[Single lung transplantation retrospective analysis of intraoperative cardiovascular problems]. / Trapianto di polmone singolo. Analisi retrospettiva delle problematiche cardiovascolari intraoperatorie.

BACKGROUND: Analysis of haemodynamic problems during single-lung transplantation and of methodologies employed for their treatment. DESIGN OF THE STUDY: clinical retrospective study. SETTING: General University Hospital. PATIENTS: patients with irreversible lung disease, either parenchymal or vascular, undergoing single lung transplantation. INTERVENTIONS: recording of circulatory failure episodes and treatment with pharmacologic support or cardiopulmonary bypass. Modifications occurring during the study period with respect to drugs administered. Evaluation of the consequences of cardiopulmonary bypass on the postoperative outcome, namely on the duration of mechanical ventilation and length of stay in the intensive care unit. RESULTS: During the last 9 years 69 single-lung transplantations have been performed. In 50% of cases a pharmacologic support has been employed; the drug association dobutamine/nitroprusside has been gradually replaced by the association norepinephrine/nitric oxide for the treatment of right ventricular failure. Twenty patients required cardiopulmonary bypass and this caused a significant increase of the duration of mechanical ventilation and length of stay in the intensive care unit. CONCLUSIONS: Hemodynamic changes during lung transplantation are complex and often severe, leading to a clinical status of right ventricular failure, that sometime requires a mechanical circulatory support. The introduction of nitric oxide in clinical practice significantly contributed to the optimization of intraoperative cardiocirculatory profile of patients, leading to a reduction in the use of vasoactive drugs and cardiopulmonary bypass.

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.

[Risk management from the psychological point of view]. / La gestione del rischio dal punto di vista psicologico.

Main directions of psychological research in risk factors and risk reducing interventions in work settings are discussed. Cognitive and social communication components that enhance or reduce risk behaviours are stressed. The author states that knowing and valuing risks are only a portion of the cognitive factors implied in the process, not sufficient to explain phenomena. With reference to current literature data, the central role of representations, of direct reinforcement procedures and of self-efficacy is affirmed.

[Current views on the use of vasodilators in pulmonary hypertension]. / Attuali vedute sull'impiego dei vasodilatatori nell'ipertensione polmonare.

Vasodilators represent one of the main steps for the medical treatment of pulmonary hypertension; the rationale for their use is the reversibility of the pulmonary vasoconstriction, to be tested with a correct pharmacological trial. In this report the authors consider the use of calcium-channel blockers, prostaglandin and nitric oxide. Calcium blockers, the only drugs active when administered orally, provide a satisfactory clinical response in 25-30% of treated patients. Prostaglandins are active in a higher percentage of patients and can be infused in a domiciliary regimen with portable pumps even for long periods of time. Nitric oxide is the only selective pulmonary vasodilator; it is used in paediatric and adult cardiac surgery and in patients affected by respiratory distress syndrome, but its use is restricted to intensive care units and many cautions must be adopted. Finally some future therapeutic strategies are briefly reviewed: endothelin inhibitors, cGMP phosphodiesterase inhibitors etc.

Management of anesthesia during dynamic cardiomyoplasty.

STUDY OBJECTIVE: To review experience with anesthetic management in ten patients undergoing dynamic cardiomyoplasty (CMPL), a new surgical technique that serves as an alternative to heart transplantation. DESIGN: Retrospective clinical study. SETTING: Cardiothoracic operating room at a university hospital. PATIENTS: Ten male functional New York Heart Association (NYHA) class III and IV patients, aged 39 to 60 years, awaiting heart transplantation, 7 of whom were diagnosed with dilated cardiomyopathy, 3 with postischemic cardiomyopathy. INTERVENTIONS: Under general anesthesia, the latissimus dorsi muscle was harvested and rotated into the chest through a window in the second rib. The muscle was then wrapped around the heart. Starting from the second postoperative week, the latissimus dorsi was stimulated to provide assistance to a failing heart. MEASUREMENTS AND MAIN RESULTS: The mean left ventricular ejection fraction (LVEF) of the 10 patients was 24.89% +/- 9.17% (range 10% to 37%). No intraoperative death occurred. Two patients died of multiple organ failure and an apparent arrhythmia on the 15th and 25th postoperative days, respectively. The rest of the patients regained good working capacity postoperatively, as evidenced by improvement in NYHA grade. Nevertheless, the LVEF improved in only one patient. No significant differences were evident between preoperative and postoperative blood values, hemodynamic data, or spirometry. CONCLUSIONS: Dynamic CMPL is a considerable challenge for the anesthesiologist because these patients have poor cardiac reserve preoperatively and do not benefit from the procedure in the first two postoperative weeks. To date, CMPL seems to be an important alternative to heart transplantation because experience has shown an improvement in the quality of life with low intraoperative and postoperative complications.

[Comparison between propofol and isoflurane in patients undergoing aorto-coronary bypass. Effect on systemic and coronary circulation]. / Confronto tra propofol e isoflurano in pazienti sottoposti ad intervento di bypass aorto-coronarico. Effetti sul circolo sistemico e coronarico.

The Authors report their experience with the use of two different anaesthetic techniques (propofol-fentanil versus isoflurane-fentanyl) for induction and maintenance of anaesthesia in patients undergoing coronary artery surgery. Haemodynamic data (regarding systemic and coronary circulation) showed an almost similar pattern of change after induction, intubation, skin incision and sterotomy, except for a greater decrease of systemic vascular resistances after induction in patients who received propofol. Cardiac output decreased more in the isoflurane group while changes in coronary sinus flow were equal in the two groups.

Biochemical changes induced in the myocardial cell during cardioplegic arrest supplemented with creatine phosphate.

The purpose of this work was to evaluate the biochemical changes in the myocardial cell using cardioplegia supplemented with creatine phosphate (CP). Many previous studies have demonstrated the beneficial effect of CP on the ischemic myocardium and its mechanism of action has been assumed to be mainly extracellular. Based on the assumption that CP could also exert some influence on myocardial cellular metabolism, this investigation was carried out. Forty patients undergoing mitral valve replacement were divided into two groups: group 1 was treated with standard cardioplegic solution, and group 2 was treated with cardioplegic solution enriched with CP at a concentration of 10 mmol/L. Samples of papillary muscle, obtained from the removed valve, were studied by means of biochemical methods in order to assess the enzyme activities and the metabolites of the different biochemical pathways related to energy metabolism in the myocardial cell. One papillary muscle sample was used to determine enzyme activities spectrophotometrically; another was used to evaluate metabolite concentrations by spectrophotometric or spectrophotofluorimetric methods. The rate of spontaneous functional recovery after rewarming and weaning from cardiopulmonary bypass (CPB) also was evaluated. In group 2, the Vmax of enzymatic activities was significantly greater (hexokinase, malate dehydrogenase, glutamate dehydrogenase, total NADH cytochrome c reductase) and a better functional state of the heart was observed after CPB. On the basis of the clinical and biochemical data, it is concluded that the myocardium was better preserved when CP was added to the cardioplegic solution. Therefore, the results suggest a possible interaction of exogenous CP with cellular metabolism.

[Pseudoaneurysm of the left ventricle. Description of a clinical case]. / Pseudoaneurisma del ventricolo sinistro. Descrizione di un caso clinico.

The paper describes a case of pseudoaneurysm of the left ventricle following an earlier operation to close a post-infarction interventricular defect. The nosological entity is described paying particular attention to preoperative functional tests and intraoperative anesthesiological procedures. The careful monitoring of refilling pressure and cardiac load represents an essential for the correct infusion of drugs and optimal volemic refilling.

[Role of creatine phosphate in myocardial protection in heart surgery]. / Ruolo del creatinfosfato (CP) nella protezione miocardica in cardiochirurgia.

The Authors report their experience with the use of Creatine Phosphate (CP) in cardiac surgery. Forty patients undergoing mitral valve replacement are randomly divided into two groups: the former is treated with plain cardioplegia, the latter with CP-enriched cardioplegia at a concentration of 10 mmol/l. A sample of papillary muscle, obtained from the removed valve, is studied by means of spectrophotometric analysis in order to assess the enzyme activities and the intermediate metabolites of the different biochemical pathways of the myocardial cell. Our results suggest a possible interaction of exogenous CP with the cellular metabolism: all the mechanisms involved with the production of energy seem to be shifted towards a better preservation of the available pool of high-energy compounds.

[Between safety and risk: the propensities and resistance to prevention in the daily behavior of adolescents]. / Fra sicurezza e rischio: propensioni e resistenze alla prevenzione nel comportamento quotidiano degli adolescenti.

Various levels of awareness and attitudes in 2500 High School students regarding prevention of daily risk were examined before and after a special training program on prevention (promoted by the Clinica del Lavoro della Università di Pavia). The concept of prevention was examined in four analytical realms, through questionnaire and projective tests: actual notion, cognitive organization of knowledge, emotional level, social approval. The data collected showed that the tendency towards prevention of risk is limited in adolescents: from a cognitive point of view, since the conceptual probability of risk is comprehended with difficulty; emotionally, since risk-producing behavior usually provides gratification at various levels; socially, since adolescent usually views risk-producing behavior as associated with a positive social image. The informative training session proved to effectively orient the students towards a more rationally controlled behavior, therefore favoring a more positive attitude towards prevention.

Medical and surgical treatment of sustained and recurrent post-infarction ventricular tachycardia.

Over a five-year period 57 patients (pts) with sustained, recurrent, post-infarction ventricular tachycardia (VT) refractory to conventional antiarrhythmic treatment were evaluated. In 28 (49%) pts VT was controlled by amiodarone (A) in a dose of 3000 mg week-1. During long-term follow-up 5/28 (18%) pts died; no severe side-effects were observed with this dosage. In 17 of the 29 pts not controlled by this regimen, the dosage of A was increased to 6000-8000 mg week-1; short-term control of VT was achieved in 9/17 (53%) pts, but over a long-term follow-up 5/9 (56%) died and severe side-effects (11% pulmonary fibrosis and 11% hepatitis) occurred in 22%. Twenty pts, resistant to a low (12 pts) or high (8 pts) doses of A, underwent map-guided surgical treatment. In conclusion A is superior to conventional drugs in the treatment of sustained, recurrent, post-infarction VT, but when high doses are necessary to prevent VT, long-term results are poor and severe side-effects frequent. In pts refractory to standard doses of A, map-guided surgery is the treatment of choice.