[Death conference: hindsight in heart surgery]. / Death conference: il "senno di poi" in cardiochirurgia.

We report eight cases of death or decerebration occurred during major cardiothoracic surgery. The technical aspects that contributed to the failure are analyzed on the basis of the Italian Criminal Code (art. 43). When this type of event occurs, a case review frequently identifies failure to take action or imprudent behavior. The informed consent regulation currently in force may be helpful in identifying and following the most prudent conduct for the patient. The "death conference" should be a formalized and binding instrument for hospital accreditation.

Left-ventricular diastolic dysfunction during pneumonectomy--a transesophageal echocardiographic study.

Left-ventricular dysfunction, with acute increase in capillary pulmonary pressure, can unexpectedly develop in patients submitted to pneumonectomy. In order to study the morphofunctional modifications induced by pneumonectomy on the left cardiac chambers, we performed intraoperative transesophageal echocardiography (TEE) in 8 patients (7 males, mean age 66 years) undergoing pneumonectomy for lung cancer. No patient had any cardiac involvement before surgery. The opening of the pericardium was associated with a slight paradoxical movement of the basal interventricular septum. After ligature of the pulmonary artery, the interventricular septum changed its geometry, losing the normal curvature and becoming rectilinear. These changes were related to an increase in right-ventricular (RV) dimensions. In all patients the pulmonary vein flow-profile (pulsed Doppler) showed an increased turbulence, associated with a reduced amplitude (5 patients) or an inversion (3 patients) of the second systolic component and with the development of mild mitral regurgitation (color Doppler). These changes disappeared at the end of intervention, before chest closure. No alteration in left-ventricular systolic function was found. These results suggest that the altered geometry of the interventricular septum, mainly due to acute RV overload, induces a transient left-ventricular diastolic dysfunction, associated with mild mitral regurgitation.

[Features and evolution of postoperative pain in patients undergoing thoracotomy]. / Caratteristiche ed evoluzione del dolore postoperatorio in pazienti sottoposti a toracotomia.

We examined in this perspective study 30 patients (15 males and 15 females) who undergone classic thoracotomy for lung or mediastinal diseases, without postoperative complications. Intensity and different qualitative components of postoperative pain have been evaluated in the 1st, 3rd, 5th, the day after last pleural drainage removal and 2 months after the operation. All patients answered a schedule adherent to Questionario Italiano del Dolore (QUID). Pain became less intense chiefly with drainage removal with the same time trend for both sex (parallel curves). Pain is probably stronger in women. From a qualitative point of view, the sensorial component is the same in both sexes. Affective and evaluative component is greater in women: in other words, women realize more than men the painful stimulus and are more troubled. A computerized analysis of answers to a questionnaire like QUID or, better, its evolution, may be helpful for a more effective pharmacological choice between pure analgesics, sedative analgesics and ataractic drugs.

[Mitral valve replacement with the Björk-Shiley monostrut prosthesis: a 4-year clinical experience]. / Sostituzione valvolare mitralica con la protesi Björk-Shiley monostrut. Esperienza clinica di 4 anni.

Mitral valve replacement with Björk-Shiley monostrut prostheses was performed in 142 patients, aged 18 to 73 (mean age: 53.8). A group of 101 patients underwent isolated mitral replacement (group A), while both mitral and aortic (in one case tricuspid) valves were replaced in 41 (group B). In 19 of group A patients and in 9 of group B patients a tricuspid annuloplasty was added. Hospital mortality was one case in each group (group A: 1%; group B:2.4%). The cause of death was low output in both cases (i.e. not valve-related). Late mortality occurred in 4 cases (4%) in group A, and in 3 cases (7.3%) in group B (follow-up: 6 to 58 months; mean follow-up: 24 months). Actuarial survival was 93.79% in group A and 89.94% in group B one year after surgery; it was 93.79% in group A and 81.76% in group B after 3 years. All deaths from undetermined causes, as well as any new unexplained neurological deficit or peripheral emboli, were considered to be valve-related: 84.18% of group A patients, as well as 67.90% of group B, were event free after 3 year (actuarial). most valve-related events occurred in the first year after surgery. We observed thromboembolism in 3 cases for each group: one patient in group B had pannus formation over the prosthetic annulus; prosthetic valve endocarditis in 1 case of group A and 2 of group B; significant hemorrhage due to anticoagulant therapy in 1 (group A); one patient in each group died suddenly, 4 and 7 months postoperatively. One group A patient and 2 group B patients were reoperated: a new valve prosthesis was implanted in two patients. Mean transvalvular gradient, as determined by echocardiography, was 3.8 +/- 2.3 (SD) mmHg in the case of isolated mitral replacement. In conclusion, we believe these results are highly encouraging, especially in the isolated mitral replacement group. Björk-Shiley monostrut prosthesis has been demonstrated to be a reliable valve substitute, with an acceptable incidence of complications. No Björk-Shiley monostrut prosthesis structural deterioration was seen, and its hemodynamic behaviour may be considered satisfactory.

High-dose aprotinin: hemostatic effects in open heart operations.

Two groups of patients were prospectively studied to evaluate the hemostatic effects of high-dose aprotinin in open heart operations. Group A patients (n = 22) received aprotinin during the entire surgical procedure. Group B patients (n = 12) served as controls. The groups were homogeneous for base variables and for cardiopulmonary bypass duration. Postoperative bleeding was lower in group A (mean, 486 mL) than in group B (830 mL) (p less than 0.01). The need for banked blood decreased by approximately half in the aprotinin patients (mean: group A, 213 mL; group B, 409 mL). Hemoglobin levels were similar in the two groups (postoperative day 7: group A, 11.29 g/100 mL; group B, 11.26 g/100 mL; NS). Platelet count decreased at the end of operation in both groups (99,000 and 95,000/mL, respectively; NS) and then increased beyond baseline levels before discharge. No complications were observed that could be attributed to aprotinin. In conclusion, we believe that the use of high-dose aprotinin is safe and effective. It decreases blood loss and reduces the need for banked blood in cardiac operations, particularly in select groups of patients (eg, those undergoing reoperation, Jehovah's Witnesses, those with renal failure).

[Transesophageal color-coded Doppler echocardiography: diagnosis of regurgitation of mitral valve prosthesis]. / Ecocardiografia Doppler a codice di colore per via transesofagea: diagnostica dei rigurgiti protesici mitralici.

In patients with mechanical mitral prosthesis, the presence of dysfunction and regurgitation of the prosthesis may be difficult to assess by standard precordial color flow Doppler. Moreover, the kind of mitral prosthesis regurgitant jet is often impossible to determine. We have recently studied 4 patients with clinically suspected mitral prosthesis dysfunction. In all of them the conventional transthoracic color flow technique was unable to evidentiate prosthesis regurgitation, whereas the transesophageal color flow Doppler assessed a partial displacement with a peri-prosthetic regurgitation in 3 patients, and a prosthetic endocarditis with intra-prosthetic regurgitation in 1. All studies were performed using an Aloka SSD 860 and 5 MHz transesophageal color Doppler transducer, using a topical anesthesia with 10% lidocaine. The procedure was well tolerated without any complication in all patients. Transesophageal color flow Doppler has specific improved capabilities over transthoracic conventional color flow Doppler and represents an important advance even for the noninvasive evaluation of patients with suspected mitral prosthesis regurgitation.

[Compliance problems in the oral anticoagulant treatment of patients wearing heart valve prostheses]. / Problemi di "compliance" nel trattamento anticoagulante orale dei portatori di protesi valvolari cardiache.

The need for and the efficacy of oral anticoagulation in patients who have undergone prosthetic valve replacement is widely demonstrated. The aim of this study is to assess how dicumarolic treatment is understood and actually accomplished by patients. A 30-question form was sent to 292 patients discharged following valve replacement, 5 to 45 months (mean: 19 months) after surgery. All of the 220 patients who submitted their answers, were effectively on oral anticoagulants. More than 95% of them knew exactly the suggested optimal prothrombin activity range. About one fifth of the patients has laboratory tests performed weekly, and nearly one half does so every 10-15 days. One fourth of the patients does not consult a physician for decision making about drug dosage. Difficulties in maintaining anticoagulation in the desired range, occurring at least once every month, are reported by 18.6% of patients. Haemorrhage was never experienced by 83.18%; in one single case thromboembolism was apparent. A few patients (2.27%) think of oral anticoagulation as a "difficult" treatment. We conclude that complete information is needed, about the aim, the modality, and the potential hazard of oral anticoagulation, so that a better understanding of the treatment and an improved cooperation between physicians and patients can result in benefits, in terms of the safety and efficacy of life-long antithrombotic therapy.

Giant left atrium and mitral valve disease: early and late results of surgical treatment in 40 cases.

Forty consecutive patients undergoing mitral valve replacement with a giant left atrium, form the basis of this report. Two groups could be identified: (a) isolated giant left atrium (11 cases); (b) combined left and right atrial enlargement (29 cases). Tricuspid regurgitation was only detected in the latter group. The early hospital mortality was 20% and was related to the pulmonary arterial systolic pressure. A giant left atrium increased the operative mortality from 7% to 20% among patients submitted to mitral valve replacement in our unit (p less than 0.05).

Autologous monocusp pulmonary valve: preliminary results of a new surgical technique.

A new technique for constructing a pulmonary valve from the wall of the pulmonary artery is described. Hemodynamic studies conducted following this procedure demonstrated no systolic gradient and good diastolic competence. A long-term study of this procedure is needed to determine whether or not the technique has clinical applicability.

[Emergency surgical treatment of infectious endocarditis. Experience developed on 19 consecutive cases]. / Terapia chirurgica di urgenza dell'endocardite infettiva. Esperienza svolta su 19 casi consecutivi.

Our experience with the emergency surgical treatment of 19 consecutive cases of infective endocarditis (IE) is reported. The aortic valve was always affected, either alone (n = 16) or together with the mitral valve (n = 3). All patients were male. In 10 cases it was possible to identify the infecting agent (a staphylococcus was found in 6). Congestive heart failure (CHF) was the principal indication for surgery in 14 cases (in 6 active IE was associated). Five patients (1 with CHF) underwent operative treatment because of systemic emboli. Fifteen patients were in New York Heart Association (NYHA) functional class IV, 3 in class III and 1 was in class II. Two patients (10.5%), both operated on for CHF, died in the early postoperative period. Early prosthetic valve dehiscence occurred in 2 cases, reoperation was successful in both. Follow-up of operative survivors ranges between 7 and 108 months (mean = 53.24 +/- 41.89). One patients died 10 months after operation with CHF following late prosthetic dehiscence. Out of 16 currently surviving patients 14 are in NHYA functional class I, 1 is in class II and 1 in class III. No one of them has had relapse of IE.

[Use of the endocrine artificial pancreas (GCIIS; Biostator) in heart surgery]. / Applicazione del pancreas artificiale endocrino (GCIIS; Biostator) nella cardiochirurgia.

It is well known that deep hypothermia used in open-heart surgery is usually associated with a marked reduction in carbohydrate tolerance, especially dangerous in the diabetic patient, since it might result in severe metabolic complications, namely ketosis and hyperosmolar coma. In order to prevent the occurrence of such complications we treated an insulin-dependent diabetic patient undergoing cardiovascular surgery, with a feed-back insulin infusion operated by an artificial pancreas (GCIIS, Biostator). The Biostator was then used to perform a continuous (minute by minute) blood glucose monitoring in 2 more patients, a type II (non insulin-dependent) diabetic and a non diabetic. Blood samples were drawn sequentially in order to determine plasma free insulin concentration. The glycemic profile observed in the insulin-dependent diabetic under artificial pancreas treatment was similar to that in the non-diabetic. Plasma free insulin levels dropped near to zero during by-pass cooling, returning toward basal level during the rewarming phase. Such results are then discussed by the Authors and given a pathogenetic interpretation.

[Epicardial lipoma. Report of a surgical case and review of the literature]. / Lipoma epicardico. Descrizione di un caso clinico sottoposto ad intervento chirurgico e revisione della letteratura.

A case of massive epicardial lipoma in an asymptomatic patient is presented. The diagnosis of solid intrapericardial mass was achieved by two-dimensional echocardiography without cardiac catheterization. The complications of postoperative course, which included myocardial infarction, cerebral embolism, and the patient's late sudden death, suggest that the cardiopulmonary bypass should be used in similar circumstances. Lipomas of the heart should be kept in mind in patients with unexplained enlargement of the cardiac silhouette whenever pericardial effusion and heart disease may be excluded.