RESUMEN
BACKGROUND: Coronary artery reoperation represents about 20% of coronary artery operations. In this study we compared mortality and morbidity of first intervention and redo operation. EXPERIMENTAL DESIGN: a retrospective study. SETTINGS: patients who underwent coronary artery reoperations in a University Cardiac Surgery Division in 1991-1994. PATIENTS: our clinical survey was composed of two groups: group A included 44 consecutive patients (mean age 60+/-7 years, males/females=41/3) who underwent a coronary artery reoperation in the years 1991-1994 at the University Cardiac Surgery Division of Turin; group B included 344 patients (mean age 58+/-8 years, males/females=289/55) randomly selected among those who underwent a first coronary operation in the above indicated period of time and centre. All patients had angina pectoris refractory to maximal medical therapy. INTERVENTIONS: all patients underwent a coronary artery operation in extracorporeal circulation (ECC), under mild hypothermia (30-32 degrees C), during a single aortic clamp period, with antegrade cold crystalloid cardioplegia (St. Thomas). MEASURES: comparison of clinical preoperative features, risk factors and postoperative mortality and morbidity between the two groups. RESULTS: In reoperated patients we observed a greater mean akinesis score (p<0.001) and severe left ventricular dysfunction presence (p=0.014). Reoperation mortality was 11.4% against first operation mortality of 3.2% (p=0.03). Female gender (p=0.03), intra-aortic balloon counterpulsation need (p=0.002), adrenaline use (p=0.004) and low cardiac output syndrome (p=0.007) were all perioperative risk factors in group A. CONCLUSIONS: Coronary artery reoperation involves a higher mortality and morbidity compared to the first operation, especially related to the reduced left ventricular function which characterises the population that undergoes reoperation.
Asunto(s)
Puente de Arteria Coronaria/mortalidad , Reoperación/mortalidad , Disfunción Ventricular Izquierda , Circulación Extracorporea , Femenino , Humanos , Italia/epidemiología , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Factores SexualesRESUMEN
OBJECTIVE: Hemodynamic and clinical performances of 21-mm and 23-mm St Jude Medical Hemodynamic Plus aortic valves (St Jude Medical, Inc, St Paul, Minn) were compared with those of 21-mm and 23-mm St Jude Medical standard cuff aortic valves in the first such multicenter, prospective, randomized study. Hemodynamic Plus valves are mechanical, bileaflet prostheses suitable for the small aortic anulus. METHODS: Patients with 21-mm and 23-mm anulus diameters were randomized to receive either a Hemodynamic Plus or a standard cuff valve. Postoperatively and at 6 months after the operation, patients underwent 2-dimensional Doppler echocardiography. Ejection fraction, cardiac output, peak gradient, mean gradient, effective orifice area, effective area index, and performance index were calculated. Postoperative and 6-month echocardiographic measurements and their variations across observation times were analyzed statistically. RESULTS: Of the 140 patients enrolled, 5 died at operation and 1 died of aortic dissection during the follow-up period. Eight patients were lost to follow-up. A total of 125 patients completed the study. In 1 patient a sewing cuff escaped intraoperatively. At 6 months the 21-mm and 23-mm Hemodynamic Plus valves showed significantly lower peak gradients and mean gradients than those of the 21-mm and 23-mm standard cuff valves. The 21-mm Hemodynamic Plus valves had gradients similar to those of the 23-mm Hemodynamic Plus valves. The effective orifice area did not differ significantly between the Hemodynamic Plus and standard cuff valves at either measurement. No valve mismatch was found in the 4 groups of patients. A more enhanced decrease of peak gradients and mean gradients and a more enhanced increase of effective orifice areas, effective area indices, and performance indices were found across observation times for patients with Hemodynamic Plus valves compared with those with standard cuff valves. CONCLUSIONS: Clinical hemodynamic performances of 21-mm and 23-mm St Jude Medical Hemodynamic Plus valves correspond closely with those of standard cuff valves, and gradients are substantially better than those of standard cuff valves of the same diameter. Therefore, use of this valve may minimize the need for aortic anulus enlargement. Early follow-up results with the Hemodynamic Plus valves were excellent, although more time is required to confirm this outcome.
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Válvula Aórtica , Prótesis Valvulares Cardíacas , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/fisiopatología , Femenino , Estudios de Seguimiento , Hemodinámica , Humanos , Italia , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Diseño de Prótesis , UltrasonografíaRESUMEN
A case is reported of a 30-year-old patient with an intrapericardial tumour with heart failure. After the diagnostic protocol, surgery was performed initially without extra-corporeal circulation (ECC). Due to the location, size and to the large connection with the most important vascular structures, the ascending aorta ruptured accidentally during resection and was replaced after using ECC in emergency. The post-surgical course was regular and the tumour was identified histologically as a fibroma.
Asunto(s)
Rotura de la Aorta/etiología , Fibroma/complicaciones , Neoplasias Cardíacas/complicaciones , Complicaciones Intraoperatorias , Adulto , Rotura de la Aorta/diagnóstico , Fibroma/patología , Fibroma/cirugía , Neoplasias Cardíacas/patología , Neoplasias Cardíacas/cirugía , Humanos , MasculinoRESUMEN
Although rare, aortobronchial fistula complicates thoracic aortic surgery. Correct diagnosis and the infectious nature of the lesion are the most important conditions to define, for the following best therapy. We presented a case of non-infectious postsurgical aortobronchial fistula, revealed by computed-tomographic scan and angiography procedure, treated with prosthetic graft replacement and broad spectrum antibiotic therapy. In the case of infection our policy is homograft replacement. Computed tomography, being able to make diagnosis, should be performed as the initial technique.
Asunto(s)
Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/cirugía , Implantación de Prótesis Vascular/efectos adversos , Fístula Bronquial/etiología , Procedimientos Quirúrgicos Torácicos , Fístula Vascular/etiología , Disección Aórtica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aortografía , Prótesis Vascular , Fístula Bronquial/diagnóstico por imagen , Fístula Bronquial/cirugía , Broncoscopía , Diagnóstico Diferencial , Humanos , Masculino , Persona de Mediana Edad , Falla de Prótesis , Reoperación , Tomografía Computarizada por Rayos X , Fístula Vascular/diagnóstico por imagen , Fístula Vascular/cirugíaRESUMEN
BACKGROUND: Cardiac myxomas have varying clinical presentation, uncertain histogenesis, and debatable immunohistochemical profile. A few malignant cases have been previously reported. METHODS: Fifty-three consecutive cardiac myxomas were histologically investigated and results compared with clinical data. The main goal of the study was to investigate the immunohistochemical differentiation and the clinicopathologic correlations. RESULTS: Stromal cells were characterized by the expression of the von Willebrand factor endothelial marker (12 of 53 cases) and diffuse cytoplasmic neuropeptides such as protein gene product 9.5 (50 of 53 cases), S100 protein (47 of 53) and neuron-specific enolase (30 of 53), all of which were expressed in 30 (57%) of 53 tumors. Stromal cells did not show endocrine granules, epithelial, or smooth muscle immunoreactivity. Non-cardiac-related symptoms were observed in 7 of 53 patients and promptly disappeared after tumor excision; median values and percentages of total immunoreactivity scores for neuropeptides were higher in these 7 cases, but data analysis showed no statistical significance. Glands were detected in 2 myxomas, and they showed epithelial (cytokeratins and carcinoembryonic antigen), protein S100, and neuron-specific enolase immunoreactivity; this pattern has been previously detected in human gut. All tumors showed benign behavior, and no mitosis was detected. CONCLUSIONS: The results of this study support the hypothesis that stromal cells originate from multipotent mesenchyme capable of neural and endothelial differentiation; rare myxoma glands would represent entrapped foregut rests. A correlation could exist between neuroendocrine differentiation and non-cardiac-related symptoms.
Asunto(s)
Neoplasias Cardíacas/patología , Mixoma/patología , Neuropéptidos/análisis , Adulto , Anciano , Biomarcadores de Tumor/análisis , Biopsia con Aguja , Estudios de Cohortes , Femenino , Neoplasias Cardíacas/mortalidad , Neoplasias Cardíacas/cirugía , Humanos , Inmunohistoquímica , Masculino , Persona de Mediana Edad , Mixoma/mortalidad , Mixoma/cirugía , Probabilidad , Sensibilidad y EspecificidadRESUMEN
BACKGROUND: Between March 1980 and September 1997, 91 patients underwent evaluation and treatment for primary cardiac neoplasms. METHODS: Tumors were grouped into three categories: atrial myxomas, benign nonmyxomas, and malignant tumors. Survivors were contacted; no one was lost to follow-up. The mean follow-up for this series is 7 +/- 5 years. RESULTS: Eighty-three patients were diagnosed with atrial myxomas (Male/Female: 29/54), average age 55 +/- 13 years. The hospital mortality was 3.6% (3/83), the late mortality was 6.5% (5/80). No recurrent myxomas have been identified clinically or by echocardiography in any patient. Three patients were diagnosed with benign nonmyxoma tumors. (Male/Female: 2/1), average age 64 +/- 8 years. There were no perioperative deaths and 1 patient died 4 years postoperatively from fibroma, with no linked causes. No recurrent tumors have been identified. Five patients were diagnosed with malignant tumors. (M/F: 1/4), average age 53 +/- 16 years. The hospital mortality was 20% (1/5); in 3 patients a redo-operation was necessary after 8, 11, and 12 months because of tumor recurrence. All patients died within 3 years of the first operation (mean 13 +/- 14 months). CONCLUSIONS: Surgical resection, when possible, is the treatment of choice for all primary cardiac tumors. Patients with benign tumors are probably cured by resection and in our experience there was no known tumor recurrence. Effective palliation is possible with resection of malignant tumors, but more effective adjuvant therapy will be necessary to improve long-term prognosis.
Asunto(s)
Neoplasias Cardíacas/cirugía , Mixoma/cirugía , Sarcoma/cirugía , Adulto , Anciano , Femenino , Estudios de Seguimiento , Neoplasias Cardíacas/mortalidad , Neoplasias Cardíacas/patología , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Miocardio/patología , Mixoma/mortalidad , Mixoma/patología , Recurrencia Local de Neoplasia/mortalidad , Recurrencia Local de Neoplasia/patología , Recurrencia Local de Neoplasia/cirugía , Estadificación de Neoplasias , Reoperación , Sarcoma/mortalidad , Sarcoma/patología , Tasa de SupervivenciaRESUMEN
In this article, we report a 65-year-old man with a large atrial myxoma arising from the posterior wall and from the base of the right inferior pulmonary vein. The big neoplastic mass showed a large implant site. A rare atrial myxoma neovascularity arising from the atrial circumflex artery was very clearly visualized by selective coronary arteriography. The surgical approach used to resect this tumor was an isolated left atriotomy that provided excellent exposure and safe excision.
Asunto(s)
Neoplasias Cardíacas/cirugía , Mixoma/cirugía , Anciano , Angiografía Coronaria , Atrios Cardíacos/diagnóstico por imagen , Atrios Cardíacos/cirugía , Neoplasias Cardíacas/irrigación sanguínea , Neoplasias Cardíacas/diagnóstico por imagen , Humanos , Masculino , Mixoma/irrigación sanguínea , Mixoma/diagnóstico por imagenRESUMEN
BACKGROUND: The Bjork-Shiley convexo-concave (BS-CC) heart valves represent the improved model of the standard valve first introduced with a different design of the disc valve to ameliorate hemodynamic performances and reduce thromboembolic complications. About 86,000 BS-CC were implanted during 1979-1986 and of them a small number developed an intrinsic dysfunction resulting in sudden death. METHODS: From 1979 to 1986 we implanted in 117 patients (48 males, 69 females, mean age 46.35+/-12.47, range 8-65 years) 125 BS-CC. In 38.5% (45/117) of the cases heart valve replacement represented the second cardiac procedure after a previous closed heart digital commissurotomy. The mean size of the implanted prosthesis was 25.6+/-2.8 for aortic valve and 29.5+/-1.2 for mitral valve. RESULTS: Hospital mortality was 4.27% (5/117) and survival rate at 10 years is 71.4% and at 17 years 54.7% (Kaplan-Meier). At follow-up causes of death proved valve related in most of the patients but with no evidence of valve fracture. We had 1 case of sudden death in patients at high risk (largest size, aortic position) and 30 cases of death by unknown causes but they did not have an autopsy to confirm the cause of death. CONCLUSIONS: We conclude that in our population with BS-CC at the moment there is no indication for prophylactic replacement because of the higher risks of a reoperation (third or fourth in the 35.4% of our patients) than a strut fracture. Nevertheless we believe an autopsy mandatory in all these patients at risk, when sudden death occurs.
Asunto(s)
Prótesis Valvulares Cardíacas/estadística & datos numéricos , Diseño de Prótesis/estadística & datos numéricos , Adolescente , Adulto , Anciano , Niño , Muerte Súbita Cardíaca/epidemiología , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Falla de Prótesis , Reoperación , Tasa de SupervivenciaRESUMEN
BACKGROUND: The aim of this study was to analyse long term results of mitral valve repair of degenerative mitral regurgitation compared to valve replacement. METHODS: A hundred-twenty-five consecutive patients with severe mitral valve insufficiency who underwent cardiac surgery from January 1987 to December 1995 were included in the study. Mean age was 55+/-16 years (77 males, 48 females). Mitral repair was performed in 62 patients and mitral valve was replaced in 63 patients. Mean follow-up was 5 years. The repair procedures were based on quadrangular resection of the posterior leaflet, chordal replacement and transposition. Annuloplasty was performed in 100% of cases. The technique of valve replacement was conventional with complete excision of the valve in the majority of cases. RESULTS: Operative mortality following valve repair was 1.6%, no death occurred in the prosthesic group. In the repair group overall survival and re-operation rate were respectively 95.2% and 6.5%, while in the replacement group were 93.7% and 7.9%. No endocarditis and thromboembolic accidents were observed following valvuloplasty, while in the prostheses 6.3% of patients had endocarditis and 1.6% had a thromboembolic event. Mild or moderate left ventricular dysfunction was present in 5 patients after valvuloplasty and in 9 patients with prostheses. CONCLUSIONS: Considering these results we conclude that, in patients with severe degenerative mitral insufficiency, mitral valve repair is warranted whenever it is possible. The advantages given by maintaining the native valve suggest that surgery should be considered in asymptomatic patients before the occurrence of the left ventricular dysfunction.
Asunto(s)
Implantación de Prótesis de Válvulas Cardíacas , Insuficiencia de la Válvula Mitral/cirugía , Válvula Mitral/cirugía , Anciano , Endocarditis Bacteriana/etiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Insuficiencia de la Válvula Mitral/etiología , Insuficiencia de la Válvula Mitral/mortalidad , Insuficiencia de la Válvula Mitral/fisiopatología , Prolapso de la Válvula Mitral/complicaciones , Prolapso de la Válvula Mitral/fisiopatología , Complicaciones Posoperatorias , Reoperación , Estudios Retrospectivos , Tasa de Supervivencia , Resultado del Tratamiento , Función Ventricular IzquierdaRESUMEN
BACKGROUND: The pericardial bovine prosthesis Pericarbon should offer some advantages in comparison with the former generations, because its development is focused on solving previous problems and resulted in the variation of the pericardial fixation method, of valve structure and of stent coating. This hypothesis was evaluated through a retrospective follow-up. METHODS: Between 1985 and 1989, 78 Pericarbon prostheses O 29 were implanted in mitral position by the same surgeon. All patients received warfarin for the first three months to maintain an International Normalized Ratio between 2.5 and 3.5; after which they received antiaggregant therapy indefinitely. With an average follow-up period of 7.34 years for a total of 573 patient-years, we evaluated perioperative and late mortality, late morbidity (thromboembolic and haemorrhagic events, reoperations, primary tissue failures, endocarditic events) and patient clinical conditions. RESULTS: Perioperative mortality was 1.28% (1/78), late mortality was 11.6% (9/77) with 5 valve-related deaths. 5-year survival was 93% and 10-year survival 97%. Fifteen patients required reoperation for prosthetic replacement, fourteen for primary tissue failure. There were ten minor thromboembolic events, one major event, one haemorrhage and one prosthetic endocarditis (the last two with patient exitus). After 10 years (75% of patients were in New York Heart Association class I-II. CONCLUSIONS: Besides the known better haemodynamic performance, Pericarbon bioprosthesis seems to present a survival and redofreedom curve comparable to the best porcine prosthesis, with less incidence of endocarditis, thromboembolic events and prosthesis leakage.
Asunto(s)
Implantación de Prótesis de Válvulas Cardíacas , Válvula Mitral/cirugía , Pericardio/cirugía , Anciano , Animales , Bovinos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Tasa de Supervivencia , Resultado del Tratamiento , Warfarina/uso terapéuticoRESUMEN
BACKGROUND: Stent deformation seems to be effective in the long term performances of bioprostheses. METHODS: The Inward Banding Angle (IBA) of three different models of bioprostheses explanted during the period 1991-1992 at our Division of Cardiac Surgery in 45 different patients (26 males; 9 females; mean age 59.71 +/- 10.74, range 26-75) has been measured. Explanted valves were as follow: Hancock, (H = 13); Carpentier-Edwards (C = 14) e Xenomedica (X = 18). Primary tissue failure was the most common cause of re-operation (n = 30; 66.7%) but also endocarditis (n = 6; 13.3%) and paraprothetic leak (n = 10; 22.2%). A semi-quantitative score (0-4) was used to assess calcifications (1.51 +/- 1.56); tears (0.41 +/- 0.98); vegetation's (0.51 +/- 0.99) and fibrosis (2.7 +/- 1.27). The mean follow-up was 7.77 +/- 3.79 years (range 1.5 +/- 16 years). The mean IBA evaluated after explantation was 3.34 +/- 2.29 degrees. RESULTS: Statistical analysis showed a significance in term of IBA in the Hancock group vs Carpentier (P < 0.02); a less duration in the Xenomedica group vs H and C (p < 0.001) and an increased susceptibility to vegetation's and fibrosis in the Xvs C (p < 0.01) and H (p < 0.05) respectively. A suggestive correlation between IBA and time and between IBA and diameter was found but no statistical significance was observed. CONCLUSIONS: In conclusions, it is suggested that all materials tends to deform during time and a possible explanation of stent deformation can be the different material used in the stent fabrication. Moreover, mechanical stress and compression around the ring can be another mechanism of creep.
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Bioprótesis , Enfermedades de las Válvulas Cardíacas/cirugía , Prótesis Valvulares Cardíacas , Falla de Prótesis , Stents , Adulto , Anciano , Femenino , Prótesis Valvulares Cardíacas/clasificación , Implantación de Prótesis de Válvulas Cardíacas , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/cirugíaRESUMEN
BACKGROUND: Morbidity and mortality of emergency repair of type A dissecting aneurysms of the aorta are high. This is an attempt to investigate the risk determinants of early and late results. METHODS: A series of preoperative and operative variables were retrospectively collected from the clinical records of 291 patients operated on between January 1, 1979, and December 31, 1995. Risk factors for surgical death were investigated with univariate analysis and stepwise logistic regression. Follow-up was conducted between December 1995 and February 1996. Analysis of late results was conducted by means of actuarial survival curves (life method). After removing the surgical deaths, risk factors for late deaths were analyzed by a Cox model. RESULTS: The in-hospital mortality rate was 36.1%. Significant independent determinants of operative or early death were preoperative shock, preoperative neurologic impairment, operation before 1986, perioperative bleeding, and prolonged clamping time. The 10-year survival rate was 36.9% +/- 4.4%. Twenty-six patients required repeat operation. The long-term prognosis was significantly worse in patients who needed reoperation. CONCLUSIONS: Growing awareness of this disease and quicker diagnosis have increased the number of patients with acute dissection of the ascending aorta who are taken early to operation. This new challenge must be met by better preoperative support and intraoperative monitoring, and by surgical techniques that focus on lowering the rate of late complications, for which lifelong follow-up must be provided.
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Aneurisma de la Aorta/mortalidad , Aneurisma de la Aorta/cirugía , Disección Aórtica/mortalidad , Disección Aórtica/cirugía , Complicaciones Posoperatorias , Adulto , Anciano , Procedimientos Quirúrgicos Cardíacos , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
From January 1989 to December 1994, 56 patients, 43 male and 13 female, mean age 61.21 +/- 10.05 years, underwent surgical procedures on the aortic arch at our institution. Forty-six patients underwent emergency or urgent operations, fourty-four of them presented acute aortic dissections involving the aortic arch. All operations were performed in cardiopulmonary by-pass, 39 operations in deep hypothermic circulatory arrest, 10 in deep hypothermic circulatory arrest and hypothermic retrograde cerebral perfusion. The overall hospital mortality was 17.9% (10 patients). The main causes of hospital mortality were: multiorgan failure (3 patients) and major neurological damage (2 patients). In the group of patients that underwent hypothermic retrograde cerebral perfusion there was no major neurological damage. In the follow up there were no deaths and 4 reoperations related to the aortic pathology. The cerebral protection represents the main problem in the aortic arch surgery. The deep hypothermic circulatory arrest is an effective method to reduce the cerebral and visceral ischemia, in particular in acute dissection; nevertheless this method leads to more bleeding complications and lengthening of the cardiopulmonary bypass in time. In our experience, the hypothermic retrograde cerebral perfusion associated with deep hypothermic circulatory arrest appears to be a useful method to prevent cerebral damage. However this procedure needs further investigation.
Asunto(s)
Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/cirugía , Disección Aórtica/epidemiología , Aorta Torácica , Aneurisma de la Aorta Torácica/epidemiología , Isquemia Encefálica/prevención & control , Puente Cardiopulmonar , Urgencias Médicas , Femenino , Estudios de Seguimiento , Paro Cardíaco Inducido , Humanos , Hipotermia Inducida , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/prevención & control , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND AND AIMS OF THE STUDY: The aim of this study was to evaluate the long-term follow up of the Pericarbon pericardial bioprosthesis implanted in the mitral position. METHODS: Between January 1985 and January 1991, 78 patients (26 males, 52 females; mean age 56.9 +/- 7.8 years) underwent isolated mitral valve replacement with a Pericarbon valve. All bioprostheses were size 29 mm and implanted by the same surgeon. RESULTS: Total follow up was 663.2 pt-years and it was 97% complete. Early mortality was 1.3% (1/78); two minor cerebral embolisms were observed as early complications. At 12 years the overall survival rate was 85.0 +/- and valve-related survival 93.1 +/- 3.0%; freedom from embolic events was 83.0 +/- 4.5% and from endocarditis 98.7 +/- 1.3%. Freedom from primary tissue failure was 56.8 +/- 6.6%; it was 86.3 +/- 7.5% in patients aged > 60 years and 36.8 +/- 8.2% in younger patients. There were 27 reoperations, 26 for primary tissue failure, one for endocarditis. Comparison between basal and follow up echocardiographic studies showed a significant stenotic deterioration of the bioprosthesis and a negligible incidence of regurgitation. Morphological findings of explanted bioprostheses were characterized by stenotic and diffuse microcalcification, but no tissue tear was observed. CONCLUSIONS: These results confirm that the Pericarbon bioprosthesis is structurally safe and free from the fatigue problems which afflicted the first and second generation of pericardial valves. As with other tissue valves, the rate of calcification is age-dependent, suggesting preferential use of the Pericarbon prosthesis in elderly people.
Asunto(s)
Bioprótesis , Prótesis Valvulares Cardíacas , Insuficiencia de la Válvula Mitral/cirugía , Estenosis de la Válvula Mitral/cirugía , Ecocardiografía Doppler en Color , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Válvula Mitral , Insuficiencia de la Válvula Mitral/epidemiología , Estenosis de la Válvula Mitral/epidemiología , Complicaciones Posoperatorias/epidemiología , Diseño de Prótesis , Tasa de Supervivencia , Factores de TiempoRESUMEN
Total aorta replacement is a major and increasingly successful surgical procedure. The paper describes a patient whose progressive aneursymatic disease spread from the ascending segment to the bifurcation over a three-years period during which time after three separate operations, the aorta was totally replaced. The paper describes the diagnostic and surgical procedures deployed and shows the results of angiographic and CT scans. Credit for the success of the replacement is also given to the highly skilled anaesthetists and nurses involved.
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Aneurisma de la Aorta Torácica/cirugía , Implantación de Prótesis Vascular , Aneurisma de la Aorta Torácica/diagnóstico , Implantación de Prótesis Vascular/métodos , Femenino , Paro Cardíaco Inducido , Humanos , Hipotermia Inducida , Persona de Mediana EdadRESUMEN
From 1979 to 1993, 139 patients had reduction of left ventricular aneurysm (LVA) by plication (PL) (25 cases) linear repair (74 cases) or ventricular reconstruction (VR) (40 cases). Coronary bypass grafting was performed in 89 patients. We retrospectively reviewed our experience in order to identify predictore of early and late outcome and determine whether ventricular reconstruction (VR) can improve postoperative and late prognosis. Operative mortality (OM) was 7.2%. Among 129 hospital survivors, 48 died during FU (LM). OM was related to a more recent myocardial infarction (p=0.0001), a higher residual score (RS) (p=0.02), a lower EF (p=0.038), a higher left ventricular score (p=0.059), a three-system disease (TSD) (p=0.09) and a right coronary disease (RCD) (p=0.13). At Multivariate Analysis (Stepwise Logistic Regression) TSD (p=0.001), RCD (p=0.008) and RS (p=0.04) are independent risk factors. Actuarial survival rate at 15 years is 33.5+/-6.9% (OM included). According to the comparison of the Actuarial Curves (Tests of Mantel and Breslow, OM excluded) the most significant risk factors were: non use of left internal mammary artery (LIMA) (p=0.004), VR (p=0.01), TSD (p=0.03) and higher NYHA class (p=0.019). Multivariate Analysis (Co Model) confirms that late prognosis is influenced by non use of LIMA (p=0.03) and TSD (p=0.04); outcome is also affected by preoperative arrhythmias (p=0.022). Five-year survival after VR is 87.5+/-5.7% vs 64.9+/-5.5% after simple linear closure or PL (p=0.1075 and p=0.2252). Our results confirm that OM and LM are influenced by extent of myocardial ischemic damage; in agreement with the majority of Authors we advocate a complete revascularization using IMA, when appropriate, on left anterior descending artery. Our limited experience with VR fails to demonstrate this technique as an independent factor of late survival.
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Procedimientos Quirúrgicos Cardíacos , Aneurisma Cardíaco/cirugía , Ventrículos Cardíacos/cirugía , Infarto del Miocardio/complicaciones , Adulto , Anciano , Procedimientos Quirúrgicos Cardíacos/métodos , Puente de Arteria Coronaria , Femenino , Estudios de Seguimiento , Aneurisma Cardíaco/etiología , Aneurisma Cardíaco/fisiopatología , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Complicaciones Posoperatorias/mortalidad , Procedimientos de Cirugía Plástica , Estudios Retrospectivos , Tasa de Supervivencia , Función Ventricular Izquierda/fisiologíaRESUMEN
Increased GH together with decreased IGF-I levels pointing to peripheral GH insensitivity in critically ill patients have been reported by some but not by other authors. To clarify whether elevated GH levels are coupled with low IGF-I levels in all catabolic conditions, basal GH and IGF-I levels were evaluated in patients with sepsis (SEP, no.=13; age [mean+/-SE]=59.2+/-1.2 yr), trauma (TRA, no.=16; age=42.3+/-3.4 yr), major burn (BUR, no.=26; age=52.8+/-4.2 yr) and post-surgical patients (SUR, no.=11; age=55.0+/-4.7 yr) 72 hours after ICU admission or after cardiac surgery. GH and IGF-I levels were also evaluated in normal subjects (NS, no.=75; age=44.0+/-1.5 yr), in adult hypopituitaric patients with severe GH deficiency (GHD, no.=54; age=44.8+/-2.3 yr), in patients with liver cirrhosis (LC, no.=12; age=50.4+/-2.8 yr) and in patients with anorexia nervosa (AN, no.=19; age=18.7+/-0.8 yr). Basal IGF-I and GH levels in GHD were lower than in NS (68.6+/-6.4 vs 200.9+/-8.7 microg/l and 0.3+/-0.1 vs 1.4+/-0.2 microg/l; p<0.01). On the other hand, AN and LC showed IGF-I levels (70.4+/-9.1 and 52.4+/-10.5 microg/l) similar to those in GHD while GH levels (10.0+/-2.8 and 7.9+/-2.1 microg/l) were higher than those in NS (p<0.01). IGF-I levels in SEP (84.5+/-8.8 microg/l) were similar to those in GHD, AN and LC and lower than those in NS (p<0.01). IGF-I levels in BUR (105.2+/-10.9 microg/l) were lower than in NS (p<0.01) but higher than those in GHD, AN, LC and SEP (p<0.01). On the other hand, in TRA (162.8+/-17.4 microg/l) and SUR (135.0+/-20.7 microg/l) IGF-I levels were lower but not significantly different from those in NS and clearly higher than those in GHD, AN, LC, SEP and BUR. Basal GH levels in SEP (0.6+/-0.2 microg/l), TRA (1.8+/-0.5 microg/l), SUR (2.2+/-0.5 microg/l) and BUR (2.2+/-0.5 microg/l) were similar to those in NS, higher (p<0.05) than those in GHD and lower (p<0.01) than those in AN and LC. In conclusion, our data demonstrate that low IGF-I levels are not always coupled with elevated GH levels in all catabolic conditions. Differently from cirrhotic and anorectic patients, in burned and septic patients GH levels are not elevated in spite of very low IGF-I levels similar to those in panhypopituitaric GHD patients. These findings suggest that in some catabolic conditions peripheral GH insensitivity and somatotrope insufficiency could be concomitantly present.