Environmental risk factors analysis in paediatric oral health: a cross-sectional study.

AIM: The aim of the present study was to evaluate the association between environmental risk factors [adherence to the Mediterranean diet (MD), eating habits, hygiene habits, body mass index (BMI)] with the presence of caries in a university-based cohort of paediatric patients. MATERIALS: A total of 118 paediatric patients were included in the study. In addition to the evaluation of clinical (vitality test, percussion test) and radiographic (X-ray bitewing, OPT) parameters, patients' lifestyle was investigated through validated questionnaries. Data regarding decayed, missing, filled teeth index were recorded for both permanent (DMFT) and deciduous teeth (dmft). Logistic/linear regression models (crude estimates) and multiple regression models (logistic/linear) adjusted for confounding factors were built to evaluate the association between lifestyle habits and caries. The results were reported as Odds Ratio (OR - con 95% CI) for logistic regression models and Mean Difference (MD - con 95% CI) for linear models. CONCLUSION: The present study confirmed the role of nutritional habits in caries development in the paediatric population, especially for deciduous dentition. Further clinical studies are needed to improve the quality of administered questionnaires and evaluate the cause/effect relationship between environmental risk factors and caries.

Effectiveness and safety of carotid endarterectomy under remifentanil.

AIM: The aim of this study was to evaluate the effectiveness and safety of carotid endarterectomy (CEA) with conscious sedation under remifentanil (Remifentanil anesthesia - RA) vs conventional loco-regional anesthesia (Conventional-LRA) in the current practice of a vascular surgery unit. METHODS: We introduced the ''Remifentanil-RA'' in our practice according to a two-step protocol. In the first step we performed a pilot prospective study to assess the procedure's safety and reproducibility in our setting on 60 consecutive patients with symptomatic and/or high-grade (>70%) internal carotid artery stenosis and alternately assigning them either to ''Remifentanil-RA'' or ''Conventional-LRA'' CEA. In the second step we analysed our routine operative records as to effectiveness and safety on 533 patients who consecutively underwent ''Remifentanil-RA'' CEA. We compared them with 533 age- and sex-matched historical controls who underwent ''Conventional-LRA'' CEA. RESULTS: The patients' mean age was 71.2+/-6.8 vs 71.8+/-6.1 (''Remifentanil-RA'' vs ''Conventional-LRA''). About 73% of them were male and 56% had a symptomatic carotid stenosis. Neither the pilot study nor second step comparison showed differences in outcome measures. We found only higher peri-operative nausea/ vomit (3.6% vs 0.4% ''Remifentanil-RA'' vs ''Conventional-LRA'', P<0.0002) and fewer re-operations for post-operative hematomas (3% vs 5.4% respectively, P=0.048). CONCLUSIONS: We found that ''Remifentanil-RA'' CEA was safe, effective and satisfactory. Nevertheless, with the potential problems of intubation and those already found with side effects, a randomized control trial (RCT) is needed in order to prove that this method is superior to ''Conventional-LRA'' CEA.

"Hybrid" percutaneous and surgical coronary revascularization: selection criteria from a single-center experience.

BACKGROUND: The association of minimally invasive direct coronary artery bypass (MIDCAB) to percutaneous transluminal coronary angioplasty (PTCA) of large arteries with focal lesions can be an alternative therapeutic method for patients with multivessel coronary artery disease. We reviewed our experience regarding 42 patients treated at our Institute. METHODS: MIDCAB and PTCA of the circumflex or right coronary arteries > 3 mm were performed in 42 patients from September 1997 to December 1999. RESULTS: One patient died after MIDCAB in the operating room because of rupture of the left anterior descending anastomosis. Postoperative angiography confirmed patency of the internal mammary artery (IMA) graft in 92.3% of cases: 3 early IMA graft failures occurred. The success rate for PTCA was 98%: in 1 case the wire just would not cross a chronically and totally occluded right coronary artery. The in-hospital morbidity was 12.2%: 2 patients required urgent sternotomy respectively for cardiac tamponade and coronary artery bypass grafting on cardiopulmonary bypass. One patient developed atheroembolism after PTCA with recurrence of symptoms, progressive multiorgan failure and death. Two patients required PTCA on the IMA anastomosis because of early failure of the arterial graft. At a medium follow-up of 535 days, all 40 survivors are in Canadian Cardiovascular Society class I. CONCLUSIONS: Hybrid revascularization appears to be an effective treatment for selected patients with multivessel coronary artery disease. The immediate success seems related to the learning curve for MIDCAB.

Limited posterior left atrial cryoablation in patients with chronic atrial fibrillation undergoing valvular heart sugery.

OBJECTIVES: We sought to evaluate whether a limited surgical cryoablation of the posterior region of the left atrium was safe and effective in the cure of atrial fibrillation (AF) in patients with associated valvular heart disease. BACKGROUND: Extensive surgical ablation of AF is a complex and risky procedure. The posterior region of the left atrium seems to be important in the initiation and maintenance of AF. METHODS: In 32 patients with chronic AF who underwent heart valve surgery, linear cryolesions connecting the four pulmonary veins and the posterior mitral annulus were performed. Eighteen patients with AF who underwent valvular surgery but refused cryoablation were considered as the control group. RESULTS: Sinus rhythm (SR) was restored in 25 (78%) of 32 patients immediately after the operation. The cryoablation procedure required 20 +/- 4 min. There were no intraoperative and perioperative complications. During the hospital period, one patient died of septicemia. Thirty-one patients reached a minimum of nine months of follow-up. Two deaths occurred but were unrelated to the procedure. Twenty (69%) of 29 patients remained in SR with cryoablation alone, and 26 (90%) of 29 patients with cryoablation, drugs and radiofrequency ablation. Three (10%) of 29 patients remained in chronic AF. Right and left atrial contractility was evident in 24 (92%) of 26 patients in SR. In control group, two deaths occurred, and SR was present in only four (25%) of 16 patients. CONCLUSIONS: Linear cryoablation with lesions connecting the four pulmonary veins and the mitral annulus is effective in restoration and maintenance of SR in patients with heart valve disease and chronic AF. Limited left atrial cryoablation may represent a valid alternative to the maze procedure, reducing myocardial ischemic time and risk of bleeding.

[Myocardial revascularization in patients with severely depressed left ventricular function]. / La rivascolarizzazione miocardica nei pazienti con funzione ventricolare sinistra severamente depressa.

BACKGROUND: Improvements in anesthetic and surgical management of patients with left ventricular dysfunction have resulted in a decline in perioperative mortality and morbidity. Nevertheless, coronary artery bypass grafting (CABG) in patients with left ventricular ejection fraction < or = 0.30 remains a surgical challenge. METHODS: Fifty-one patients with end-stage coronary artery disease and left ventricular ejection fraction between 16 and 30% underwent CABG. Mean age at operation was 66.1 +/- 7.85 years. Selection criteria included the clinical diagnosis of ischemic heart disease with angiographic demonstration of critical coronary artery obstructive lesions. Mean number of grafts per patient was 2.94 (range 1-5). Average duration of cardiopulmonary bypass was 74.5 +/- 22.4 min and mean aortic cross clamp time was 47.6 +/- 17 min. RESULTS: No operative and in-hospital deaths occurred. Eight patients (15.7%) had postoperative low cardiac output syndrome, requiring intraaortic balloon counterpulsation. There were two major neurological complications (3.9%). There were four late deaths (7.8%), due to recurrence of untreatable congestive heart failure. Left ventricular ejection fraction increased from a mean of 25.51 +/- 4.75% preoperatively to 31.35 +/- 9.9% postoperatively (p < 0.001). Improvement in NYHA functional class (preoperatively 2.98 +/- 0.79 vs 2.35 +/- 0.6 postoperatively, p < 0.001) was found in this group at follow-up. CONCLUSIONS: CABG leads to an excellent prognosis in high risk patients with ischemic heart disease and low left ventricular ejection fraction, improving their functional and clinical outcome and consequently their life expectancy.

Coronary artery spasm after coronary artery bypass grafting.

We report a case of a 62-year-old man with severe manifestations of postoperative coronary artery spasm following effective coronary artery bypass grafting. The coronary artery spasm was manifested by ST segment elevation, hypotension and wall motion abnormalities on echocardiography. Urgent angiography confirmed the diagnosis and intracoronary infusion of nitroglycerine and verapamil relieved the coronary spasm.

"Hybrid" and combined percutaneous and surgical intervention to treat selected cardiac patients: a new strategy.

The term "hybrid revascularization" describes the combined use of minimally-invasive surgery without cardiopulmonary bypass and percutaneous coronary revascularization in selected cases. The theoretical advantage of a less invasive surgical intervention must be weighted against the need for additional percutaneous procedures, with their own risks and limitations. We describe our initial experience with hybrid revascularization at the Istituto Clinico Humanitas in Milan. From 7/97 to 10/98, twelve patients underwent hybrid revascularization or a combined percutaneous and surgical intervention. A "classic" hybrid approach, consisting of minimally-invasive direct coronary artery bypass to the left anterior descending coronary artery and angioplasty or stenting of arteries in the right coronary artery or circumflex territories, was used in nine patients. In three patients, myocardial revascularization could be completed with percutaneous procedures after bypass surgery without cardiopulmonary bypass (in two patients because of severe aortic calcification) or valve surgery in a patient with two previous bypass operations. In-hospital complications were observed in three patients. Two required urgent median sternotomy (one for impending cardiac tamponade, one for conversion to bypass on extra-corporeal circulation). One patient developed atheroembolism after percutaneous intervention: after hospital discharge, there was a recurrence of symptoms, clinical deterioration with renal failure and eventually death. At a mean follow-up of 152 +/- 91 days (range 17 to 283) after minimally-invasive surgery and 166 +/- 122 days (range 13 to 397) after angioplasty, all surviving patients are well and free of anginal symptoms. Closer collaboration between surgical and interventional operators may offer a novel approach to effective treatment of difficult patient subsets. However, our initial experience suggests that a cautious evaluation of possible risks and benefits must carefully be entertained in each patient who may be considered a candidate for hybrid revascularization or combined percutaneous and surgical intervention.

Detection of right ventricular ischaemia during coronary surgery by means of a right precordial lead.

This study was designed to determine the intra-operative incidence of right-sided ventricular ischaemia and any association with left ventricular ischaemia. In 60 patients, undergoing coronary artery bypass grafting surgery, a right-sided precordial lead V5R was used. ST segment deviation of more than 1 mm in V5R was considered significant for myocardial ischaemia. Right ventricular ischaemia occurred in 14 patients (23.3%) but was not associated with left ventricular inferior wall ischaemia. In 4 patients (6.6%) presenting with right ventricular ischaemia, ischaemia of the left inferior wall also developed but in all cases was transient and disappeared by the end of surgery. No myocardial infarction was detected in the post-operative period. The present study showed that the use of a right-sided lead may improve intra-operative electrocardiographic monitoring, by revealing ischaemia in those patients in whom ECG abnormalities were not detected by conventional leads. The transient right ventricular ischaemia recorded in this study was probably related to a reduced hypothermic protection of the right ventricle during aortic cross clamping.

Early and late results of aortic root replacement with antibiotic-sterilized aortic homograft.

Between November 1972 and November 1986, 108 patients aged 5 to 73 years had complete replacement of the aortic root with an aortic homograft into which the coronary arteries were implanted. The main indications were (1) a tunnel type of aortic obstruction involving a hypoplastic ring, (2) a para-aortic annular abscess, (3) prosthetic valve dysfunction, mainly a previous aortic homograft, and (4) aortic stenosis with a small aortic anulus. Eighty-four patients (78%) had previous aortic valve operations. Concomitant cardiac procedures were done in 34 patients (32%). The 30-day mortality rate was 14% (15 patients). The cumulative follow-up period was 180.3 patient-years. The late mortality rate was 6.1% per patient-year (11 patients). The patients were not given anticoagulants postoperatively, but the entire group has been completely free from thromboembolism. The actuarial 5-year survival rate including operative deaths was 72%. The freedom from valve-related death at 5 years after operation is 86% and freedom from reoperation at 5 years is 96%. The use of homografts for replacement of the aortic valve and root in patients with complex lesions affecting these structures has shown encouraging early and late results, with regard to both survival and valve performance.