[Postoperative follow-up of type A aortic dissectionexperience with 67 patients]. / Follow-up postoperatorio della dissezione aortica di tipo A; esperienza su 67 pazienti.

BACKGROUND: The surgical treatment of type A aortic dissection is usually palliative and most surviving patients remain at considerable risk to develop late postoperative complications; consequently, there is the need for careful long-term follow-up. The present study reports on our experience in the postoperative follow-up of a consecutive series of patients with type A aortic dissection. METHODS: Between January 1986 and December 1996, 89 patients underwent emergency surgery for type A acute aortic dissection; the overall hospital mortality rate was 22% (20/89). This study includes the 69 hospital survivors (49 men and 20 women). Forty-six patients had ascending aortic graft replacement, 13 patients underwent replacement of aortic valve and ascending aorta by a composite graft. The surgical repair was extended to the aortic arch in 5 patients. All patients were serially evaluated by clinical examination and imaging techniques (transthoracic echocardiography in all patients, magnetic resonance imaging in 40, transesophageal echocardiography in 33 and computed tomography in 25). Follow-up was complete in 97% of patients (two patients were lost to follow-up and excluded from the study) and extended to a maximum of 152 months (mean 74 +/- 39 months). The postoperative quality of life was assessed by a questionnaire in 51 current survivors. Risk factors for cardiovascular death, reoperation and poor quality of life were investigated with univariate and multivariate analysis. RESULTS: During the follow-up period 15 patients (22%) died; in 13 cases death was due to cardiovascular causes and in 6 of them it was related to aortic disease. The Kaplan-Meier survival was 92 +/- 3%, 87 +/- 5%, 78 +/- 6% and 70 +/- 8% at 2, 4, 6 and 8 years, respectively. A persistent aortic dissection was demonstrated in 50 patients (75%) and 42 of them showed the presence of flow in the false lumen. A dilatation of one or more aortic segments was found in 59 patients (88%), with a diameter > or = 50 mm in 17 and > or = 60 mm in 8. In 30 patients who underwent transesophageal echocardiography the relation between aortic dimensions and flow pattern in the false lumen was examined; the presence of aneurysmal dilatation with a diameter > or = 50 mm was significantly correlated with a "high flow" pattern. Ten patients (15%) underwent reoperation from 13 to 83 months postoperatively. Reoperation was indicated for: sinus of Valsalva aneurysm and severe aortic regurgitation (2 patients), severe aortic regurgitation (2 patients), aneurysm of the arch (1 patient), thoracoabdominal aneurysm (1 patient), periprosthetic pseudoaneurysm (4 patients). The hospital mortality rate was 20% (2 patients). Sixty-two% of current survivors are asymptomatic; 30 patients returned to their predissection status. Quality of live is judged "good" by 23 patients, "fairly good" by 21 patients and "poor" by 7 patients. No significant independent risk factor for cardiovascular death, reoperation and poor quality of life was identified. CONCLUSIONS: The long-term prognosis after surgical treatment of type A aortic dissection is not satisfactory because of a significant risk of late complications. However, the results of our study can be judged fairly good, particularly if we consider the natural history of the disease.

Diagnostic criteria and management of subacute ventricular free wall rupture complicating acute myocardial infarction.

In this prospective study we evaluated the value of the main diagnostic criteria for postinfarction subacute rupture of the ventricular free wall. Two-dimensional echocardiograms and recordings of right atrial pressure and waveform were immediately obtained in every patient exhibiting rapid clinical and/or hemodynamic compromise in the acute infarction setting. The same protocol was applied to patients referred from other hospitals for suspected myocardial rupture. In 28 cases a subacute free wall rupture was identified. In most of the patients the diagnosis was based on the demonstration of hemopericardium and cardiac tamponade by echocardiography, cardiac catheterization and, occasionally, by pericardiocentesis. In 2 instances, the identification of intrapericardial echo densities suggesting clots, in the absence of cardiac tamponade, allowed a diagnosis of subacute rupture. Direct, but indistinct visualization of myocardial rupture was obtained in 4 cases. Among the 28 patients with this complication, 4 died while awaiting surgery and 24 underwent surgical repair (mortality rate 33%). Long-term outcome of survivors was favorable. Various myocardial lesions underlie postinfarction subacute free wall rupture. Clinical presentation varied widely. The diagnosis was based, usually but not always, on the association of hemopericardium and signs of cardiac tamponade. An organized approach to management of this complication of acute myocardial infarction was suggested.

[Occlusive aorto-arteropathies: surgical treatment and long-term results in 4 cases treated surgically]. / Las aortoarteriopatías estenosantes: tratamiento quirúrgico y resultados a largo plazo de cuatro casos operados.

A rare disease with an obscure etiology is described. It affects predominantly the aorta and occasionally some of its branches, producing a decrease on the lumen vessel. In our experience it has been diagnosed in four young patients and the most important symptom has been arterial hypertension. In three cases the thoracic aorta was involved, with aneurysmal dilatation in one of them. In the rest the thoracic as well as the abdominal aorta were involved. All of them were treated surgically; on three, a latero lateral by pass was performed and in the fourth an aneurysmal resection was done and the aorta reconstructed with a dacron prosthesis. The clinical follow up 4 1/2 years later, showed normal arterial pressure, and patent by-passes, on angiography. We conclude that the revascularization technique can change the natural history of this disease.

[Cardiac echinococcosis simulating myocardial necrosis in a 9 year-old boy. Diagnosis and surgical treatment (author's transl)]. / Echinococcosi cardiaca in paziente di 9 anni, simulante necrosi miocardiac. Diagnosi e trattamento chirurgico.

The case of a 9 year-old, admitted for precordial pain, electrocardiographic signs of myocardial necrosis, deformity of the cardiac border at X Rays examinations, is reported. The diagnosis of cardiac echinococcosis was suspected once excluded other causes of myocardial infarction in children. Angiocardiography was the most useful diagnostic tool. The cyst was successfully removed with the aid of cardiopulmonary bypass. Cardiac echinococcosis gives rise, usually, to minor electrocardiographic changes; nevertheless, patients with electrocardiographic signs of necrosis can undergo surgical treatment without increased operative risk. Follow-up at several months after successful operation does not show return to normal electrocardiogram.

[Hypoplasia of left pulmonary artery secondary to aorta-right pulmonary artery anastomosis. Diagnostic and therapeutical considerations (author's transl)]. / Ipoafflusso polmonare sinistro secondario ad anastomosi aorta-arteria polmonare destra. Considerazioni diagnostiche e terapeutiche.

Three cases of tetralogy of Fallot treated under twelve months of life with aorta-right pulmonary artery anastomosis are reported, in which severe hypoplasia of left pulmonary artery secondary to palliation was present. In the first two cases this complication was not recognized during investigation prior to repair and both died of low cardiac output due to severe right ventricular hypertension. In the third case the complication was evidenced and treated with interposition of a prosthetic valved conduit between right ventricle and confluence of the pulmonary arteries. Hypoplasia or atresia of left pulmonary artery and right pulmonary vascular obstructive disease, secondary to a long-functioning aortopulmonary anastomosis, require surgical consideration identical to tetralogy of Fallot with single pulmonary artery, which is corrected with the use of a valved conduit. The Authors suggest that aortopulmonary shunts should be dismantled within two years and investigation prior to repair should include: 1) exploring of all cardiac chambers and right pulmonary artery through the fistula; 2) injection of contrast medium in right pulmonary artery, aortic root, right ventricle or pulmonary trunk. These diagnostic methods should demonstrate continuity between right ventricle and pulmonary arteries, confluence of pulmonary arteries, and rule out acquired left pulmonary artery atresia, right pulmonary vascular obstructive disease, right ventricular outflow tract atresia.

Abdominal aorta-caval fistula: treatment with aortic and caval synthetic grafts (one year follow-up).

A fistula located between the abdominal aorta and the inferior vena cava is an unusual acquired condition which necessitates prompt diagnosis and, in most instances, emergency surgical repair. The signs and symptoms are related to the size of the shunt. The classical findings are those of a continuous abdominal bruit, edema and venous pooling of the legs, wide pulse pressure, and sudden progressive high-output cardiac failure. Aortography is the definitive diagnostic procedure. However it is impractical in those situations presenting an asymptomatic fistula and contraindicated in presence of signs of progressive renal failure, where emergency surgical treatment is required. In these instances aorta-caval fistula can be correctly diagnosed by means of radionuclide aortography. The fistula can usually be repaired from within the aneurysm after endoarterectomy. Then the aortic graft replacement is completed. In rare cases the pathology at operation is such that this type of repair cannot be performed and an unexpected replacement of the inferior vena cava may be required. The purpose of this paper is to present the description of a patient in whom the diagnosis of aorta-caval fistula was confirmed by means of an isotope angiogram, followed by a successful surgical graft replacement of the abdominal aorta and a dacron tubular graft replacement of the inferior vena cava.

Post-infarction ventricular septal rupture: surgical considerations and results on five operated patients.

Five patients were operated on for ventricular septal rupture following myocardial infarction. The mean time interval between occurrence of infarction and surgery was 37 days (from 4 to 54 days). At EKG, the infarction site was anteroseptal in two cases and postero-inferior in three. Progressive deterioration of cardiac function leading to cardiogenic shock was noticed in four patients. Four patients had cardiac catheterization before surgery: the mean pulmonary to systemic flow ratio was 2.5:1 (from 3.8:1 to 1.8:1); in each case L.V.E.D.P., pulmonary wedge and pulmonary arterial pressures were elevated. Left ventricular angiograms and selective coronariograms were obtained in three patients, demonstrating the presence of left ventricular aneurysm in all three. In two patients, repair was performed through right ventriculotomy; in patients with left ventricular aneurysm, a left ventriculotomy and aneurysm resection were performed. This technique seems to permit much clearer view of the rupture site. In all patients the V.S.D. was closed by a dacron patch, reinforced with teflon pledgets. Two of the five patients died in the early postoperative period. Both had been operated within the first week from the onset of the ventricular septal rupture, because of cardiogenic shock, refractory to medical therapy. The three survivors showed remarkable improvement after surgery and they are in functional class II at a mean follow up period of 20 months. Emphasis is put on factors influencing surgical treatments and prognosis of these patients.

Repair of traumatic aortic arch to innominate vein fistula under deep hypothermia and circulatory arrest.

Penetrating injuries of the thoracic aorta are usually rapidly lethal. Few patients survive for long enough to undergo surgical treatment. When penetrating injuries of the thoracic aorta are complicated by arteriovenous fistula a correct preoperative diagnosis is important for adequate planning of the surgical repair, and so selective angiography is essential. The best approach is through a median sternotomy with the use of total cardiopulmonary bypass with or without deep hypothermia and circulatory arrest. Fistulae between aorta and innominate vein invariably lead to congestive cardiac failure. A review of the literature suggests that signs of cardiac failure rarely appear early. Congestive failure developed within 30 days of the initial trauma in only two of the 12 reported cases. In our case, the early onset of cardac failure refractory to therapy and the appearance of an expanding pulsatile mass at the base of the neck, threatening rupture, necessitated emergency surgical treatment.

[Clinical and hemodynamic long-term result of substituting the mitral valve using a Beall prosthesis]. / Resultado clínico y hemodinámico a largo plazo de la substitución de la válvula mitral por una prótesis de Beall.

A follow-up study of 31 patients, 1 1/2 years after they underwent a mitral valve replacement with a Beall prosthesis, is reported. Eighty-four per cent of the patients experienced marked improvement of symptoms and are fully active. Late cardiac recatheterization has showed a decrease of pulmonary wedge pressure, both at rest and under exercise. The prosthesis area has been found to be smaller than the original size. Hemolysis related to the prosthesis is of moderate degree and the incidence of systemic embolism was 3.1%.

Emergency operations for left ventricular asynergy.

Thirty-two patients were submitted to an emergency surgical procedure for left ventricular asynergy, following myocardial infarction. Indications and results are analyzed. All patients were operated upon with the aid of cardiopulmonary by-pass; an aneurysmectomy was performed in twenty-nine patients, a plication technique in three. These procedures were combined with mitral and/or aortic replacement in five patients, closure of ventricular septal defect in five, aorto-coronary saphenous vein by-pass in five. Early over all post-operative mortality was 75%: 80% in patients operated within three months from myocardial infarction, 67% in patients operated after three months from myocardial infarction.