David operation: single center 10-year experience.

AIM: Aortic valve-sparing operation has been progressively widely performed for the treatment of aortic root aneurysm. Nowadays, this procedure has been proposed even in presence of a bicuspid aortic valve, severe aortic regurgitation or in primary aortic dissection repair. We present our ten-year experience focusing on mid-term echocardiographic follow-up. METHODS: Between June 2002 and February 2012, 139 patients (mean age of 61±12 years) underwent aortic valve-sparing operation with valve reimplantation. Twenty-seven patients (19%) had bicuspid aortic valve; in eighteen cases (13%) cusp motion or anatomical abnormalities concurred in determining aortic regurgitation and needed an adjunct cusp repair. A Gelweave Valsalva™ graft was implanted in all the patients. RESULTS: The mortality pre-discharge was 0.7% (1 patient). The cumulative 1-year, 5-years and 8-years survival rates were 99%, 93% and 87% respectively. Postoperative aortic regurgitation more than mild degree (>2+/4+) was the only significant risk factors for redo aortic valve surgery Freedom from reoperation due to aortic valve regurgitation was 96% at 1 year, 90% at 5 years and 86% at 8 years. When comparing freedom from reoperation in patients with bicuspid vs tricuspid aortic valve, no differences were found (P=0.31) and the rate of aortic valve reoperation was significantly higher (P<0.001) in patients who received leaflet's repair. CONCLUSION: The durability of valve reimplantation was found to be excellent in patients with tricuspid aortic valve and normal or nearly normal cusps. Cusp prolapse and complication after cusp repair turned out to be the main causes for early failure.

Comparison between single and double internal mammary artery grafts: results over ten years.

BACKGROUND: In view of the superior patency of the internal mammary artery (IMA), grafting of this vessel to the left anterior descending artery is advantageous in terms of survival and quality of life; the benefits of using both the mammary arteries remain unproved. METHODS: Among the patients operated upon during the period 1988-1990, we randomly selected 150 patients in whom one IMA (group 1) was grafted and 150 patients in whom both IMAs (group 2) were grafted. The survival and event free curves of these two groups of patients were designed using the Kaplan-Mayer method; the log-rank test was used to assess the statistical difference between the curves and to determine whether, in the long term, benefits were superior in patients in whom both IMAs were grafted. RESULTS: Patients in group 1 were older (p = 0.002). In this group there were more patients with diabetes (p = 0.004) and with peripheral vascular disease (p = 0.047). There were more female patients in group 2 (p < 0.02) and more coronary vessels were grafted (p = 0.03). Follow-up was complete (100%) and equivalent in duration for both groups (109 +/- 30 months for group 1 and 110 +/- 33 months for group 2, p = NS). The survival rate at 10 years was equal for both groups (82.5 +/- 3.4% for group 2 vs 82.9 +/- 3.2% for group 1, p = NS) and so was the freedom from cardiac death. The provocative test for myocardial ischemia was more frequently positive in group 1 than in group 2 (21 vs 10 cases, p = 0.054). Freedom from new myocardial infarction (p = NS), angina recurrence (p = NS) and reoperation (p = NS) was equally distributed during follow-up. Group 2 patients more frequently necessitated coronary angioplasty but the difference was not significant (p = 0.17). Survival free from angina recurrence, new myocardial infarction, coronary angioplasty and reoperation was more frequent in group 2 (respectively 74.6 +/- 3.8 vs 70.7 +/- 4.1%) but the difference was not statistically significant (p = NS). CONCLUSIONS: After 12 years of follow-up, patients submitted to grafting of a single IMA more frequently presented with inducible myocardial ischemia, but neither survival nor the quality of life were superior in the patients in whom both IMAs were grafted.

[Surgical repair of degenerative atrial valve: long-term results]. / Riparazione chirurgica della mitrale mixomatosa: risultati a lungo termine.

BACKGROUND: The advantages of mitral valve repair in myxomatous regurgitation are well established. The durability of this reconstructive procedure is variable. The timing of operation is the surgeon dilemma. The aim of this study was to evaluate the early and long-term results of mitral valve repair in myxomatous regurgitation. METHODS: Between January 1990 and December 1997, 121 patients (77 males, 44 females) were operated on for myxomatous regurgitation with mitral valve repair. The surgical indication was based on the severity of mitral valve insufficiency and left ventricular dysfunction rather than the functional class. The surgical techniques were: quadrangular resection of the posterior mitral leaflet and sliding suture, triangular resection of the anterior mitral leaflet, chordal transposition and neo-chords suture, prosthetic ring (Carpentier-Edwards and Biflex rings) suture. RESULTS: There was 1 hospital death (0.8%). Long-term follow-up between 6 months and 107 months was available in 100% surviving patients. There were 6 late deaths, 3 for cardiac and 3 for non-cardiac events. CONCLUSIONS: Valve repair in mitral regurgitation caused by myxomatous disease provides excellent survival results at 51 months. Adverse outcome occurs in patients with preoperative left ventricular dysfunction, even if asymptomatic.

[The use of bilateral mammary artery in myocardial revascularization. The risk factors emergent from a multivariate analysis conducted on 474 patients]. / L'uso della arteria mammaria bilaterale nella rivascolarizzazione miocardica. Fattori di rischio emersi da un'analisi multivariata condotta su 474 pazienti.

BACKGROUND: The internal mammary artery is used as coronary artery graft conduit because of its superior patency. According to some authors, the bilateral IMA can increase perioperative morbidity. The aim of this study was to determine the risk factors increasing perioperative mortality and morbidity in the use of bilateral IMA. METHODS: We analyzed the data of 474 patients operated consecutively with the use of bilateral IMA between January 1987 and December 1995 at the Department of Cardiac Surgery of the Varese Hospital. The univariate analysis was done on 17 ordinal variables using a "Fisher exact test" and on 4 continuous variables by "pooled-variance t-test" to investigate risk factors for mortality, mediastinitis, superficial wound infection and aseptic dehiscence of the sternum; a p-value lower than 0.1 was used as cut-off point to introduce the variables into a stepwise multiple logistic regression analysis. RESULTS: From the univariate analysis are: postoperative low-output syndrome (p = 0.01), LVEF (p = 0.02) and number of grafts (p = 0.04) are correlated to hospital mortality (1.5%); obesity (p < 0.001) and peripheral arteriopathy (p = 0.009) are correlated to postoperative mediastinitis (5%); obesity (p < 0.001), peripheral arteriopathy (p = 0.009), surgeon (p = 0.001), year of operation (p < 0.001), reoperation for bleeding (p = 0.004) and length of extracorporeal circulation (p = 0.02) are correlated to superficial wound infection (7%); obesity (p = 0.002) and COPD (p = 0.05) are correlated to aseptic dehiscence of the sternum (2%). The multivariate analysis identified low LVEF as the only independent risk factor for hospital mortality (p = 0.03), whereas obesity (p = 0.01) and peripheral vasculopathy (p = 0.03) proved to be correlated to postoperative mediastinitis; obesity (p < 0.001), year of the operation (p < 0.001), low LVEF (p = 0.007) and reoperation for bleeding (p = 0.01) were correlated to superficial infection of the wound and obesity turned out to be the only risk factor for aseptic dehiscence for the sternum (p = 0.003). The infection of the wound did not increase mortality, but it did increase the mean postoperative length of hospital stay (6 days for patients free of any complications of the wound versus 29.7 days for patients with complications of the wound). CONCLUSIONS: In patients with bilateral mammary grafts, obesity is the main risk factor for complications of the wound and this event greatly increases the length of the patient's hospital stay. Consequently, we suggest that bilateral mammary artery grafts be used carefully in this subset of patients.

Reoperation for myocardial revascularization using the internal mammary artery.

From October 1984 up to February 1989, 40 patients had "redo" myocardial revascularizations using one or both internal mammary arteries (IMA) in over 1000 cases operated upon in our Department for coronary bypass grafts. Thirty-one patients had a further operation for unstable angina difficult to control with drugs. Mean interval of recurrence of angina after previous surgery was 48.5 months for all the cases, but the mean interval before the second bypass operation was 68 months. Severe disease of previous vein grafts was the reason for surgery in 25 patients and progressive atherosclerosis in native coronary arteries in 15 patients. Twenty-one patients had a single mammary artery; both mammary arteries were used in 19. Two cases had endarterectomy on left anterior descending (LAD). Four patients had peroperative acute myocardial infarction (AMI), 3 a low cardiac output syndrome, postoperative bleeding occurred in 3 cases and wound infection in one case. An intraaortic balloon pump was used preoperatively in one case and coming off bypass in two others. One patient died on the second day postoperatively from cardiac arrest following bilateral pneumothorax. There were no late deaths. At a mean follow-up of 20.5 months, 28 patients are free of symptoms but 11 are complaining of angina, 5 during exercise and 6 at rest. An exercise test was positive in 8 patients.

[Emergency myocardial revascularization in acute evolving myocardial infarct]. / Rivascolarizzazione miocardica d'emergenza nell'infarto miocardico acuto evolvente.

Immediate coronary artery bypass for acute evolving myocardial infarction could be the elective therapy if provided on useful time, because myocardial salvage can be achieved by early reperfusion. Thirty eight patients had emergency coronary artery by-pass graft for acute evolving myocardial infarction during the early phase: 35 were male, the mean age was 51 years (34 to 74). The mean interval between the onset of symptoms and surgery in this series of patients was two hours and a half. This interval seems to be also the time limit in our experience to get a partial or complete recovery of ischemic area. Four patients died in hospital, but they were in severe cardiogenic shock before emergency surgery. Twenty nine cases were free of symptoms at a mean follow-up of 18 months (6 to 36) and two suffered for residual angina. Three patients died after discharge few months later: two during redo emergency vein grafts operations, one in deep left ventricular failure, while he was waiting for heart transplant. All these patients operated on as emergency developed acute myocardial infarction during their stay in hospital waiting for catheter study, surgical operation or during percutaneous transluminal coronary angioplasty. Saphenous vein grafts, were used in twenty nine patients, left internal mammary artery in nine cases, single in four and associated to saphenous vein in five, with an average number of anastomoses of 2.6 (1 to 6) for patient. ECG was found to be normal in 76% of the patients operated on within two hours and a half from the beginning of symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)

[Multiple anastomosis with the internal mammary arteries]. / Anastomosi multiple con le arterie mammarie interne.

Between February 1984 and June 1985 90 consecutive patients underwent a surgical procedure of myocardial revascularization with multiple anastomoses, using one or both internal mammary arteries by single or sequential anastomoses. In 53 cases venous graft were also used. 86 cases had elective surgery and 4 had emergency surgery for unstable angina. Most of the patients had triple vessels disease; left main stenosis was present in 14. Left ventricular ejection fraction was less than 0.35 in 8 cases. A single internal mammary artery was used in 61 patients with sequential anastomoses; in 3 of these a triple sequential anastomoses was performed. In 29 patients both mammaries were used, 6 of these were anastomosed in double sequential way. Right mammary was always sewn on the marginal branch of the circumflex artery through the transverse sinus. The incidence of perioperative myocardial infarction was 2.2%. There was no hospital mortality. Reparative surgery to control immediate postoperative bleeding was required in 5 patients (5.5%). 5 cases presented a wound infection. 32 sequential anastomoses were restudied angiographically: 30 of these were patent and 2 malfunctioning. There were two late deaths: one 5 months postoperative, for gastric hemorrhage and the second one 6 months after surgery for inferior myocardial infarction. Mean follow-up of 10 months was complete in 88 surviving patients of whom 80 (91%) were asymptomatic, and 8 cases had residual angina: 5 only during exercise, 3 at rest. We conclude that the extended use of the internal mammary artery grafting, as single or sequential anastomoses, is technically feasible and provides adequate perfusion to the area of myocardium supplied by such grafts.

[The internal mammary artery in myocardial revascularization]. / L'arteria mammaria interna nella rivascolarizzazione miocardica.

Internal mammary artery by-pass graft is a very usefull alternative to venous by-pass graft for myocardial revascularization. From February 1982 up to August 1984, 111 patients with coronarosclerosis have been operated on with left internal mammary artery. Right internal mammary artery has been also used in 2 cases. Left internal mammary artery has been used as a sequential graft 13 times. Vein grafts have been associated in more than 2/3 of the patients who had surgery with internal mammary artery and the mean of anastomoses per patient was 2.9. Five patients had a perioperative myocardial infarction and one an infarction shortly after the operation. Ten patients had immediate reoperation: 5 for postoperative bleeding, 2 for arterial graft anastomosis occlusion, 2 for sudden ST elevation and 1 for acute myocardial infarction. Only one patient died for acute myocardial infarction post-operatively, following coronary artery spasm. Eighty-six patients have been followed-up 3 to 31 months after surgery. Advantages and limits of this surgical technique are discussed.

[Angioplasty of the common trunk of the left coronary artery with venous patch]. / Angioplastica del tronco comune della coronaria sinistra con patch venoso.

Surgical angioplasty of the left main coronary artery for severe iatrogenic stenosis has been done on a 40 year old female patient operated upon five months before for mitral and aortic valve prosthetic replacement. Postoperative angiocardiographic study showed patent left main trunk and the patient is angina-free six months post-operatively. Operative indication and surgical technique are discussed as an alternative to aorto-coronary by-pass surgery for left main proximal stenosis without peripheral lesions. It does not result from literature that this surgical technique has ever been employed in patients previously operated with open heart surgery.