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Background: The study was designed to evaluate short and long-term benefits of coronary artery bypass graft in patients with coronary artery disease and severely depressed left ventricular ejection fraction and to identify contemporary risk factors associated with significantly greater mortality in this high-risk subgroup., Methods: From 1985 to 1995, 200 consecutive pts with EF < or = 0.30 underwent CABG. Among these patients, 60% were older than 70 years. NYHA functional class III/IV was present in 31% of pts. Preoperative mean cardiac index was 2.7 +/- 7 l/min/m2, mean pulmonary artery pressure was 29.9 +/- 7 mm Hg and contractility score (generated by appropriate software for left ventricular kinesis analysis) mean value was 50.1 +/- 11.6 points. Urgent operation was required in 32 pts (16%). The majority of pts were completely revascularized., Results: Operative mortality was 9% (18 pts). Low output syndrome was the most common postoperative complication (13.5%) followed by ventricular arrhythmia (8%), mean length of postoperative hospitalization for survivors was 13 +/- 10 days. Of 23 possible operative risk factors evaluated, four were associated with significantly greater mortality: cardiac index < or = 2.1 l/min/m2, urgent operation, contractility score > or = 80 and associated surgical procedures. Survivors experienced significant improvement in CHF class (p < 0.001) and follow up EF (p < 0.001). Kaplan-Meier estimate of survival at 1 year, 5 years and 8 years was 85%, 65% and 54%., Conclusion: Through more careful assessment of preoperative risk factors, patients selection and perioperative management, actually coronary artery bypass graft may be offered to pts with low ejection fraction with reduced morbidity and mortality.

Since September 1985 to June 1994, 252 patients (70 years and older) underwent coronary artery bypass grafting isolated or combined with other surgical procedures. Mean age was 73 +/- 4.3 years (range: 70-84). Associated non-cardiac diseases were present in 131 patients (52%). Concomitant surgical procedures were performed in 34 patients (13.5%). Myocardial revascularization was accomplished under emergency conditions in 18.1% of patients. Overall operative mortality was 5.5% (n = 14). Isolated coronary artery bypass grafting operative mortality was 3.9% (n = 10). In-hospital death rate was higher (11.7%; n = 4) for coronary artery bypass grafting associated with other procedures. During the same period, the overall mortality rate for patients younger than 70 years was 3.4% (p = NS). The 30-days in-hospital mortality was significantly higher for emergency procedures (8.7%) than for elective surgery (4.9%) (p = 0.01). Multivariate stepwise logistic regression analysis identified concomitant diseases as independently significant risk factor. Morbidity was 36.1% (n = 91). Mean intensive care unit stay was 2.8 +/- 2.2 days vs 2.1 +/- 1.2 days for patients < 70 years (p = 0.01). Total charges per case for surgical treatment were 15% higher for elderly patients. Follow up ranged from 1 to 108 months, averaging 32 months. Long-term survival was 92%, 78% and 58% at 1, 5 and 10 years from operation. With current techniques, cardiac surgery is performed in the elderly with acceptable mortality and morbidity and with slightly increased average costs.

Short- and long-term results of valve repair for degenerative mitral insufficiency are reported in 127 consecutive patients with a mean age of 57 years (range 25-76). Preoperatively, 32 patients (25%) were in NYHA functional class IV, 65 (51%) in class III, 29 (23%) in class II, and 1 (0.8%) in class I. The mitral lesions and the mechanism of valvular regurgitation were assessed preoperatively by echocardiography (transthoracic and/or transesophageal) and intraoperatively by inspection of the valvular structures. Cardiac catheterization was performed only in 14 patients with some evidence of concomitant coronary artery disease, and critical stenoses were found in 5 cases. The mitral valve prolapse was posterior in 66 cases (52%), anterior in 29 (23%) and of both leaflets in 32 (25%). The posterior prolapse was corrected by quadrangular resection technique. The anterior and both leaflet prolapses were managed by transposition of chordae from the mural leaflet to the prolapsed part of the anterior leaflet. To give more stability to the repair in all cases except one, the valve repair was completed by posterior annuloplasty, using a PTFE 4 mm conduit (73 pts) or an autologous pericardium graft (53 pts). One patient died perioperatively (operative mortality 0.7%) and in only one case (the one in which posterior annuloplasty was not performed) was mitral valve replacement necessary two days after operation, for dehiscence of the valvar reconstruction.(ABSTRACT TRUNCATED AT 250 WORDS)

Considering the morphological aspects of diffuse coronary disease one must argue that, in their presence, myocardial revascularization can be performed only by coronary endarterectomy (EA), together with conventional bypass grafting. A variety of EA techniques ("blind" and "open" EA) are analyzed. Indications, long and short-term results (operative risks, symptomatic improvement, grafts patency) of each procedure are evaluated on the basis of the current experiences. We conclude that EA is a valuable complement to coronary artery bypass grafting which allows: a) a larger number of conventionally inoperable patients to benefit from the surgical treatment; b) more complete revascularization in patients with diffuse coronary disease.

Bilateral internal mammary artery (IMA) grafting is recognized as a preferred method of myocardial revascularization. However, for multivessel coronary artery disease, saphenous veins often have to be added to complete myocardial revascularization. The right gastroepiploic artery (rGEA) has been recently recognized as a suitable arterial conduit to obtain with both IMAs a complete myocardial revascularization without conventional vein graft. From December 1985 to July 1990, 87 selected patients underwent coronary artery bypass grafting using only the two IMAs and, from December 1988, the rGEA. There were a total of 220 coronary artery bypass grafts (mean 3.06/patient) and 267 coronary artery anastomoses (mean 1.21 anastomoses graft). There was one perioperative death (1.14%), 3 patients (3.5%) developed a perioperative myocardial infarction, and 7 patients (8.04%) needed a transitory inotropic pharmacological support. Two patients (2.29%) underwent reoperation for bleeding, and a third (1.14%) for sternal diastase. Fifty-five patients (63.2%) underwent postoperative angiography: 6/139 grafts (4.31%) (3 rGEA free, 2 rIMA free, 1 rIMA in situ) were occluded. After follow-up, ranging from 12 to 66 months (30.54 average), 77 patients (92.77%) were free from angina, one patient underwent reoperation 7 months later and a third died for sudden death 55 months after the operation. There were no gastric complications due to rGEA harvesting. Actually, bilateral IMA grafting is the best investment for the patient who needs myocardial revascularization. The rGEA is a promising conduit whose only concern could be the long-term patency; this will be resolved in the future. Up-to-date combined arterial graft utilizing the IMA and the rGEA can facilitate complete revascularization by arterial grafts safely and effectively.

The aim of conservative management of mitral regurgitation caused by floppy mitral valve is to restore a valvular function which closely resembles that of normal physiology. Fifty-eight patients affected by floppy mitral valve underwent surgical procedures for severe mitral regurgitation due to chordal elongation and/or rupture. Of these, 28 presented posterior mitral prolapse corrected by quadrangular excision of the prolapsed part and posterior anuloplasty achieved by apposition of a polytetrafluoroethylene conduit. The remaining 30 patients presented anterior or bilateral prolapse corrected by transposition of chordae from the posterior leaflet to the anterior cusp together together with anuloplasty. A complete echo-Doppler study was performed preoperatively, 10 days after the operation and every 6 months thereafter. Mean follow-up was 16.1 +/- 6.3 months. Preoperatively, 44 patients presented severe mitral regurgitation and 14 had moderate regurgitation (quantified by means of pulsed Doppler). All patients showed severe enlargement of the left cavities (LVDD 67.1 +/- 8.6 mm, left atrium 53.4 +/- 10.9 mm) with normal mitral area (6.08 +/- 2.14 sqcm, Doppler measurement). Following surgery we found a significant reduction in: 1) the degree of mitral regurgitation (29 patients had no regurgitation; 20 had mild protosystolic mitral regurgitation (29 patients had no regurgitation; 20 had mild protosystolic mitral regurgition, confirmed by color-M-mode; moderate or severe regurgitation was found in 6 cases); 2) the left ventricle and left atrium dimensions (LVDD 53.4 +/- 5.2 mm, p less than 0.01; left atrium 43.8 +/- 11.1 mm, p less than 0.01). Color flow imaging provided information about the recovery of a normal valvular function.(ABSTRACT TRUNCATED AT 250 WORDS)

Twelve patients with corrected transposition of the great arteries, who underwent surgical repair, are reported. In four cases a ventricular septal defect was present; in six cases, a ventricular septal defect and pulmonary stenosis and in two an incompetence of the systemic atrio-ventricular valve. The anatomic types of corrected transposition and the pertinent diagnostic characteristics were reviewed and discussed. The problems related to the surgical correction and the different approaches to the intracardiac lesions are considered and the difficulties of treating the obstruction of the venous ventricle successfully are emphasized.

Retrograde coronary sinus perfusion as a means of delivering cardioplegia was evaluated in 20 patients undergoing cardiac valve surgery. Other 10 patients, undergoing similar operation with antegrade coronary cardioplegic perfusion served as a control. Results showed no significant differences between the two groups of patients in terms of: myocardial cooling; pre-ischemic and post-perfusion myocardial lactate extraction; post-operative clinical findings (myocardial infarction occurrence, need for inotropic support, mortality). We conclude that retroperfusion through the coronary sinus is a safe and effective alternative of cardioplegic delivery. Since it simplifies the operative procedure (it allows the cardioplegia delivery at any desired time of the operation, without discontinuing the procedure), we recommended its use during valvular cardiac operations, especially on aortic valve replacement.

Twenty-three patients with ventricular spetal rupture complicating acute myocardial infarction underwent surgical repair. In 15 patients the interval between occurrence of myocardial infarction and operation varied from 2 to 18 days and in 8, from 2 to 9 months. In the group of the patients operated on early after the myocardial infraction (less than three weeks) the hospital mortality was 60%; in the group of patients operated on later, the ospital mortality was 12%. Tir six patients had a cardiac catheterization which showed a decrease of the end diastolic left ventricular pressure and a decrease of the pulmonary pressure. In two patients a residual small left-to-right shunt was present. The Aentricular septum is surgical; B) the surgical closure of the rupture should be delayed when possible from three to six w-eks after the infarction; C) in the patients operated on early after the myocardial infarction the operative risk is high, but the long-term results are good, as they are in the patients operated on later after infarction.

From June 1982 until January 1986, 173 coronary endarterectomies (EA) with bypass were performed in 143 patients. The series includes 130 conventional EA and 43 open EA with coronary reconstruction. In 9 cases of open EA the revascularization of the reconstructed coronaries was accomplished with internal mammary artery (AMI). 70 (40.4%) EA were performed on the right coronary artery, 75 (43.3%) on the left anterior descending coronary artery and 28 (20.1%) on the left circumflex coronary artery. The early mortality rate in the entire group was 3.5% (respectively 2.0% for the conventional EA and 7.3% for the open EA) and the rate of perioperative myocardial infarction was 8.4% (7.8% in patients receiving conventional EA and 9.7% in those receiving open EA). With mean follow-up of 18.4 months, most (89.8%) of the surviving patients were either symptoms-free or greatly improved. Coronary endarterectomy is a worth-while procedure and it allows surgical management of otherwise inoperables arteries.

Coronary endarterectomy (EA) allows to recanalize and bypass what appear to be an otherwise inoperable vessel. Although the application of this procedure is still controversial, there is now an increasing tendency to use the EA more frequently and recent studies confirm this trend. A variety of individualized techniques of performing coronary EA (local EA, conventional "blind" EA, open EA with coronary reconstruction, laser EA) are analyzed. Technical aspects, indications and results (operative risk, symptomatic improvement, grafts patency) of each procedure are evaluated on the basis of the current experiences. Although hospital mortality and perioperative infarction rates are moderately higher than in routine grafting, it is stressed that EA is a valuable supplement to coronary artery bypass grafting extending the indications of myocardial revascularization: a) larger number of conventionally inoperable patients can benefit from the surgical treatment; b) more complete revascularizations are possible in patients with diffuse coronary disease.

Between January 1986 and November 1987, 31 patients (pt.) underwent reconstructive surgery for mitral regurgitation secondary to floppy valve. Six pt. were in NYHA functional class IV, 22 in III class and 3 in II class. The mitral valve prolapse was posterior in 20 cases, anterior in 7 cases and bilateral in 4 cases. Chordal rupture was present in 18 pt. The mitral valve was repaired by quadrangular excision of the mural leaflet and posterior annuloplasty performed by insertion of polytetrafluoroethylene graft. The anterior prolapse was managed by transposition of chordae from the mural leaflet to the prolapsed part of the anterior leaflet (11 cases). One patient died perioperatively from myocardial infarction. Subsequent follow-up (length: 12.1 +/- 4.9 months) revealed good functional and clinical results: all pt. were alive, in NYHA class I or II (3 pt.). Echocardiographic studies revealed a decrease in diastolic (3.68 +/- 0.6 vs. 3.17 +/- 0.3 cm/m2) and systolic (2.4 +/- 0.5 vs. 2.15 +/- 0.4 cm/m2) diameter. The shortening fraction did not decline significantly. The mitral area fell from 6.0 +/- 2.0 cm2 to 3.1 +/- 1.1 cm2. A moderate residual regurgitation was present in two pt. and a severe regurgitation was found in only one pt. Our experience suggests that valve repair may be considered the most suitable type of operation for mitral regurgitation secondary to floppy valve.

To improve the benefits from coronary artery grafting with internal mammary artery (IMA) several technical manoeuvres and methods have been developed to increase the number of coronary arteries and their branches that can be bypassed with internal mammary arteries. Between November 1985 and December 1986, 50 patients underwent a surgical myocardial revascularization procedure using both internal mammary arteries by single or sequential anastomoses and supplemental saphenous vein graft. In 42% of these patients complete revascularization was achieved employing only internal mammary artery grafts. One hundred and twenty-six internal mammary artery grafts (77% of the total coronary bypass performed), were placed. One patient developed perioperative myocardial infarction. Reparative surgery to control immediate post-operative bleeding was required in two patients. Post-operative coronary angiography performed in 30 patients showed all patent internal mammary artery grafts but one. No late deaths occurred. Mean follow-up of 10 months was complete in 50 patients, of whom 94% are symptom free. We conclude that bilateral internal mammary artery grafting can be performed with low operative risk and can provide excellent long-term functional improvement and survival employing only high patency arterial conduit. Moreover, it doesn't significantly increase surgical morbidity.

Operative and late post-operative results in 52 patients undergoing operation for chronic postinfarction left ventricular aneurysm are described. Aneurysm resection was performed in 33 patients. This procedure was combined with myocardial revascularization by means of insertion of a venous aorto-coronary by-pass graft in 14 cases. Hospital mortality for the total group was 3,8% (2 deaths). Surviving patients were followed-up 3 to 66 months. Two late deaths occurred. Clinical and functinal improvement occurred in the majority of surviving patients. The impact of simultaneous aorto-coronary by-pass grafting on operative results is discussed.

Blood autotransfusion has entered a new phase in blood transfusion technique, since it represents an important alternative in eliminating the risks connected with blood transfusion: viral hepatitis, AIDS, blood transfusion reactions, and alloimmunization. Transfusion requirements during cardiac surgical procedures have steadily decreased; nowadays most adult patients require no transfusion during surgery. Patients (pts) receiving bank-blood may develop infectious diseases (hepatitis, AIDS, etc.). We have studied how to avoid the risk of infections with homologous blood transfusions. We present our experience of day-hospital pre-operative autologous blood collection. One-hundred-eighty-nine patients undergoing primary myocardial revascularization or valvular replacement were submitted to the drainage of 350 ml of blood three times every four days before surgery. The blood was centrifuged at once, to separate red cells from plasma. Surgeries were performed 21 days after the first drainage; iron therapy was recommended. After surgery pts received blood only if haematocrit was lower than 28%. The following data were recorded: no. of pts who received homologous blood; blood loss and homologous total blood volume used for each pt. Average blood loss was 1230 cc for ischemic pts and 701 cc for valvular pts. Non-A non B hepatitis occurred in 3/189 pts (1.5%). All of them had received homologous blood transfusions. Our data show clearly that autotransfused pts had a better post-operative period; less bank-blood and fewer transfusions have been used. No pt had collateral effects such as angina or hypotension from blood drawing. Our data show that severe cardiac diseases do not represent an absolute contraindication to heavy blood drainage.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiac hydatid disease represents 0.02-2% of the possible locations of the parasite. In these last few years we have seen an increase in the percentage of cardiac hydatid disease treated with surgery. The Authors report on two patients who underwent surgery for the excision of cardiac hydatid cysts. The Authors agree that in spite of the rarity of cardiac hydatid disease it should be investigated routinely by two-dimensional echocardiography in the presence of hepatic or pulmonary hydatid disease in order to prevent the possible spread of the parasite throughout the body.

Nineteen patients with ventricular septal defect (V.S.D) and valvular aortic insufficiency (A.I.), who underwent surgical repair, were reported. In the majority of patients the V.S.D. was localized in the supracristal region and the most frequent aortic valve abnormality was a prolapsing right cusp. Closure of the V.S.D. was effected with a patch in 15 patients and by direct suture in 4. Surgical management of A.I. consisted of: a) replacement of the aortic valve in 12 patients; b) no procedure on the aortic valve in 6 patient; c) plastic repair of the aortic valve in 1 patient. Only one patient died. Conservative management of the A.I. is advocated, but this is possible only if early repair is attempted. In adults, replacement with a prosthesis is indicated for severe A.I.

Primary tumours of the heart are uncommon and, among them, hemangioendotheliomas are exceptionally rare. The purpose of this paper is to present a rare case of right ventricular hemangioendothelioma treated surgically with success.

A 68-year-old woman with obstruction of the superior vena cava due to sclerosing mediastinitis was successfully operated on. A composite spiral vein graft was interposed between the left innominate vein and the right atrium to bypass the occluded superior vena cava. The graft was made using the patient's own saphenous vein, which was divided longitudinally and sutured around a cannula in a spiral fashion. Indications to surgical intervention in patients with superior vena cava syndrome are discussed.

26 patients (pts) (8 males and 18 females), mean age 50 +/- 9 years, with rheumatic valve (MV) disease, candidates to MV replacement, were examined by contrast echocardiography (CE) before and after surgery. This was done in order to assess pre and postoperatively the presence of associated tricuspid regurgitation (TR) and to evaluate the short and long-term results of the operation on the TR itself. For assessing TR, the systolic presence, intensity and persistence of the microbubbles of the contrast medium injected into an antecubital vein, were observed within the inferior vena cava (IVC). We used synchronous time motion (TM) and two dimensional (2D) echocardiography from subcostal view. TR was classified as follows: severe (massive systolic opacification and persistence of the microbubbles in the IVC for at least 20 seconds); moderate (moderate systolic opacification lasting less than 20 seconds); mild (slight systolic opacification lasting less than 10 seconds); insignificant TR (sporadic appearance of the contrast medium into the IVC). On the average, the examination was carried out 48 hours before surgery, 15 days after and, in pts undergoing De Vega tricuspid valvuloplasty, 14 months after the operation. At pre-operative examination, massive TR was found in 16 pts, only 6 of whom showed clinical signs of TR. The findings were confirmed at surgery in 15 pts who underwent not only MV replacement but also tricuspid repair. In the other pts, agreement was found between CE and surgery as far as moderate TR was concerned, meanwhile mild CE TR was not confirmed at surgery. Sensitivity (SN) was 100%, specificity (SP) 38%, positive predictive value (PPV) 78%, negative predictive value (NPV) 100%. Excluding CE mild TR, SP and PPV raised to 75% and 95% respectively, meanwhile SN and NPV remained 100%. Short term post-operative follow-up CE performed on 13 out of the 15 pts with tricuspid repair showed no signs of TR in 7 and slight signs in 6. Furthermore, in those pts undergoing simple MV replacement, CE showed a marked reduction of the contrast echographic effect. Long term post-operative follow-up CE performed in the 13 pts with tricuspid repair showed no signs of TR in 9, slight signs in 3. Moreover in two pts massive TR due to late mitral prosthesis detachment was diagnosed by means of CE and confirmed at cardiac catheterization and surgery.(ABSTRACT TRUNCATED AT 400 WORDS)

Forty-six patients were operated on from 1979 to 1980 in the Department of Cardiovascular Surgery "A. De Gasperis" in Milan, to relieve left main coronary artery stenosis. There was only one death (2,1%) in a patient with "untractable angina". Three patients had per-operative infarction. No other complication were noted. The follow-up varies from 4 to 30 months: 40 patients are asymptomatic, 2 are improved, 1 patient had a recurrence of angina after 15 months. There were no deaths nor myocardial infarctions in the long-term follow-up.

Our experience with 16 patients operated upon for chronic mitral insufficiency secondary to coronary artery disease is reported. The patients ranged from 40 to 65 years in age; all were in class III or IV of the N.Y.H.A. classification (10 in class IV), 3 were resuscitated from ventricular fibrillation and 11 had a cardiac index less than 2.2 1/min/m2. 15 patients had replacement of the mitral valve with a mechanical or biological prosthesis and 1 had mitral valve repair. 11 of the 16 patients also underwent aorocoronary bypass procedures. There were 2 deaths within the first 30 days following the operation (operative mortality 12.5%) and 6 more deaths during the follow-up period. 6 patients died of heart failure, correlated in 3 cases with extremely severe impairment of left ventricular function (wall motion abnormalities in all segments of the ventriculographic perimeter). Death was sudden in 2 cases. In the 8 surviving patients the clinical result is good. Preoperative factors affecting post-operative prognosis are investigated and guidelines of the indications for the surgical treatment are discussed.

83 patients who underwent resection of postinfarction aneurysms involving the anterior wall of the left ventricle were studied to identify possible determinants of operative outcome, long-term survival and long-term improvement. The indications for aneurysmectomy (either isolated or combined with direct revascularization) were congestive heart failure, angina or life-threatening arrhythmias; six patients were asymptomatic at the time of surgery. Operative mortality rate was 14.4% (11.5% for patients operated more than 60 days following myocardial infarction). The over-all survival rate, at a mean follow-up of 31.5 months (range 2 to 82 months), was 74.39%; 80.88% of patient discharged from hospital, exhibited clinical improvement. Mean values of ejection fraction and excess ejection fraction were significantly higher in the group of operative survivors (31.28 +/- 8.26% and 0.17 +/- 0.08 respectively) than those of surgical deaths (20.25 +/- 8.37% and 0.08 +/- 0.06) (p less than 0.005); the coronary score was significantly lower in the group of survivors (6.81 +/- 2.35 vs 8.33 +/- 2.29) (p less than 0.025). Presence of arrhythmias increased operative mortality (33.3% vs 11.2%, p = 0.05), as did a low cardiac output, impaired contraction of the postero-lateral wall and mitral regurgitation. Long-term survival and improvement were not related to anyone of preoperative parameters taken into consideration: however, a higher percentage of clinical improvement was observed when myocardial revascularization was associated to aneurysmectomy (85% vs. 67.7%).