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Cardiac magnetic resonance imaging (MRI) has become an accurate noninvasive imaging procedure for the study of postischaemic residual cardiac function, thanks to the evolution of MRI machines, postprocessing software and, above all, sequences. After infarction, and in chronic myocardial ischaemia, the degree of contractile dysfunction is one of the main determinants of longterm survival. The identification and quantification of viable dysfunctional myocardium and the possibility of improving its contractility after revascularisation improves patient prognosis and quality of life. In current clinical practice, myocardial viability is evaluated with stress echocardiography and nuclear methods. Thanks to its intrinsic characteristics and to the delayed-enhancement technique (DE-MRI), MRI has recently emerged as the only noninvasive modality able to provide a three-dimensional (3D) evaluation of cardiac viability with a multiparametric approach.

Coronary angiography is nowadays the diagnostic standard in the evaluation of coronary artery anatomy, in the identification of stenoses and in the follow-up of revascularization procedures (PTCA-stenting, bypass). The limitations of such technique in terms of invasivity and high cost has targeted research efforts towards the development of non invasive diagnostic tools. Technological evolution in the field of helical CT has provided 2, 4, 8 and 16 detector-row multislice scanners characterized by progressive improvements in terms of spatial and temporal resolution that have made them increasingly suitable for the analysis of moving structures with high quality anatomic detail. The main cardiologic applications of multislice CT include coronary calcium scoring, the evaluation of coronary vascular anatomy and disease, follow-up of revascularization procedures (stenting, bypass), and the evaluation of cardiac walls and chambers. The aim of this paper is to describe the applications of sixteen detector-row multisclice CT in non invasive evaluation of cardiac and coronary diseases.

The purpose of this study is to evaluate perioperative and mid-term results of total arterial coronary revascularization in our experience and to establish its safety. One-hundred and ninety-one patients underwent total arterial coronary revascularization at our Institution from February 1997 to August 2000. The mean age was 60.1 years. Of the patients, 45% had three coronary vessels disease, 12% a left main coronary artery disease and 2.6% of them were classified urgent. Mean ejection fraction was 59.6%. Three hundred and thirty-four comprehensive anastomoses were performed; mean grafts per patient was 1.8. A Y or T graft with the left internal thoracic artery was used in 21 patients. The in-hospital mortality rate was 1% (2 patients). Complications included low cardiac output syndrome in 2.8% of patients, acute myocardial infarction in 0.9% and acute renal insufficiency in 3.1%. Intraaortic balloon pump was used in 1.8% of patients. At a mean follow-up of 899 days the first 81 patients contacted are all free of angina but two (one experienced an acute myocardial infarction and another one died for a pulmonary neoplasia). We conclude that total arterial coronary revascularization is a safe surgical technique, providing excellent perioperative and mid-term results.

Repeat cardiac surgical procedures are associated with increased technical difficulty and risk related to the presence of dense adhesions between the heart and the surrounding tissues. We examined the efficacy of a bioabsorbable membrane containing hyaluronic acid in the prevention of pericardial adhesions in 23 rabbits. After thoracotomy and pericardiotomy the animals were divided in three groups: Group 1 (9 animals) in which the epicardial surfaces were covered by Seprafilm membrane, Group 2 (9 animals) treated with both Seprafilm membrane and Sepracoat solution, and Group 3 (5 animals) as controls. The animals were reexplored at 10, 30 and 60 days: no intrapericardial adhesions were found in all the animals of Group 2. In 4 animals (44%) of Group 1 localized post-operative adhesions were detected, in absence of epicardial hyperplasia; in contrast, dense and diffuse adhesions were present in all the control animals. The use of the bioabsorbable membrane Seprafilm significantly reduces adhesion formation even if better results are possible with the previous intrapericardial administration of Sepracoat solution. Application of these biocompatible products could reduce the technical difficulty and risk of repeat surgical procedures.

From February 1998 and March 2000 fourteen patients underwent "custom made" aortic self-expanding endoprostheses implantation (World Medical Talent Sunrise): nine of them for dilative pathology of thoracic aorta and 5 for abdominal aortic aneurysm below renal arteries. The etiology was degenerative in 8 patients, false aneurysm in 2, chronic dissection in 2 cases, acute dissection in one patient and post traumatic in the last one. All patients underwent preoperative Computed Tomography and Substraction Angiography studies. Stent-graft implantation was successful in all cases but one who required the conversion of the endovascular procedure in traditional surgery for technical problems. There were no perioperative deaths or major complications. We registered 2 cases of dissection of the femoral artery used to introduce the stent-graft, and treated with an iliac-femoral prosthetic bypass. There were no cases of paraplegia or renal failure or bowel ischemia. With the exception of one patient, died for a car accident, the others are alive and continue their scheduled follow-up controls. Our experience shows that this procedure is safe, allowing favorable results, if compared to traditional surgery, even if it requires further long-term evaluations.

Left ventricular free wall rupture is a catastrophic complication of acute myocardial infarction and prognosis will depend on the prompt diagnosis by echocardiography, extension of infarct size and prompt surgical treatment. From november 1984, 21 patients (14 M, 7 F, mean age 68.4 +/- 6 years) underwent emergency operation at our Institution. Surgical technique included resection of necrotic or scarred myocardium and repair by Teflon strips-reinforced sutures, or by patching with Dacron or autologous pericardium. Associated procedures were LV aneurysmectomy, CABG, LV endoaneurysmorraphy and mitral valve replacement. Hospital mortality was 33% (7/17 pts). The postoperative course was prolonged in one patient, who needed hemodialysis and in 5 patients who needed IAPB counterpulsation. The mean length of stay in UCI was 3-10 days. Mean follow up is 70.4 +/- 41 months and 3 patients died of non cardiac related death. We conclude that despite high hospital mortality, satisfactory results may be obtained by surgical repairy under emergency condition, with good-long term survival, depending on prompt diagnosis and infarct size extension.

From 1984 to 1997, 112 patients have been operated at the Department of Cardiac Surgery of the Azienda Ospedaliera of Parma for acute dissection of ascending aorta. They were 73 males and 39 females of mean age 59.2 years (range 19-79); in the majority they presented a history of essential hypertension and atherosclerotic disease: the first diagnostic suspicion has been confirmed either by angio-CT scan or by CT scan plus aorthography and, from 1994, with transesophageal color doppler echocardiography that is becoming a valuable and precise tool wich can be used in emergency room. Bentall type composite repair or modified Bentall technique has been possible in 37 patients, while in the remaning 75, surgical aortic repair has been achieved by interposition of a dacron vascular prosthesis. Cardiac procedures that were performed in addition were coronary bypass grafthing, resuspension of the aortic valve, AVR. Total arch replacement with reimplantation of brachiocephalic vessels were performed in 6 patients and partial in 10, when intimal tear extended into the arc. Thirthythree in hospital deaths (29.4%) occurred (15 in S.O. and 18 in UCI). Follow up of the hospital survivors was conducted at a mean postoperative interval of 55 months (range 2 to 149 months with 6 late death related to aortic dissection). Our experience shows an increased incidence hypertension and aortic atherosclerosis, compared with marfan's syndrome as a source of acute aortic dissection in the late years, transesophageal echocardiography is a excellent tool for aortic dissection but it may miss dissection localized in other aortic portion, the need of an individualized and conservative surgical approach tailored to the pathology encountered.

Whole-body oxygen consumption (VO2) is universally considered both a measure of the metabolic activity of the body and an indicator of the adequacy of tissue perfusion during cardiopulmonary bypass as well. There is little agreement in the literature about the main determinants of oxygen consumption during CPB, except for the role of temperature in reducing the metabolic activity of the body. Many studies, which have been performed both on animals and in humans, have reached some contradictory conclusions about the role of delivery and perfusion flow rates, of haemodynamic variables, of the acid-base status, and of drugs influencing the variations of oxygen consumption during CPB. Aim of this paper is to review the evidences in literature about the determinants of whole-body oxygen consumption during cardiopulmonary bypass in man.

The authors report an investigation of 331 consecutive patients submitted to major surgery to evaluate the reliability of temperature monitoring in different body sites in relation to central temperature. After having considered the minimal temperature changes and the difficulties due to the different techniques used, it is concluded that the measurement at the middle 3rd of the oesophagus is the most reasonable measurements site.

The authors report the use of a total intravenous anaesthesia in CABG. An association of propofol-fentanyl-pancuronium with a bolus at induction, then with continuous perfusion was used. Hemodynamic and oxymetric data obtained from the right heart and radial artery samples show good hemodynamic stability during surgery. It is underlined that, in order to reduce possible hemodynamic changes it is very important to use, during the surgical procedure, the lowest drug concentration.

The authors report on a group of 8 patients in septic shock, treated with NA in association with dopamine and/or dobutamine, according to a personal therapeutic protocol. The use of NA in septic shock with low SVR showed an improvement in hemodynamic condition and a higher survival rate in the treated patients. During the study many clinical, laboratory and microbiologic data were also recorded.

The great risk of severe infectious diseases transmission through blood transfusion, has increased during the last years the effort to reduce the bank blood and its derivates use. Many techniques have proposed to achieve this purpose during and post cardiopulmonary bypass: normovolemic hemodilution, perioperative blood autotransfusion, postoperative return of extra corporeal circuit and chest drains blood and the particular use of some drugs. In the last few years several reports have been presented in the literature concerning the reduction of intra and postoperative bleeding in cardiac surgery by high dose Aprotinin administration. A randomized study with the use of this pharmacologic agent is presented: a group of patients was treated with Aprotinin (shared in two subgroups receiving respectively a different dose of the drug) and a control group. The results were highly encouraging both because of the reduction of peri and postoperative bleeding and because of the bank blood use important reduction.

A patent ductus arteriosus in adults is a rare eventuality. After correct diagnosis, an accurate evaluation of pulmonary vascular resistances is necessary with, in case of normality, a straightforward indication to surgery, because the evolution of the disease cannot be predicted. In case of pulmonary hypertension irreversible pulmonary vascular damage must be excluded. Haemodynamic data such as pressures, flows and resistance ratios are not reliable. According to the majority of Authors the value of pulmonary resistances seems to be more accurate, and when more then 8 u/m2 an histological specimen must be obtained. In our experience a comparative study between the Health and Edwards method and the Yamaki et al., one shows, confirmed by postoperative follow-up, a greater reliability of the second one.

A drastic reduction in homologous blood or plasma transfusion becomes necessary to prevent the risks of severe infections disease transmission. The authors studied the possibility of homologous blood save in cardiac surgery by peroperative autotransfusion. This procedure, although it diminished the average blood bank requirements, above all for an unexplained decrease in postoperative bleeding, did not obtain the good results that other authors had with the technique of 2 or 3 preoperative withdrawal, storage and postoperative reinfusion. In future our trend is to associate preoperative and intraoperative withdrawals to take advantage of both techniques.

In clinical practice SVC syndrome is an important problem, given both the nature of the disease and its fast lethal evolution. Therapy must be instituted as soon as possible because the chances of a positive result are directly related to the staging of the primary illness. Surgery, chemotherapy and high energy therapy can be used. From the literature, although controversial, the superiority of surgical therapy is clear; particularly if up-to-date vascular reconstruction techniques are employed. From March 1980 to March 1988 8 cases of SVC syndrome were observed in which the aetiology was as follows: Hodgkin's disease (2 cases); secondary catheter thrombosis (1 cases); lung carcinoma (5 cases). The 2 cases of Hodgkin's disease were treated by chemotherapy; the secondary thrombosis by open thrombectomy. In the other 5 cases an innominate vein right appendage by-pass was used (3 PTFE, 2 pericardial grafts). The results were encouraging: complete, long-term remission was observed in the Hodgkin and thrombectomy patients. A PTFE graft thrombosis occurred in 2 cases but in the other cases the by-pass is functioning well at a mean 13 months follow-up.

A personal venous thrombectomy technique employing a modified Fogarty catheter is described. The end of the catheter to which the syringe is normally applied is cut off to enable it to be used in a retrograde manner. In this way, thrombectomy is always performed in the direction of the current, irresapective of the site of the thrombosis in the venous axis of the lower limbs. This type of operation offers two advantages. It preserves the integrity of the valves and does away with the risk of intraoperative embolisms. It is described as "physiological thrombectomy". If the thrombosis involves the entire iliac-femoro-popliteal axis, the catheter is inserted retrogradely via the small saphenous at the, and removed via an iliac phlebotomy obtained by means of an extraperitoneal abdominal incision. When the thrombosis is femoropopliteal only, the catheter is inserted through the origin of the small sphenous and withdrawn via the venous incision. Lastly, in cases where the common iliacofemoral axis alone is involved, retrograde insertion takes place through the large saphenous vein in the inguinal region. Preliminary results obtained with the technique are described.

The importance of a knowledge of the relations between recurrent nerve and inferior thyroid artery, in order to minimise the incidence of injuries to the nerve during thyroidectomy, is stressed. These relations are analysed from the anatomo-surgical standpoint, with particular emphasis on the great variability to which they are subject. It is concluded by asserting the utility of prior location of the recurrent nerve, with an indication of some basic concepts that must always be borne in mind when performing thyroid surgery.

Two new familial cases of Peutz-Jeghers syndrome are reported. The cases present a number of original aspects with regard to anomalous transmission of the defect, the common finding of a single ileal polyp and associated malformations in the first of the two cases. The clinical aspects of the disease are discussed together with the histology of the polyps in relation to their possibility or otherwise of degenerating. Finally, the various surgical techniques indicated for the treatment of this rare condition are examined.

Six cases of popliteal entrapment syndrome are presented with emphasis on the diagnostic difficulties related to this disease in its initial functional phase. The utility of Doppler ultrasonography associated with dynamic angiography is underlined. Normally surgical treatment of the disease is problem-free. The important determining factor seems to be medial gemellus hypertrophy. In this case the procedure of choice is thought to be vascular reconstruction associated with the disinsertion of this muscle followed by its reimplantation in a lower and medial position on the semi-membranous tendon muscle in order to avoid any secondary arterial compression.