Perfusion techniques for minimally invasive valve procedures.

In this paper, we present, in detail, the simplified perfusion technique that we have adopted since January 2009 and that we have utilized in 200 cases for cardiac minimally invasive valvular procedures that were performed through a right lateral mini-thoracotomy in the 3(rd)-4(th) intercostal space. Cardiopulmonary bypass was achieved by means of the direct cannulation of the ascending aorta and the insertion of a percutaneous venous cannula in the femoral vein. A flexible aortic cross-clamp was applied through the skin incision and cardioplegic arrest was obtained with the antegrade delivery of a crystalloid solution. Gravity drainage was enhanced by vacuum-assisted aspiration. There were no technical complications related to this perfusion technique that we have adopted in minimally invasive surgical procedures.

Off-pump coronary surgery in a patient with multiple sclerosis.

Surgery in patients with multiple sclerosis, the most common autoimmune demyelinating disorder of the central nervous system, represents a challenge for surgeons and anesthesiologists because of the reported risk of relapse of the neurologic symptoms in the perioperative period. In this report, we describe the management of a patient with relapsing-remitting multiple sclerosis and critical coronary artery disease, who underwent an uneventful off-pump coronary artery revascularization. The issues pertaining to the performance of coronary surgery revascularization on patients with multiple sclerosis are discussed.

Reduced transfusion requirements with a closed cardiopulmonary bypass system.

AIM: The aim of this investigation is to reduce blood transfusion in cardiac surgery patients with preoperative conditions predictive for transfusion requirements. We compared the amount of blood transfused in two groups of patients undergoing cardiopulmonary bypass (CPB) with two different circuit systems. METHODS: Sixty patients undergoing cardiac surgery were randomly assigned to two groups: in group A (N=30) cardiopulmonary bypass was accomplished with an open circuit and in group B (N=30) with a closed circuit. The open circuit consisted of a cardiotomy reservoir, a membrane oxygenator and an arterial line filter, while the closed circuit was made up of a collapsible venous reservoir, a membrane oxygenator, an arterial line filter and a cardiotomy reservoir. The amount of transfused packed red cells in each patient was measured until discharge from the hospital. RESULTS: Groups were similar regarding age, gender, body surface area (BSA), New York Heart Association (NYHA) class and comorbidity risk factors. Moreover, there were no significant differences between groups regarding the type of procedures, CPB and aortic cross-clamp times, total amount of cardioplegia and urinary output during CPB. Priming volume was 1180+/-84 mL (group A) and 760+/-72 mL (group B) (P<0.001). Significant differences in transfusion requirements emerged in the two groups: the total volume of packed red cells transfused for each patient was significantly higher in the open system group compared to the closed system group (717+/-486 mL versus 378+/-364 mL) (P=0.003). Clinical outcomes were similar in both groups. CONCLUSION: In patients with preoperative conditions predictive for the need of transfusions, the use of a closed cardiopulmonary bypass circuit can diminish the amount of transfused blood products.

Pseudoaneurysm of the left ventricle: a rare sequela to mitral valve endocarditis.

Pseudoaneurysms of the left ventricle are a very unusual sequela to mitral valve endocarditis. We report the case of a 62-year-old woman who developed postendocarditis submitral left-ventricular pseudoaneurysm, which was diagnosed by means of transesophageal echocardiography. The mitral valve was replaced with a prosthesis, and the mouth of the pseudoaneurysm was closed with a patch. We discuss the possible mechanism of development of this unusual sequela to mitral valve endocarditis and emphasize the diagnostic value of transesophageal echocardiography.

Aortic valve fibroelastoma: transesophageal echocardiographic diagnosis and surgical excision.

An asymptomatic 31-year-old woman was admitted for evaluation of a heart murmur accidentally discovered at a routine medical examination. A transesophageal echocardiogram disclosed an ostium secundum atrial septal defect and a small mass attached to the inner surface of the non-coronary cups of the aortic valve. The patient underwent closure of the atrial septal defect and excision of the mass without damage to the aortic valve. Hystological analysis of the mass was consistent with the diagnosis of papillary fibroelastoma. Papillary fibroelastoma is the most common of the cardiac valve tumors. It is benign, generally small and asymptomatic, but it has a definite tendency to produce serious embolic complications. Therefore, elective surgical resection is usually recommended. The tumor is most often an incidental finding at autopsy; occasionally it is recognized during life in patients evaluated for embolic events of unclear ethiology. This is one of a few cases in which the diagnosis of a completely asymptomatic fibroelastoma has been accomplished preoperatively, thus allowing a successful surgical therapy.

Surgical revascularization for acute coronary insufficiency: analysis of risk factors for hospital mortality.

BACKGROUND: A retrospective study of 444 patients undergoing urgent and emergent coronary artery bypass grafting for acute coronary insufficiency was performed to identify the risk factors for hospital death specifically associated with the clinical severity of the acute coronary insufficiency syndrome. METHODS: The patients were divided into three groups-urgent, emergent A, and emergent B-on the basis of the evolution of the clinical pattern of the acute coronary insufficiency syndrome on full medical treatment. The three categories were defined as follows: urgent (257 patients), surgical revascularization could be delayed for 24 to 36 hours after surgical consultation because of adequate control of ischemia; emergent A (127 patients), prompt myocardial revascularization was required because medical treatment achieved only transient regression of an unrelenting ischemic pattern; and emergent B (60 patients), prompt myocardial revascularization was required because the acute coronary insufficiency was entirely refractory to medical treatment. RESULTS: Mortality rates were 7.4% for the urgent group, 13.4% for the emergent A group, and 31.7% for the emergent B group. Multivariate analysis identified the following as risk factors for hospital mortality: ejection fraction (p = 0.023) and aortic cross-clamp time (p = 0.10) for the urgent group; aortic cross-clamp time (p = 0.017), ejection fraction (p = 0.03), and nonuse of blood cardioplegia (p = 0.04) for the emergent A group; and cardiogenic shock (p = 0.00), preoperative ischemic interval (p = 0.00), aortic cross-clamp time (p = 0.018), and nonuse of blood cardioplegia (p = 0.012) for the emergent B group. CONCLUSIONS: A more exact definition of patient risk can be achieved when predictive outcome models are constructed using the risk factors specifically related to each level of clinical severity of the ischemic syndrome.

Repair of a ruptured sinus of Valsalva aneurysm. Associated with annuloaortic ectasia and coarctation of the aorta in a patient with Marfan syndrome.

We report the case of a 16-year-old boy with Marfan syndrome who presented in severe congestive heart failure secondary to rupture of an aneurysm of the sinus of Valsalva into the right atrium, a condition that was aggravated by coarctation of the aorta. The patient also had a large aneurysm of the ascending aorta with the characteristics of annuloaortic ectasia. The patient underwent successful surgical correction and is asymptomatic 3 years after the repair.

[Asymptomatic left ventricular myxoma in pregnancy: echocardiographic diagnosis and surgical treatment]. / Mixoma ventricolare sinistro asintomatico in gravidanza: diagnosi ecocardiografica e terapia chirurgica.

Myxoma arising from the endocardial wall of the ventricles is rare. We describe here the case of a young woman in whom an asymptomatic left ventricular myxoma was incidentally discovered at the 35th week of pregnancy by transthoracic echocardiography. The echocardiogram revealed a huge intraventricular mass attached to the apex and prolapsing to the aortic valve during systole. On the basis of this ominous feature, the woman was promptly submitted to caesarean section and, after 10 days, to surgical removal of the mass.

Pseudoaneurysm of the free wall of the left ventricle without obstruction of major coronary arteries.

We report a case of a 63-year-old woman who presented with pseudoaneurysm of the free wall of the left ventricle secondary to myocardial infarction, in the presence of angiographically normal major coronary arteries. This is the only such case we know of, in which the patient underwent successful surgical correction. At last follow-up, the patient was in good condition with no evidence of cardiac disease, at 9 years after surgery.

Repair of acute dissection of the ascending aorta associated with aortic coarctation.

A 54-year-old man with coarctation of the thoracic aorta and acute dissection of the ascending aorta ruptured into the pericardium underwent emergency repair of the dissection by means of replacement of the ascending aorta and the aortic valve. Correction of the aortic coarctation was performed 4 months later. The authors examine the special problems encountered in the treatment of this infrequent clinical emergency, which include decisions on the optimal sequence and timing of repair, on the best surgical exposure, and on the technique and adequacy of circulatory support (especially the choice of the arterial cannulation site.

[Surgical revascularization in acute coronary insufficiency: an analysis of the risk factors for hospital mortality in urgencies and emergencies]. / Rivascolarizzazione chirurgica dell'insufficienza coronarica acuta: analisi dei fattori di rischio di mortalitaà ospedaliera in urgenza ed emergenza.

OBJECTIVES: A retrospective analysis of 444 patients (Pts) with acute coronary insufficiency (A.C.I.) submitted to coronary artery bypass grafting between January '85 and December '92 was performed in order to identify incremental risk factors associated with perioperative mortality and to evaluate whether prediction of mortality can be accomplished utilizing risk models specifically linked to the severity of myocardial ischemia. METHODS: Based on clinical and ECGraphic standpoints three different groups were identified: urgent group, comprehensive of 257 Pts. in whom, because of full medically controlled ischemia, myocardial revascularization could be delayed until to 24-48 hours. Emergency-A group, comprehensive of 127 Pts with recurrent ischemia despite medical therapy, but with no signs of coronary insufficiency at the time of institution of cardiopulmonary bypass (CPB). Emergency-B group, comprehensive of 60 Pts operated on after a mean preoperative ischemic interval of 3.9 +/- 2.4 hours who presented unrelenting signs of ischemia, either persisting since the inception of the clinical picture or lasting for over 30 minutes at the time of institution of CPB; among those, 27 Pts were in cardiogenic shock. RESULTS: Mortality rate in the three groups was respectively: 7.4%, 13.4%, 31.7%. Multivariate analysis identified the following risk factors of in-hospital mortality: urgent group: aortic cross-clamping time (A.C.C.T.) (p = 0.10) and ejection fraction (E.F.) (p = 0.023). Emergency-A group: A.C.C.T. (p = 0.017), E.F. (p = 0.023) and non-use of blood cardioplegia (B.C.) (p = 0.04). Emergency-B group: cardiogenic shock (p = 0.00), preoperative ischemic interval > 6 hours (p = 0.00), A.C.C.T. (p = 0.018) and non-use of B.C. (p = 0.012). CONCLUSIONS: A useful stratification of Pts with A.C.I. in three different groups, each with its own risk model, can be obtained by means of clinical-ECGraphic criteria alone. Different prognostic weights can be attributed to the variables A.C.C.T., E.F. and non-use of B.C. depending on clinical status. A significant reduction of mortality rate in Pts with cardiogenic shock can be achieved by the utilization of individually-tailored surgical management.

[AQRS left axial deviation of more than -30 degrees and incomplete right branch block in isolated ventricular septal defects]. / Deviazione assiale sinistra di AQRS oltre -30 gradi e blocco di branca destra incompleto nei difetti isolati del setto ventricolare.

Electrocardiographic findings in five out of forty-three cases of isolated Ventricular Septal Defects (VSD) demonstrated incomplete Right Bundle Branch Block (RBBB) with left AQRS deviation of more than -30 degrees. These features are said to be characteristic of VSD of the Persistent Common Atrioventricular Canal type. However, in two of our five cases a defect of the Inlet Septum was documented angiographically; in the remaining three cases a defect of the peri-Membranous septum was clearly demonstrated. Moreover hemodynamic data in our patients indicate that right ventricular diastolic overload could not account for RBBB in all of the cases. The clinical importance derived from this experience is that ECG findings of RBBB and left AQRS deviation of more than -30 degrees are not necessarily associated with, and therefore do not represent certain proof of the presence of VSD of the A-V Canal type. The association of this ECG pattern with VSD's other than the A-V Canal type, as previously observed, appears to have an anatomic explanation, which however needs further substantiation through electrophysiologic studies.

Subaortic stenosis caused by two discrete membranes.

A case of subaortic stenosis caused by two discrete membranes is presented. Following demonstration of the two distinct sites of obstruction by intraventricular pressure gradients and angiocardiogram, the two membranes were excised through a transaortic approach. The importance of being aware of the occurrence of this rare anomaly is stressed, and its surgical implications are discussed.