac Surgery. Ninety-five patients had previously undergone mitral commissurotomy (MC). NTHA function class was III-IV in 89% of the patients. The procedures were: aortic valve replacement (AVR) + MC (63 patients; 30.2%), mitral valve replacement (MVR) + tricuspid valvuloplasty (TRVPL) (57 patients; 27.4%), AVR + MVR (50 patients; 24%), AVR + MVR+TRVPL (22 patients; 10.5%), AVR + CM + TRVPL (6 patients; 2.8%), AVR + mitral valvuloplasty (6 patients; 2.8%), AVR-TRVPL (2 patients; 0.9%), AVR + MVR + tricuspid valve replacement (2 patients; 0.9%), AVR + MVR + TRVPL + ventriculoplasty (1 patients; 0.5%). The inserted valves were mostly (147/209) Bjork-Shiley tilting disc type. The mean cardiopulmonary bypass (CPB) time was 119.6 +/- 53.9 and the mean aortic clamp time was 69.2 +/- 31.6. A complete follow-up was possible in 158/209 patients (75%) with a mean observation time of 8.11 +/- 4.92 years (total of 778 patients years). Thromboembolism was defined as the cause of any new focal neurologic deficit. All cases of peripheral embolisation were considered to be valve-related. The valve related early and late complication are as follow: fifteen patients in NYHA class III-IV, died perioperatively (7%). We had a thrombotic encapsulation of valve in one patient who required a redo operation after 8.25 years, 6 cases of thromboembolism in patients who interrupted anticoagulants (2 deaths), 4 cases of prosthetic leak, 8 cases of prosthetic valve endocarditis (1 death) 9 cases of anticoagulant-related hemorrhage (2 deaths).(ABSTRACT TRUNCATED AT 250 WORDS)

[Office surgery: organization, legislative, and medico-legal problems. Personal experience]

INTRODUCTION

The authors approach the subject of office surgery by underlining the advantages of this procedure. In particular, they focus attention on the anesthesiological and legislative problems. Depending on the setting used for surgery and the duration of hospitalisation, ambulatorial surgery can be divided into: day-hospital, office surgery, one-day surgery, short-stay surgery, same-day surgery,

MATERIALS AND METHODS

The authors report their own experience relating to 103 cases with relative complications. A total of 103 operations of medium-to- major ambulatorial surgery were performed (100 females and 3 males, mean age 36.8). One week prior to surgery all patients attended a medical out-patient examination in order to fill in medical records and be prescribed routine hematochemical tests, chest X-ray and ECG. The preoperative anesthesiological evaluation was made at the time of surgery. All patients received antibiotic prophylactic treatment.

RESULTS

Postoperative complications were reported above all following neuroleptoanalgesia and amounted to a total of 5 cases: nausea (4 cases) associated with vomit (1 case), and postural hypotension (1 case). No infective complications were observed.

DISCUSSION AND CONCLUSIONS

The authors emphasise the importance of a careful preoperative selection of patients; an out-patient structure equipped with the appropriate instrument and machinery for surgery and the constant presence of anesthetists to ensure correct anesthesia (local, neuroleptoanalgesic, peridural general), reanimation and postoperative care. The aims of ambulatorial surgery are, in broad terms, the safety of procedures, convenience for the patient and organisational and economic savings for health structures. Ambulatorial surgery has an extremely high acceptance rate by patients. Lastly, the authors also report the juridical and bureaucratic problems faced by ambulatorial surgery and look forward to its wider diffusion. In the future office surgery might represent an important contribution to surgical therapeutic strategies, allowing, if well organised, an excellent compromise between safety, convenience and reduced costs for the patient.

[Autohemotransfusion in cardiac reoperations]

OBJECTIVE

To evaluate the efficacy of intraoperative autotransfusion with hemodilution (AHT) to reduce postoperative transfusion of blood or blood products (BT) after cardiac surgery reoperation.

DESIGN

Retrospective study, follow-up control.

SETTING

Italian Institution of Cardiac Surgery (IICC).

PATIENTS

169 patients (51 males, 118 females; mean age 49.5 years) undergoing a reoperation from May 1982 to December 1991.

INTERVENTIONS

143 patients single valve replacement, 16 patients double valve replacement and 10 patients radical correction for tetralogy of Fallot. AHT (mean 620.2 +/- 226.9 ml) was performed in all patients. The shed blood was reinfused at the end of the surgery. PT, PTT, TT, TT Coagulase, FDP, pre- and postoperative platelet count, bleeding and needs for BT were recorded.

RESULTS

Preoperatively: PT 71.3 +/- 8.1, PTT (sec.) 36.9 +/- 3.5, TT (sec.) 16.2 +/- 2.3, TTC (sec.) 16.9 +/- 1.7, FDP (ng% ml) 3.8 +/- 2.7, Platelet count (No./mu 11 170 +/- 58. Postoperatively: PT 36.5 +/- 6.5, PTT(sec.) 49.5 +/- 8.7, TT(sec.) 19.1 +/- 1.8, TTC(sec.) 18.9 +/- 2.1, FDP (ng% ml) 13.5 +/- 8.9, Platelet count (No./mu 11) 85 +/- 34. We had one reentry because of bleeding. The mean units of blood or blood products need after surgery were 2.2 +/- 1.02. Bleeding from the drainage was 105.2 +/- 103.8. Two patients died in the postoperative period because of low output syndrome. In a period of one year of F.U. we had only one patient with hepatitis B.

CONCLUSIONS

These data suggest that AHT is a safe method, reduces needs for banked blood or blood products, risks of infectious disease transmission and of immunologic reactions and presents hemorheologic benefits because of the diminished blood viscosity.

Long-term follow-up of cardiac myxomas (7-31 years)

Between 1961 and 1985, 14 patients (9 males, 5 females; mean age 42.3 +/- 7.26 years) underwent surgery for excision of cardiac myxoma. Origin of the neoplasm was left atrium in all patients. In the last 7 cases diagnosis was obtained by echocardiographic examination. The clinical manifestations were dyspnea in 8 cases, palpitation in 5 and neurological symptoms in 3. One patient with concomitant mitral and aortic incompetence died on the 13th postoperative day because of low-output syndrome. All 13 operative survivors are alive and well without echocardiographic evidence of neoplastic recurrence at a follow-up ranging from 7 to 31 years. These results indicate a low incidence of recurrence with a complete tumor excision even without its extension to the normal atrial endocardium.

[Antibiotic pretreatment of heart valve prostheses]

Bacterial endocarditis on cardiac valvular prosthesis is still a frequent and dangerous complication: septicemia, embolism, valvular dysfunction and mortality. To prevent these complications, intraoperative treatment of prosthesis, by immersion in antibiotic solution, was performed in 1262 patients. The postoperative results have been compared with results of a nontreated group. The incidence of endocarditis in the treated group was 1.3%, in non-treated cases 5.45%. The cases of early endocarditis, was 0.08% of total cases of complications in the treated patients group; and 4.54% in the nontreated patient group. This study's results, confirm the utility of valvular prosthesis antibiotic treatment in cardiac surgery.