The current role of surgery in treating adult patients with patent ductus arteriosus.

OBJECTIVE: Surgical closure of patent ductus arteriosus (PDA) is still required in selected adult patients. We analyzed the morphology of the anomaly and coexisting pathological findings in adult patients who were recently referred to our institute for surgical PDA repair. PATIENTS AND INTERVENTIONS: Six adult PDA patients who were not considered candidates for percutaneous closure underwent surgical PDA correction. In three patients with isolated PDA, computed tomographic scan revealed short, wide, and distorted ductus. In the remainder three patients, concomitant heart or aortic disease was found. Transpulmonary approach under total cardiopulmonary bypass or hypothermic circulatory arrest was performed. RESULTS: In all patients, a Dacron patch was used to close the duct. The balloon occlusion technique with normothermic cardiopulmonary bypass was performed in four patients. In one of these patients, the balloon occlusion was not feasible because of unfavorable ductal anatomy, and PDA was closed in short hypothermic circulatory arrest. In two patients with aortic aneurysm, PDA closure and aortic reconstruction were performed in deep hypothermic circulatory arrest. No significant complications occurred during postoperative course. After the mean follow-up period of 48 months, neither ductal reopening nor aneurysmal degeneration of remnant ductal tissue was found. CONCLUSION: Surgical PDA closure in adults remains the treatment of choice in wide, deformed PDAs unsuitable for percutaneous closure and PDAs associated with surgical aortic or heart disease.

Steroids and statins: an old and a new anti-inflammatory strategy compared.

OBJECTIVES: This study compared the anti-inflammatory effects of methylprednisolone (MP) and atorvastatin and analysed their influences on clinical variables in patients undergoing coronary revascularization. METHODS: Ninety patients with compromised left ventricular ejection fraction (≤30%) undergoing elective coronary surgery were equally randomized to one of three groups: statin group, treatment with atorvastatin (20 mg/day) 3 weeks before surgery; methylprednisolone group, a single shot of methylpredniosolone (10mg/kg); and control group. RESULTS: Postoperative IL-6 was higher in the control group when compared to the methylprednisolone and statin groups (p<0.01). IL-6 was higher in the statin-treated patients (p<0.05 versus methylprednisolone). Administration of methylprednisolone as well as statin treatment increased postoperative cardiac index, left ventricular stroke work index, decreased postoperative atrial fibrilation rate and reduced ICU stay (p<0.05 versus control). The number of patients requiring inotropic support was lower in the methylprednisolone group when compared with the other two groups (p<0.01). Tracheal intubation time was reduced in patients who received methylprednisolone (p<0.01 versus control). CONCLUSIONS: Preoperative administration of either methylprednisolone or atorvastatin reduced pro-inflammatory cytokine release, improved haemodynamics, decreased postoperative atrial fibrilation rate and reduced ICU stay in patients with significantly impaired cardiac function undergoing coronary revascularization. Treatment with methylprednisolone was associated with less inotropic support requirements and reduced mechanical ventilation time.

Transecting the aorta to close the aortic prosthetic valve paravalvular space.

The residual aortic prosthetic valve paravalvular space beneath the left coronary artery is very difficult and risky to repair. To improve visualization of this area, we transected the ascending aorta and mobilized both the aortic root and the left coronary artery from the surrounding tissue. Subsequently, we retracted the left coronary artery aside and pulled the posterior aortic root upwards. This maneuver has provided enough space for the safe placement of stitches and the closure of the paraprosthetic defect in this very delicate area.