[Emergency coronary surgery after failed angioplasty: 11 years of experience (1987-1997)]. / Chirurgia coronarica d'emergenza dopo angioplastica fallita: undici anni d'esperienza (1987-1997).

METHODS: From January 1987 to December 1997, thirty patients underwent emergent or urgent coronary artery bypass grafting after failed elective percutaneous transluminal coronary angioplasty. Dissection/occlusion of the target artery was the commonest complication, but we also had two cases of stent dislocation and one case of coronary artery wall perforation. Two-thirds of the patients experienced extreme preoperatory hemodynamic instability (i.e., cardiac arrest or cardiogenic shock) and half had to be intubated in the Catheterization Laboratory. An average of 1.73 grafts/patient was performed. Complete coronary revascularization was achieved in 93% of the cases; the internal mammary artery could be employed in one-third only. RESULTS: In-hospital mortality was 10%, and perioperatory myocardial infarction or persistent ischemia could be detected in half of the patients. The need for aortic counterpulsation, and the use of inotropic and antiarrhythmic drugs were higher than average in this group of patients; while intensive care unit and hospital stay were longer. Patients with deteriorated preoperative hemodynamics fared significantly worse. Late results were encouraging: seventy-five per cent of all patients (and 84% of hospital survivors) were still alive an average of 52 months after surgery. Two-thirds of all patients (and 72% of hospital survivors) were alive and angina-free. CONCLUSIONS: Even in the current era, revascularization surgery after failed coronary angioplasty still carries an increased risk for postoperative complications and death, especially for patients with deteriorated preoperative hemodynamic conditions. On the other hand, postoperative middle- and long-term results are encouraging, as hospital survivors were similar to elective bypass patients regarding survival and freedom from return of angina.

[Clocking diagnostic and therapeutic procedures in coronary care unit patients: analysis of clinical performance times]. / Le prestazioni diagnostiche e terapeutiche nel paziente di unità coronarcia: valutazione dei tempi di effettuazione e dei fattori correlati.

BACKGROUND: An optimal use and exploitation of professional personnel is of paramount importance for health management organizations, as human resources are both their greatest asset and heaviest financial burden. To better understand the amount of medic and paramedic work and time required for the typical diagnostic and therapeutic procedures in a coronary-care unit setting, we measured their average times and analyzed their inherent co-factors. METHODS: This study was conducted on 206 consecutive coronary-care unit patients. These patients were divided into subgroups according to their admission diagnosis: acute myocardial infarction, unstable angina, acute cardiac failure, pulmonary embolism or other pathologies. Each subgroup was then subdivided even further according to the severity of their clinical status. Diagnostic and therapeutic procedures ("macroactivities") have been identified and each one was subdivided into sub-procedures ("microactivities"). All microactivities were carefully clocked in every patient in order to calculate the average execution time for every macroactivity. RESULTS: Our data show that myocardial infarction patients and, in general, a more severe clinical status required a longer stay in the coronary-care unit. Again, longer overall clinical performance times were necessary in myocardial infarction patients as compared to the unstable angina subgroup. There were no statistically significant differences among other subgroups. More severely ill patients required longer clinical performance times because of both a longer coronary-care unit stay and longer clinical performance time per day. More than half of the total clinical performance time for each patient was spent during the first two days. Paramedics supplied more than 80% of the total performance time. CONCLUSIONS: The authors undertook a study of typical coronary-care unit clinical activities by clocking the performance times of the usual diagnostic and therapeutic procedures. The data thus obtained come from direct measurements and describe the clinical performance of both medics and paramedics in a real-life setting. This could thus be used as a yardstick to verify current workload standards. It is hoped that a deeper understanding of these activities will optimize the full exploitation of available human resources.

Left main coronary artery atresia: literature review and therapeutical considerations.

OBJECTIVE: Left main coronary artery atresia is a rare coronary anomaly in which there is no left coronary ostium, the proximal left main trunk ends blindly, blood flows from the right coronary artery to the left via small collateral arteries and retrogradely in at least one of the left-sided arteries. Since published case reports are few and rather scattered, no comprehensive information about this uncommon anomaly is available. METHODS: A through search for published cases of left main coronary atresia was performed in the major medical journals by electronic (MEDLINE and INTERNET) and hand-scanning. RESULTS: The authors found 28 cases of left main atresia (including two from their own experience), 15 of which were pediatric; five of these cases had associated cardiac anomalies. While pediatric patients were usually overtly symptomatic early in their life (syncope, dyspnea, sudden death, failure to thrive, infarction, ventricular tachycardia), adult patients began showing symptoms (angina, dyspnea, sudden death) only at an advanced age; associated coronary atherosclerosis seemed to be uncommon, though (2/13 adult patients, 15%). We know of only one asymptomatic patient, a 76-year old lady who had died of unrelated causes; in her case left main atresia was an unforeseen autopsy finding. Four untreated patients had died suddenly; most of the others were highly symptomatic and required surgical therapy, usually as direct coronary artery revascularization via one or more saphenous vein or mammary artery grafts to the left-sided arteries; all revascularized patients were reported to be alive and well; in one pediatric case the left main coronary artery was reconstructed using an aortic wall baffle, with a good result. In contrast, the outcome of patients who did not receive revascularization has been poor. CONCLUSION: In light of the favorable results obtained by surgical therapy, the authors endorse prompt coronary artery revascularization for all patients with left main coronary artery atresia.

Postoperative infections after neurosurgery and cardiosurgery: the value of labelled white blood cells.

Post surgical-infections in neurosurgery and cardiosurgery are infrequent, but potentially fatal complications. The aim of this study was to compare the utility of 99mTc-HMPAO white blood cells scintigraphy (WBCS) with traditional diagnostic approaches in post-surgical complications, in order to obtain timely demonstration of a current infection. We studied 23 patients with a suspicion of infection after major cardiosurgery or neurosurgery. Planar imaging was performed at 4 and 20 hours after injection of autologous white blood cells labelled with 99mTc-HMPAO. Eight patients underwent CT scan, but only in one case did CT findings lead to a clear definition of a bulky inflammation process of the chest. WBCS identified one or more sites of focal increased uptake of the radiopharmaceutical in 6 patients: five of these patients were scheduled for a "second look" surgical operation that confirmed the sites and extention of the primary infection, thus confirming the presence of an abscess. In 3 cases WBCS showed only a weak increase of focal uptake and in 14 cases there was no evidence of abnormal uptake. The absence of deep infections was confirmed at surgery or at clinical follow-up. Thus WBCS seems to be useful in evaluating patients with the clinical suspicion of infective complications after surgery.

The technique of radial artery bypass grafting and early clinical results.

There is renewed interest in the use of the radial artery as a conduit for coronary artery bypass. Fifty patients underwent bypass surgery using the radial artery in addition to other conduits between November 24, 1992 and November 8, 1994 at our institution. The mean age was 54.4 +/- 9.1 years (mean +/- SD) and 47 of the patients were male. There were 3.6 +/- 0.9 and stomses per patient, of which 2.2 +/- 0.4 were arterial anastomoses. The most common target vessel for the radial artery has been the obtuse marginal (58.8%), with the aorta as the usual site for proximal anastomosis (80.4%). There have been no ischemic hand complications and no radial nerve deficits. There have been no early or late deaths and no myocardial ischemic complications related to the use of the radial artery. We present the techniques used at our institution for the use of the radial artery as a conduit for coronary artery bypass.

[Surgical revascularization of the myocardium for atresia of the left main coronary artery and atherosclerotic coronary disease]. / Rivascolarizzazione chirurgica del miocardio per atresia del tronco comune e coronaropatia aterosclerotica.

The authors report a rare case of atresia of the left main coronary artery in an adult patient, symptomatic for effort angina. At coronarography, the left main coronary artery was not found; instead, the arteries of the left coronary tree were filled via a single collateral vessel arising from the ostium of the right coronary artery and ending in the trunk of the left anterior descending artery. All left arteries had very narrow calibres, almost hypoplastic, while the right coronary artery had a normal calibre. All the principal arteries had important stenoses. The patient underwent complete cardiac revascularization, and, sixteen months later, is free from angina. Rest and stress myocardial scintigraphy, control coronary angiography and Doppler analysis of internal mammary artery flow demonstrated normal myocardial perfusion, adequate blood flow through the grafts and good runoff in the native vessels. Hence, the authors conclude that such patients should be referred for coronary artery revascularization, since surgical results are good and the small calibre of the left coronary arteries is no contraindication.

[The use of systemic phosphocreatine in heart surgery]. / L'uso della fosfocreatina per via sistemica in cardiochirurgia.

Phosphocreatine (PC) has been widely used in cardiac surgery as a component of cardioplegic solutions because of its positive effects in preventing ischemic heart damage; we have researched the efficacy of PC in cardiac surgery when infused through the intravenous route before and after cardiac arrest. Two groups of patients who had undergone aortocoronary by-pass grafts were matched: group A (20 patients) did not receive any particular treatment; PC was administered intravenously to patients in group B after the induction of anaesthesia, immediately prior to cardiac arrest and after the release of aortic cross-clamp. To test the efficacy of the drug, the following parameters were evaluated: the recovery as the incidence of low cardiac output and/or need of inotropic drugs; dysrhythmias; electrocardiographic signs of myocardial ischemia or infarction; release of cardiac necrosis enzymes. Treated patients were found to have a better recovery, a lower incidence of dysrhythmias, an easier resumption of normal sinus rhythm with a lower number of electric defibrillations and a significantly lower release of cardiac enzymes. It can be therefore said that PC has a marked protective effect on myocardial anoxia in cardiac surgery, even when administered intravenously.

[Aortic coarctation with hypoplasia of the arch: description of a new surgical technic]. / La coartazione aortica con ipoplasia dell'arco: descrizione di una nuova tecnica chirurgica.

The aortic coarctation is frequently associated with aortic arch tubular hypoplasia, especially in early infancy. The treatment in one time of both lesions is mandatory in these cases. We propose therefore a new surgical technique: after resection of the isthmic coarctation and appropriate cutting of both ends, the anastomosis is widely extended in the concavity of transverse aortic arch, beyond the hypoplastic region. We discuss the advantages of this technique over the classic end-to-end anastomosis, patch graft and subclavian flap angioplasty.