The Actis-gouge: a simple cutting tool for proper muscular resection in hypertrophic cardiomyopathy.

BACKGROUND: Surgical treatment of hypertrophic cardiomyopathy (HC) may be challenging for the risk of surgical complications or insufficient resection. We present our cutting tool to perform proper muscular resection in HC. MATERIAL AND METHODS: Ten patients (5 males, mean age 43,1 +/- 19,6 years, range 9-70 years) were operated on for HC using this semicircular cutting device. Combined procedures were : mitral valve repair (n = 1), mitral valve replacement (n = 2), right ventricular myectomy (n = 1), aortic valve replacement (n = 1), mitral and aortic replacement (n = 1). RESULTS: There was one early death. All the surviving patients are alive over a variable follow up from 2 to 8 years, with consistent reduction of symptoms: in fact, no patient had residual angina with significant reduction of the NYHA class from 3,2 +/- 0,6 to 1,3 +/- 0,5 postoperatively (p < 0,05). Muscular resection was effective with significant reduction of sub-valvular gradient from 84.5 + 33,4 mmHg to 14,1 +/- 17,6 mmHg (p < 0,05) without complications such as complete atrio-ventricular block or ventricular septal defects. CONCLUSION: Our semicircular myotome is an effective tool to perform a safe myectomy and it avoids surgical complications such as atrio-ventricular blocks or sub-valvular injuries. Our experience suggests that this cutting tool offers a reproducible method for muscular resection and it shows appreciable effects in the reduction of sub-valvular gradient with promising results in terms of morbidity and mortality.

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.

[Cardiovascular and urological combined operation in a patient with severe aortic stenosis and renal cell carcinoma]. / Intervento combinato cardiochirurgico e urologico in paziente con grave insufficienza cardiaca secondaria a stenosi aortica e voluminosa neoplasia renale sintomatica.

The simultaneous treatment of cardiovascular and urological diseases is at present discussed concerning indication and the increasing postoperative complications. Rarely these cases are observed with simultaneous critical diseases for both apparatuses thus conditioning the manner and timing of procedures. Authors report a case of sequential cardiosurgical and urological treatment in a patient affected by severe aortic stenosis and kidney neoplasm with bleeding. Authors performed the combined approach in the cardiosurgical department, starting with the aortic valve replacement with extracorporeal circulation (ECC) procedure and subsequently with the radical right nephrectomy. We believe that, with limitations according to each case, this approach can be taken into account in selected cases with severe cardiac valve disease refractory to medical therapy with persistent hematuria or bleeding.

[Thrombotic thrombocytopenic purpura (TTP) or Moschowitz syndrome. Our experience]. / Porpora trombotica trombocitopenica (TTP) o sindrome di Moschowitz. Nostra esperienza.

AIM: The aim of this study was to report that Moschcowitz's syndrome was an inexorable cause of death in our Centre in the cases we observed, all of which failed to respond to the treatment used. This severe prognosis was attributed to the irreversible nature of the pathology when the patients were admitted to intensive care. METHODS: Three cases are described which were brought to our attention with this pathology. The following association was present in all cases: low platelet count, anemia with schistocytosis and indirect hyperbilirubinemia. Plasmapheresis was the main treatment used in all cases. SETTING: the intensive care unit of our Hospital is the regional reference centre where plasmapheresis is performed. PATIENTS: Three patients were studied: two females aged 62 and 42 respectively, and one male aged 63. All three patients came from this region and no special features were found in their long-term medical history. INTERVENTIONS: all patients underwent blood transfusion, plasmapheresis and received targeted antibiotic and corticosteroid treatment, and parenteral nutrition. RESULTS: All three cases died. CONCLUSIONS: The analysis of these cases highlights the need for an early diagnosis, even if this is not easy, in order to commence successful therapy.

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.

Effects of induced mood on self-reported life events and perceived and received social support.

This study tested the relation between mood (depressed [D], elated [E], or neutral [N]), induced by the Velten (1968) procedure, and college students' responses on a subjectively scored life events questionnaire and measures of perceived and received social support. A manipulation check showed that the mood manipulation was successful. There was a significant mood effect on the number of self-reported negative life events, with E subjects reporting the fewest. However, mood had no significant effect on the number of self-reported positive life events or the rated intensity of negative and positive events. Mood had a significant effect on perceived social support, with D subjects scoring the lowest. Self-report of received social support, however, was not affected by the mood manipulation. The findings challenge the widespread use of life event and perceived social support questionnaires whose independence from a mood-related response bias has not been adequately demonstrated. The findings also challenge causal interpretation of significant effects for self-reported life stress and perceived social support obtained in cross-sectional prediction studies of concurrent psychological distress.