Experience with an elective vacuum assisted cardiopulmonary bypass in the surgical treatment of renal neoplasms extending into the right atrium.

PURPOSE: We evaluate the results of an elective cardiopulmonary bypass conceived to minimize the surgical risk related to its use with temporary circulatory arrest and deep hypothermia in the treatment of patients with renal tumor extending into the right atrium. MATERIALS AND METHODS: From July 1996 to December 2000, 19 patients with renal neoplasm and venous involvement were admitted to our department. Three patients 4, 57 and 58 years old with a right (2) and left (1) renal tumor extending into the right atrium underwent radical nephrectomy and tumor thrombus removal using a normothermic cardiopulmonary bypass. The bypass circuit was connected with a vacuum assisted venous drainage giving a negative pressure of 20 to 40 mm. Hg. Neither circulatory arrest nor hypothermia was used. Tumor thrombus was extracted through a longitudinal "cavotomy" and removed along with the kidney. RESULTS: Total cardiopulmonary bypass time was 14, 19 and 22 minutes, respectively. No intraoperative or postoperative complications due to surgical technique occurred. No significant bleeding was observed at the time of cavotomy and all neoplastic tissue was removed. Pathological examination documented renal cell carcinoma in 2 cases and Wilms tumor in 1. All the patients are alive 30, 42 and 15 months, respectively, after the operation. CONCLUSIONS: Normothermic cardiopulmonary bypass with vacuum assisted venous drainage makes circulatory arrest and hypothermia unnecessary and avoids the potential complications associated with these procedures. With respect to veno-venous shunts this technique guarantees complete surgical control of the thrombus and avoids the need for extensive dissection of the retrohepatic vena cava and Pringle maneuver.

Systemic leukocyte filtration during cardiopulmonary bypass.

Cardiopulmonary bypass (CPB) induces a whole body inflammatory response leading to postoperative lung dysfunction. Activated leukocytes may play a role in the pathogenesis of pulmonary dysfunction. We evaluated postoperative lung function after the use of leukocyte-depleting filters incorporated in the extracorporeal circuit during CPB. From November 1997 to March 2000, 40 patients underwent isolated coronary artery bypass grafting. Patients were randomly allocated to the leukocyte-depletion group (group F, 20 patients) or to the control group (group C, 20 patients). There was no significant difference between the two groups with respect to age, sex, weight, height, body surface area, haemoglobin and haematocrit levels, preoperative left ventricular ejection fraction, cooling temperature, aortic crossclamping and CBP duration. Blood samples were drawn preoperatively, at aortic declamping, 60 min after CPB, after arriving at the intensive care unit (ICU) and 24 h after the operation. We analysed blood cell count, elastase, interleukin-8 (IL-8) and tumour necrosis factor (TNF-alpha) levels and continuous monitoring of arterial blood gases in the intensive care unit (ICU). The analysis of total circulating white blood cells (WBCs) showed a significant reduction of WBCs in both groups soon after aortic declamping [from the right atrium: 6.4 x 10(9)/l +/- 1.4 x 10(9)/l in group F vs 10.3 +/- 1.8 x 10(9)/l in group C (p<0.05); from the left atrium: 5.8 +/- 1.3 x 10(9)/l in group F vs 8.4 +/- 1.9 x 10(9)/l in group C (p<0.05)] and after 60 min of CPB [7.1 +/- 2.2 x 10(9)/l in group F vs 10.4 +/- 1.8 x 10(9)/l in group C (p<0.05)]. The analysis of circulating neutrophils showed similar findings in both groups. Elastase levels increased during CPB in both groups with a peak at the end of CPB without significant difference between the two groups (group C: 260 +/- 148 microg/l vs group F: 371 +/- 68 microg/l). The decrease of plasmatic elestase levels was observed, for both groups, in the 24 h after CPB. There was no difference in intubation time between the two groups (16.4 h for group C vs 11.2 h for group F). Pulmonary function tested by pulmonary respiratory index [RI = partial pressure of oxygen/fraction of inspired oxygen (PaO2/FiO2 x 100)] did not show significant difference between the two groups, either arriving in the ICU (group C RI 265 vs group F RI 322), or after 3 h (group RI 304 vs group F RI 305) or after 6 h (group C RI 292 vs group F RI 319). Leukocyte-depleting filters reduce with blood cells count during CPB, but, in this study, WBC depletion did not significantly improve clinical conditions or laboratory finding.

Evaluation of valve-related complications in patients with Sorin Bicarbon prosthesis: a seven-year experience.

BACKGROUND AND AIM OF THE STUDY: The study aim was to evaluate the medium-term results of aortic valve replacement (AVR), mitral valve replacement (MVR) and double valve replacement (DVR) with the Sorin Bicarbon prosthesis. METHODS: A total of 990 patients (568 men, 422 women; mean age 60+/-10 years; range: 20-86 years) was reviewed who received 1,108 Sorin Bicarbon prostheses between 1992 and 1998 at three institutions. AVR was performed in 541 patients (55%), MVR in 330 (33%) and DVR in 119 (12%). Concomitant procedures, mainly coronary artery grafting, were performed in 222 patients (22%). Follow up was 98% complete; total cumulative follow up was 3,091 patient-years. RESULTS: Hospital mortality was 3.7% (n = 37). There were 49 late deaths; actuarial survival at seven years was 88+/-2% after AVR, 86+/-5% after MVR, and 78+/-8% after DVR. At last follow up, 915 survivors were in NYHA functional class I or II. At seven years, actuarial freedom from valve-related deaths, valve thrombosis, embolism and bleeding respectively was 96+/-1%, 99+/-1%, 93+/-2% and 91+/-3% after AVR; 97+/-2%, 97+/-3%, 90+/-3% and 86+/-7% after MVR; and 92+/-6%, 98+/-1%, 64+/-2% and 82+/-2% after DVR. Reoperation was required in 20 patients (due to valve thrombosis in six, endocarditis in five and periprosthetic leak in nine). At seven years, actuarial freedom from reoperation was 97+/-1%, 96+/-2% and 84+/-9% after AVR, MVR and DVR, respectively; actuarial freedom from endocarditis was 99+/-1%, 99+/-1% and 95+/-5%. Nine patients experienced a nonstructural valve dysfunction (all periprosthetic leak), while no cases of structural failure were observed. CONCLUSION: The Sorin Bicarbon prosthesis has shown good medium-term results with regard to clinical improvement, and low incidence of valve-related complications. Thus, it appears to be a reliable valve substitute when the use of a mechanical prosthesis is indicated.

Accelerated aortic allograft fibrocalcification after right ventricular outflow tract reconstruction in pediatric patients: report of two cases.

Two cases are presented of accelerated aortic allograft fibrocalcification after right ventricular outflow tract (RVOT) reconstruction occurring within 2 months after surgery in a 5-year-old and 22-month-old. Potential determinants of early calcification, clinical management after implantation and surgical alternatives are discussed.

Cardiac myxoma of the tricuspid valve: description of a case and review of the literature.

Although myxomas are the most common cardiac neoplasms in the adult population, they are very rare in pediatric patients. Tricuspid valve myxomas are even more exceptional at all ages, with only 16 cases being reported in the literature. We describe the case of a 10-year-old boy with a myxoma of the tricuspid valve, who was successfully operated without valve replacement.

Ball fracture with the 6120-model Starr-Edwards mitral valve prosthesis occurring late after implantation.

The Starr-Edwards (S-E) mitral valve, Model 6120, has been widely used in the last three decades. Fatty infiltration and subsequent damage of the silastic ball, a phenomenon termed ball variance, has been described only in the first generation aortic ball-valve prostheses, used until 1965. A case of partial ball fracture in a 6120-Model S-E mitral valve prosthesis, occurring 27 years after implantation and presenting with thromboembolism and progressive valve dysfunction, is described.