[Evaluation and management of patients with mitral valve stenosis]. / Valutazione e gestione dei pazienti con stenosi valvolare mitralica.

A review of the guidelines of the American College of Cardiology and the American Heart Association for the management of patients with valvular heart disease, published in 1998, is presented. The therapeutical advances introduced during the past decade, percutaneous mitral balloon valvotomy and surgical ablation of atrial fibrillation, have modified the therapeutical approach to patients with mitral stenosis. In this article some controversial aspects are examined with a review of the recent literature. The definition of "valve morphology favorable for percutaneous balloon valvotomy", which is based on echocardiographic examination, is still debatable. Different echocardiographic scores published until now are reported. Some patients, who have no or mild symptoms, develop irreversible pulmonary hypertension: in order to avoid this complication early interventional procedure is suggested, but only in those patients at low post-procedural risk. In symptomatic patients, NYHA class II/III, with atrial fibrillation it is possible to consider a conservative surgical approach combined to crioablation of atrial fibrillation. The possibility of maintaining sinus rhythm and avoiding anticoagulation leads to a revaluation of surgical repair as option to valve replacement and percutaneous mitral balloon valvotomy.

[A case of pulmonary thromboembolism after interruption of treatment with unfractionated heparin]. / Un caso di tromboembolia polmonare dopo la sospensione del trattamento con eparina non frazionata.

Pulmonary embolism is a quite frequent event (incidence 1/10000/year), and blood stasis, endothelial lesions and coagulation disorders are predisposable factors. Elective treatment is heparin, but the use of this medication is associated with a possible ipercoagulative rebound effect. The case presented is a patient with unstable angina treated with heparin infusion, who developed pulmonary embolism after discontinuation of heparin treatment; the patient didn't present a genetic coagulopathy. Others risk factors have been analyzed and it was observed that discontinuation of heparin infusion could have a predominant role in the development of thrombosis. A MedLine research on the rebound effect of heparin and how to reduce it has been carried out.

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.