Simultaneous surgical treatment of chronic post-traumatic aneurysm of the thoracic aorta, diaphragmatic hernia and giant emphysema bulla.

Thoraco-abdominal blunt trauma can lead to multiple injuries of several organs. We report a case of a patient in whom, 10 years after a trauma, a chest X-ray showed visceral herniation into the left thorax. Angio computed tomographic scan (CTS) and magnetic resonance imaging (MRI) confirmed these lesions and also showed a saccular thoracic aortic aneurysm. During the surgical procedure a giant post-traumatic emphysema bulla of the left lower pulmonary lobe was discovered and repaired. In the presence of diaphragmatic injuries, CTS and MRI are mandatory for excluding other organ involvement, and during the surgical procedure, careful inspection of left thorax and abdomen should always be done to repair other possible injuries not seen before.

An unusual source of massive intra-abdominal hemorrhage during cardio-pulmonary bypass.

Intra-abdominal hemorrhage occurring while on cardio-pulmonary bypass (CPB) is a rare and potentially lethal event during coronary artery bypass procedures. We herein report an unusual case in which massive intra-abdominal bleeding during CPB originated from a previously undiagnosed ovarian tumor, leading to acute anemization and hemodynamic instability and requiring emergency gynecologic surgery.

Mediastinitis following graft replacement of the ascending aorta: conservative approach by omental transposition.

A 57-year-old patient underwent prosthetic replacement of a previously implanted ascending aorta graft and developed a periprosthetic purulent collection 1 month later. He was successfully treated by debridement of infected tissues, antiseptic irrigation and transposition of an omental flap. The postoperative course was uneventful. A chest computed tomography scan performed 15 months later showed no signs of perigraft infection. Prompt conservative surgical treatment including omental transposition can be effective in the treatment of mediastinitis following graft replacement of the ascending aorta.

Topical use of tranexamic acid in coronary artery bypass operations: a double-blind, prospective, randomized, placebo-controlled study.

OBJECTIVES: We sought to investigate the effect of topical application of tranexamic acid into the pericardial cavity in reducing postoperative blood loss in coronary artery surgery. METHODS: A prospective, randomized, double-blind investigation with parallel groups was performed. Forty consecutive patients undergoing primary coronary surgery were randomly assigned to group 1 (tranexamic acid group) or group 2 (placebo group). Tranexamic acid (1 g in 100 mL of saline solution) or placebo was poured into the pericardial cavity and over the mediastinal tissues before sternal closure. The drainage of mediastinal blood was measured hourly. RESULTS: Chest tube drainage in the first 24 hours was 485 +/- 166 mL in the tranexamic acid group and 641 +/- 184 mL in the placebo group (P =.01). Total postoperative blood loss was 573 +/- 164 mL and 739 +/- 228 mL, respectively (P =.01). The use of banked donor blood products was not significantly different between the two groups. Tranexamic acid could not be detected in any of the blood samples blindly collected from 24 patients to verify whether any systemic absorption of the drug occurred. There were no deaths in either group. None of the patients required reoperation for bleeding. CONCLUSIONS: Topical application of tranexamic acid into the pericardial cavity after cardiopulmonary bypass in patients undergoing primary coronary bypass operations significantly reduces postoperative bleeding. Further studies must be carried out to clarify whether a more pronounced effect on both bleeding and blood products requirement might be seen in procedures with a higher risk of bleeding.

Posterior-septal pseudo-pseudoaneurysm with limited left-to-right shunt: an unexpected easy repair.

Cardiac rupture represents a fatal complication of acute myocardial infarction within the first two weeks. In exceptional cases, the postinfarction rupture of the myocardium is not transmural but remains circumscribed within the wall itself as a cavity joined to the left ventricle through a narrow neck. This finding is usually defined as pseudo-pseudoaneurysm. We report a rare case of postinfarction posterior pseudo-pseudoaneurysm of the left ventricle, perforated into the right ventricle. This unusual anatomy resulted, over a period of several years, by progressive intramural dissection of the surrounding necrotic myocardium with late formation of a large, partially fibrotic chamber, communicating either with left and right ventricles. Despite correct preoperative diagnosis was not achieved by 2D echocardiography, pulsed Doppler and contrast ventriculography, a successful surgical treatment was possible with a really good outcome.

Marked elevation of myocardial trace elements in idiopathic dilated cardiomyopathy compared with secondary cardiac dysfunction.

OBJECTIVES: We sought to investigate the possible pathogenetic role of myocardial trace elements (TE) in patients with various forms of cardiac failure. BACKGROUND: Both myocardial TE accumulation and deficiency have been associated with the development of heart failure indistinguishable from an idiopathic dilated cardiomyopathy. METHODS: Myocardial and muscular content of 32 TE has been assessed in biopsy samples of 13 patients (pts) with clinical, hemodynamic and histologic diagnosis of idiopathic dilated cardiomyopathy (IDCM), all without past or current exposure to TE. One muscular and one left ventricular (LV) endomyocardial specimen from each patient, drawn with metal contamination-free technique, were analyzed by neutron activation analysis and compared with 1) similar surgical samples from patients with valvular (12 pts) and ischemic (13 pts) heart disease comparable for age and degree of LV dysfunction; 2) papillary and skeletal muscle surgical biopsies from 10 pts with mitral stenosis and normal LV function, and 3) LV endomyocardial biopsies from four normal subjects. RESULTS: A large increase (>10,000 times for mercury and antimony) of TE concentration has been observed in myocardial but not in muscular samples in all pts with IDCM. Patients with secondary cardiac dysfunction had mild increase (< or = 5 times) of myocardial TE and normal muscular TE. In particular, in pts with IDCM mean mercury concentration was 22,000 times (178,400 ng/g vs. 8 ng/g), antimony 12,000 times (19,260 ng/g vs. 1.5 ng/g), gold 11 times (26 ng/g vs. 2.3 ng/g), chromium 13 times (2,300 ng/g vs. 177 ng/g) and cobalt 4 times (86,5 ng/g vs. 20 ng/g) higher than in control subjects. CONCLUSIONS: A large, significant increase of myocardial TE is present in IDCM but not in secondary cardiac dysfunction. The increased concentration of TE in pts with IDCM may adversely affect mitochondrial activity and myocardial metabolism and worsen cellular function.

Comparison of response to serotonin of radial artery grafts and internal mammary grafts to native coronary arteries and the effect of diltiazem.

We studied the response of radial artery (RA) or left internal mammary artery grafts to the intraluminal infusion of serotonin in 22 consecutive patients 1 year after the operation, subsequently evaluating the effect of diltiazem in 9 patients. Serotonin causes a significant vasoconstriction of the RA grafts, but not of the left internal mammary artery grafts, whereas oral diltiazem treatment does not prevent the effect of the higher dose of serotonin on RA grafts.

Aortic valve replacement via ministernotomy: early results of a two-center study.

BACKGROUND: The reversed T ministernotomy has been proposed by Gundry to perform different congenital and common acquired heart valve operations. In this study we assessed the technical aspects of this approach for aortic valve replacement before starting a prospective randomized study. We evaluated the results of a two-Center study on the technical feasibility of aortic valve replacement via the reversed T ministernotomy according to the Gundry's approach. METHODS: From January to October 1998 aortic valve replacement via ministernotomy was successfully accomplished in 16 patients at the Catholic University of the Sacred Heart of Rome (Italy) and the Academisch Ziekenhuis of Groningen (The Netherlands). RESULTS: No complications were reported, except for the damage to the internal mammary artery during the opening of the sternum. The mean postoperative stay was 5.1 days. The postoperative respiratory recovery was easy and fast. CONCLUSIONS: Prospective randomized studies are needed to evaluate the effectiveness of the minimally invasive approach compared to standard sternotomy.

The use of pulmonary allografts for aortic valve replacement. Short term results and comparative morphometric analysis of the aortic and pulmonary valves.

UNLABELLED: The satisfactory results of aortic valve replacement with pulmonary autograft and the limited availability of aortic allografts prompted us to use the pulmonary valve as an aortic valve substitute and to perform a morphometric analysis of the two valves in cadavers. CLINICAL STUDY: From March 1994 to March 1995 20 patients underwent an aortic valve replacement (AVR) with a pulmonary allograft (PA). Twelve patients were men, 8 women; age ranged from 15 to 58 years. In 4 cases the indication to AVR was an infective endocarditis which was acute in two patients. Functional class was NYHA II in 18 cases and NYHA III in 2 patients with active endocarditis. Left ventricular ejection fraction (LVEF%) was preserved in the majority of patients (mean LVEF=53% range 36% to 65%). End diastolic aortic valve diameters were measured by bidimensional echocardiography in parasternal long axis view and ranged from 18 mm to 29 mm. The diameters of the allografts implanted ranged from 19 mm to 27 mm. Donors age ranged from 19 years to 55 years. We tried to use the allograft from the youngest donor available. The surgical technique was the classic "Ross" coronary freehand implantation in 11 cases, a "Miniroot" implant in 8 instances and a "Miniroot" implant combined with a "Nicks" annular enlargment in 1 case. Aortic cross clamping ranged from 66 mm to 118 m (92m+/-10m). One patient died (5%) of infarction. In this patient the allograft was replaced with a mechanical valve because the echocardiography showed a rapidly increasing aortic regurgitation. At hospital discharge a slight aortic regurgitation was detected in 2 cases. In these two patients, whose annulus diameters were 26 mm and 28 mm respectively, we adopted a classic freehand technique of implantation. Mean postoperative transvalvular gradient was 4 mmHg+/-3 mmHg. The follow-up ranges from 45 days to 14 months (mean 8 months). The aortic regurgitation in the two cases remains stable and no new aortic regurgitations have been detected to date. No embolic or infective episodes occurred during the follow-up. ANATOMIC STUDY: Analysis was performed on 6 couples of valves obtained from cadevers without evidence of previous valvular disease. The normalized Free Edge (FE) dimensions and Leaflet Surfaces (LS) of the pulmonary valve (PV) proved to be larger than the corresponding aortic (AV) measurements (Free edge/Diameter: PV 1.25+/-0.2 vs AV 1.16+/-0.2 p<0.05; Annular Attachment/Diameter PV 1.9+/-0.1 vs AV 1.74+/-0.2 p=NS; Valve Surface/Leaflet Surface PV 0.97+/-0.2 vs AV 0.80+/-0.2 p=0.004) indicating that the PV has a larger coapting surface.

Use of the radial artery for myocardial revascularization.

BACKGROUND: The radial artery was first used as a coronary graft by Carpentier and associates in 1973 but, due to the disappointing results, it was abandoned. In 1992 its revival coincided with the widespread use of calcium-channel blockers in cardiovascular surgery, in the belief they could prevent spasm. METHODS: From January 1993 to October 1995 we operated on 109 patients for myocardial revascularization employing the radial artery with two different surgical techniques: in 95 patients (group 1) it was "pretreated" by opening its fascia after a gentle hydrostatic dilation and then anastomosed to the aorta; in 14 patients (group 2) it was branched to another conduit. We had two operative deaths (1.82%). RESULTS: At a mean interval of 532.42 days 105 patients are still alive, 2 (1.86%) having died of abdominal tumors. Fifty-six patients (52.33%) underwent angiography at a mean interval of 334.42 days: the patency of the radial artery was 88.88% in group 1 and 62.50% in group 2. Indications and contraindications are discussed. CONCLUSIONS: The radial artery is an easily manageable conduit whose early patency is very promising, although a longer follow-up is mandatory.

Safe removal of the radial artery for myocardial revascularization: a Doppler study to prevent ischemic complications to the hand.

Radial artery harvesting has recently been reintroduced for myocardial revascularization. Harvesting the radial artery may jeopardize the vascularization of the hand; cautious selection of candidates must therefore be pursued. The study involved 188 consecutive patients. We verified the patency of the upper limb's arteries and the adequacy of the ulnar supply by static and dynamic Doppler evaluations. The use of the radial artery was contraindicated in 14 cases (three for stenosis of the subclavian artery and 11 for inadequate collateralization). One hundred patients were operated on with the radial artery used as a graft; the remaining 74 patients had a different conduit placed. The vascularization of the hand was restudied within 10 days in all patients who underwent operation; in 63 patients, it was studied again at 1 year. The early Doppler examination showed significant increase in blood flow velocities in the ulnar artery, with a flow redistribution in the common digital palmar arteries (decreased in the first and increased in the second and the third). The late Doppler examination showed superimposable findings. No local ischemic complications were observed. We conclude that Doppler study is a useful tool in preoperative screening of candidates for radial artery harvesting for myocardial revascularization.

Creatine-kinase isoenzyme pattern in colonic infarction consequent to acute aortic dissection. A case report.

Bowel infarction can complicate acute aortic dissection (AAD); in that case early diagnosis, which decreases the high mortality, is often difficult. We report the case of one patient who underwent surgery for AAD and developed a colonic infarction, which was clinically manifest on the 4th postoperative day. However, bowel ischemia was suspected already 48 hours after surgery, on the basis of the suggestive CK pattern and the absence of myoglobin in plasma. Total CK activity reached the highest level only 48 hours after surgery (92,800 U/l); the peak was coincident with LDH, which increased proportionally less; CK-MM constituted 100% of total CK activity. The absence of myoglobin in plasma excluded the presence of rhabdomyolysis. We conclude that such laboratory findings suggest the occurrence of severe bowel ischemia.

Preliminary experience with a percutaneous cardiopulmonary support system.

Percutaneous cardiopulmonary bypass has been introduced to support circulation in critical patients. In our preliminary experience we resuscitated two patients who sustained a prolonged cardiac arrest (52 min. and 31 min.) after coronary angiography and elective cardiac surgery, respectively. Cannulation was achieved percutaneously within 10 min. in both cases. Pump flow ranged from 2 to 31/m. Total support lasted from 52 min. to 180 min.. Both patients were successfully weaned. Patient 1 was declared brain dead and expired 17 days later. Patient 2 was discharged from the hospital and is doing well. Cannulation was attempted in a third patient after 30 min. of cardiac arrest. Despite surgical cut down of the femoral vessels, it was impossible to advance the arterial cannula because of bilateral occlusive disease. We conclude that PCPS is a powerful technique in selected patients to recover a stable cardiac function after prolonged cardiac arrest.

Somatomedin-C plasma levels after coronary revascularization.

The decrease of Somatomedin-C (SM-C) plasma levels has been recently proposed as an index of acute malnutrition in critically ill patients. In this study SM-C values were determined before surgery for coronary revascularization, on the 2nd and 5th postoperative day. Twenty-four patients were admitted to the study; most of them (16 cases; 66%) presented with an increase of SM-C levels after surgery unlike 8 patients who showed unchanged or decreased levels. Multivariated analysis was applied to the factors that may affect SM-C values. SM-C significantly related to the Modified Predictive Nutritional Index, which was calculated prior to surgery, while no significant relationship was observed with patient age and type of oxygenator. No sign of liver damage was observed, so we concluded that decreased and, perhaps, unchanged SM-C levels after coronary revascularization were probably caused by acute nutritional deficiency. The incidence of this finding was remarkably high (33%) in spite of the absence of apparent malnutrition before surgery.

Surgical treatment of cardiac arrhythmias.

This report describes 20 consecutive patients who underwent surgical procedures for treatment of cardiac arrhythmias. 16 patients have been operated for WPW syndrome, always using the epicardial approach, without extracorporeal circulation. Three patients underwent surgery for atrio-ventricular nodal reentrant tachycardia, using a discrete perinodal cryotreatment, during normothermic extracorporeal circulation. In one case we used cryoablation of the atrial myocardium below the coronary sinus to treat atrial flutter. This operation was performed under normothermic extracorporeal circulation. In our observations, there was no early or late death; postoperative complications developed in 1 patient (5%) due to pericarditis. Ablation of the AP was completely successful in all the cases (100%) operated for WPW as well as for AVNRT syndromes and atrial flutter.