[Hybrid revascularization: a combined approach to multivessel coronary artery lesions].

Analysis of effectiveness and feasibility of hybrid approach to multivessel coronary artery disease and problems of interaction between cardiac surgeons and interventional cardiologists in deciding on the choice of revascularization method is performed in the article. Hybrid approach to multivessel disease defined as sternal sparing, off-pump, minimally invasive, hand sewn left internal mammary - left anterior descending (LAD) arteries by-pass graft with percutaneous coronary revascularization of non-LAD lesions to achieve functionally complete revascularization is described in detail. Data of multicenter studies and clinical recommendations for myocardial revascularization is discussed.

A quadricuspid aortic valve associated with severe aortic regurgitation and left ventricular systolic dysfunction.

We report a case of a quadricuspid aortic valve associated with severe aortic regurgitation and left ventricular systolic dysfunction.

Coronary blood flow, metabolism, and function in dysfunctional viable myocardium before and early after surgical revascularisation.

OBJECTIVES: To assess the link between perfusion, metabolism, and function in viable myocardium before and early after surgical revascularisation. DESIGN: Myocardial blood flow (MBF, thermodilution technique), metabolism (lactate, glucose, and free fatty acid extraction and fluxes), and function (transoesophageal echocardiography) were assessed in patients with critical stenosis of the left anterior descending coronary artery (LAD) before and 30 minutes after surgical revascularisation. SETTING: Tertiary cardiac centre. PATIENTS: 23 patients (mean (SEM) age 57 (1.7) years with LAD stenosis: 17 had dysfunctional viable myocardium in the LAD territory, as shown by thallium-201 rest redistribution and dobutamine stress echocardiography (group 1), and six had normally contracting myocardium (group 2). RESULTS: LAD MBF was lower in group 1 than in group 2 (58 (7) v 113 (21) ml/min, p < 0.001) before revascularisation and improved postoperatively in group 1 (129 (133) ml/min, p < 0.001) but not in group 2 (105 (20) ml/min, p = 0.26). Group 1 also had functional improvement in the LAD territory at intraoperative echocardiography (mean regional wall motion score from 2.6 (0.85) to 1.5 (0.98), p < 0.01). Oxidative metabolism, with lactate and free fatty acid extraction, was found preoperatively and postoperatively in both groups; however, lactate and free fatty acid uptake increased after revascularisation only in group 1. CONCLUSIONS: MBF is reduced and oxidative metabolism is preserved at rest in dysfunctional but viable myocardium. Surgical revascularisation yields immediate perfusion and functional improvement, and increases the uptake of lactate and free fatty acids.

Left-side approach to the mitral valve.

BACKGROUND AND AIM OF THE STUDY: The standard, minimally invasive surgical approach to the mitral valve is usually accomplished from the right side, through a longitudinal incision posterior and parallel to the interatrial groove. The left-side approach should perhaps be reconsidered for its suitable exposure of the mitral valve. METHODS: Eleven consecutive patients underwent mitral valve surgery via a left lateral minithoracotomy, with cardiopulmonary bypass performed through the left femoral artery and vein. The left internal mammary artery was used as a coronary graft in one patient. Cardioplegic solution was delivered through the ascending aorta. After direct aorta cross-clamping, mitral surgeries were performed, including mechanical and bioprosthetic implants, redo operations, annuloplasties and repairs. RESULTS: An excellent view of the mitral valve was obtained in all cases, with optimal vision of the whole annulus, chordae tendineae, papillary muscles and aortic valve possible. Exposure of the mitral valve was superior to that achieved with the standard approach from the right, notably with a wider angle of vision and greater flexibility of movement available. Moreover, mitral valve structures were closer to the operator, making the procedure easier to perform. CONCLUSION: The left-side approach to the mitral valve offers excellent vision and exposure of the valve. Although awaiting additional cases to validate results, in the absence of major complications we recommend this technique.

The LAST operation is safe and effective: MIDCABG clinical and angiographic evaluation.

BACKGROUND: The aim of this study was to prospectively evaluate the angiographic results of a cohort of consecutive patients who underwent minimally invasive coronary artery revascularization. METHODS: From May 1997 to December 1998, 150 consecutive patients underwent left internal mammary artery to left anterior descending artery anastomosis through a left minithoracotomy on a beating heart in the Cardiovascular Department of Cliniche Gavazzeni, Bergamo, Italy. The mean age was 61.6 years (range, 36 to 84 years); 121 patients (81%) were men. Isolated left anterior descending artery disease was present in 74 patients. RESULTS: In-hospital patency was observed in 100% of the 149 angiographically controlled patients with no anomalies in 99.3% of the anastomoses. Anastomosis was performed on a diseased tract of the target vessel in 3 patients and a stenosis of the target vessel beyond the anastomosis was documented in 3 patients. In one case early angiographic control was not performed due to death of the patient on the 1st postoperative day. The morbidity included postoperative bleeding that required reopening (3.3%) and intraoperative myocardial infarction (2%). CONCLUSIONS: A left internal mammary artery to left anterior descending artery anastomosis on a beating heart through a left minithoracotomy is an alternative approach to myocardial revascularization. Surgical invasiveness is limited, cardiopulmonary bypass risks are avoided, and the procedure is safe and effective. In our consecutive series, postoperative angiographic controls demonstrated graft patency in all patients and very high quality anastomoses. Midterm clinical follow-up (14 months) appears favorable.

[The early angiographic follow-up of myocardial revascularization in a minithoracotomy: the results of the first 100 consecutive cases]. / Il controllo angiografico precoce della rivascolarizzazione miocardica in minitoracotomia: risultati dei primi cento casi consecutivi.

The use of the left internal thoracic artery anastomized to the left anterior descending coronary artery via a small left thoracotomy to revascularize the anterior wall of the left ventricle has gained wide acceptance since its introduction into clinical practice a few years ago. A mandatory, postoperative angiographic control was suggested in order to check the surgical results of this new method of revascularization. We herein analyze the results of the in-hospital angiographic control of a series of 100 consecutive patients who underwent minimally invasive coronary artery bypass. In all 100 patients the thoracic graft, the anastomosis and the target vessel were patent, with no anomalies in 90 subjects. In 4 patients, a sharp angulation of the thoracic artery in the last third before the anastomosis to the native vessel was observed; in 3 subjects, the arterial graft had been anastomized to a diseased tract of the target vessel and in 3 cases a significant stenosis of the target vessel beyond the anastomosis was documented; in 2 cases the persistence of a thoracic artery branch was discovered. Since 1) neither in-hospital total occlusion of the thoracic graft to the left anterior descending coronary artery via a small thoracotomy was documented nor a significant incidence of major anomalies was observed; 2) the anomalies documented seem to be clinically negligible and may regress in the midterm postoperative period; 3) Doppler flow analysis is able to detect not only the patency but also the presence of significant stenosis in the arterial graft; the in-hospital angiographic control of this surgical technique should be limited to patients with abnormal ultrasonic data or with reappearance of myocardial ischemia in the anterior wall of the left ventricle, thus not reducing the advantages in terms of speed and cost-control of this type of myocardial revascularization.

[Surgical therapy for prosthetic infections of the thoracic aorta. Conservative approach]. / La terapia chirurgica delle infezioni protesiche dell'aorta toracica. Approccio conservativo.

The prosthetic graft infection of the thoracic aorta is a dreaded complication and it is associated with a high mortality rate. There is not substantial agreement in literature about how to manage a vascular graft infection, except for local anti-septic irrigation with a systemic antibiotic therapy. The main point of discussion is if it is mandatory to remove or not the infected thoracic aorta prosthesis: some authors prefer to eliminate all the thoracic aortic prostheses which may be infected, while others propose graft removal only when the sutures lines are involved. In this paper we report our experience on the conservative management of infected thoracic aorta prostheses using a local antiseptic irrigation, a perigraft debridement and leaving the original graft "in situ" when there is evidence of graft damage especially or involvement of the sutures lines. This approach has been performed in three patients: two had an infected aortic arch prosthesis, while one had a descending thoracic aorta prosthesis infection.

Myocardial revascularization procedures on multisegment diseased left anterior descending artery: endarterectomy or multiple sequential anastomoses (jumping)?

Complete revascularization is the primary goal in coronary surgery because of its superior long term results. However, in some patients the extent of the coronary artery disease is such that the usual coronary bypass technique may not allow to perform a complete myocardial surgical revascularization and, consequently, a satisfactory myocardial perfusion: so complementary revascularization techniques may become mandatory, especially when the diseased vessel is LAD or its branches. As a consequence, alternative procedures should be undertaken: coronary endarterectomy (EA) and multiple sequential anastomoses on a single vessel (jump), which guidelines are actually somehow controversial. Between January, 1989, and May, 1992, 53 patients underwent a myocardial revascularization procedure on LAD system unsuitable for single distal bypass; of them 35 (66%) underwent coronary endarterectomy, while in 18 (34%) multiple sequential anastomoses (jumping) were performed on the same vessel. About preoperative variables, average NYHA class (2.7 jump vs 2.1 EA group, p < 0.05), the history of more than 1 myocardial infarction (22.2% jump vs 2.9% EA, p < 0.04) and the presence of preoperative nitrates e.v (33.3% vs 8.6%, p < 0.04) were statistically higher in the jump group, suggesting a more unstable clinical status, while other clinical echocardiographic and catheterization features were not statistically different. For what operative and postoperative features are concerned, the number of anastomoses performed was statistically higher in the jump group, as exasperated (3.8 vs 2.7, p < 0.002) while perfusion (138 vs 141 min) and crossclamp time (103 vs 106 min) were similar. Furthermore we found a statistically lower incidence of perioperative myocardial infarction (0% jump is 22.8% EA group, p < 0.04); the postperfusion inotropic drugs requirement (22.2% vs 37.1%), the need of an intraaortic counterpulsation (0% vs 2.9%) and the in-hospital mortality (0% vs 5.7%) were lower in the jumping group too, also if they didn't reach statistical significance. Our experience suggest, also with the limits imposed by a retrospective case review and by a low number of cases reported, that myocardial revascularization of a multisegment diseased LAD system may be safely performed with the jumping technique with a low incidence of postoperative complications: it should be the first choice technique when conventional revascularization procedures are not enough to achieve complete myocardial revascularization. We advocate the use of EA technique only in that cases characterized by a diffuse atherosclerotic core and a well delimited plane of dissection, associated to a very poor runoff, which really excludes any chance to multiple anastomoses.

Straddling endoventricular pericardial patch in mitral valve repair with the sliding leaflet technique.

Calcification of the mitral annulus is always a technical complication in mitral surgery and standard procedures are often difficult to perform; mitral valve replacement can be dangerous with a high risk of perioperative heart rupture, and reconstructive surgery is often contraindicated. Nevertheless in this case of posterior leaflet prolapse with annular calcification valve repair was performed, after complete calcium debridement causing annulus disruption and atrio-ventricular discontinuity, by means of a straddling atrio-ventricular pericardial patch and the sliding leaflet technique.

[Heart surgery, cardiopulmonary bypass and inflammatory response. I. Changes in hemostasis and complement]. / Chirurgia cardiaca, bypass cardiopolmonare e risposta infiammatoria dell'organismo. Parte I: Alterazioni a carico dei processi emostatici e del complemento.

The use of cardiopulmonary bypass for surgical cardiac procedures is characterized by a whole-body inflammatory reaction due to the contact of blood through nonendothelialized surfaces; this stimulates the organism to recognize the cardiopulmonary bypass system as "nonself" and to activate specific (immune) and nonspecific (inflammatory) responses. These responses are then related with postoperative damage to many body systems, like pulmonary, renal or brain dysfunction, excessive bleeding and postoperative sepsis. In this paper, present knowledge on untoward responses of the patient to the use of cardiopulmonary bypass in cardiac surgery is reviewed and discussed, particularly focusing on the perturbation of the hemostasis and of the complement activation system.

Fluoroscopic functional evaluation of bileaflet prostheses: effect of different intraoperative valve orientation.

Fluoroscopy is a reliable, easy, and readily available technique to follow-up prosthesis functioning after heart valve surgery. The different orientation given to the prosthesis may represent a limitation of the technique accounting for unsatisfactory results in 10% to 40% of the cases. The aim of the study was to evaluate whether and to what extent different intraoperative valve orientation influence feasibility and accuracy of postoperative fluoroscopic evaluation of bileaflet prostheses. We prospectively evaluated 90 patients who had aortic, mitral, and/or tricuspid valve replacement with Sorin Bicarbon or CarboMedics bileaflet prostheses. Fifty percent of the patients in each group were randomly assigned to receive prostheses oriented in a perpendicular or a parallel position with respect to the ventricular septum. Fluoroscopic evaluation was considered appropriate when the prosthesis' "tilting disk" projection was obtained. The valve's hemodynamic performance was investigated through Doppler study. A proper fluoroscopic evaluation was rapidly (15 +/- 5 seconds) achieved in all patients with the former orientation, whereas it was impossible to obtain it in 8 of 20 (40%), 19 of 20 (95%), and 4 of 5 (80%) of patients with the latter orientation. In the remaining patients extremely angulated, uneasy projection was often required to get a correct fluoroscopic image. The Doppler study showed a similarly favorable hemodynamic performance regardless of valve orientation. Prosthesis orientation crucially affects the rate of success of the fluoroscopic evaluation. The orientation perpendicular to the ventricular septum greatly facilitates the postoperative feasibility and accuracy of fluoroscopy, and it is not detrimental to the valve's hemodynamic performance. This valve orientation may provide a better fluoroscopic window whenever a valve dysfunction is suspected.

Valve design characteristics and cine-fluoroscopic appearance of five currently available bileaflet prosthetic heart valves.

Bileaflet prostheses are low profile, central flow orifice devices that show excellent hemodynamic performance and low thrombogenicity. Five models are currently used for heart valve replacement. Comprehensive and comparative studies regarding valve characteristics and functioning are lacking, making the updating and the familiarization by physicians and cardiologists with these prostheses difficult. We describe the valve design characteristics and evaluate the cine-fluoroscopic appearance and functioning of 387 bileaflet prostheses that have been implanted in 367 consecutive patients. The valve types are St Jude Medical (n = 69), Edwards-Duromedics (n = 74), Carbomedics (n = 1290) Sorin Bicarbon (n = 88) and Jyros (n = 27). The prostheses' fluoroscopic appearance was evaluated through multiple radiographic views (Siemens-Elema equipment with C-arm); the prostheses' functional evaluation was performed by obtaining the "tilting disk projection" (ie, with the radiographic beam parallel to both the valve ring plane and the tilting axis of disks) to calculate opening, closing, and travel angles of the disks. This study shows that each of the five bileaflet valves has distinctive design characteristics. Fluoroscopy is an easy, readily available, and useful technique that correctly identifies the prosthesis type and properly evaluates its functioning in the majority of cases.

Mitral annuloplasty with a flexible linear reducer.

Although the ideal technique is still controversial, mitral valve reconstruction for mitral insufficiency usually includes an annuloplasty. From August 1985 to June 1993, 126 cases of pure, acquired mitral insufficiency were repaired by means of a posterior annuloplasty. Whatever the etiology, all types of mitral insufficiency allowing a mitral reconstruction were included. The annuloplasty, performed with a flexible linear reducer, was associated with valvular (62%) and subvalvular (11%) repairs. An associated surgical procedure was necessary in 62% of the patients. Operative mortality was 2.4%, and follow-up (mean 29 months) was complete for all survivors. Five-year survival was 90%. Five-year complication-free rate for emboli was 91%. Only one patient at 12 months underwent reoperation to treat recurrent mitral insufficiency. Ninety-seven patients were in New York Heart Association Class I or II. Follow-up echocardiographic studies on 75% of eligible patients showed a free rate for significant regurgitation of 99%. Mean valve area was estimated at 2.88 +/- 0.85 cm2. These findings suggest that the flexible linear reducer seems to be a reliable device and a valid alternative for annuloplasty.

Cinefluoroscopic identification of Björk-Shiley prosthetic heart valves.

Numerous mechanical prostheses are currently utilized for heart valve replacement. Fluoroscopy is a useful technique to identify prosthetic valves, to evaluate their function and to follow-up the patients' condition. Scattered and contrasting data, however, have been reported about the radiographic appearance of Björk-Shiley heart valves. This study shows that each Björk-Shiley valve model has characteristic radiographic features that can be readily determined by fluoroscopic evaluation, leading to easy and accurate non-invasive identification.

Straddling endoventricular pericardial patch in prevention of type I myocardial rupture.

Type I myocardial rupture due to atrioventricular discontinuity in the region of the posterior mitral annulus is a fearsome and nearly unpredictable complication of mitral valve replacement. We report a case of a 49-year-old patient who had been operated on for mitral valve replacement. The posterior mitral leaflet had heavy calcifications embedded through the annulus in the posterior ventricular wall. After removal of calcifications we avoided the risk of myocardial rupture by suturing a straddling pericardial patch on the atrioventricular junction. The operation resulted in complete recovery.

Echocardiography detects myocardial damage in AIDS: prospective study in 102 patients.

Few data are available about cardiac involvement in AIDS. We examined 102 consecutive patients with AIDS diagnosed clinically and serologically (Walter Reed Stage 5 and 6), by means of TM and cross-sectional echocardiography with the aim of detecting cardiac abnormalities. None of the patients had overt clinical signs of heart failure. Fifty-five (54%) patients showed persistent tachycardia, diminished left ventricular (LV) wall thickness (mean 7.6 +/- 0.2 mm) and decreased percentage LV fractional shortening (27 +/- 5). In 42 (41%) there was a globular and poorly contracting LV. Thirty-nine (38%) patients had pericardial effusion which was moderate in 30 and small in nine. In four patients, valvular endocarditic vegetation was shown--on the tricuspid valve in three, on the aortic valve in one: all of them were drug addicts; in three (2.9%) patients a cardiac mass was found which proved to be a localization of Kaposi's sarcoma in two. Twenty-five (24.5%) patients died; necropsy showed cardiac chamber dilation, and thin LV walls in 18. On microscopic examination, myocardial fibrosis and lymphocyte infiltration with cell necrosis were observed. We conclude that cardiac abnormalities are common in AIDS. Impairment in LV contractility as assessed from fractional shortening appears to be the most common echocardiographic finding, followed by LV wall thinning, pericardial effusion and eventually by LV cavity dilation. This evolution is suggestive of myocardial damage and supports the hypothesis that dilated cardiomyopathy may be a cardiac complication of AIDS.

Focal lymphocytic myocarditis in acquired immunodeficiency syndrome (AIDS): a correlative morphologic and clinical study in 26 consecutive fatal cases.

In 26 consecutive cases with acquired immunodeficiency syndrome (AIDS) the main cardiac findings were Kaposi's sarcoma in 2 cases, microfocal myocardial abscess in 1, subendocardial infarct necrosis in 2, contraction band necrosis in 13, lymphocytic myocarditis in 9, intramyocardial lymphocytic infiltrates without myocell necrosis in 7 and epicardial lymphocytic infiltrates in 4. No patient had congestive heart failure. However, two-dimensional echocardiography performed in eight patients demonstrated functional abnormalities in six (fractional shortening ranging from 18 to 30%, globular shape, hypokinesia, mild ventricular dilation). Four of these six patients had lymphocytic myocarditis and two had lymphocytic infiltrates in the myocardium and epicardium without myocell necrosis. No lymphocytic infiltrates were seen in the two cases with a normal echocardiogram. Quantitative analysis indicated that involvement of the heart by lymphocytic myocarditis is inadequate in itself to explain dysfunction. It remains to be established 1) whether lymphocytic myocarditis is a possible indication of a more widespread molecular disorder, and 2) what its eventual relation with dilated cardiomyopathy will be.

An examination of heart proteins by two-dimensional electrophoresis.

We examined specimens from explanted human hearts by two-dimensional electrophoresis. The protocol selected includes: (a) solubilization of the sample in a urea-detergent mix; (b) charge fractionation in the presence of urea and nonionic detergent on a pH 4-10 immobilized pH gradient; (c) size fractionation on a polyacrylamide concentration gradient in the presence of sodium dodecyl sulfate; and (d) staining with silver nitrate. The method is sensitive enough for analysis of biopsies in the 1-3 mg range (wet tissue). We saw, for explanted hearts, variations in the protein pattern with the site of sample dissection. Results are presented for 11 explanted human hearts: one control organ and 10 pathological samples. The recorded pathologies included dilatative cardiomyopathy (six cases), valvulopathy (one case), ischemic cardiopathy (two cases), and graft rejection (one case). The patterns for whole extracts as well as for cytoplasmic proteins and myofibril components are compared. Extensive individual variability was observed both between control and pathological cases and among the abnormal samples.