Massive Retro-Pneumoperitoneum and Lower Limb Subcutaneous Emphysema After Pediatric Heart Transplantation: A Case Report.

An emphysema in a lower limb is usually a clinical sign of a severe and life-threatening infection. We report a rare case of subcutaneous emphysema of the left lower limb associated with a massive retro-pneumoperitoneum and pneumatosis intestinalis after cardiac transplantation in a 4-year-old girl. The child was nearly asymptomatic beside an abdominal distension. A benign pneumoperitoneum associated with an extensive pneumatosis intestinalis is a rare complication after organ transplantation and should be treated conservatively. The association with an emphysema in a lower limb in a child has not been previously reported to our knowledge in the literature.

Prospective incidence study of bloodstream infection in infants and children with central venous catheters after cardiac surgery in Italy.

This prospective observational study was designed to assess the incidence of, risk factors for, and outcome of catheter-related bloodstream infection in children undergoing cardiac surgery. A staff specifically trained to handle the central venous catheters with proper aseptic techniques and an appropriate patient to medical staff ratio remain the most effective measures to prevent this infection.

Mortality and morbidity in reoperation comparing to first intervention in coronary revascularization.

BACKGROUND: Coronary artery reoperation represents about 20% of coronary artery operations. In this study we compared mortality and morbidity of first intervention and redo operation. EXPERIMENTAL DESIGN: a retrospective study. SETTINGS: patients who underwent coronary artery reoperations in a University Cardiac Surgery Division in 1991-1994. PATIENTS: our clinical survey was composed of two groups: group A included 44 consecutive patients (mean age 60+/-7 years, males/females=41/3) who underwent a coronary artery reoperation in the years 1991-1994 at the University Cardiac Surgery Division of Turin; group B included 344 patients (mean age 58+/-8 years, males/females=289/55) randomly selected among those who underwent a first coronary operation in the above indicated period of time and centre. All patients had angina pectoris refractory to maximal medical therapy. INTERVENTIONS: all patients underwent a coronary artery operation in extracorporeal circulation (ECC), under mild hypothermia (30-32 degrees C), during a single aortic clamp period, with antegrade cold crystalloid cardioplegia (St. Thomas). MEASURES: comparison of clinical preoperative features, risk factors and postoperative mortality and morbidity between the two groups. RESULTS: In reoperated patients we observed a greater mean akinesis score (p<0.001) and severe left ventricular dysfunction presence (p=0.014). Reoperation mortality was 11.4% against first operation mortality of 3.2% (p=0.03). Female gender (p=0.03), intra-aortic balloon counterpulsation need (p=0.002), adrenaline use (p=0.004) and low cardiac output syndrome (p=0.007) were all perioperative risk factors in group A. CONCLUSIONS: Coronary artery reoperation involves a higher mortality and morbidity compared to the first operation, especially related to the reduced left ventricular function which characterises the population that undergoes reoperation.

Aortobronchial fistula after aortic dissection type B.

Although rare, aortobronchial fistula complicates thoracic aortic surgery. Correct diagnosis and the infectious nature of the lesion are the most important conditions to define, for the following best therapy. We presented a case of non-infectious postsurgical aortobronchial fistula, revealed by computed-tomographic scan and angiography procedure, treated with prosthetic graft replacement and broad spectrum antibiotic therapy. In the case of infection our policy is homograft replacement. Computed tomography, being able to make diagnosis, should be performed as the initial technique.

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.

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.

[Correlation between malfunction of a bioprosthesis and deformation of a valve stent. Comparison of three different vale models]. / Correlazione tra malfunzionamento di protesi biologiche e deformazione dello stent valvolare. Confronto tra diversi modelli di valvola.

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.

[Transeptal access to the mitral valve. Long-term results]. / Accesso transettale alla valvola mitrale.

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.

[Female sex is not an independent risk factor in mortality during myocardial revascularization]. / Il sesso femminile non rappresenta un fattore di rischio indipendente di mortalità negli interventi di rivascolarizzazione miocardica.

To assess if female sex is an independent risk factor for perioperatory mortality and morbidity, we have evaluated 971 consecutive patients (16% women) undergoing coronary artery bypass graft surgery at the Cardiovascular Disease Institution of the University of Turin from 1988 to 1990. In this study at baseline women were older and more likely to have diabetes, lower ventricular score and body surface area than men. As compared to men, women underwent surgery with delay: the surgical mortality rate and prevalence of arrhythmias were higher, and the size of the left anterior descending was smaller. At univariate analysis perioperative risk factors were as follows: age, diabetes, clinical instability, low body surface area, perioperatory infarction, postoperative infections, extracorporeal circulation time and left coronary size. At multivariate analysis only diabetes, left ventricular score, left anterior descending coronary size and emergency surgery were independent risk factors while sex, age and body surface area were not predictors of perioperatory mortality and morbidity. It is concluded that gender is not the cause of worse outcome in women.