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1.
J Vasc Surg Cases Innov Tech ; 10(4): 101515, 2024 Aug.
Article in English | MEDLINE | ID: mdl-38873328

ABSTRACT

We present a rare case of eosinophilic granulomatosis with polyangiitis (EGPA), involving a 26-year-old woman with a history of asthma and nasal polyps. The patient presented with acute aortoiliac thrombosis and mitral insufficiency, which was successfully treated with thrombolysis, aortic thromboendarterectomy, and valve replacement. Peripheral hypereosinophilia with eosinophilic infiltration of the heart led to the diagnosis of antineutrophilic cytoplasmic antibody-negative EGPA. Treatment with prednisone and mepolizumab was started, resulting in a positive outcome. This case showcases an unusual manifestation of EGPA with large size vessel involvement and requiring surgical and pharmacological treatment. It also highlights the importance of early detection for timely intervention and an improved prognosis.

2.
Front Cardiovasc Med ; 10: 1295108, 2023.
Article in English | MEDLINE | ID: mdl-38124896

ABSTRACT

Frailty is a geriatric condition characterized by the reduction of the individual's homeostatic reserves. It determines an increased vulnerability to endogenous and exogenous stressors and can lead to poor outcomes. It is an emerging concept in perioperative medicine, since an increasing number of patients undergoing surgical interventions are older and the traditional models of care seem to be inadequate to satisfy these patients' emerging clinical needs. Nowadays, the progressive technical and clinical improvements allow to offer cardiac operations to an older, sicker and frail population. For these reasons, a multidisciplinary team involving cardiac surgeons, clinical cardiologists, anesthesiologists, and geriatricians, is often needed to assess, select and provide tailored care to these high-risk frail patients to optimize clinical outcomes. There is unanimous agreement that frailty assessment may capture the individual's biological decline and the heterogeneity in risk profile for poor health-related outcomes among people of the same age. However, since commonly used preoperative scores for cardiac surgery fail to capture frailty, a specific preoperative assessment with dedicated tools is warranted to correctly recognize, measure and quantify frailty in these patients. On the contrary, pre-operative and post-operative interventions can reduce the risk of complications and support patient recovery promoting surgical resilience. Minimally invasive cardiac procedures aim to reduce surgical trauma and may be associated with better clinical outcome in this specific sub-group of high-risk patients. Among postoperative adverse events, the occurrence of delirium represents a risk factor for several unfavorable outcomes including mortality and subsequent cognitive decline. Its presence should be carefully recognized, triggering an adequate, evidence based, treatment. There is evidence, from several cross-section and longitudinal studies, that frailty and delirium may frequently overlap, with frailty serving both as a predisposing factor and as an outcome of delirium and delirium being a marker of a latent condition of frailty. In conclusion, frail patients are at increased risk to experience poor outcome after cardiac surgery. A multidisciplinary approach aimed to recognize more vulnerable individuals, optimize pre-operative conditions, reduce surgical invasivity and improve post-operative recovery is required to obtain optimal long-term outcome.

4.
Ann Thorac Surg ; 105(5): e233-e234, 2018 05.
Article in English | MEDLINE | ID: mdl-29410328

ABSTRACT

Coronary reimplantation is a key step of aortic root replacement and may present special challenges under specific circumstances. Particularly in reoperations, mobilization of the coronary ostia can be hazardous and reattachment may require one or more interposition grafts to avoid tension, as originally described by Cabrol. We report a modified reimplantation technique of the coronary arteries that allows the creation of wide neo-ostia with minimal prosthetic material in case of a small aortic root.


Subject(s)
Aortic Aneurysm/surgery , Blood Vessel Prosthesis Implantation/methods , Coronary Vessels/surgery , Replantation/methods , Aged , Female , Humans
5.
Interact Cardiovasc Thorac Surg ; 23(4): 674-6, 2016 10.
Article in English | MEDLINE | ID: mdl-27252240

ABSTRACT

Indications for transcatheter valve implantation have been extended to treat native valve aortic regurgitation in case of disproportionate risk for open surgery. Transcatheter aortic valves are also an attractive alternative in patients who refuse blood transfusions. We report the successful off-label implantation of a self-expandable transcatheter valve in a Jehovah's Witness with prior replacement of the ascending aorta for Type A dissection, residual severe aortic regurgitation and refractory heart failure.


Subject(s)
Aorta/surgery , Aortic Aneurysm, Thoracic/complications , Aortic Dissection/complications , Aortic Valve Insufficiency/surgery , Blood Transfusion/ethics , Heart Valve Prosthesis , Jehovah's Witnesses , Aged , Aortic Dissection/surgery , Aortic Aneurysm, Thoracic/diagnosis , Aortic Aneurysm, Thoracic/surgery , Aortic Valve/surgery , Aortic Valve Insufficiency/diagnosis , Aortography , Female , Humans , Imaging, Three-Dimensional , Severity of Illness Index , Tomography, X-Ray Computed
8.
Interact Cardiovasc Thorac Surg ; 14(6): 866-7, 2012 Jun.
Article in English | MEDLINE | ID: mdl-22419793

ABSTRACT

Despite a decline in the last three decades, postinfarction ventricular free wall rupture still complicates more than 3% of acute ST-elevation myocardial infarctions and remains a surgical challenge. TachoSil (Nycomed, Zurich, Switzerland) is an equine collagen patch coated with human fibrinogen and human thrombin, which has recently been used for haemostasis in cardiovascular surgery, but its potential usefulness in free wall rupture has not been reported. Initial clinical experience with an on-pump sutureless technique without cardioplegia, using wide TachoSil patching to achieve free wall rupture repair, has been described.


Subject(s)
Cardiac Surgical Procedures , Fibrinogen/therapeutic use , Heart Rupture, Post-Infarction/surgery , Hemostatic Techniques , Hemostatics/therapeutic use , Thrombin/therapeutic use , Aged , Cardiac Tamponade/etiology , Cardiac Tamponade/surgery , Cardiopulmonary Bypass , Drug Combinations , Female , Heart Rupture, Post-Infarction/etiology , Humans , Male , Treatment Outcome
10.
Interact Cardiovasc Thorac Surg ; 12(1): 54-6, 2011 Jan.
Article in English | MEDLINE | ID: mdl-20923829

ABSTRACT

Surgical revascularization for postinfarction cardiogenic shock carries 20-50% mortality. Beating-heart techniques have been favoured, but their impact on the avoidance of additional myocardial injury is unknown. Ten consecutive patients with postinfarction cardiogenic shock, unsuitable anatomy for percutaneous coronary intervention (Syntax score 34.0±7.5; triple-vessel disease, 10/10; left main stenosis, 5/10), and no associated cardiac procedure, were selected for salvage/emergent on-pump beating-heart coronary bypass surgery. Remote muscle was sequentially substrate-enhanced reperfused through the grafts after construction of distal anastomoses. Early/late mortality, preoperative/peak postoperative enzyme release, and baseline/pre-discharge ventricular function were analysed. One early death occurred. Patients received 2.9±0.6 grafts, always employing the left internal mammary artery. Cardiopulmonary bypass duration was 140±62 min. Left ventricular ejection fraction (29.4±5.8 vs. 37.5±8.3%), wall motion score index (2.10±0.29 vs. 1.86±0.28), and end-systolic volume index (42.1±11.5 vs. 33.1±14.0 ml/m(2)) acutely improved (P≤0.001), whereas functional mitral regurgitation decreased from 1.4±0.8 to 0.8±0.4 (P=0.051). Total creatine kinase levels significantly increased (P=0.017), but myocardial band isoenzyme did not (P=0.18). After 3.1±1.4 years, eight patients are alive and seven are free of recurrent heart failure. Satisfactory functional outcome can be achieved with beating-heart on-pump revascularization for postinfarction cardiogenic shock. Perioperative enzyme releases and ventricular functional variables may suggest reduced perioperative myocardial injury.


Subject(s)
Cardiopulmonary Bypass , Coronary Artery Bypass , Myocardial Infarction/surgery , Shock, Cardiogenic/surgery , Aged , Biomarkers/blood , Cardiopulmonary Bypass/adverse effects , Cardiopulmonary Bypass/mortality , Chi-Square Distribution , Coronary Artery Bypass/adverse effects , Coronary Artery Bypass/mortality , Creatine Kinase/blood , Female , Humans , Italy , Kaplan-Meier Estimate , Logistic Models , Male , Middle Aged , Myocardial Infarction/complications , Myocardial Infarction/mortality , Myocardial Infarction/physiopathology , Prospective Studies , Recovery of Function , Risk Assessment , Risk Factors , Shock, Cardiogenic/etiology , Shock, Cardiogenic/mortality , Shock, Cardiogenic/physiopathology , Stroke Volume , Time Factors , Treatment Outcome , Ventricular Function, Left
12.
Interact Cardiovasc Thorac Surg ; 10(5): 839-41, 2010 May.
Article in English | MEDLINE | ID: mdl-20150190

ABSTRACT

Emergency repair has been successfully performed in acute type A aortic dissection complicated by cerebral malperfusion. Despite the lack of criteria to define irreversible brain damage, immediate surgery is often denied in case of stroke or coma. We report two patients presenting with coma and altered brainstem reflexes shortly after onset of aortic dissection, in whom aortic repair was successfully undertaken.


Subject(s)
Aortic Aneurysm, Thoracic/surgery , Aortic Dissection/surgery , Brain Ischemia/diagnosis , Vascular Surgical Procedures/methods , Aortic Dissection/complications , Aortic Dissection/diagnosis , Aortic Aneurysm, Thoracic/complications , Aortic Aneurysm, Thoracic/diagnosis , Brain Ischemia/etiology , Brain Ischemia/therapy , Cerebrovascular Circulation/physiology , Emergency Treatment , Follow-Up Studies , Glasgow Coma Scale , Humans , Male , Middle Aged , Neurologic Examination , Recovery of Function , Risk Assessment , Severity of Illness Index , Tomography, X-Ray Computed , Treatment Outcome
13.
Eur J Cardiothorac Surg ; 37(5): 1093-100, 2010 May.
Article in English | MEDLINE | ID: mdl-20060737

ABSTRACT

OBJECTIVE: Post-infarction ventricular remodelling has been graded (I-III) according to the loss of systolic left ventricular silhouette curvature changes. Although surgical ventricular restoration (SVR) has been extended to type III ischaemic cardiomyopathy, the results are less satisfactory. We sought to identify geometric and functional predictors of late outcome after SVR. METHODS: Among 144 patients who underwent SVR since 1998, a subgroup of 31 patients (age: 65.2+/-7.6 years) was analysed. Inclusion criteria were: type III cardiomyopathy, no associated procedure except coronary artery bypass grafting, prior anterior infarction, absent-to-2+ mitral regurgitation, elective operation, follow-up > or =18 months (mean: 44+/-26; longest: 96 months). Probability of events was estimated with the Kaplan-Meier method. A Cox multivariable regression model was constructed selecting eight potential predictors of four adverse events: death, cardiac death, recurrent heart failure (New York Heart Association class III or IV) and left ventricular re-remodelling, defined as a 25% increase of end-systolic volume index after SVR, or an end-systolic volume index > or =50 ml.m(-2). RESULTS: Early and late mortality were zero and 6% (2/31 patients, one cardiac-related death). NYHA class and all echocardiographic functional variables significantly improved early after SVR. Freedom (+/-standard error (SE)) from heart failure was 97%+/-3%, 93%+/-5%, 77%+/-11% and 64%+/-15%, whereas freedom from left ventricular re-remodelling was 97%+/-3%, 80%+/-8%, 60%+/-12% and 39%+/-15%, respectively, 1, 3, 5 and 7 years after SVR. Multivariable analysis identified baseline mitral regurgitation degree and sphericity index as independent predictors of recurrent heart failure (p=0.025; hazard ratio (HR)=7.80 (95% confidence intervals (CIs): 1.29-47.19)) and left ventricular re-remodelling (p=0.047; HR=2.84 (95% CIs: 1.01-7.95)). Both predictors also correlated with a higher recurrence of end-systolic volume index > or =50 ml.m(-2) at late follow-up. CONCLUSIONS: Despite advanced cardiomyopathy, SVR determines left ventricular volume reduction and improved systolic function. Baseline absent-to-moderate mitral regurgitation and a more spherical left ventricular geometry predict a less favourable clinical and functional outcome, suggesting a possible rationale for wider indications for combined correction of 2+ mitral regurgitation and undersizing of the mitral annulus, particularly in patients with sphericity index > or =0.75.


Subject(s)
Cardiomyopathy, Dilated/surgery , Heart Ventricles/surgery , Aged , Aged, 80 and over , Cardiomyopathy, Dilated/diagnostic imaging , Cardiomyopathy, Dilated/etiology , Cardiomyopathy, Dilated/physiopathology , Epidemiologic Methods , Female , Heart Failure/etiology , Heart Failure/prevention & control , Heart Ventricles/diagnostic imaging , Humans , Male , Middle Aged , Mitral Valve Insufficiency/complications , Mitral Valve Insufficiency/diagnostic imaging , Myocardial Infarction/complications , Postoperative Complications , Prognosis , Treatment Outcome , Ultrasonography , Ventricular Remodeling/physiology
14.
Eur J Cardiothorac Surg ; 37(4): 972-4, 2010 Apr.
Article in English | MEDLINE | ID: mdl-19853470

ABSTRACT

The optimal surgical management of simultaneous abdominal aortic aneurysm and cardiac disease remains a major challenge in case of larger aneurysms and severe cardiac disease. In case of symptomatic aneurysms or impending rupture, a single-stage combined operation is the most widely accepted procedure. We report the successful use of closed-chest cardiopulmonary bypass, with femoral venous and axillary arterial peripheral cannulation, to support cardiac function on the beating heart during resection of a giant abdominal aortic aneurysm and ischaemic cardiomyopathy. One month later, the patient underwent a second-stage deferred cardiac operation, consisting of triple coronary bypass grafting, undersized mitral annuloplasty and epicardial left ventricular lead implantation for cardiac resynchronisation therapy.


Subject(s)
Aortic Aneurysm, Abdominal/surgery , Cardiopulmonary Bypass/methods , Myocardial Ischemia/surgery , Aged , Angiography, Digital Subtraction , Aortic Aneurysm, Abdominal/complications , Aortic Aneurysm, Abdominal/diagnostic imaging , Coronary Artery Bypass/methods , Humans , Male , Myocardial Ischemia/complications , Tomography, X-Ray Computed
15.
J Thorac Cardiovasc Surg ; 139(6): 1529-38, 2010 Jun.
Article in English | MEDLINE | ID: mdl-19969313

ABSTRACT

OBJECTIVE: We sought to identify determinants of clinical and functional outcome after myocardial revascularization and associated undersized annuloplasty in patients with intermediate-degree ischemic mitral regurgitation. METHODS: Fifty-seven patients with 2+ or 3+ ischemic mitral regurgitation underwent coronary bypass surgery and implantation of undersized semirigid or flexible complete ring or autologous pericardial band and were followed up to 8.6 years. RESULTS: Operative mortality was 5%. Baseline left ventricular end-systolic volume index, the strongest multivariable predictor of early postoperative outcome, was correlated with end-systolic volume index (P < .001, R(2) = 0.67) and ejection fraction (P < .001, R(2) = 0.40) after repair. More compromised ejection fraction and end-systolic volume index predicted comparatively greater early functional improvement but higher residual postoperative end-systolic volume index (P < .01). Cox multivariable analysis identified wall motion as the best baseline predictor of late death and heart failure and regional inferoposterior wall motion as the strongest predictor of recurrent mitral regurgitation (P < or = .01). More rigid annuloplasty carried a higher probability of functional recovery in terms of ejection fraction, wall motion, and the occurrence and earlier timing of left ventricular reverse remodeling, expressed by different degrees of end-systolic volume index reduction (P < .001, hazard ratio >6). CONCLUSIONS: Combination of undersized mitral annuloplasty and coronary revascularization presents low operative mortality and determines left ventricular unloading in patients with intermediate-degree ischemic mitral regurgitation. Global and regional wall motion are powerful predictors of late outcome. Stiffer mitral annular repair promotes functional recovery and predicts higher probability and earlier timing of reverse remodeling.


Subject(s)
Coronary Artery Bypass , Heart Valve Prosthesis , Mitral Valve Insufficiency/surgery , Mitral Valve/surgery , Myocardial Ischemia/surgery , Ventricular Function, Left , Ventricular Remodeling , Aged , Aged, 80 and over , Female , Humans , Male , Middle Aged , Mitral Valve Insufficiency/complications , Mitral Valve Insufficiency/physiopathology , Myocardial Ischemia/etiology , Myocardial Ischemia/physiopathology , Prognosis , Recovery of Function , Retrospective Studies , Severity of Illness Index , Treatment Outcome
18.
Eur J Cardiothorac Surg ; 32(4): 674-5, 2007 Oct.
Article in English | MEDLINE | ID: mdl-17692529

ABSTRACT

We report the case of a 39-year-old man who underwent life-saving aortic valve replacement with a bioprosthesis for acute endocarditis while on the liver transplant waiting list, followed by successful transplantation and late valve re-replacement with a mechanical prosthesis, 10.8 years after primary valve surgery.


Subject(s)
Aortic Valve/surgery , Endocarditis/surgery , Liver Transplantation/methods , Adult , Aortic Valve/transplantation , Follow-Up Studies , Humans , Male , Sternum/surgery , Time Factors , Treatment Outcome
20.
Ann Thorac Surg ; 81(4): 1348-51, 2006 Apr.
Article in English | MEDLINE | ID: mdl-16564270

ABSTRACT

BACKGROUND: Syncope or new onset focal neurologic deficits are described in as many as one fifth of patients with acute aortic dissection referred for surgery. Coma or stroke caused by involvement of the arch vessels and secondary brain malperfusion is considered a major contraindication for emergency aortic repair. Initial experience with emergency operation in selected patients with acute type A aortic dissection complicated by coma is described. METHODS: Five comatose (median Glasgow coma score, 5.5), hemodynamically stable (systolic blood pressure > or = 100 mm Hg) patients with preserved pupillary reactivity and coma duration of less than 12 hours underwent emergency surgical repair. The ascending aorta was always replaced using profound hypothermic circulatory arrest. RESULTS: There were no operative deaths. No hemorrhagic brain infarction developed postoperatively. Ischemic strokes were documented by radiology in 3 patients, and were always right-sided. Four patients returned to normal life with no neurologic sequelae, whereas 1 patient showed partially recovered left hemiparesis and mild cognitive impairment. CONCLUSIONS: Coma may not represent an absolute contraindication for resuscitative surgery in hemodynamically stable patients with acute type A aortic dissection. A larger experience is necessary to draw more definitive conclusions.


Subject(s)
Aortic Aneurysm, Thoracic/complications , Aortic Aneurysm, Thoracic/surgery , Aortic Dissection/complications , Aortic Dissection/surgery , Coma/complications , Emergency Treatment , Acute Disease , Aged , Contraindications , Female , Humans , Male , Middle Aged
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