Papillary fibroelastoma of an anomalous mitral valve chorda.

Cardiac papillary fibroelastoma (CPF) is a rare primary cardiac tumour. This tumour constitutes about 10-15% of all primary cardiac tumours. We report here a case of CPF of an anomalous mitral valve chorda.

A stitch in time saves nine: closing the hole after removal of the aortic root cannula.

BACKGROUND: On completion of the surgical procedure the hole in the ascending aorta has to be closed after withdrawal of the aortic root cannula. The aorta is usually pinched by a double transversal stitch or it is crumpled by a purse string suture. Nevertheless, hemostasis is difficult to obtain because closure is done under recovered pressure. Additional stitches buttressed with teflon-felt pledgets are often required. Unfortunately, sensitivity to bacterial implantation and the proximity to the sternotomy line could make the foreign material of the pledgets responsible for chronic infections and fistulas. METHODS: Two simple square stitches orthogonal to each other could be a very useful suture combining simplicity with effectiveness. To do this, two 4-0 polypropylene half-threads are put obliquely through the full thickness of the aortic wall, to and fro with inverse obliquities. Each of them draws a cross inside the aortic wall and two sides of a square outside. As a result a little square is drawn by the threads around the hole. RESULTS: For years we have never needed to reinforce the closure by supplemental stitches with hundreds of patients. CONCLUSION: This type of closure has some advantages. In contrast to common stitches the aortic wall is not bent, crumpled or deformed, bites pass all aortic layers and the crossing of the threads covers the hole from inside rather than outside. Moreover, each thread can be tied with half of the tension required by other sutures because the two stitches act together but in the opposite direction. Finally, the technique is speedy and it requires only two half-threads. Most importantly, there is no need for teflon-felt pledgets. As a result, we have no longer seen any type of chronic infection or fistula.

A rare case of anterior chest closure only with omental flap after devastating mediastinitis: case report.

We describe a case of 73-year-old patient who has been operated in emergency on triple coronary artery bypass graft (CABG), which was complicated with respiratory insufficiency and devastating mediastinitis. The anterior mediastinum was closed with an omental flap that was allowed to epithelize spontaneously. The patient was discharged after 110 days. Despite the large number of cases with mediastinitis described in the literature, the chest closure with only an omental flap without closure of subcutaneous tissue and skin is rare.

New device for saphenous vein-to-aorta proximal anastomosis without side-clamping.

BACKGROUND: Side clamping to perform saphenous vein-to-aorta proximal anastomosis is a well known cause of cerebral embolization during coronary bypass surgery. Automatic and manual devices have been introduced to avoid aortic clamping and facilitate proximal anastomosis but the manual ones only allow the traditional hand-sewing running suture. Nevertheless, they are not easy to use and very expensive to buy. METHODS: We developed a simple object that helps to perform a manual proximal anastomosis without the need to clamp the side of the aorta. This device is a steel bar which blocks the aortic hole and simultaneously it provides a slit to receive the needle. Through the slit comes out a thin, sharp, straight, but also well directed and predictable jet of blood which could be easily controlled during the suture. RESULTS: The function of the object is quite different from other devices. Nothing is deployed in the aorta. The object is only placed on the aorta with the small appendage slipped into the hole. The main advantage of the device is that while manipulation of the aorta is avoided no foreign bodies are incorporated in the suture and - most importantly - the aortic intima is not touched at all. The main drawback of the device is the blood jet coming from the slit so that the blood pressure has to be lowered by vasodilators during the anastomosis. Moreover, the suture has to change direction and the needle has to enter the aortic wall first to slip out through the slit. CONCLUSION: The object was named "Slit Device" and is not a routine instrument. It would be only an alternative to other anastomotic devices with the same surgical indications. In the case of ascending aortic disease and saphenous vein grafting, the Slit Device avoids aortic clamping thereby preventing atheroembolism and also avoiding the need for hypothermic circulatory arrest in patients with unclampable aorta.

Safe wrapping of the borderline dilated ascending aorta during aortic valve replacement.

BACKGROUND: Techniques of reduction aortoplasty are widely published in the literature with conflicting results. External support seems to be an important factor in preventing recurrence but, in some cases, this technique caused erosion of the aorta because of the wrinkles the prosthesis creates in the rear side of the aorta. CASE PRESENTATION: A 73 year old patient with aortic valve stenosis and borderline dilated ascending aorta had aortic valve replacement and simple wrapping without aortoplasty. To avoid the formation of wrinkles, the dacron external support was tailored appropriately to obtain a curved, custom-made prosthesis. This custom-made prosthesis had the same diameter as the dilated aorta and, after valve replacement, fitted it properly. After 18 months neither computerized axial tomography nor ecocardiography detected wrinkles or dilatation recurrence. CONCLUSION: A safe, simple and probably new way to prepare an external wrapping is presented, which in this patient respected the shape of the aorta and prevented the formation of wrinkles in the prosthesis and possible complications such as wall erosion.

Left ventricle remodelling by double-patch sandwich technique.

BACKGROUND: The sandwich double-patch technique was adopted as an alternative method for reconstruction of the left ventricle after excision of postinfarction dysfunctional myocardium to solve technical problems due to the thick edges of the ventricular wall. METHODS: Over a 5-year period, 12 of 21 patients with postinfarction antero-apical left ventricular aneurysm had thick wall edges after wall excision. It was due to akinetic muscular thick tissue in 6 cases, while in the other 6 with classic fibrous aneurysm, thick edges remained after the cut of the border zone. The ventricular opening was sandwiched between two patches and this is a technique which is currently used for the treatment of the interventricular septum rupture. In our patients the patches are much smaller than the removed aneurysm and they were sutured simply by a single row of single stitches. However, in contrast to interventricular septum rupture where the patches loosen the tension of the tissues, in our patients the patches pull strongly and restrain the walls by fastening their edges and supporting tight stitches. In this way they could narrow the cavity and close the ventricle. RESULTS: The resected area varied from 5 x 4 to 8 x 8 cm. Excision was extended into the interventricular septum in 5 patients, thus opening the right ventricle. CABG was performed on all patients but two. Left ventricular volumes and the ejection fraction changed significantly: end-systolic volume 93.5 +/- 12.4 to 57.8 +/- 8.9 ml, p < 0.001; end-diastolic volume 157.2 +/- 16.7 to 115.3 +/- 14.9 ml, p < 0.001; ejection fraction 40.3 +/- 4.2 to 49.5 +/- 5.7%, p < 0.001. All patients did well. One patient suffered from bleeding, which was not from the wall suture, and another had a left arm paresis. The post-operative hospital stay was 5 to 30 days with a mean 10.5 +/- 7.5 days/patient. At follow-up, 9 to 60 months mean 34, all patients were symptom-free. NYHA class 2.5 +/- 0.8 changed to 1.2 +/- 0.4, p < 0.001. CONCLUSION: The double-patch sandwich technique (bi-patch closure) offers some advantages and does not result in increased morbidity and mortality. In the case of excising a left ventricular aneurysm, this technique in no way requires eversion of the edges, felt strips, buttressed and multiple sutures, all of which are needed for longitudinal linear closure. Moreover, it does not require purse string sutures, endocardial scar remnant to secure the patch or folding the excluded non-functional tissue, all of which are needed for endoventricular patch repair.

[Cardiac surgery in octogenarians: a five-year experience]. / La cardiochirurgia nell'ultraottantenne: cinque anni di esperienza.

BACKGROUND: Cardiac surgery in octogenarians is increasing in industrialized countries and therefore represents a growing population. The aim of this study was to evaluate characteristics and outcomes of octogenarian patients undergoing cardiac surgery. METHODS: We reviewed all consecutive octogenarians operated on during the last 5 years. Among 1912 patients operated on between April 2000 and December 2004, we identified 223 patients (11.6%) aged > 80 years. Median age was 82.17 +/- 2.11 years, and 52.5% were males. The mean EuroSCORE score was 9.4 +/- 1.8. Among them 43 patients (19.3%) had isolated aortic valve replacement, 127 patients (57%) had isolated coronary artery bypass graft, 40 patients (17.9%) had aortic valve replacement combined with coronary artery bypass graft, 11 patients (4.9%) had mitral valve repair, and 2 patients (0.9%) had ventricular septal rupture repair. RESULTS: The overall hospital mortality was 5.4%; cumulative actuarial survival at 4 years was 77.6%. CONCLUSIONS: We conclude that for unselected octogenarians the operative mortality is acceptable and only slightly increased than in younger age groups; the late survival rate is good.

Transatrial approach of acquired posterior ventricular septal rupture and double orifice technique in tricuspid valve repair.

We present a successful transatrial repair of ventricular septal rupture and tricuspid valve reconstruction, using the "edge-to-edge" technique, as a serious complication of a posterior myocardial infarction in an 83-year-old woman.