Talc-induced interstitial pneumonitis with respiratory failure.

Talc is the most frequently used chemical agent to induce pleurodesis and complications after this procedure, usually benign and self-limiting, are resolved easily. Pneumonitis with acute respiratory distress after talc pleurodesis is a rare complication, it requires intensive treatment and may be fatal. We describe a patient who developed pneumonitis with bilateral interstitial infiltrates and respiratory distress after talc pleurodesis. This complication required the transfer of the patient into the intensive care unit and an aggressive treatment management. After an uneventful talc pleurodesis, close surveillance of the patient and a high index of suspicion are mandatory.

Combined endoscopic approach in the treatment of benign broncho-oesophageal fistula.

The treatment of benign broncho-oesophageal fistula is usually surgical but sometimes other methods of treatment are preferred. The case history is described of an adult in poor general condition in which an endoscopic approach combined with the use of fibrin glue on the bronchial side and metallic clips on the oesophageal side was used to close the fistula.

Aortic valve replacement and coronary artery surgery: determinants affecting early and long-term results.

BACKGROUND: We studied factors influencing early and late results in patients operated on for aortic valve replacement and coronary artery bypass graft. METHODS: 175 patients were retrospectively analysed over a 10-year period ending in December 2002. There were 135 males and 40 females with a mean age of 62.7 +/- 8.9 years; 109 were in NYHA class III/IV; 45 required an urgent operation, and 103 mechanical valves and 72 biological valves were implanted. RESULTS: There were 11 operative deaths (6.3 %). Statistical analysis (logistic regression) showed that previous myocardial infarction, poor NYHA class, and low LVEF had a significant effect on early death. There were 52 late deaths at a mean follow-up of 82.7 +/- 38.8 months. Using a Cox survival analysis for any causes, age, urgent operation, low LVEF, and creatinine had a strong impact on unfavourable late outcome. CONCLUSIONS: A combination of a patient-related factor (age), cardiac-related condition (low LVEF), co-morbid condition (renal dysfunction), and operative cause (urgent operation) is the most important predictor of late clinical outcome for this combined surgical procedure.

Endovascular vs. open surgery of abdominal aortic aneurysm in high-risk patients: a single center experience.

BACKGROUND: We compared two groups of high-risk patients with abdominal aortic aneurysm to assess the safety and efficacy of endovascular repair vs. open surgery. METHODS: From January 1998 to July 2003, sixty-two high-risk patients were divided into two groups: group A consisted of 28 (46 %) open surgery patients and group B consisted of 34 (54 %) patients who underwent endovascular repair. RESULTS: Four patients (14.3 %) in the open surgery group died, while no deaths occurred in the endovascular group ( p < 0.05). There were 14 complications in 8 patients of the open surgery group versus 2 complications in 2 patients of the endovascular group ( p = 0.01). At follow-up there were 4 (16.6 %) deaths in group A and 3 (8.8 %) in the endovascular group ( p = n. s.). CONCLUSIONS: While the use of endovascular repair in patients who are physiologically fit for open surgical repair remains controversial, we believe that patients with multiple or advanced comorbidities, i.e. high-risk patients, can benefit from the endografting procedure.

Discrete subaortic stenosis: long-term prognosis on the progression of the obstruction and of the aortic insufficiency.

BACKGROUND: We sought to determine the long-term rate of progression of left ventricular outflow tract (LVOT) obstruction and aortic insufficiency (AI) in adult patients operated on for discrete subaortic stenosis (DSS). METHODS: Between 1975 and 1995, 52 patients underwent surgery for DSS; their mean age was 25.4 +/- 14.8 years. Mean preoperative LVOT gradient was 72.8 +/- 25.7 mm Hg. Excision of the subaortic membrane was carried out in all patients, myectomy of the interventricular septum was additionally carried out in 8 patients (15.4 %), and aortic valve replacement (AVR) was performed in 15 patients (28.8 %). RESULTS: There were 2 operative deaths (3.8 %). Early postoperative LVOT gradient was 9.7 +/- 6.5 mm Hg. Follow-up ranged from 8.1 to 26.6 years. There were 8 late deaths (16.3 %), and mean LVOT gradient was 13.3 +/- 10.7 mm Hg. Five patients required reoperation for recurrent obstruction; 4 patients had a gradient of more than 30 mm Hg. The AI, in patients who did not undergo aortic valve replacement, did not substantially change during follow-up. CONCLUSIONS: DSS is a variable, unpredictable and progressive disease; recurrent obstruction may reappear despite the adequacy of surgical excision, and is not related to preoperative gradient. Mild AI remains substantially unchanged and AVR is indicated in severe AI.

Clinical outcome for on-pump myocardial revascularization in patients with mild renal dysfunction.

BACKGROUND: Coronary artery disease is the major cause of death in patients with chronic renal failure. We studied the early and long-term outcome of patients with mild chronic renal impairment, preoperative regular diuresis, and normal potassium levels having undergone pump myocardial revascularization. METHODS: From January 1992 to December 2000, 67 patients with serum creatinine level higher than 1.7 mg/dl and less than 2.5 mg/dl underwent on-pump myocardial revascularization. The patients were divided into 2 groups and treated with renal doses of dopamine in the postoperative or preoperative period, respectively. A homogeneous group of 100 patients was selected as control. RESULTS: There were no statistically significant differences in mortality and morbidity between the two groups A, while there was a significant difference in cardiac and respiratory complications, ICU stay and LOS between the A and B group in the early and long-term follow-up. Survival at 12-year follow-up is significantly higher in the B group. CONCLUSIONS: Patients with relatively mild renal insufficiency should be evaluated carefully for open cardiac surgery due to the significant increase in early and long-term morbidity and mortality.

Can epsilon-aminocaproic acid balance the off-pump bleeding advantage?

BACKGROUND: Aprotinin improved the control of bleeding in patients undergoing surgery with cardiopulmunary bypass, but its use was halted because of the risk of bovine spongiform encephalopathy. We then started to use epsilon-aminocaproic acid and the results in the control of bleeding were satisfactory. To assess its effectiveness in the control of postoperative bleeding precisely, we compared the results for patients operated on for myocardial revascularization on-pump and treated with epsilon-aminocaproic acid with those for patients who decidedly bleed less: off-pump patients. METHODS: Two groups of patients who had had either on- or off-pump double aortocoronary bypass surgery were retrospectively reviewed for postoperative bleeding. These two almost homogeneous group had two grafts only: left anterior descending and circumflex arteries operated on with cardiopulmonary bypass and treated with the epsilon-aminocaproic acid, and left anterior descending and right coronary arteries operated on off-pump. RESULTS: Postoperative bleeding through chest drainage at 4 h was 265+/-91.7 mL in the off-pump group and 328.4+/-131.4 mL in the on-pump group (p=0.004). But at 24 h it was 671.6+/-311.5 mL in the off-pump group and 827.8+/-514.4 mL in the on-pump group (p=0.07). CONCLUSIONS: epsilon-Aminocaproic acid is effective in controlling postoperative bleeding in patients operated on for myocardial revascularization with the aid of cardiopulmonary bypass.

Mid-term results of the valve-on-valve technique for bioprosthetic failure.

OBJECTIVE: Redo operations for bioprosthesis malfunction can sometimes be technically very demanding and cardiac structures may be damaged. Excising only the leaflets of the damaged bioprosthesis and leaving the old ring in situ on which the 'new' mechanical valve is sutured can, in very selected cases, represent a solution. METHODS: Twenty-two patients were operated on, with the valve-on-valve technique, from September 1991 through December 1992. There were three operative deaths. RESULTS: The surviving 19 patients were followed-up from 83 to 98 months (mean 90.5 months.). There were two late deaths. The patients were examined clinically and with transthoracic and transesophageal echocardiograms. All patients were in good condition and the echocardiographic examinations showed no clinically important gradients across the prostheses. CONCLUSIONS: The valve-on-valve technique, in certain difficult situations, can give successful mid-term results.

Bioprosthetic replacement after bioprosthesis failure: a hazardous choice?

BACKGROUND: Following bioprosthetic failure, replacement is usually done with mechanical valves to avoid repeated reoperations. METHODS: From 1986 to 1996 we operated on 130 patients with bioprosthetic failure, implanting a new bioprosthesis; this group included patients with contraindication to anticoagulation, tricuspid replacement, and specific patient requests. Mean age was 63+/-8 years. RESULTS: The perioperative mortality was 13.8%. At 10 year follow-up the actuarial estimate of survival was 77.4%+/-6.6%. Freedom from structural valve deterioration was estimated at 81.8%+/-6.3%. Freedom from a third operation was estimated at 85.5%+/-5.2%. No patient was permanently anticoagulated. Freedom from thromboembolism was estimated at 91.5%+/-4%, and there were no hemorrhages. Freedom from cardiac-related deaths was estimated at 85.7%+/-5%. CONCLUSIONS: This group of patients received the first valve between 1976 and 1986; the range of the cumulative follow-up reaches 20 years, and the extended survival compares favorably with survival of mechanical valves.

Annular abscesses and GRF glue.

Infective endocarditis of the aortic prosthesis is a serious complication of valve surgery. The correction of this condition is difficult and complex procedures are often required. Two patients with aortic bioprosthetic endocarditis complicated with annular abscesses were operated on. The aortic valve was replaced with a bioprosthesis and the annular abscesses were debrided and closed with the aid of gelatin-resorcin-formalin (GRF) glue, which completely sealed the abscess cavities. One year later the patients were asymptomatic and had no clinical or echocardiographic signs of aortic incompetence.

[Use of enoximone in the postoperative course of heart surgery]. / Impiego dell'enoximone nel decorso postoperatorio in cardiochirurgia.

The aim of this study was to evaluate the efficacy and safety of enoximone, an imidazolonic compound inhibiting cardiac phosphodiesterase III, during the postoperative period. The drug was administered prior to the usual stages of weaning the patient off extracorporeal circulation, to a group of 20 subjects who presented an ejection fraction of less than 35% following hemodynamic studies. Patients were randomly subdivided into 4 groups each of which received a different dose of enoximone according to the following protocol: Group A, 1 mg/kg bolus and slow infusion at 10 gamma/kg/min; Group B, 0.5 mg/kg bolus and slow infusion at 15 gamma/kg/min; Group C, 0.5 mg/kg bolus and slow infusion at 10 gamma/kg/min; Group D, slow infusion at 10 gamma/kg/min. The best results in hemodynamic terms and with regard to the positive inotropic and vasodilatory action of the drug in question were obtained in Group C. Increased cardiac output was observed in all patients within 120 minutes of enoximone administration and reduced systemic vascular resistance after approximately 6 hours of infusion. Special attention should be drawn to the use of the drug in patients who do not respond to conventional therapy due to its mechanism of action which is not dependent on beta receptors, thus enabling good results to be achieved even when these are down regulated. Special care must be taken however in administrating enoximone to platelet-deficient patients since the reduction of platelet levels is one of its collateral effect. Other collateral effects observed were: supraventricular arrhythmias and ventricular tachyarrhythmias.

Bioprosthesis replacement with mechanical valve implantation on the bioprosthetic ring. Surgical and 2D echo considerations.

Removal of a failing bioprosthesis can be a delicate operation and extensive damage can be caused. Eighteen patients with failing bioprostheses underwent excision of the leaflets, then the "new" mechanical valve was sewn onto the "old" bioprosthetic ring. At follow-up, clinical and 2D color-flow echo-Doppler evaluations showed good hemodynamic performance of the mechanical valves.

Bioprosthetic valve endocarditis: factors affecting bad outcome.

Prosthetic valve endocarditis (PVE) remains an uncommon but serious complication of cardiac valve replacement. We analysed several risk factors (active or healed, early or late endocarditis, congestive heart failure, arterial emboli etc.) in order to identify the factors which may predict bad outcome. The overall mortality rate was 46.8% (15/32 patients). There was a significantly higher mortality rate in patients with early endocarditis (80%) than in those with late endocarditis (38%) (p less than 0.01). In the group of patients who underwent reoperation, the mortality rate was higher in those with active endocarditis (70%) than in those with healed endocarditis (28.5%) (p less than 0.05). We believe that combined medical and surgical treatment is the best management for bioprosthetic valve endocarditis, with the institution of appropriate preoperative antibiotic therapy, to attempt to achieve sterilization.

Double valve Implantation. Long-term evaluation of 8 different bioprostheses.

From January 1976 through December 1987, 194 patients with a mean age of 43.3 +/- 13.7 years (range, 11 to 74 years) underwent double (mitral and aortic) replacement of native valves with 8 types of bioprostheses: Carpentier-Edwards, 127 valves; Hancock, 76 valves; Liotta-Bioimplant, 57 valves; Ionescu-Shiley, 53 valves; Vascor, 27 valves; Carpentier-Edwards Pericardial, 22 valves; Angell-Shiley, 20 valves; and Implamedic, 6 valves. Concomitant cardiac procedures were performed in 25 patients (12.8%). There were 18 operative deaths (9.27%). Our retrospective analysis was restricted to 352 bioprostheses implanted in the 176 patients who survived surgery and were considered at risk for valve tissue failure. The overall cumulative duration of follow-up was 1,174.1 patient-years (range, 1 to 13 years). The durations of follow-up for specific valves were: Carpentier-Edwards, 920.2 valve-years; Hancock, 383.8 valve-years; Liotta-Bioimplant, 310.2 valve-years; Ionescu-Shiley, 357.7 valve-years; Vascor, 131.2 valve-years; Carpentier-Edwards Pericardial, 52.0 valve-years; Angell-Shiley, 167.0 valve-years; and Implamedic, 31.0 valve-years. Thirty patients had thromboembolic accidents, for a linearized incidence of 2.5% per patient-year. At 13 years, the actuarial freedom from thromboembolic accidents was 85.8% +/- 10.7%. Nine patients had endocarditis, for a linearized incidence of 0.7% per patient-year. At 13 years, the actuarial freedom from endocarditis was 92.0% +/- 1.5%. Twenty-four patients had valve tissue failure, for a cumulative linearized incidence of 1.87% per valve-year. The cumulative actuarial probability of freedom from valve tissue failure was 78.6% +/- 3.7% at 10 years and 51.2% +/- 10.7% at 13 years. The 24 patients with valve tissue failure all underwent reoperation: 20 of these had double valve replacement, 3 had aortic valve replacement alone, and 1 had mitral valve replacement alone. The mean interval between initial valve implantation and reoperation was 66.9 +/- 28.8 months. At reoperation, the hospital mortality was 15.1% (5 patients). This study showed that the long-term results of valve implantation are not significantly influenced by either prosthesis design or material. Moreover, the incidence of degenerative change was similar in the aortic and mitral positions.

Bioprostheses at twelve years.

From January 1976 through December 1986, seven different types of bioprostheses have been implanted in our center. The following bioprostheses (total 1,414) were implanted in 1,098 patients: Carpentier-Edwards 567, Hancock 302, Liotta 268, Ionescu-Shiley 127, Angell-Shiley 72, Vascor 68, Implamedic 10. Follow-up ranged from 1 to 12 years, cumulative duration of follow-up was 6,747 patient-years and 8,637 valve-years, being 95.4% complete. Cumulative actuarial probability of being free from tissue valve failure (TVF) was 85.1% +/- 2.0% at 10 years, and 61.6% +/- 9.6% at 12 years. Actuarial probability of being free from TVF was 71.2% +/- 10.8% at 12 years for Carpentier-Edwards, 51% +/- 21.7% at 12 years for Hancock, 73.4% +/- 14.1% at 11 years for Angell-Shiley, 53% +/- 27.4% at 9 years for Liotta, 68% +/- 14.8% at 11 years for Ionescu-Shiley, 53.2% +/- 22.2% at 7 years for Vascor, 72.2% +/- 21.5% at 5 years for Implamedic bioprostheses. In this comparison of seven different bioprostheses, there is a large group of valves behaving in a very similar way. Only a few prostheses showed a constant and early negative trend.

Surgical A-V fistula in aortocoronary snake graft. Preliminary report.

In coronary artery surgery, when a poor distal run of can predict an early graft failure, it might be useful to perform the last anastomosis to a low pressure chamber thus creating a small arterio-venous (A-V) fistula. From January throughout December 1984, 4 patients underwent coronary angiography for severe symptoms of angina. The coronary angiography showed multiple stenoses on the left anterior descending (LAD), ventricular branches of the circumflex (CX), and posterior descending of the right coronary artery (PD). At operation the patients received a sequential aortocoronary bypass graft with reversed saphenous vein, plus the creation of a small A-V fistula into the right atrium in order to improve the graft flow and patency. All patients experienced a clinical improvement. No adverse effects have been observed and the patients, controlled clinically with non invasive and in two cases with invasive techniques, showed satisfactory revascularization.

Late innominate vein thrombosis. Unusual complication following sternal closure.

An unusual complication of the median sternotomy is reported. A 37-year-old male experienced a left innominate vein thrombosis 20 months after surgery. The combined treatment consisting of local infusion with Urokinase, surgical removal of the wire and balloon catheter dilatation, was completely successful.