[Intima flap of the external carotid and postoperative stroke in a patient surgically treated with thromboendarterectomy of the internal carotid]. / Flap intimale della carotide esterna e stroke postoperatorio in paziente operato di tromboendoarteriectomia della carotide interna.

Retrograde thrombosis of the carotid bifurcation rising from an intimal flap of the external carotid artery represent a rare complication of carotid surgery. We present the case of a patient who had undergone carotid thromboendarterectomy (TEA) whose postoperative course was complicated by the appearance of left hemiplegia and coscience disorders. The timely diagnosis of acute carotid thrombosis and the immediate reoperation prevented neurological deficits becoming settled. An attentive intraoperative evaluation of carotid bifurcation showed only the presence of an intimal flap of the external carotid artery from which a big occluding thrombus, involving the bifurcation, rose. The internal and common carotid arteries showed a successful result of the TEA and a good retrograde flow through the internal carotid artery. The authors underline the existence of this perioperative complication and the need for a timely recognition and treatment to avoid serious neurologic consequences.

[Heart surgery with cardiopulmonary bypass in patients on chronic dialysis treatment: our experience]. / Interventi cardiochirurgici in circolazione extracorporea in pazienti in trattamento dialitico cronico: nostra esperienza.

METHODS: To determine the mortality and the morbidity of cardiac surgery in patients on chronic hemodialysis, we retrospectively reviewed eighteen adult patients (13 males and 5 females) with a mean age of 54.7 years (range: 30-67 years) who underwent cardiopulmonary bypass procedures between 1987 and 1995. The operations included: isolated coronary artery bypass grafting in 12 patients, coronary artery bypass grafting plus mitral ring annuloplasty in 1 patient, mitro aortic valve replacement in 2 patients, isolated aortic valve replacement in 1 patient, aortic valved conduit implantation in 1 patients and mitral valve replacement plus tricuspid annuloplasty in 1 patient. There were 10 and 3 patients in CCS functional classification III and IV respectively; 1 and 4 patients were in NYHA classification II and III respectively. All of them were hemodialyzed the day before surgery: the average time they had been on hemodialysis was 6.5 years. Anesthesia and the cardiopulmonary bypass (CPB) in these patients required attention in order to provide the optimal fluids and electrolytes balance: particularly intravenously administered fluids were kept to a minimum and drug dosages were reduced to recommended levels for anephric patients. An hemoconcentrator was used in all patients during the CPB and, in the last 4 cases, we used a dialysis filter and a sterilized perfusional solution to reduce the level of potassium and to put off postoperative dialysis. RESULTS: In three patients there were major bleeding problems resulting in reoperation; 5 perioperative deaths occurred: two of them due to myocardial infarction and three due to irreversible low cardiac output state. In our experience there were four late deaths: one patient died four months after surgery for chronic heart failure, another one died twelve months after surgery for dilated cardiomyopathy and two patients died respectively seventeen and seventy two months after discharge for myocardial infarction. Two of the remaining patients reported recurrence of angina while the others achieved symptomatic improvement. CONCLUSIONS: In conclusion, cardiac surgery is performed on chronic renal dialysis patients with high mortality and morbidity and it's indicated only if medical treatment is ineffective. The successful surgical results, obtained with an adequate management between surgeons, anesthesiologists and nephrologists, don't assure the long-term survival of the patients.

Effect of glutathione monoethyl ester on glutathione level and cardiac energetics in reperfused pig heart.

The GSH level in myocardial tissue represents an important defense mechanism against oxygen toxicity. Since the ischemia-induced depletion of GSH might favour the cytotoxicity of oxygen-derived free radicals produced during reperfusion, we assessed the effects of the GSH donor, glutathione monoethylester, in anaesthetized pigs subjected to 90 minutes of coronary occlusion followed by 30 minutes reperfusion. The drug was infused intracoronarily at a dose of 1 mg/ml (0.5 ml/min) throughout the experimental period. After coronary occlusion and reperfusion, we found a decrease in GSH, ADP, ATP and phosphocreatine levels in reperfused compared with non-ischemic tissue. Less evident were the differences in mitochondrial function, there being only a reduction in the reperfused tissue of the respiratory control index and state 3 respiration values when pyruvate was used as substrate. The infusion with glutathione monoethylester decreased the depletion of tissue GSH and improved the GSH/GSSG ratio, particularly in the non-ischemic tissue. Moreover, the drug decreased the mitochondrial dysfunction at the level of pyruvate utilization and partially prevented the fall in ATP in the reperfused tissue. This study confirms a possible protective effect of glutathione monoethylester in the prevention of reperfusion-induced myocardial damage.

Changes in myocardial mitochondrial respiration after ligation of the coronary artery in pigs.

After ligation of the left coronary artery, porcine cardiac mitochondria were isolated by homogenizing the tissue and treating the myofibrillar pellet with nagarse. When compared with unligated controls, the ischemic myocardium showed decreases in phosphocreatine (to 41%), ATP (to 56%) and in the mitochondrial respiratory control index (to 69% and 78% as measured with glutamate and succinate respectively). No changes were found in the corresponding P/O ratios. Similar results were obtained upon separation of the mitochondria into two main fractions by a density gradient technique, though only one of these fractions showed a fall in succinate-supported respiration. The results suggest that ischemia decreases the NADH-dehydrogenase activity of cardiac mitochondria.

[Surgical therapy for prosthetic heart valve endocarditis: immediate results and follow-up]. / Terapia chirurgica dell'endocardite su protesi valvolare cardiaca: risultati immediati e follow-up.

Between January 1980 and May 1990 17 patients underwent surgery for prosthetic valve endocarditis at Cardiosurgical Department of Bologna University. Ten patients were female and seven male, the average age was 33 years (range 19 to 67 years). The interval from valve replacement to onset of symptoms of prosthetic valve endocarditis was less than 2 months in 5 patients and longer than 2 months in 12 patients. Sixteen of 17 infected prostheses were mechanical and one biological. All patients were surgically treated and the infected prostheses replaced with new valve prostheses. The hospital mortality rate for early prosthetic valve endocarditis was 60%, for late endocarditis was 16.5%, global hospital mortality was 29.4%.