[Surgical treatment of left ventricular aneurysms--midterm results with two types of repair--linear resection and endoventricular repair].

OBJECTIVES: The optimal surgical technique for correction of left ventricular aneurysms is still debated. This study compares the midterm results achieved with linear resection or endoventricular repair. METHODS: In the period February 2002-February 2004 forty-five consecutive patients with anterior LVA have been operated. The patients were divided in two groups according to the applied surgical technique--Group-I endoventricular repair in 23 pts (52%) and Group-II linear resection in 22 pts (47%). The mean age was in the whole group was 65.4 years, of them 34 (75.6%) were man, 41 (91%) were in NYHA class III or IV, 31 (68.8%) with congestive heart failure and 35 (77.7%) with stenocardia. Bypass grafting was performed in 41 (93.3%), trombectomy of the left ventricle 18 (40%), mitral valvuloplasty in 4 (8.8%) and VSD closure in 1 (2.2%) patients. RESULTS: Early mortality was 8.6% in Group-I and 9% in Group-II. Low cardiac output treated with IABP and catecholamines was present in 13 (28.8%) patients and there was one ischemic stroke and one revision for bleeding. Important reduction in the ventricular volumes (56 ml) and in the functional class (from 3.2 to 1.3 NYHA) were observed. The reduction in EDVI and ESVI and the increase in EF were significantly higher in Group-I than in Group-II and a trend for future improvement in Group-I was observed at follow-up. CONCLUSIONS: Both surgical techniques show similar good results in terms of mortality, improvement of functional capacity and survival. Endoventricular reconstruction shows advantages in volume reduction, increase of EF and reshaping of the left ventricle.

[Mitral valve repair for mitral regurgitation--15 year results].

UNLABELLED: Mitral valve repair (MVR) for mitral regurgitation (MR) has many advantages over mitral valve replacement. However, durability and reoperations after repair still remain major problems. The aim of our study was to analyze the outcome of MVR and to determine the significant risk factors for death and reoperations. METHODS: From June 1989 to June 2005, 259 patients underwent MVP for MR. The mean age was 57.5 years, 89 (34.3%) were female, in 82% the NYHA class was III or IV, in 43 (16.6%) the ejection fraction (EF) was low < 30% and 27 patients (10.4%) were operated on emergency. The causes of MR were ischemic in 128 (49.4%) patients, rheumatic disease in 60 (23.1%), degenerative in 66 (25.4%) and endocarditis in 5 (0.2%) patients. The valve pathology was annular dilatation in 142 (54.8%) patients, restricted leaflet motion in 120 (46.3%) and valve prolapse in 88 (33.9%) patients. RESULTS: There were 13 (5%) early and 15 (6%) late deaths in the whole group, with higher mortality for urgent operations--25.9%, for those with EF < 30%-11.6% and for ischemic patients--8.5%. Thirteen patients (5.2%) were reoperated from 1 to 62 months after the first operation. Most patients were in NYHA class I or II at follow-up. The results of the mitral reconstruction are excellent in 75.2% (MR? gr. I), good in 22.3% (MR < or = gr. II) and bad in 2.4% (MR - gr. II-III). Non-use of ring and Key's annuloplasty were identified as independent predictors for reoperation. The long-term survival at 15 years was 43.5% for ischemic patients and 75.6% for nonischemic patients. CONCLUSIONS: Ischemic etiology of MR, low EF and urgent operations remains the main predictors for high operative mortality and suboptimal long-term survival. Severe perioperative TEE control and routine application of ring are crucial for improving the short and long-term results of mitral valve repair.

[Surgical treatment of acquired mitral valve diseases--five-year analysis of early and late results]. / Khirurgichno lechenie na pridobitite porotsi na mitralnata klapa--5-godishen analiz na rannite i kusnite rezultati.

UNLABELLED: The indications for mitral valve repair or mitral valve replacement are worldwide accepted, but they still depend of the personal experience of the surgeon and the tradition in the respective cardio-vascular clinic. Valve repair had many advantages over the replacement, but the long-term durability and the reoperations remain a major problem. In this retrospective review we examine the five years results of the surgical treatment of mitral valve diseases and the factors influencing the choice of the operation, the mortality and morbidity. METHODS: From January 1998 to December 2002, 76 patients underwent mitral valve repair and 194 underwent mitral valve replacement. The mean age was 50.6 years, and 52.8% were NYHA class III or IV. The causes of mitral valve disease were ischemic in 45, rheumatic in 133, degenerative in 68 and endocarditis in 18 patients. Mitral valve repair was accomplished by Carpentier's techniques, Key, Alfeiri or ring implantation and mitral valve replacement with mechanical or biologic valve. RESULTS: In the ischemic group early mortality occurred in 7 patients (15.5%), in endocarditis group in 3-16.6%, in degenerative group in 2 (2.9%) and in the rheumatic group in 3 (2.2%). Overall mortality in the replacement group was 5.1% and in the repair group (6.5%). Six patients needed reoperation in the repair (7.8%) and 12 patients in the replacement group (6.1%). Survival at 5 years was 90% in the repair and 83% in replacement patients. CONCLUSIONS: Mitral valve repair are used almost always in ischemic and degenerative etiology, but they also show good results and long-term survival in cases of rheumatic mitral valve disease. The ischemic etiology, endocarditis and bad function of the left ventricle are the most important predictors for early death and poor long-term survival.

[Multiple coronary endarteriectomy in patients with diffusial coronary disease]. / Mnozhestveni koronarni endarterektomii pri patsienti s difuzna koronarna bolest.

UNLABELLED: In recent years the profile of patients with CAD is continuously changing, often with previous operation or stenting. Multiple coronary endarterectomies have been utilized as an adjunct to CABG in this select group of patients to achieve complete revascularization because of the diffuse CAD. METHODS: Between January 1997 and December 2001 eighty eight consecutive patients undergoing first time CABG with more than two CE were compared with a control group of 967 patients undergoing CABG without CE. RESULTS: More than 9% of the CABG patients need two or more endarterectomies, with involvement of the RCA in 96% and LAD in 59%. The extended time of aortic clamping and the higher rate of perioperative MI lead to higher mortality in Group 1 without significant difference between groups. The 5 years survival was 69% in Group 1 and 84% in Group 2. CONCLUSIONS: The operative results--mortality and morbidity, are similar in both groups instead of the highest complexity of the procedures with multiple endarterectomies. The use of this method together with CABG allows complete revascularization in 10% of the operated patients with diffuse atherosclerosis.

[Effect of antegrade brain perfusion on neurogical complications after surgical treatment of aneurysm and dissection with circulatory arrest]. / Vliianie antegradnata mozuchna perfuziia vurkhu nevrologichnite uslozhneniia sled khirurgichno lechenie na anevrizmi i disekatsii s tsirkulatoren arest.

From January 2001 until December 2003 twenty patients have been operated for acute or chronic dissection with involvement of the aortic arch. 16 of them were men, and 4--women, with middle age of 57 years. Two methods of cerebral perfusion have been used--hypothermic circulatory arrest (HCA) or selective antegrade cerebral perfusion (ACP). Direct cannulation or suturing of vascular prosthesis to the brachiocephalic trunk has been used for ACP. Twelve (12) partial and 8 total arch replacements have been done. The duration of ACP (54 min.) is longer than the time of HCA (32 min.). The neurological postoperative complications--coma (7.6%) and ischemic encephalopathy (30.4%), were significantly lower in the group with ACP than in the group of the HCA--14.2% and 42.6% respectively. Overall mortality is 15%--3 patients dying after the 30th day. Preoperative hemodynamic instability and neurological symptoms are strongly related with postoperative neurological complications. The method of cerebral protection did not influence the mortality, but the postoperative neurological complications are significantly lower in the group with ACP. We recommend ACP in all cases of acute aortic dissection and all aneurisms with arch involvement needing extended surgical operation.

[Valve repair for mitral regurgitation--early and late results]. / Plastika na mitralnata klapa pri mitralna nedostatuchnost--ranni i kusni rezultati.

UNLABELLED: Mitral valve repair for regurgitation has many advantages over mitral valve replacement. However, durability and reoperation after repair still remain major problems. We examined the outcome of mitral repair for valve regurgitation and analyzed several pre- and intraoperative factors to determine their impact on mortality and morbidity. METHODS: From January 1990 to December 2000, 69 patients underwent mitral valve repair. The mean age was 52.8 years, and 82.6% were NYHA class III or IV. The causes of mitral valve disease were ischemic in 32, rheumatic in 20 and degenerative in 17 patients. Mitral valve repair was accomplished by Carpentier's techniques, Key commisuroplasty and ring implantation. RESULTS: There were 5 early and 6 late deaths in the ischemic group and no early mortality and two late deaths in the mixed rheumatic and degenerative group. Seven patients needed reoperation, 4 in the ischemic group and 3 with rheumatic disease. Actuarial overall survival at 5 years was 100% in rheumatic, 86% in degenerative and 75% in ischemic patients. CONCLUSIONS: Mitral valve repair for mitral regurgitation provides excellent results and long-term survival in rheumatic and degenerative disease. The ischemic etiology is the most important predictor for early death and poor long term survival.

[Surgical treatment of coronary disease with ischemic mitral regurgitation--early and late results]. / Khirurgichno lechenie na iskhemichnata bolest na surtseto (IBS) s vtorichna mitralna reguritatsiia--ranni i otdalecheni rezultati.

UNLABELLED: Patients with ischemic mitral incompetence have a high operative risk and the advantage of repair over replacement in those patients is unclear. In cases of moderate mitral regurgitation and coronary artery disease operative strategy continues to be debated between coronary artery bypass grafting (CABG) alone and concomitant valve replacement or repair. The objective of the study is to review our experience with the different surgical treatments and to assess the impact of pre- and intraoperative factors on mortality, morbidity and long-term survival. METHODS: From July 1990 to May 2000, 102 patients with ischemic mitral regurgitation > 2 + grade underwent operative treatment. CABG alone was performed in 52 and combined procedures in 50 cases (18 replacements and 32 repairs). Mitral repairs were accomplished by Carpentier or Key techniques and/or ring implantation. All replacements were done with preservation of the posterior mitral valve leaflet. RESULTS: Overall mortality is 11(10.8%)-3 patients (5.8%) in the CABG group and 8 (16%) in the combined group (3-16.7% for replacement and 5-15.6% for repair). There was 7 late deaths in both groups. Five year survival was 78% for CABG, 78% for repair and 76 for replacement. CONCLUSIONS: In high risk patients with ejection fraction < 35% and mitral regurgitation < 3 + grade we recommend CABG alone. Valve replacement is the procedure of choice in case of papillary muscle rupture. All patients need complete revascularisation. Good results are obtained with repair techniques and ring implantation.

Simultaneous pectus and open heart surgery.

Various surgical approaches to pectus excavatum repair concomitant with surgery have been recommended. In this article the authors describe their approach to the problem that they applied in 1989 and onward, successfully, in six consecutive patients. The favorable early and long-term results of these cases illustrate that the simultaneous correction of pectus excavatum and the underlying diseases of the ascending aorta, aortic arch, and the heart can be performed successfully even in emergency situations. The technique recommended provides good cosmetic results and a stable chest wall. It is well applicable in patients of adult age.

[The surgical correction of the right aortic arch with aberrant left subclavian artery and left ligamentum arteriosum--a rare case from clinical practice]. / Khirurgichna korektsiia na diasna aortna duga s aberantna liava podkliuchichna arteriia i liav ligamentum arteriosum--riaduk sluchai ot klinichnata praktika.

Reports on the surgical management of the vascular ring formed by the right aortic arch with aberrant retroesophageal left subclavian artery and left ligamentum arteriosum are relatively few. The authors present a case of a thirty-three-year old woman with cough, dysphonia and stridor without dysphagia. Surgical management which was performed through a bilateral thoracotomy with transversal sternotomy, included division of the ligamentum arteriosum and of the aberrant left subclavian artery and suture of the latter. There was no need to resect the Kommerell's diverticulum, because of lack of any dysphagia despite of the well documented severe compression of the esophagus. The authors experience proved that in difficult cases the bilateral thoracotomy and transversal sternotomy is an useful approach to perform complete surgical repair of this abnormality.

[The anatomical characteristics of the a. mammaria interna and their importance for the surgical results in aortocoronary bypass (a report on 2 clinical cases with large intercostal branches of the a. mammaria interna)]. / Anatomichni osobenosti na a. mammaria interna i znachenieto im za operativnite rezultati pri aorto-koronaren baipas (suobshtenie za 2 klinichni sluchaia s golemi interkostalni klonove na a. mammaria interna).

OBJECTIVES: This study attempted to determine the possibility for steal phenomenon after coronary surgery using internal mammary artery (IMA) as graft with unligated big side branches. The internal mammary artery (IMA) is considered to be the conduct of choice in coronary artery bypass grafting (CABH). The more IMA grafts are used, the more increases the significance of IMA anomalies and notably the large side branches for the surgical results. The importance of coronary subclavian steal syndrome is well known. We represent two clinical cases with big intercostal branches visualised at the postoperative coronary angiography, performed to evaluate the coronary and graft status cause of recurrent postoperative anginal pain. After cardiac catheterization we performed ECG stress test as follows: 1. A conventional stress test on treadmill (for control) and 2. Modified stress test loading the chest wall muscles in spine position. We expected to provoke and to evaluate steal phenomenon by the main IMA graft to the big lateral branches. At both of the patients on the arteriographic study IMA graft was patent and both had unusual large (> 50% of the IMA lumen) side branches, reducing the blood flow in the IMA graft. The modified stress test loading the chest wall muscles didn't provoke anginal pain at both patients. At the first (50 years old white male, CABG x 3-July 1193) it was evident non significant ST depression (< 2 mm) in V4-V% (suspicion of silent ischemia). At the second (70 years old white male, anterior MI-1990, GABG x 4-1992) the stress test was interrupted because of fatigue at the arm. No evident significant ecg changes. Despite we couldn't prove steal phenomenon through the angiographic study and the modified ECG stress test we suggest several logic.

[An analysis of our experience using the bilateral arteria thoracica interna (ATI) in patients undergoing aortocoronary bypass]. / Analiz na nashiia opit s izpolzvane na bilateralna arteria thoracica interna (ATI) pri patsienti s aorto-koronaren baipas.

The well established long-term patency of the internal thoracic artery (ITA) makes it a conduit of choice for coronary revascularization. Recent data suggest that patients with bilateral ITA grafts have a greater survival benefit and improved life-style quality, but it is worth noting that increased use of both ITA may have an adverse effect on morbidity and mortality. It is the purpose of this report to assay the first series of patients with bilateral ITAs, and analyze morbidity and mortality rates. In the period April 1992 through January 1994, ten patients undergo coronary revascularization using both ITAs, supplemented by saphenous grafts. In the series analyzed hospital mortality amounts to zero, and there is no perioperative myocardial infarction--neither respiratory deficiency, nor reoperations for bleeding. There is a single case of sternal infection--10 per cent. As shown by the early results, the use of bilateral ITA for coronary artery bypass grafting is a safe procedure, and does not increase operative mortality and morbidity.

[The surgical reconstruction of the chest wall using muscle flaps in patients with mediastinitis following heart operations]. / Operativna rekonstruktsiia na grudnata stena s muskulni lamba pri bolni s mediastinit sled surdechni operatsii.

An assessment is made of the results of plastic closure of the chest in cases presenting mediastinitis. The analysis covers nineteen patients with a history of mediastinitis following open-heart surgery, treated by the same method of plastic reconstruction of the chest. The technique of plastic closure of the chest using a rotation muscle flap (pectoralis and right rectus abdominis muscles) is described.