Laparoscopic sacrocolpopexy plus ventral rectopexy as combined treatment for multicompartment pelvic organ prolapse.

BACKGROUND: Pelvic organ prolapse (POP) is a dynamic disorder that affects the entire pelvic diaphragm. POP may often involve multiple organs. Abdominal sacrocolpopexy is considered the gold standard to treat female anterior and apical prolapse. Abdominal ventral mesh rectopexy has gained increasing acceptance as an effective treatment for rectal prolapse. The aim of the present study was to assess the safety, feasibility and 1-year outcomes of laparoscopic sacrocolpopexy plus ventral rectopexy as a combined treatment of multicompartment POP. METHODS: All female patients at our institution with anterior and apical prolapse with symptoms of obstructed defecation were examined by an urogynecologist and a colorectal surgeon, and were judged suitable for the study. Patients with Pelvic Organ Prolapse Quantification (POP-Q) system stage III and IV and concomitant rectal prolapse were treated by laparoscopic sacrocolpopexy plus ventral rectopexy. After surgery, 1- and 12-month follow-up was performed and the data were retrospectively analyzed. Patients' symptoms were evaluated using the Female Sexual Distress Scale (FSDS), Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ-12), and Wexner-Agachan constipation score. RESULTS: A total of 98 patients underwent surgery. No intraoperative or postoperative morbidity occurred. At the time of follow-up, all women expressed great satisfaction with the surgical treatment: all the patients had at most POP-Q Stage 1 and 78.8% had a Patient Global Impression of Improvement (PGI-I) score < 3. Significant improvement of symptoms related to POP and to obstructed defecation syndrome, as shown by the FSDS, PISQ-12, and Wexner-Agachan constipation score, was observed in all patients at follow-up CONCLUSIONS: Laparoscopic sacrocolpopexy with ventral rectopexy is a feasible and safe procedure for the combined surgical management of anterior, apical, and posterior prolapse, and provides excellent objective and subjective outcomes.

Hydroacoustic estimation of fish biomass in the Gulf of Nicoya, Costa Rica.

A stratified sampling design was used for a hydroacoustic survey of the inner parts of the Gulf of Nicoya in 1987 and 1988. The bottom topography of the inner Gulf was modeled by introducing the concept of a topographical basin model, as the basis for the projection of the sample survey estimates to the entire inner gulf. The bottom depth contours and volumes for the basin model were constructed from nautical charts. The estimates of sample abundance were made for the fish in the inner Gulf using the acoustic methods, EMS (Expectation Maximization and Smoothing) and echo integration. The estimates of population were made by the multiplication of the topographic model's estimate of water volume and a model of fish density dependent on bottom depth. The results showed a general decrease in fish density biomass with bottom depth, and a simultaneous tendency for maximum concentrations over bottom depths of about four meters. The four meter bottom depth includes a broad expanse of the inner Gulf located south of Isla Chira. Overall estimates of volumetric density (0.269 fish/m3) and of areal densities (1.88 fish/m2) are comparable to other estuarine shallow water environments.

Effects of ischemia on sarcoplasmic reticulum and contractile myofilament activity in human myocardium.

The effects of global ischemia on the contractile system and on sarcoplasmic reticulum (SR) function were studied by measuring the isometric tension and the SR Ca2+ release activity of chemically skinned cardiac fiber preparations from seven patients undergoing open-heart surgery. Ten minutes of ischemia caused 1) a decrease in the myofilament sensitivity to Ca2+ (expected Ca2+ concentration giving half-maximal tension; from 0.69 +/- 0.04 to 1.38 +/- 0.06 microM, n = 7) and in the cooperativity index (Hill coefficient; from 2.61 +/- 0.45 to 0.92 +/- 0.15, n = 7), 2) a decrease in myosin light chain phosphorylation, and 3) a 300% increase in the threshold caffeine concentration for SR Ca2+ efflux channel activation, with a 30% reduction in the rate of Ca2+ release by caffeine at threshold concentrations and a 23% reduction in the rate of release by 20 mM caffeine. After preincubation with 5 microM trifluoperazine, a calmodulin antagonist, the caffeine threshold of ischemic and control cardiac muscle became comparable. Most changes were reversed by reperfusion, while the caffeine threshold was still two times greater than control. These results indicate that ischemia caused alterations of the cardiac muscle contractile apparatus and the SR that were reversed only after reperfusion.

[Acute rejection: the diagnostic and therapeutic problems]. / Il rigetto acuto: problemi diagnostici e di terapia.

Acute allograft rejection is still a leading cause of both early and late mortality and morbidity after cardiac transplantation. Besides cell-mediated acute rejection, a "humoral" form exists which is more frequent in younger patients in the early postoperative period, and less likely to respond to the usual therapy. Cyclosporine therapy has deeply affected the clinical, laboratory and histological aspects of acute rejection. Though endomyocardial biopsy remains the most reliable diagnostic tool, other noninvasive procedures are of great value for a final diagnosis; among these are electrocardiography and two-dimensional echocardiography, which are the two elective techniques for post-transplantation follow-up in children. The laboratory and immunological assays, on the contrary, share a very low specificity. In conclusion, the diagnosis of acute rejection is still a clinical one, though supported by laboratory and histological evidence. In our experience, the natural evolution of many mild and mild-moderate rejection episodes toward regression does not support an excessive prophylaxis or an early treatment of symptom-free acute rejection. In addition, treatment of rejection must be personal and specific to each patient.

[Controversies in the selection of donors in heart transplants]. / Controversie sulla selezione del donatore nel trapianto cardiaco.

The shortage of ideal donor hearts has led to an increasing number of would-be heart transplant recipients who die while on the waiting list: an extension of the classical donor criteria seems necessary to expand the donor pool. In this paper, the major controversies on donor selection are presented, along with the clinical results obtained in cardiac transplantation with donor grafts not complying with standard criteria. The extension of donor age over 35 years is supported by the decreased incidence of coronary artery disease (CAD) in the Western world. In our experience, the number of donors over 40 years has increased steadily, without concomitant significant increase in postoperative short- and medium-term mortality after cardiac transplantation. The relative importance of CAD risk factors in the older heart donor is to be weighed out on a case-by-case basis. The performance of coronary angiography in 90% of the donor grafts over 50 years has led to more accurate selection. ECG minor alterations and ECHO diagnosed dyskynesias are of uncertain significance. Localized infection, transitory hypotension, brief cardiac arrest and thoracic trauma do not necessarily contraindicate heart donation. The importance of donor/recipient weight mismatch over 20% is critical only in face of high pulmonary vascular resistance. Prolonged dopamine infusion above 10 micrograms/kg/min may predict poorer function outcome. From our data, severe donor dysionemia may be very hazardous. In conclusion, our experience demonstrates that extended donor criteria do not compromise short- and medium-term clinical results of cardiac transplantation. Nevertheless, several controversial aspects of donor graft selection remain open.

A new, noninvasive method to monitor the aging of bioprosthetic valves in the mitral position.

Bioprosthetic valves undergo a tissue degeneration of unpredictable onset and amount. This process alters the structure and function of the valve and consequently shortens its lifespan. The echocardiographic technique usually used in the follow-up of these patients does not provide accurate information concerning the amount of prosthesis tissue degeneration. A new technique has been developed based on the spectral analysis of the first heart sound, which enables the evaluation of prosthetic leaflet stiffness. The Young's modulus (E) and stress (s) of the valve leaflets were derived as functions of the inner diameter of the heterograft and its primary vibration frequency, which can be obtained from the frequency spectrum of the first heart sound. Thirty-six patients with a mitral bioprosthetic valve were studied. Fifteen had thickening or calcification, or both, of the valvular leaflets at echocardiographic examination. In patients with a normal valve, E and s showed a good correlation with the duration of implantation (r = 0.909, p < 0.001; and r = 0.828, p < 0.001; respectively). Patients with abnormal leaflets had values of E and s that were greater than the theoretical values expected for their duration of implantation. The procedure is sensitive, accurate and easy to perform, and enables monitoring of the aging of the prosthetic valve and early identification of valve tissue degeneration. Together with echocardiography, this procedure yields a more complete evaluation of prosthetic valves for the follow-up of patients.

Contractile properties and Ca2+ release activity of the sarcoplasmic reticulum in dilated cardiomyopathy.

BACKGROUND: We performed a comparative study on Ca2+ release activity of the sarcoplasmic reticulum and calcium sensitivity of contractile apparatus of chemically skinned myocardial fibers obtained from four nonfailing human hearts and 13 excised hearts from patients with idiopathic dilated cardiomyopathy. METHODS AND RESULTS: Ca2+ sensitivity of contractile apparatus was studied by following the isometric tension developed by chemically skinned myocardial fibers challenged with solutions of decreasing pCa. Ca2+ release from sarcoplasmic reticulum was monitored indirectly by measurement of the isometric tension developed by skinned fibers challenged with caffeine. We observed no significant difference of Ca2+ sensitivity and cooperativity between normal myocardium (pCa50 = 6.00 +/- 0.05; Hill coefficient, nHill = 2.07 +/- 0.10) and dilated cardiomyopathy (pCa50 = 6.03 +/- 0.07; nHill = 2.72 +/- 0.30) when the fibers were stretched to 130% of the resting length. We also found that both in normal myocardium and dilated cardiomyopathy, stretching to 150% of the resting length increased the Ca2+ sensitivity of the contractile system; pCa50 = 6.21 +/- 0.01 and 6.13 +/- 0.04 in normal and dilated cardiomyopathy, respectively, whereas in dilated cardiomyopathy there was a decrease of Hill coefficient with stretching that was not observed in the control group. The caffeine threshold in idiopathic dilated cardiomyopathy was markedly increased compared with the control group, 1.94 +/- 0.27 mmol/l and 0.29 +/- 0.04 mmol/l caffeine, respectively, whereas there were no significant differences in the extent and rate of caffeine-induced Ca2+ release. CONCLUSIONS: These results indicate that in idiopathic dilated cardiomyopathy there is no alteration of contractile and regulatory proteins; on the contrary, the gating mechanism of the Ca2+ release channel of sarcoplasmic reticulum is abnormal, suggesting a possible involvement of the excitation-contraction coupling in the pathogenesis of this disease. It should also be taken into account, however, that the increased caffeine threshold in dilated cardiomyopathy would be a result of the enhanced resistance to the skinning procedure secondary to the modification of lipid species and/or content in sarcoplasmic reticulum membrane.

Heart valve replacement with the Sorin tilting-disc prosthesis. A 10-year experience.

From 1978 to 1988, 697 patients with a mean age of 48 +/- 11 years (range 5 to 75 years) received a Sorin tilting-disc prosthesis; 358 had had aortic valve replacement, 247 mitral valve replacement, and 92 mitral and aortic valve replacement. Operative mortality rates were 7.8%, 11.3%, and 10.8%, respectively, in the three groups. Cumulative duration of follow-up is 1650 patient-years for aortic valve replacement (maximum follow-up 11.4 years), 963 patient-years for mitral valve replacement (maximum follow-up 9.9 years) and 328 patient-years for mitral and aortic valve replacement (maximum follow-up 9.4 years). Actuarial survival at 9 years is 72% +/- 4% after mitral valve replacement, 70% +/- 3% after aortic valve replacement, and 50% +/- 12% after mitral and aortic valve replacement, and actuarial freedom from valve-related deaths is 97% +/- 2% after mitral valve replacement, 92% +/- 2% after aortic valve replacement, and 62% +/- 15% after mitral and aortic valve replacement. Thromboembolic events occurred in 21 patients with aortic valve replacement (1.3% +/- 0.2%/pt-yr), in 12 with mitral valve replacement (1.2% +/- 0.3% pt-yr), and in seven with mitral and aortic valve replacement (2.1% +/- 0.8%), with one case of prosthetic thrombosis in each group; actuarial freedom from thromboembolism at 9 years is 92% +/- 3% after mitral valve replacement, 91% +/- 3% after aortic valve replacement, and 74% +/- 16% after mitral and aortic valve replacement. Anticoagulant-related hemorrhage was observed in 15 patients after aortic valve replacement (0.9% +/- 0.2%/pt-yr), in 9 after mitral valve replacement (0.9% +/- 0.3%/pt-yr), and in 6 with mitral and aortic valve replacement (0.9% +/- 0.5%/pt-yr); actuarial freedom from this complication at 9 years is 94% +/- 2% after aortic valve replacement, 91% +/- 4% after mitral valve replacement, and 68% +/- 16% after mitral and aortic valve replacement. Actuarial freedom from reoperation at 9 years is 97% +/- 2% after mitral and aortic valve replacement, 92% +/- 4% after mitral valve replacement, and 89% +/- 3% after aortic valve replacement, with no cases of mechanical fracture. The Sorin valve has shown a satisfactory long-term overall performance, comparable with other mechanical prostheses, and an excellent durability that renders it a reliable heart valve substitute for the mitral and aortic positions.

Extended follow-up of the standard Hancock porcine bioprosthesis.

We have reviewed 665 patients in whom the standard Hancock porcine bioprosthesis (HPB) was used for aortic (AVR = 173), mitral (MVR = 437), and mitral and aortic (MAVR = 55) valve replacement in the time interval from 1970 to 1983. After AVR, HPB-related deaths occurred in 24 patients (1.7% +/- 0.4% per patient-year); 11 had thromboembolic episodes (0.8% +/- 0.2% per patient-year), 6 hemorrhages related to anticoagulants (0.4% +/- 0.2% per patient-year), 9 endocarditis (0.7% +/- 0.2% per patient-year), 7 prosthetic leak (0.5% +/- 0.1% per patient-year), and 59 structural deterioration (4.3% +/- 0.6% per patient-year). At 16 years, actuarial survival is 40% +/- 6%, freedom from thromboembolic episodes 89% +/- 4%, from hemorrhages 90% +/- 5%, from endocarditis 94% +/- 2%, from prosthetic leak 95% +/- 2%, and from structural deterioration 36% +/- 6%. After MVR, HPB-related deaths occurred in 64 patients (1.6% +/- 0.2% per patient-year); 68 had thromboembolic episodes (1.7% +/- 0.2% per patient-year), 28 hemorrhages (0.7% +/- 0.1% per patient-year), 12 endocarditis (0.3% +/- 0.1% per patient-year), 9 prosthetic leak (0.2% +/- 0.1% per patient-year), and 158 structural deterioration (4.0% +/- 0.3% per patient-year). At 18 years, actuarial survival is 33% +/- 4%, freedom from thromboembolic episodes 57% +/- 13%, from hemorrhages 81% +/- 6%, from endocarditis 91% +/- 4%, from prosthetic leak 98% +/- 1%, and from structural deterioration 18% +/- 5%.(ABSTRACT TRUNCATED AT 250 WORDS)

The risk of reoperation in patients with bioprosthetic valves.

The risk of operative mortality in patients undergoing a first reoperation for bioprosthetic failure was assessed in a series of patients reoperated upon during the last two decades (1970-1990). A total of 330 such patients underwent replacement of 351 bioprostheses: 88 had aortic; 221 mitral; and 21 mitral and aortic bioprosthetic replacement. Indication for reoperation was in most cases structural valve deterioration (87%), followed by periprosthetic leak (7%) and endocarditis (6%). The operative mortality was significantly higher in patients who preoperatively were in New York Heart Association Functional Class IV or had a lower left ventricular function, in those reoperated because of prosthetic infection, and in those reoperated on an emergency basis. Structural valve deterioration was associated to a substantially low risk; operative mortality has improved in recent years, regardless of the indication for reoperation, partly due to the increasing experience and improved surgical techniques. Our results indicate that in recipients of bioprosthetic valves, careful follow-up with closer surveillance of valve and cardiac function and earlier prosthetic replacement might contribute to reducing the risk of reoperation.

Influence of type of prosthesis on late results after combined mitral-aortic valve replacement.

The influence of type of prosthesis on the late outcome of patients with combined mitral-aortic valve replacement was analyzed by comparing, at a 14-year follow-up, patients receiving two biological prostheses (group 1; n = 135), two mechanical prostheses (group 2; n = 221), or a mechanical prosthesis in the aortic position and a bioprosthesis in the mitral position (group 3; n = 97). No difference was found among the three groups in terms of actuarial survival and incidence of and freedom from valve-related deaths, thromboemboli, and hemorrhages. Patients with biological prostheses had a significantly greater incidence of structural valve deterioration, reoperations, and overall complications when compared with patients with only mechanical prostheses. The results of an extended follow-up of patients with combined mitral-aortic valve replacement indicate that mechanical prostheses perform better in the long-term owing to their superior durability when compared with biological valves. The use of bioprostheses should be confined to old patients with limited life expectancy because of their cardiac disease, provided that anticoagulants are not used. Combination of mechanical and biological prostheses in the same patient should be avoided because the advantages of each type of prosthesis are lost.

Failure of Hancock pericardial xenografts: is prophylactic bioprosthetic replacement justified?

The incidence of major valve-related complications was evaluated in a series of patients in whom the Hancock pericardial xenograft was used for aortic (AVR; n = 84), mitral (MVR; n = 17) and mitral-aortic (MAVR; n = 13) valve replacement. At 7 years actuarial survival is 66% +/- 8% after AVR, 64% +/- 13% after MVR, and 41% +/- 15% after MAVR, whereas actuarial freedom from valve-related death is 79% +/- 7% after AVR, 78% +/- 13% after MVR, and 81% +/- 12% after MAVR. Actuarial freedom from thromboemboli and anticoagulant-related hemorrhage at 7 years is 93% +/- 4% and 98% +/- 2% after AVR and 83% +/- 10% and 88% +/- 11% after MVR; no such complications occurred after MAVR. Structural valve deterioration determined at reoperation, at autopsy, or by clinical investigation was observed in 34 patients with AVR (10.0 +/- 0.2%/patient-year), in 10 with MVR (10.6 +/- 3.3%/patient-year), and in 9 with MAVR (16.6 +/- 5.5%/patient-year). After AVR, 19 patients underwent reoperation and 2 died before reoperation; 4 patients with MVR underwent reoperation, and 7 patients with MAVR underwent reoperation and 1 died before reoperation. Seventy-eight percent of the current survivors (13 patients with AVR, 7 with MVR, and 1 with MAVR) have clinical evidence of valve failure. At 7 years actuarial freedom from structural deterioration of the Hancock pericardial xenograft is 25% +/- 7% after AVR, 29% +/- 14% after MVR, and 0% after MAVR.(ABSTRACT TRUNCATED AT 250 WORDS)

Is lung biopsy useful for surgical decision making in congenital heart disease?

Sixty patients with congenital heart disease (CHD), age range 3 months-45 years (median 2 years), underwent lung biopsy to exclude pulmonary vascular disease (PVD): 25 had an atrioventricular (AV) septal defect, 14 a ventricular septal defect (VSD), 7 a complete transposition of the great arteries (TGA) + VSD, 3 an atrial septal defect, and 2 a patent ductus arteriosus; 9 had other malformations. Scoring of histological section (0-4) according to a modified Heath-Edwards classification disclosed that 30 patients had severe "irreversible" PVD (greater than or equal to grade 3) (11 AV septal defect, 8 VSD, 6 TGA + VSD and 5 others); 8 patients were younger than 1 year. Pulmonary vascular resistance (PVR) was calculated in 51 patients and exceeded 7 U/m2 in 1 of 2 patients with grade 0, in 9 of 18 with grade 1, in 1 of 4 with grade 2, in 11 of 18 with grade 3, and in 8 of 9 with grade 4. PVR was also calculated after 100% oxygen administration in 19 patients, 14 of whom had a resting PVR greater than or equal to 7 U/m2. PVR persisted greater than or equal to 7 U/m2 in 5 patients: 4 had PVD greater than or equal to grade 3 and died after surgery. PVR fell to under 7 U/m2 in 14 patients, 3 of whom had PVD greater than or equal to grade 3:1 patient with grade 4 was not operated upon and 2 with grade 3 were operated upon: all are alive. Follow-up in discharged living patients was 100%, with a mean of 50 months. Fifty-five patients underwent surgery with 10 early and 2 late deaths. Among the 12 subjects with a fatal outcome, 10 had irreversible lesions. The 5 non-operated patients all had irreversible lesions at biopsy, and are still alive.(ABSTRACT TRUNCATED AT 250 WORDS)

Constrictive epicarditis after open heart surgery: the turtle cage operation.

A 60-year-old man developed constrictive epicarditis within 1 year after isolated mitral valve replacement (MVR). At reoperation, decortication of the thick epicardial layer resulted, impossible without a high risk of injury of the myocardium and major coronary arteries. Therefore, multiple longitudinal and transverse incisions were performed on the epicardial peel, which at the end acquired a turtle cage appearance allowing myocardial reexpansion, relief of constriction, and restoration of adequate hemodynamics.

The pathology of Hancock standard porcine valve prosthesis: a 20-year span of experience.

A spectrum of events leading to tissue failure is responsible for late dysfunction of Hancock porcine valve xenografts: (a) Primary failure: dystrophic calcification, thrombosis, fibrous tissue overgrowth, primary tears, cuspal hematomas, and stent postbending. (b) Secondary failure: endocarditis and paravalvular leak. Dystrophic calcification is the main factor influencing long-term durability and accounts in our experience for 88% of primary failure, through different clinical presentations; particularly, incompetence by cusp tearing and egg-shell fragmentation is by far the most frequent mode of failure. Cusp degeneration by primary tears (in the absence of dystrophic calcification) is an uncommon event, due to lipid infiltration or to right coronary muscle shelf spontaneous or immuno-related disruption.

Influence of prosthetic design on durability of the Liotta porcine valve in the mitral position.

From March 1979 to December 1984, the Liotta low-profile porcine bioprosthesis was employed for mitral valve replacement in 71 patients to avoid potential left ventricle-prosthesis mismatch occasionally observed with the standard, high-profile, Hancock porcine xenograft. Follow-up of 61 operative survivors showed at 10 years an actuarial survival of 67% +/- 7%, freedom from thromboemboli of 96% +/- 2%, freedom from structural deterioration of 63% +/- 11% and freedom from all Liotta bioprosthesis-related complications of 53% +/- 10%. Complications related to excessive protrusion of the stent into the left ventricular cavity were eliminated with the Liotta bioprosthesis; the peculiar stent configuration, however, was responsible for an increased rate of structural deterioration requiring reoperation in 10 patients (2.8% +/- 0.9%/patient-year) at a mean interval of 76 +/- 18 months after mitral valve replacement (range, 45 to 106 months). Common findings in all explants were cusp prolapse, cusp tears, and commissural rupture related to various degrees of tissue calcification, constantly leading to severe prosthetic incompetence. As also shown experimentally, such structural changes have been attributed to increased systolic stresses on the closed cusps, favored by excessive reduction of the stent height. Our experience shows that the Liotta bioprosthesis used for mitral valve replacement does not provide any clear-cut advantage over standard porcine bioprostheses and that its long-term durability appears affected by the unique prosthetic design.