Plaque composition in plexogenic and thromboembolic pulmonary hypertension: the critical role of thrombotic material in pultaceous core formation.

BACKGROUND: Patients with pulmonary hypertension develop intimal plaques in large pulmonary arteries. OBJECTIVE: To test the hypothesis that the composition of such plaques differs depending on whether the aetiology of the disease is thromboembolic or hypertensive. DESIGN: Chronic thromboembolic and plexogenic pulmonary hypertension (primary and secondary (Eisenmenger syndrome)) were investigated. These are spontaneous human models and were used to examine the independent role of thrombus and hypertension in plaque composition. SETTING: A national tertiary referral centre for lung transplantation and pulmonary thromboendoarterectomy. PATIENTS: Thirty nine patients with chronic thromboembolic pulmonary hypertension who had undergone thromboendoarterectomy (n = 32) or lung transplantation (n = 7), 28 with plexogenic diseases (nine primary and 19 Eisenmenger), and three with Eisenmenger syndrome complicated by thromboembolic events. INTERVENTIONS: The lung and thromboendoarterectomy samples were sectioned, stained with Movat pentachrome, and immunostained with antibodies for fibrin, platelets, inflammatory cells, smooth muscle cells, and erythrocyte membrane glycophorin A. MAIN OUTCOME MEASURE: Composition of the plaques affecting large pulmonary arteries. RESULTS: Two types of intimal lesion were distinguished in chronic thromboembolic pulmonary hypertension: fibrous plaques with angioneogenesis; and core-rich atherosclerotic plaques with pultaceous cores largely consisting of glycophorin immunoreactive material, with cholesterol clefts (61.5%), CD68 positive macrophages (84.6%), T lymphocytes (87%), and calcification (46.1%). The samples from the patients with Eisenmenger syndrome and thromboembolic complications had similar characteristics, whereas those from patients with uncomplicated primary pulmonary hypertension had core-free fibrous plaques, spotted with macrophages and T lymphocytes. CONCLUSIONS: Chronic thromboembolic pulmonary hypertension is associated with atherosclerotic plaques with glycophorin-rich pultaceous cores, and plexogenic pulmonary hypertension with fibrous plaques. Thromboembolic material thus plays a critical role in the formation of pultaceous cores, of which erythrocyte membrane derived glycophorin is a major component.

[Acute postoperative mediastinitis: retrospective analysis of various treatment methods]. / Mediastinite acuta postoperatoria: analisi retrospettiva di differenti metodiche di trattamento.

Infective acute mediastinitis is a postoperative complication reported in 0.5-1% of patients undergoing open chest operations. The treatment of choice for this life-threatening complication is still a matter of debate. The aim of this study was to retrospectively analyse the efficacy of different therapeutic approaches in the treatment of postoperative infective mediastinitis. In the 2nd Division of Cardiac Surgery, from October 1986 to May 2000, 10,234 patients underwent cardiac surgery operations. In 42 patients (0.4%) the operation was complicated by acute infective mediastinitis requiring surgical treatment. On the basis of the treatment opted for, these patients were subdivided into 5 groups: 23 patients underwent continuous iodopovidone (Betadine) mediastinal irrigation (GL) associated with surgical omentoplasty in 8 patients (GLO); 5 patients underwent isolated omentoplasty (GO), and 4 patients were treated with a pectoral muscle flap (GF). In 8 patients other different procedures were performed (GS). There were no deaths in GF and GS despite 24% and 20% mortality reported among patients who underwent mediastinal irrigation (GL) and isolated omentoplasty (GO), respectively. The mean hospital stay was 15 +/- 1 days in GF, 16 +/- 1 days in GS, 25 +/- 11 in patients who underwent omentoplasty and 27 +/- 14 in patients who underwent mediastinal irrigation. Predictors of death were low cardiac output syndrome (P < or = 0.009) and respiratory insufficiency (P < or = 0.032) when found before treatment. Our study suggests that surgical omentoplasty should be the treatment of choice in deep mediastinal infections, whereas wound sterilisation, associated with surgical chest wall reconstruction, seems to be a better procedure in superficial infective disease. A more extended clinical series would be needed to confirm these preliminary data.

Long-term results of coronary artery bypass grafting procedure in the presence of left ventricular dysfunction and hibernating myocardium.

OBJECTIVE: Long-term left ventricular (LV) performance and patient outcome after coronary artery bypass grafting (CABG) procedure in the presence of depressed LV function and hibernating myocardium (HM) have been poorly determined. Therefore, we prospectively evaluated patients undergoing CABG with severe LV dysfunction and HM to elucidate postoperative prognosis. METHODS: We enrolled 120 consecutive patients undergoing CABG with severe LV dysfunction and HM as assessed by dobutamine echocardiography and by rest-redistribution radionuclide (Thallium-201) study. Mean patient age was 60+/-9 years (range 31-77 years). Mean preoperative LVEF was 28%+/-9 (range 10-40%). All patients underwent echocardiographic study to assess LV recovery of function intraoperatively, prior to hospital discharge, at 3 months, at 1 year, and yearly during the follow-up. Univariate and multivariate analysis were performed to to evaluate predictors of postoperative survival. RESULTS: There were 2 hospital (1.6%) and 15 late (12.5%) deaths, mainly for heart failure, leading to an actuarial survival of 80+/-6% and 60+/-9% at 5 and 8 years, respectively. LVEF significantly improved perioperatively (from 28+/-9% to 40+/-2%, P<0.01). Increase in LVEF, however, was gradually offset over the time (EF of 33+/-9%, 32+/-8%, and 30+/-9% at 3 months, and 12 months, and 8 years after surgery, respectively). Furthermore, patients who experienced limited LV functional recovery perioperatively had a more remarkable decline of LVEF thereafter, and suffered from recurrence of heart failure symptoms (freedom from heart failure 82+/-5% and 60+/-8% at 4 and 8 years respectively). Advanced preoperative NYHA Class, and age were independent risks factors for reduced postoperative survival. Preoperative angina and use of arterial conduits apparently did not influence patient morbidity and mortality at long term. CONCLUSION: CABG procedure in the presence of HM enhances LV recovery of function and has a favourable prognosis. Functional benefit of the left ventricle, however, appears to be time-limited, despite remarkable improvement in patient functional capacity. Advanced preoperative heart failure, minimal perioperative improvement of LVEF, and age account for a poor long-term prognosis.

The double-orifice technique for mitral valve reconstruction: predictors of postoperative outcome.

OBJECTIVE: The 'double-orifice' (DO) technique has been recently proposed as an additional option in mitral valve repair (MVR). However, little is known regarding the long-term postoperative outcome and the predictors of DO results. Therefore, the aim of this study was to evaluate our clinical series and to identify prognostic factors of DO repair. METHODS: From 1992, 75 patients underwent DO procedure because of severe mitral regurgitation. The study population consisted of 48 male and 27 female patients with a mean age of 58+/-13 years (range 16-80 years). The aetiology of mitral incompetence was Barlow disease in 30 cases, rheumatic disease in 18 cases, acute or healed endocarditis in 16 cases and other causes in 11 cases. Carpentier rigid ring was used in 38 patients, whereas autologous pericardium was used in 24 patients. Thirteen patients had no annuloplasty procedure. Statistical analysis included univariate and multivariate Cox proportional models to evaluate the predictors of the DO failure. RESULTS: There were four hospital and three late deaths with a survival rate of 92% at 8 years. Mean follow-up was 42+/-24 months (range 1-93 months). Twelve patients underwent reoperation (five cases of early failure) and had valve replacement, leading to 80% freedom from reoperation at 8 years. At follow-up, 13 patients had no mitral regurgitation, 36 patients had trivial or mild mitral incompetence, whereas eight patients had moderate or severe mitral insufficiency at transthoracic echocardiography. Preoperative low left ventricular ejection faction, pulmonary arterial hypertension and marked left atrial enlargement were predictors (P<0.05) of DO failure at univariate analysis. Pericardial annuloplasty was also a risk factor (P<0.05) for unsuccessful DO repair at long term. Cox proportional multivariate analysis confirmed left atrial dilatation, pulmonary hypertension and pericardial annuloplasty as independent predictors of unfavourable postoperative results. CONCLUSIONS: This study suggests that preoperative factors, like pulmonary hypertension and severe left atrial dilatation, may predict late DO failure. Our findings also indicate that pericardial annuloplasty may negatively influence mitral valve reconstruction at long term when DO is employed in MVR.

Coronary artery bypass grafts in a patient with isolated cardiac dextroversion.

Despite several controversies, the term "dextrocardia" usually defines a rare type of intrinsic cardiac abnormality due to a rotation disorder and resulting in a right-sided direction of the cardiac axis. According to the majority of experts, the extent of a dextrocardia associated with a situs solitus is termed "dextroversion". In such a rare condition, therefore, the relationships between the cardiac chambers and the other structures (that is superior and inferior venae cavae, liver, stomach) are modified whereas in case of dextrocardia with situs inversus, the relationships between the cardiac chambers and neighboring structures are preserved and the classical "mirror image" is shown. In 95% of cases with dextroversion, an associated cardiac abnormality has been described and, therefore, acquired heart diseases in patients with isolated dextroversion are extremely rare. To our knowledge, the present is the first case report describing a coronary artery bypass graft performed in a patient with isolated dextroversion. The technical aspects of the surgical procedure are also discussed.

Septal dissection and rupture evolved as an inferobasal pseudoaneurysm.

We report two cases of postinfarction dissecting hematoma of the interventricular septum with restrictive ventricular septal defect that evolved as an inferobasal pseudoaneurysm. The difficult anatomical pattern was assessed by two-dimensional (2-D) echocardiography with Doppler and color analysis, left ventriculography and perioperative transoesophageal echo. Because the patient had no signs of heart failure, the surgical repair was successfully delayed until the dissecting tissue became fibrotic. Problems of diagnosis, decision making and surgical management are discussed.

Pulmonary thromboendarterectomy in patients with chronic thromboembolic pulmonary hypertension: hemodynamic characteristics and changes.

OBJECTIVE: To see whether degree of pulmonary hypertension or severity of cardiac failure affect the success of pulmonary thromboendarterectomy (PTE) in chronic thromboembolic pulmonary hypertension. METHODS: From May 1996 to June 1999, 33 patients, all in New York Heart Association (NYHA) class 3 or 4 were treated with PTE. Preoperative hemodynamic values were: central venous pressure (CVP) 8+/-6 (1-23), mean pulmonary artery pressure (mPAP) 50+/-10 (30-69), cardiac output (CO) 3.3+/-0.9 (1.8-5.2), pulmonary vascular resistance (PVR) 1056+/-344 (523-1659), and right ventricle ejection fraction (RVEF) 12+/-5 (5-21). To establish whether some hemodynamic or cardiac variables correlate with surgical failure (early death or functional non-success), these patients were divided into a low risk or a high risk group for each variable: CVP (<9 or > or =9), mPAP (<50 or > or =50), CO (> or =3.5 or <3.5), PVR (> or =1100 or <1100), and RVEF (> or = 10 or <10). The duration of 3-4 NYHA class period (<24 or > or = 24 months) was also included in the study. RESULTS: Three patients (9. 1%) died in hospital, one (3.0%) underwent lung transplant shortly after PTE, and in five cases (15.2%) mPAP and PVR at the 3-month follow-up examination corresponded with our definition of functional nonsuccess (mPAP and PVR decreased by less than 40% of preoperative values). One of the five functional nonsuccess patients underwent lung transplant 3 months after the operation and another died 17 months after the operation from a non-related cause. Thus PTE was successful in 24 patients and unsuccessful in nine. None of the hemodynamic variables considered was found to be associated with the disparate outcomes. At the 3-month examination, all surviving patients were in NYHA class 1 or 2 except for three in NYHA class 3. At 2 years, hemodynamic values were: CVP 2+/-2 (0-4), mPAP 16+/-3 (12-21), CO 5.0+/-1.0 (3.4-6.5), PVR 182+/-51 (112-282), and RVEF 35+/-5 (26-40). All differences were significant with respect to baseline values (P<0.001). Preoperative mPAP and RVEF values had a strict linear correlation (R=0.45; P=0.014). CONCLUSIONS: None of the variables considered was correlated with early death or functional nonsuccess. Neither preoperative severity of pulmonary hypertension nor degree of cardiac failure influenced the outcome of the operation. PTE leads to hemodynamic recovery even in very compromised patients.

Monitoring aspects during port-access cardiac surgery.

OBJECTIVE: To report the experience gained at our Cardiosurgical Centre with the recently introduced port-access technique. EXPERIMENTAL DESIGN: Prospective collection of data from the month of October 1997. SETTING: Regional University HospitaL Patients: Adult patients undergoing coronary bypass graft or mitral valve surgery. INTERVENTIONS: Port-access technique makes it possible to carry out open-heart procedures through a minithoracotomy and extrathoracic cardiopulmonary bypass with a set of properly designed catheters (Heartport EndoCPB system) for cardioplegia delivery and heart venting. MEASURES: Transesophageal echography and pressure traces are the main monitoring tools used for the correct placement of these catheters and for the clinical management of the patient. RESULTS: Sixty-two cases have been performed so far. A complete description of the procedure, with monitoring aspects and problems encountered is thoroughly presented. CONCLUSIONS: The major differences with traditional cardiac surgery are that interruption of myocardial perfusion is not achieved through a transversal clamp but through an endovascular occlusive balloon and that thoracic access is by minithoracotomy. Unlike traditional open surgery, the surgeon has no direct vision of the position of the clamp and the anesthesiologist can not visually inspect the contractile state of the heart. The operative team has to cope with a multifaceted system of monitored variables that must be continuously integrated and interpreted. Tight cooperation and continuous communication between anaesthesiologist, surgeons and perfusionist appear to be more important than in any other cardiac operation.

Port access cardiac surgery.

The port-access technique for cardiac surgery was recently developed at Stanford University in California as a less invasive method to perform some cardiac operations. The port-access system has been described in detail elsewhere. It is based on femoral arterial and venous access for cardiopulmonary bypass (CPB) and on the adoption of a specially designed triple-lumen catheter described originally by Peters, and subsequently modified and developed in the definitive configuration called the endoaortic clamp.

The spectrum of aortic complications after heart transplantation.

BACKGROUND: The connection between the donor and the recipient aorta is a potential source of early and late complications as a result of infection, compliance mismatch, and technical and hemodynamic factors. Moreover, the abrupt change in systolic pressure after heart transplantation involves the entire thoracic aorta in the risk of aneurysm formation. The aim of this study was to analyze the types of aortic complications encountered in our heart transplantation series and to discuss etiology, diagnostic approach, and modes of treatment. METHODS: Of the 442 patients having orthotopic heart transplantation and the 11 patients having heterotopic heart transplantation at our center, 9 (2%) sustained complications involving the thoracic aorta. These 9 patients were divided into four groups according to the aortic disease: acute aortic rupture (2 patients); infective pseudoaneurysm (3 patients); true aneurysm and dissection of native aorta (2 patients); and aortic dissection after heterotopic heart transplantation (2 patients). Surgical intervention was undertaken in 8. RESULTS: Five (83%) of 6 patients who underwent surgical treatment for noninfective complications survived the operation, and 4 are long-term survivors. One patient who underwent a Bentall procedure 71/2 years after heterotopic heart transplantation died in the perioperative period of low-output syndrome secondary to underestimated chronic rejection of the graft. One patient with pseudoaneurysm survives without surgical treatment but died several years later of cardiac arrest due to chronic rejection. Both patients operated on for evolving infective pseudoaneurysm died in the perioperative period. CONCLUSIONS: Infective pseudoaneurysms of the aortic anastomosis are associated with a significant mortality. In noninfective complications, an aggressive surgical approach offers good long-term results. The possibility of retransplantation in spite of complex surgical repair should be considered in the late follow-up after heart transplantation, due to the increasing incidence of chronic rejection.

[Minimally invasive surgery with the Port-Access method. Preliminary experience]. / La chirurgia mini-invasiva con la metodica Port-Access. Esperienza preliminare.

METHODS: Data from the initial experience of 40 patients operated on with the Port-Access technique are reported. Indication to surgery was mitral disease in 24 patients and coronary stenosis in 16 patients. Mean age was 52 years (range 32-75). Operations performed were: 8 mitral valvuloplasties, 16 valve replacements, 9 single CABG (associated with an MVR in one case), 1 double CABG, 6 triple CABG and one quadruple CABG. Coronary endarterectomy was performed in 5 patients and left atrial isolation was associated with MV surgery in 5 cases. RESULTS: There were no operative deaths and every patient was discharged after a mean postoperative stay of 5.5 days (range 3-30). Postoperative course was complicated in 7 patients: surgical revision was necessary in 4 patients due to bleeding (through the mini-thoracotomy incision in 3 cases), 1 pacemaker was implanted for A-V block, one retained pulmonary catheter was removed through the mini-thoracotomy without the aid of cardiopulmonary bypass and in one case, there was an emergency conversion to median sternotomy due to a ventricular fibrillation unresponsive to usual resuscitative maneuvers a few hours after surgery. Some of these complications can be ascribed to the learning phase of this new technique and should disappear as experience is increased. CONCLUSIONS: Port-Access surgery is a new minimally invasive technique that utilizes a cardiopulmonary bypass with femoral access and a specialized catheter system that provides endoaortic clamping, pulmonary artery venting and myocardial preservation with infusion of cardioplegic solution in the aortic bulb or in the coronary sinus. Major contraindications to this technique are iliac-femoral disease or severe dilatation of ascending aorta. The aim of the Port-Access technique is to combine the aesthetic and functional advantages of the minimally invasive surgery with the wide range of surgical options that cardiopulmonary bypass can afford (to operate on atrioventricular valves and perform all the CABG that the patient need), without the limitations characteristic of the classic minimally invasive direct coronary artery bypass (MIDCAB) technique.

Effect of L-carnitine on myocardial metabolism: results of a balanced, placebo-controlled, double-blind study in patients undergoing open heart surgery.

The effects of L-carnitine on cardiac performance after open heart surgery were evaluated in a balanced, placebo-controlled, double-blind study in 38 patients. Preoperative haemodynamic status was good in all of them. Seventeen subjects underwent mitral valve replacement and 19 patients coronary artery bypass grafting. Five grams L-carnitine were given intravenously over 2 h, twice daily for 5 consecutive days; moreover, 10 g L-carnitine in 1500 ml cardioplegia were administered through the aortic root after aortic cross-clamping. Surgery was always planned on treatment day 3. The post-ischaemic functional recovery of the heart was assessed by clinical parameters, as well as by biochemical and ultrastructure evaluations on biopsy specimens. No differences were found between the control and the treatment group with respect to all clinical parameters of cardiac performance after cardiopulmonary bypass. At anaesthesia induction, serum carnitine was significantly increased in treated patients, but carnitine concentrations in the right atrial biopsy obtained just before aortic declamping were similar in the two groups. In patients with mitral valve replacement, L-carnitine therapy was associated with significantly higher concentrations of pyruvate, ATP and creatine phosphate in papillary muscle. Glycogen levels were also higher in the treated group, but the difference was not statistically significant. Myocardial ultrastructure on septal biopsies, obtained within 5 min from weaning from extracorporeal circulation, showed better preservation scores for all considered parameters (nucleus, sarcoplasmic reticulum, mitochondria and cellular oedema) in the treated subjects, although the difference reached statistical significance only for nuclei. When biochemical and ultrastructural data are considered, these findings suggest that L-carnitine improves myocardial metabolism. However, it cannot be concluded that L-carnitine provides an advantageous support therapy for well-compensated patients requiring cardiac surgery. In contrast, the positive effects of L-carnitine on cardiac recovery after bypass might become clinically relevant in the surgical setting for haemodynamically compromised patients, in which further investigations are required.

Cardiac lipomas. Description of 3 cases.

Cardiac lipomas, extremely rare benign tumours, can develop in the pericardial surface or inside the cardiac chambers. We report three cases, 2 intracardiac (one in the left and right atrium at the level of the interatrial septum and the other in the right ventricle) and one epicardial at the level of the left atrial roof. All patients underwent surgery and are now asymptomatic.

Echo-controlled endomyocardial biopsy in orthotopic heart transplantation with bicaval anastomosis.

Starting in January 1995, we performed heart transplantation, randomly using standard and bicaval techniques. In the latter technique, the anatomy of the right atrium is maintained, since the venae cavae are anastomosed. In 38 patients who received heart transplantation with bicaval anastomosis, 339 endomyocardial biopsies (EMB) were performed. EMB was done under echocardiographic control in 309 cases, whereas the remaining 30 were done under fluoroscopy. When EMB was echo-guided there was one major complication, namely right hemothorax in a 29-year-old man, who had had heart transplantation one week before, and this required surgical exploration. Other complications, correlated to venipuncture were: left hemothorax in a 65-year-old woman determined by arterial puncture, treated by means of chest tube drainage; pneumothorax (1 case). Echocardiographic guidance during EMB allows a better choice of biopsy site, reduces the risk of damaging cardiac structures and allows immediate monitoring of heart performance. Moreover the risk of X-ray exposure to both patient and operators is reduced. In any case, because the superior vena cava suture line is not visualized by two-dimensional echocardiography, if the bioptome cannot be introduced easily through superior vena cava, fluoroscopic control should be immediately applied, particularly in the early post-operative period when cicatrization is not complete.

Staged discharge out of hospital of the Novacor left ventricular assist system (LVAS) recipients.

The mobility afforded by the wearable Novacor LVAS provides the possibility for the recipients to leave the hospital, with undoubted improvements in their quality of life. A staged program for discharging LVAS recipients from the hospital has been set up at the Policlinico San Matteo of Pavia together with the Rehabilitation Center of Montescano and Baxter Novacor Service support, in order to proceed smoothly towards patient's self sufficiency and to minimize any associated risk. The steps are: stay in the hospital ward, discharge to Rehabilitation Center and discharge to home. Several excursions with and without an LVAS team member are encouraged before final discharge to home. Simple criteria of eligibility must be fulfilled to move to the next step. Every move towards a reduced presence of specialized personnel includes an appropriate training of the patient and relatives and a technical checkout of the needed equipment. During the stay at the Rehabilitation Center primarily the physical training and psychological preparation are taken care of by means of tailored programs. When the patient is discharged to home, the check of patient condition is performed weekly at the Rehab Center, bloodwork and technical evaluation is assessed once every two weeks and technical inspections at home twice per year. Complications are reported as in hospital protocol. Control parameters of the LVAS are reported only in case of alarms or abnormal operation. Periodic review of patient training is performed during the check visits, mostly focused on how to address emergency situations. The hospital is responsible for providing one LVAS operator available on call (all hours). Up to date, 11 patients received an implant of LVAS, 9 of them with the wearable system. All of these 9 patients made excursions out of the hospital and 4 patients have successfully undergone the staged program, showing a satisfactory general condition and restoration to social life.