Fast track extubation in paediatric cardiothoracic surgery in developing countries.

In recent years, low-dose, short-acting anesthetic agents, which replaced the former high-dose opioid regimens, offer a faster postoperative recovery and decrease the need for mechanical ventilatory support. In this study, the aim was to determine the success rate of fast-track approach in surgical procedures for congenital heart disease. There is some evidence, mostly from retrospective analyses, that fast tracking can be beneficial. Ninety-one cases with moderate complex cardiac malformations were operated with fast-track protocol during cardiothoracic charitable missions. The essential aspects of early extubation in our cohort included: selected patients with good preoperative status, good surgical result with hemodynamic stability in low dose of inotropic drugs at the end of bypass, no active bleeding. In this setting a carefull choice and dosing of anesthetic agents, alongside a good postoperative analgesia are mandatory. The authors found that an early extubation (< 4 hours) can be both effective and safe as it reduces intubation and ventilator times without increasing post-operative complications in pediatric congenital heart disease. This study supports a wider use of fast-track extubation protocols in paediatric patients submitted for congenital cardiac surgery in developing countries.

Huge left ventricular pseudoaneurysm rupture in an African young adult patient.

A pseudoaneurysm of the ventricle is formed when there is rupture of the myocardial wall with the discontinuity being roofed over by the pericardium and mural thrombus or fibrous tissue without myocardial elements. Cardiac pseudoaneurysm is a rare and a potentially life-threatening event. Early prophylactic surgical aneurysmectomy has been the treatment of choice. In this context, we report an unusual case of giant left ventricular pseudoaneurysm, as a result of unknown aetiology, appearing like a pulsatile mass, which was easily seen from the chest wall, in a young female, successfully treated with surgery.

Surgical management of giant fibroelastoma of the aortic valve with repair through valve sparing technique.

BACKGROUND: Fibroelastomas account for less than 10% of all cardiac tumors, representing the most common valvular and the second most common cardiac benign tumor, following myxomas.Fibroelastomas are histologically benign, but they can result in life-threatening complications such as stroke, acute valvular dysfunction, embolism, ventricular fibrillation, and sudden death. METHODS: A valve-sparing technique with simple shave excision of the tumor was undertaken with success. RESULTS: Surgical resection should be offered to all patients who have symptoms and to asymptomatic patients who have pedunculated lesions or tumors larger than 1 cm in diameter. Valve-sparing excision produces good long-term results in most instances. CONCLUSION: We report our surgical experience of a giant fibroelastoma in the aortic valve..

Giant fibroelastoma of the aortic valve.

Fibroelastomas account for less than 10% of all cardiac tumours, representing the most common valvular and the second most common cardiac benign tumour, following myxomas. Fibroelastomas are histologically benign; they can result in life-threatening complications such as stroke, acute valvular dysfunction, embolism, ventricular fibrillation, and sudden death. Surgical resection should be offered to all patients who have symptoms and to asymptomatic patients who have pedunculated lesions or tumors larger than 1 cm in diameter. Valve-sparing excision produces good long-term results in most instances. We report our surgical experience of a giant fibroelastoma in the aortic valve.

Aorta-to-right ventricular outflow tract fistula with coronary cusp prolapse.

We describe a rare case of aorta-to-right ventricular fistula in a 20-year-old man who presented with signs and symptoms of congestive heart failure. He was successfully treated by closing the fistula with a Dacron patch from the aortic side. At follow-up, he was asymptomatic with no left-to-right shunt.

[Hospital mortality at a cardiosurgical unit in Torino: international comparisons and time trend]. / Mortalità ospedaliera in una unità di cardiochirurgia di Torino: confronti internazionali e andamento temporale.

OBJECTIVE: To compare hospital mortality in a cardiac surgery unit with external data and to assess changes in time (patients undergoing surgery in two different periods). MATERIALS AND METHODS: Data on risk factors for hospital mortality were collected from clinical records (retrospectively for the first period and prospectively for the second) for all patients undergoing open heart surgery at the Heart Surgery Unit of the University of Turin (Italy) during 1991 and 1995 (n = 1794) and 1999 (n = 892). Comparisons of in-hospital mortality, expressed as Standardized Mortality Ratios (SMR), were adjusted for risk factors defined according to EuroSCORE (European System for Cardiac Operative Risk Evaluation). RESULTS: In the first and second period, complete information on all the 17 EuroSCORE items was available for 58.3% and 89.6% patients respectively. After exclusion of patients with one or more missing data, observed and expected numbers of death were found to be very similar, with SMRs ranging between 0.82 (isolated bypass in the second period) and 1.06 ("other" surgery in the first period). Mortality was higher among patients with missing data, but at least in 1999 the latter had a limited impact on the overall estimates. Compared to the first period, mortality was reduced during 1999 (from 5.9% to 5.4%), in particular for isolated bypass (from 4.4% to 3.4%). CONCLUSIONS: In the unit under investigation, hospital mortality following heart surgery was similar to that predicted from EuroSCORE and seemed to be lower in 1999 than in 1991-95, particularly for isolated bypass. Incompleteness of data on individual risk factors may have been a source of bias, especially when data were collected retrospectively.

Sternal closure using semirigid fixation with thermoreactive clips.

Sternomy represents the standard approach to the heart and great vessels in most cardiothoracic procedures. Closure of this incision is simple; however, healing complications such as dehiscence, osteomyelitis, mediastinitis, and superficial wound infection or fistula may occur. We describe an alternative technique for sternal closure using semirigid fixation with thermoreactive clips.

Long-term outcome after valve replacement with the omnicarbon prosthesis.

BACKGROUND AND AIM OF THE STUDY: The study aim was to determine whether long-term prognosis was affected by valve replacement with a tilting-disc prosthesis. METHODS: Surgical data were recorded prospectively for all (n = 153) valve replacement cases with the Omnicarbon prosthesis during the period February 1985 to January 1986. A rheumatic valvular pathology was present in 105 patients (68.6%). There were 78 (51%) aortic (AVR), 51 (33%) mitral (MVR) and 24 (16%) double (DVR) valve replacements. The follow up was 99% complete (n = 151). RESULTS: Mean follow up was 10.2+/-4.4 years (total 1,472 patient-years (pt-yr)). Survival at 10 years was 68+/-4% (71+/-5% AVR, 61+/-7% MVR), and this fell to 57+/-4% at 14 years. No structural failure was observed. Thromboembolic and hemorrhagic events were rare, with actuarial freedom from thromboembolism of 94+/-2% and 91+/-3% at 10 and 14 years, respectively. This low incidence of thromboembolism encouraged an ease in anticoagulation; hence the AVR and MVR cohorts had a median INR of 2.8, but a higher INR (3.4) was maintained in DVR patients. All prostheses had acceptable hemodynamic performance. No cases of hemolytic anemia were detected, and mean blood counts were within normal ranges. Lactate dehydrogenase values indicated minimal hemolysis, and were lowest after AVR (median LDH 93% normal) and highest after DVR (median LDH 136% normal). Functional evaluation showed an improvement in NYHA class that remained stable over 14 years. At follow up, 95% (75/79) of patients were in NYHA class I or II. CONCLUSION: Survival and quality of life after Omnicarbon valve implantation exceeded the authors' expectations. Functional capacity remains good, and valve-related complication rates are low. The Omnicarbon tilting-disc valve has been shown to provide reliable and satisfactory service in the long term.

[Life style and adherence to the recommended treatments after cardiac transplantation]. / Stile di vita e aderenza ai trattamenti raccomandati dopo trapianto cardiaco.

BACKGROUND: All the previous studies showed an increase in survival after cardiac transplantation. Nevertheless, a certain number of patients persist, in the short- and long-term period, in leading an incorrect lifestyle. Owing to this high-risk behavioral profile clinical, psychological and social problems could arise. METHODS: We have analyzed the quality of life and adherence to the recommended treatments in 107 patients at least 6 months (range 6-132 months) after they had been submitted to heart transplant and returned to their preoperative social and family environments. RESULTS: Data analysis has shown, in these patients, the return to their previous high-risk lifestyle habits: 18.4% of them did not adhere to the suggested diet, 13.2% did not perform physical activity, and 36.7% of the smokers took up the habit again after the transplant. Perceptions of emotional distress were still there: anxiety in 10.3% of cases and depression in 13.1%. An unsatisfactory sexuality was reported by 27.1% and only 27% returned to their previous job. Their outlook towards their self-efficacy seems to be predictive of the quality of life as perceived by the patient after the heart transplant: the better their outlook towards their self-efficacy, the better the quality of life. CONCLUSIONS: These data show that following heart transplant, before implementing postoperative preparation and rehabilitation programs one must carefully study those problem areas that unfortunately still exist.

Simultaneous operation for cardiac disease and lung cancer.

Concomitant lesions of the heart and lung have been increasing and the issue of performing simultaneous pulmonary resection and cardiac surgery remains controversial. We report a retrospective study of 11 patients (ten male, one female) who underwent simultaneous lung resection and cardiac operation. In all cases the lung resection was performed before heparinization and cardiopulmonary bypass. All patients were discharged in 10 days. We did not have postoperative complications. Follow up mean was 41.2 months/patients. A combined procedure, when possible, avoids other thoracic procedure, permits to improve outcomes and provides economic benefit.

Quantitation of human cytomegalovirus DNA in peripheral blood leukocytes of heart transplant recipients: relationship with pp65 antigenemia and with antiviral therapy.

OBJECTIVE: To retrospectively determine DNA levels in blood polymorphonuclear leukocytes (PMNLs) of 21 heart transplant patients who suffered from HCMV infection and who were monitored by the antigenemia assay (pp65 test) during follow-up, by use of a quantitative competitive polymerase chain reaction (PCR) assay for human cytomegalovirus (HCMV) DNA. METHODS: Quantitation of HCMV DNA by PCR was expressed as genome equivalents (GE) per 200 000 PMNLs. RESULTS: Ten patients experienced symptomatic HCMV infection (five primary infections and five reactivations) with mild symptoms and received ganciclovir treatment, whereas 11 asymptomatic HCMV infections were not treated. Therapy was discontinued when a 90% reduction of the pretreatment antigenic load was achieved in a symptomless patient. The mean HCMV DNA and antigenic loads were significantly higher in symptomatic than in asymptomatic patients: 4.6 x 105 plus minus 4.7 x 105 GE and 1.1 x 104 GE (p<0.0001) and 390 plus minus 350 versus 25 plus minus 12 pp65-positive PMNLs (p<0.0001), and in primary than in secondary infections (583 plus minus 403 pp65-positive PMNLs versus 85 plus minus 111, p=0.002 and 5.2 x 105 plus minus 5.2 x 105 GE instead of 1.5 x 105 plus minus 3.2 x 105 GE, p=0.02). A single course of 14--21 days of ganciclovir caused a marked decrease of HCMV DNA and antigenemia in eight of 10 patients in whom a 90% reduction of the antigenic load correlated with a 98% DNA reduction of the pretreatment levels. In two primary infections, a 90% antigenic reduction was achieved by 21 days of ganciclovir treatment, but those data only correlated with a DNA load reduction of 28% and 60% of the pretreatment levels. Fifteen and 12 days later, respectively, the two patients relapsed and underwent a second ganciclovir course, at the end of which a 90% reduction of the antigenic load correlated with a >98% DNA drop. GCV was discontinued and the patients recovered completely. In those two patients we retrospectively found persistent high DNA levels before the second ganciclovir course, whereas the antigenic load slowly increased after an apparent reduction. CONCLUSIONS: Our data suggest that: (1) DNA levels have the same trend as the pp65 antigen test---they are significantly higher in symptomatic and in primary HCMV-infected patients than in asymptomatic patients and those with secondary infection; (2) a 90% antigenic load reduction from the pre-treatment level may be a less reliable predictor of the efficacy of anti-HCMV therapy than DNA load, at least in primary infection, in which a much higher viral load and much more severe disease are present; and (3) a DNA load reduction of >98% of the pretreatment value is required for therapeutic success.

Comparison of polymerase chain reaction and pp65 antigen test for early detection of human cytomegalovirus in blood leukocytes of cardiac transplant recipients.

OBJECTIVE: To establish whether polymerase chain reaction (PCR) for cytomegalovirus deoxyribonucleic acid (DNA) can provide clinical information for the management of the infection. METHODS: Leukocytes in 30 heart transplant recipients were monitored by pp65 antigen testing and PCR for 82 to 365 days after transplantation. RESULTS: Of the 30 patients, 26 developed cytomegalovirus infection, nine of whom were symptomatic. Altogether, 300 leukocyte samples were examined. The concordance between PCR and pp65 antigen test was 82.6%. In symptomatic patients after surgery, PCR detected cytomegalovirus infection after 38 plus minus 16 days and the pp65 antigen test, after 48 plus minus 15 days. Symptomatic infection correlated with a higher number of pp65-positive leukocytes than did asymptomatic infection: 310 plus minus 356 vs 24 plus minus 35 (p < 0.005)/200,000 examined, respectively. Clearance of virus was observed by PCR after 125 plus minus 73 days (range 29 to 225) in symptomatic, and after 82 plus minus 70 days (range 16 to 301) in asymptomatic, cases of infection. CONCLUSIONS: The positive predictive value of PCR for symptomatic infection was 34.6%. Our findings correlate with previous reports and show that the qualitative detection of cytomegalovirus DNA is not associated with overt disease whereas quantitation of pp65-positive leukocytes closely correlate with symptom onset. Insofar as the results are not quantitative, PCR is not a marker of clinically apparent infection. Careful monitoring of cytomegalovirus infection based on quantitative pp65 antigen assay can fulfill all clinical needs for early diagnosis and proper management of the infection