Left ventricular performance in chronic mitral regurgitation: temporal response to valve repair and prognostic value of early postoperative echocardiographic parameters.

BACKGROUND: The temporal response of the left ventricle due to the relief of volume loading after mitral valve repair, and the prognostic value of early changes in left ventricular size and function, are not fully documented. The purpose of this study was to analyze the evolution of left ventricular performance after surgery, and to evaluate how early postoperative echocardiographic parameters compare with late ventricular function. METHODS: We studied 58 patients with chronic degenerative mitral regurgitation using echocardiography, before, and 9 +/- 3 days and 38 +/- 6 months after mitral valve repair. RESULTS: Between the preoperative and early postoperative study, left ventricular end-diastolic and left atrial size, and ejection fraction decreased, whereas left ventricular end-systolic dimension did not change. Between the early and late postoperative study left ventricular end-systolic size decreased significantly, there was a further decrease in left ventricular end-diastolic dimension and a significant increase in ejection fraction; left atrial size did not change. Multivariate analysis showed that preoperative and early postoperative ejection fraction, and the early postoperative reduction in diastolic dimension were the best predictors of late left ventricular function. CONCLUSIONS: In patients with chronic degenerative mitral regurgitation, the greatest reduction in end-diastolic dimension occurs within 2 weeks of the reversal of volume overload; a significant reduction in end-systolic dimension with an increase in ejection fraction occurs later. In our experience, early postoperative echocardiographic measurements of left ventricular size and function can provide important prognostic information.

The limitations of echocardiography in the overall diagnosis of the morphological lesions associated with infective endocarditis: comparison of echocardiographic and surgical findings.

Echocardiography is commonly accepted as the method of choice for the non-invasive diagnosis of vegetations and other lesions associated with infective endocarditis. To assess the accuracy of echocardiography in the overall diagnosis of the morphological cardiac lesions we retrospectively analyzed and compared the preoperative echocardiographic data with the surgical findings of 120 consecutive cases operated for infective endocarditis. Transthoracic echocardiography (TTE) was used in 60 cases (51 with native and 9 with prosthetic valves), both TTE and transesophageal echocardiography (TEE) in 50 (26 with native and 24 with prosthetic valves) and only TEE in 10 patients who underwent emergency surgery. The echocardiographic diagnosis was correct in all the cases, but incomplete in 26 (16 with native and 10 with prosthetic valves). Most of the incomplete diagnoses occurred regarding vegetations, perforations of the valvular leaflets and perivalvular abscesses. There were no differences between aortic or mitral valves (14/66 vs 11/60; p = ns), native or prosthetic (16/79 vs 10/37; p = ns), TTE or TEE (13/60 vs 13/60; p = ns); however, TEE was performed in more complex cases and in severely ill patients. In six of the incomplete diagnoses, echocardiography preceded surgery by one week or more, and in six the mistakes were not confirmed by the reviewer. In conclusion, our study suggests that an echocardiographic diagnosis of endocarditis may be correct but sometimes incomplete. In patients without prosthetic valves who have a technically-adequate transthoracic echocardiogram, transesophageal echocardiography is not indispensable but should be chosen from time to time. However, the patients with endocarditis and no contraindication to the transesophageal procedure should undergo both transesophageal and transthoracic echocardiography before surgery in order to obtain as much and the most definite information possible. An echocardiographic study should be repeated just before any surgical procedures in patients with active endocarditis. Finally, it needs to be emphasized that the training and clinical judgement of the operator performing the study are important elements determining the results of echocardiographic study.

Measurement of mitral valve area in mitral stenosis: four echocardiographic methods compared with direct measurement of anatomic orifices.

OBJECTIVES: This study sought to compare the mitral valve areas of patients with rheumatic mitral valve stenoses as determined by means of four echocardiographic and Doppler methods with those obtained by direct anatomic measurements. BACKGROUND: There has been no systemic comparison between Doppler-determined valve areas and the true anatomic orifice in a single cohort. METHODS: In 30 patients with mitral stenosis, the mitral valve areas determined by two-dimensional echocardiographic planimetry, pressure half-time, flow convergence region and flow area were compared with the values directly measured on the corresponding excised specimen by means of a custom-built sizer. RESULTS: The correlation coefficient was r = 0.95 (SE 0.06, p < 0.0001) for two-dimensional planimetry; r = 0.80 (SE 0.09, p < 0.0001) for pressure half-time; r = 0.87 (SE 0.09, p < 0.0001) for flow convergence region; and r = 0.54 (SD 0.1, p < 0.002) for flow area. Two-dimensional echocardiographic planimetry, pressure half-time, flow convergence region and flow area overestimated the actual anatomic orifice by > 0.3 cm2 in 2, 1, 6 and 0 patients, respectively, and underestimated it by > 0.3 cm2 in 0, 4, 1 and 8 patients, respectively. CONCLUSIONS: Mitral valve areas determined by two-dimensional planimetry, pressure half-time and proximal flow convergence region reliably correlated with size of the anatomic orifice. The flow area method provided a less reliable correlation.

Papillary fibroelastoma of the mitral valve. A rare cause of embolic events.

A 66-year-old woman was admitted to our department with an 11-month history of multiple transient ischemic attacks and strokes. A 2-dimensional echocardiographic study revealed an intracardiac tumor attached both to the chordae and to the anterolateral papillary muscle of the mitral valve. The patient underwent excision of the tumor, which necessitated concomitant mitral valve replacement. She remains free of symptoms 1 year postoperatively, with no echocardiographic evidence of recurrence of the tumor. To date, 19 cases of surgically treated papillary fibroelastomas of the mitral valve have been reported in the English-language literature. We add the description of our case to emphasize the importance of this tumor as an identifiable and curable cause of cerebral and coronary embolization. The frequent occurrence of cardiac valve tumors suggests the use of 2-dimensional echocardiography in patients who are experiencing transient ischemic attacks or strokes, as well as in those who sustain a myocardial infarction despite normal coronary arteries at angiography. When papillary fibroelastoma is diagnosed, surgical treatment must be considered because of the high risk of embolization.

[Magnetic resonance in postoperative evaluation of aortic dissection]. / La Risonanza Magnetica nella valutazione postoperatoria della dissecazione aortica.

The value of MRI was investigated in the demonstration of residual alterations and postoperative complications of aortic dissection. October 1988 to December 1992, fifty-nine patients were examined with MRI. The series consisted of 53 patients affected with type A and 6 with type B aortic dissection, all of them surgically treated. The following parameters were studied: 1) aortic dilatation above and 2) below the prosthesis, 3) redissection, 4) persistent intimal flap, 5) origin of abdominal vessels from the false lumen and 6) study of supra-aortic vessels. Twelve of 59 patients were considered normal since all parameters were negative. The aorta was dilated in 19 patients distal to the graft and in 4 proximal to it. Redissection was observed in 33 of 59 patients. Residual intimal flap was clearly demonstrated in 33 of 59 patients; the state of the false lumen was clearly depicted in 12 patients with SE images alone and in 18 of the extant 21 with phase imaging. In 11 of 59 patients abdominal vessels originated from the false lumen. In 53 of 59 patients supra-aortic vessels were clearly demonstrated and appeared to be involved in 10 patients. In 6 cases MRI failed to yield enough information. In our experience MRI is the method of choice for monitoring the aorta after surgical dissection to detect changes and complications and therefore choose the most appropriate treatment.

Postoperative MR follow-up of type A aortic dissection.

OBJECTIVE: We set out to study the efficacy of MRI in the demonstration of residual alterations and postsurgical complications of type A aortic dissection. MATERIALS AND METHODS: From October 1988 to December 1990, 28 patients, 18 patients with type I and 10 with type II aortic dissection, underwent MR examinations for postsurgical evaluation. Features evaluated included caliber of the aorta (a) above and (b) below the prosthesis; (c) redissection; (d) persistent intimal flap; (e) presence of abdominal vessels arising from the false lumen; and (f) status of thoracic supraaortic vessels. RESULTS: Five of 28 patients were considered "normal," due to negative results of the assessed parameters. Dilatation of the aorta was found distal to the graft in seven patients and proximal to the graft in two. Redissection was observed in 2 of 28 patients. Residual intimal flap was seen in 15 of 28 patients; the state of false lumen was well identified in 5 patients using only SE images and in 7 of the remaining 10 using phase imaging. In 25 of 28 patients, supraaortic vessels were well evaluated with involvement seen in 2 cases. In the three other patients, adequate identification was not possible. CONCLUSION: We believe MRI is the technique of choice for monitoring the aorta after surgery in aortic dissection to identify alterations and complications and institute suitable therapy.

[Fatal aortic dissection in a young woman at the 32nd week of pregnancy]. / Dissecazione aortica fatale in giovane donna gravida alla 32 settimana di gestazione.

Aortic dissection in young women without Marfan disease is unusual. When it occurs it is often related to pregnancy. We report a fatal case of aortic dissection in a 29-year-old woman at the end of her first pregnancy. A prompt diagnosis and surgical treatment usually permits the physician to save both mother and fetus. In this case the delay in the diagnosis was fatal for both. We retain that knowledge of this rare complication of pregnancy is useful in order to refer patients early for surgical treatment.

Successful resection of a tuberculous pseudoaneurysm of the descending thoracic aorta: case report and review of the literature.

An aneurysm of the descending thoracic aorta was found in a 55-year-old woman. She had hemoptysis, fever, and weight loss beginning 1 month before hospitalization. A miliary tuberculosis developed after angiography. The patient underwent surgical resection of the aneurysm, which proved to be tuberculous. The aortic wall was reconstructed with a Dacron patch. Antituberculosis pharmacotherapy, started before operation, was discontinued after 16 months of administration. The patient is doing well 19 months after operation. The English literature reports only 7 other cases of surgical treatment of tuberculous aneurysm of the thoracic aorta. According to previous reports, early surgical intervention, combined with preoperative and prolonged postoperative antituberculosis therapy and close postoperative follow-up, is mandatory in this group of patients.

Color Doppler echocardiographic assessment of atrial septal defect size: correlation with surgical measurements.

In patients with atrial septal defect (ASD), color flow Doppler echocardiography provides visualization of the transseptal jet, the maximal dimension of which can be assumed to correspond to the maximal dimension of the true orifice. To test whether color flow Doppler echocardiography can provide an alternative method for measurement of ASD size, we studied 63 consecutive patients with echocardiographic evidence of ASD. In 48 patients the maximal dimension of the jet was measured in the parasternal, apical, or subcostal four-chamber view or in the parasternal short-axis view. In the remaining 15 patients transesophageal echocardiography was performed because of transthoracic views were inadequate. The transesophageal studies also measured, from two-dimensional images, the maximal transverse discontinuity in the atrial septum. All patients underwent surgical repair, during which the surgeon directly measured the maximal dimension of ASD. Linear regression equations were performed to compare transthoracic and transesophageal dimensions to those measured at operation. Correlation coefficients were as follows for transthoracic versus surgical measurements: r = 0.745, standard error = 4.35, p less than 0.001. Transesophageal measurements derived from both two-dimensional images and echocardiographic jet width showed similar excellent correlation with surgical measurements (n = 0.91, standard error = 4.33, p less than 0.001; and r = 0.919, standard error = 4.42, p less than 0.001, respectively). We conclude that ASD size derived from color flow Doppler echocardiography shows a good correlation with the anatomic maximal dimension observed at operation. Both transesophageal color flow Doppler echocardiography of jet width and direct surgical measurement of the defect provide an accurate estimation of ASD size.

Aneurysm of an aberrant right subclavian artery. Report of a surgically treated case.

A 53-year-old man was admitted for treatment of an aberrant right subclavian artery aneurysm that had been diagnosed 5 years earlier and had recently begun to enlarge. The aneurysm, which involved the right subclavian artery from its origin, measured 47 mm in diameter and about 10 cm in length. Because of the lesion's size and friability, a 2-stage operation was performed. In the 1st stage, the right subclavian and right vertebral arteries were revascularized with double bypass grafts via a right cervical approach. In the 2nd stage, the patient was repositioned and a left thoracotomy incision was made. With the aid of left-heart bypass, the aorta was cross-clamped proximal and distal to the lesion, and the aneurysmal orifice was closed with a Dacron patch. The patient was discharged from the hospital on the 17th postoperative day and remains asymptomatic 24 months later. We recommend the 2-stage technique for similar cases because it prevents limb ischemia and reduces the risk of hemorrhagic and embolic complications.

Combined open-heart valve surgery and elective abdominal operations.

From January 1970 to December 1984, at the "A. De Gasperis" Division of cardiac surgery in 73 patients an open-heart valvular operation and an elective abdominal surgical procedure were simultaneously performed. Abdominal surgery was indicated for: cholelithiasis (41 cases), hernia (22 cases), uterine fibroleiomyomas (7 cases), pregnancy (1 case), marginal ulcer after gastric resection (1 case), association of cholelithiasis and hernia (1 case). The etiology of valvular disease was: previous rheumatic fever (69 cases) and acute bacterial endocarditis (1 case); there were 3 cases of periprosthetic leak. All patients were classified in NYHA class III or IV. In all patients the abdominal procedure was carried out first. No significant differences were noted between this group of patients and patients with isolated open-heart operations regarding: postoperative bleeding, stay in Postoperative Intensive Care Unit, overall postoperative hospital stay. There were 5 hospital deaths, all related to cardiac causes. There were no infectious complications, nor early or late abdominal wound complications. The rationale for the combined approach to abdominal and cardiac diseases includes: risk of non cardiac surgery in patients with critical heart disease, risk of non cardiac surgery in patients with previous cardiac valve operations and anticoagulant therapy and risk of abdominal complications after cardiopulmonary bypass surgery. Simultaneous abdominal and cardiac surgery is suggested on clinical, psychological and social grounds.

[Replacement of the mitral and aortic valves with bioprostheses. Long-term results]. / Sostituzione valvolare mitralica e aortica con bioprotesi. Risultati a distanza.

The purpose of the study was to analyze the medium-term results (late mortality, thromboembolism, valve failure) in patients who underwent bioprosthetic valve replacement at "A. De Gasperis" Cardiovascular Surgery Division. From October 1975 to December 1982, 195 patients were consecutively operated on and discharged (118 with mitral prosthesis, 54 with aortic prosthesis, 22 with mitral and aortic prosthesis, 1 with mitral and tricuspid prosthesis). We reviewed 115 (97.45%) of 118 patients with mitral prosthesis (mean follow-up 46.61 months) and 54 (100%) patients with aortic prosthesis (mean follow-up 38 months). Eleven late deaths (2.4%/pt-yr) and 13 thromboembolic events (2.8%/pt-yr) occurred in patients with mitral prosthesis, 6 late deaths (3.5%/pt-yr) and 5 thromboembolic events (2.9%/pt-yr) occurred in patients with aortic prosthesis. Actuarial survival curves and actuarial incidence of thromboembolic event-free patients at 5 years are, respectively, 91.2% and 87.3% in patients with mitral prosthesis, 82.8% and 86.3% in patients with aortic prosthesis. The risk factors for thromboembolism were analyzed. Reoperation was requested in 14 cases (10 mitral and 4 aortic prostheses) for prosthetic leak (6 patients) or valve failure (8 patients). In linearized terms, the rate of valve failure requiring reoperation is 1.3%/pt-yr for mitral prostheses and 1.1%/pt-yr for aortic prostheses. The medium-term results suggest that the bioprostheses are, at the present time, an effective choice to the mechanical prostheses, nevertheless they are not free from risks of thromboembolic complications.

[Discrete subaortic stenosis. Considerations on 64 cases surgically treated]. / Stenosi sottovalvolare aortica a diaframma. Considerazioni relative a 64 casi operati.

The AA. reviewed our experience concerning 64 patients operated on for discrete subaortic stenosis due to a fibrous membrane, between 1975 and 1981 at the Department on Cardiac Surgery "A. De Gasperis" in Milan. The clinical and hemodynamic features, the indication for operation, the surgical management and the immediate and long-term results are described. No patients died at surgery or afterwards. Only in three cases complications were noted (2 atrioventricular block, 1 pleural empyema). Of all the patients 95% were asymptomatic after operation; only three cases presented symptoms correlated with the cardiac malformation, but still they were greatly improved, compared to their preoperative status. As discrete subaortic stenosis is a progressive disorder, the operative risk is poor and the results are good, surgical treatment is recommended in symptomatic patients and if the haemodynamic gradient is 50 mmHg or greater.

[Aneurysms of the Valsalva sinus. Study of ten treated subjects (author's transl)]. / Gli aneurismi del seno di Valsalva. A proposito di 10 casi operati.

The study includes 10 patients affected by aneurysm of Valsalva sinus who underwent surgery. The aneurysm involved the "non coronary" sinus in 5 cases and the right coronary sinus in 5. All the aneurysms prolapsed into the right cardiac chambers. Additional cardiac anomalies were present in 6 patients. 4 patients were asymptomatic, 2 were in NYHA class III and 4 in class IV and one was in cardiogenic shock. Indications for surgery were hemodynamic impairment due to the shunt and/or associated anomalies. Surgical treatment included resection of the aneurysm, suture of its orifice and correction of associated cardiac anomalies. Death only occurred in one patient, who arrived at surgery in cardiogenic shock. 8 patients were followed-up for a mean period of 40 months (range 11 to 84 months), after operation: satisfactory clinical conditions were found in all of them. A mild aortic regurgitation was only observed in one patient, 8 years after surgery.

[Ebstein's malformation. Report of 9 cases surgically treated (author's transl)]. / Anomalia di Ebstein. A proposito di 9 casi operati.

Nine patients with Ebstein's malformation have undergone surgical repair since 1971. Their ages ranged from 10 to 49 years. Two patients were in functional class II and six in III. Dysrhythmias were indicators for operation in the remaining patient. All patients underwent prosthetic valve replacement. Other procedures included atrial septal defect closure in eight and plication of the atrialized ventricular segment in four cases. Three patients died during the postoperative period. Three patients died during the postoperative period. Functional classification improved in five of the six operative survivors. The multiple aspects of the clinical features, the different surgical management and the variability of results are explained by the wide range of morphologic and functional aspects of the malformation.

[The incomplete atrio-ventricular canal. Operative and long term results in 100 cases (author's transl)]. / Il canale atrio-ventricolare incompleto. Risultati immediati e a distanza di 100 casi operati.

100 patients with endocardial cushion defect of the partial type underwent surgical correction between the years 1957-1975. The age of patients ranged from 3 to 57 years with a mean of 18 years. In 89 patients there was a mitral insufficiency. The repair of the mitral valve was performed in 78 patients; in 21 was repaired also the tricuspidal valve. The hospital mortality was of 8 patients. The mortality was correlated with the age of the patients, the pulmonary pressure and with the presence of malformations of the tricuspid valve. A major complication was represented by a complete atrioventricular block that occurred in 8 patients, in 5 of these the block disappeared before the dimission from the hospital. 86 patients have been followed for a period variable from 2 to 228 months and an average of 61 months. The late mortality was of 4 patients. Two patients have been reoperated of mitral valve replacement because of residual important mitral insufficiency. The phonocardiographic study, done in 50 patients, showed a presence of a holosystolic murmur in 20. The standard X-ray chest and electrocardiogram iid not show important changes between the pre and post operative examination.

[Supravalvular aortic stenosis. Report of twelve cases (author's transl)]. / La stenosi sopravalvolare aortica. A proposito di dodici casi operati.

Twelve patients having supravalvular aortic stenosis were operated. Indication to the surgery was set up with a pressure gradient across the stenosis greater than 50 Hg millimeters and/or in a presence of important symptoms and/or with electrocardiographic signs of left ventricular hypertrophy. The technique and results of operation are described. The indication criteria to surgery on the basis of clinical results are discussed.

[Cardiac fibroma: a successfully operated case and a review of the literature (author's transl)]. / I fibromi del cuore. Un caso operato con successo e revisione della letteratura

A case of cardiac fibroma in a three years old child successfully operated on is presented. The tumor was localized on the interventricular septum and was provoking an obstacle in the outflow of the right ventricle. The preoperative diagnosis was formulated by angiocardiography. A year after the operation, the hemodynamic control showed that he interventricular pressures were normal. The problems and the importance of an early diagnosis are emphasized in patients affected by cardiac fibroma. Surgical indication, technical aspects related to the operation, the immediate and more long-term results from surgical operation of this kind of pathology, with reference to the data taken from the literature, are discussed.

[Congenital coronary fistulas: report of six operated cases (author's transl)]. / Fistole coronariche congenite. A proposito di 6 casi operati

The authors report of their own experience of 6 patients suffering from congenital coronary fistula. In 3 cases the fistula originated from the right coronary artery and in the other 3, from the branches of the left coronary artery. In 2 cases the fistula ended in the right atrium and in 4 cases in the right ventricle. Three patients were asymptomatic, 2 with cardiac insufficiency and 1 suffering from angor. We normally recommend surgical operation for the symptomatic patients, and for the asymptomatic, whenever there is a considerable shunt sin/dx and/or for important electrocardiogram alteration. All of the patients was operated on, 4 of them by means of extracorporeal circulation. In 3 of them a straight ligation of the fistula was carried out: in one, ligation of the fistula associated with the removal of a myocardial aneurysm, in one the suture of the intima of the fistula after arteriotomy, and in one the suture after right atriotomy. There were no complications immediately after the surgical operation. Five of our patients were checked from 3 to 7 years after the operation. All of them showed a normal radiological picture and disappearance of electrocardiogram evidence of pre-existing myocardial ischemia.

[Rupture of interventricular septum secondary to blunt chest trauma. Report of a case surgically treated with success (author's transl)]. / Rottura del setto interventricolare da trauma chiuso del torace. A proposito di un caso operato con successo

A case of interventricular septal defect secondary to blunt chest trauma is reported. It was characterized by a disconnection of the interventricular muscolar septal in the anterosuperior part of the heart wall. The diagnosis, suspected by clinical and instrumental parameters, was definitely confirmedy by hemodynamic and contrastographic examination. Repair surgery of the defect with a dacron patch was performed, using extracorporea normothermic circulation seven months after the accident. The patient was examined three months and twelve months after the operation; the clinical examinations did not reveal any cardiac murmur and the patient's health was satisfactory. The incidence, mechanism of rupture of interventricular septum and the main surgical and clinical aspects of this type of pathology are discussed.