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In this paper, we present a new generation of omnidirectional automated guided vehicles (omniagv) used for transporting materials within a manufacturing factory with the ability to navigate autonomously and intelligently by interacting with the environment, including people and other entities. This robot has to be integrated into the operating environment without significant changes to the current facilities or heavy redefinitions of the logistics processes already running. For this purpose, different vision-based systems and advanced methods in mobile and cognitive robotics are developed and integrated. In this context, vision and perception are key factors. Different developed modules are in charge of supporting the robot during its navigation in the environment. Specifically, the localization module provides information about the robot pose by using visual odometry and wheel odometry systems. The obstacle avoidance module can detect obstacles and recognize some object classes for adaptive navigation. Finally, the tag detection module aids the robot during the picking phase of carts and provides information for global localization. The smart integration of vision and perception is paramount for effectively using the robot in the industrial context. Extensive qualitative and quantitative results prove the capability and effectiveness of the proposed AGV to navigate in the considered industrial environment., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Ettore Stella reports financial support was provided by Puglia Region., (© 2024 The Authors.)

In-flow phase-contrast tomography provides a 3D refractive index of label-free cells in cytometry systems. Its major limitation, as with any quantitative phase imaging approach, is the lack of specificity compared to fluorescence microscopy, thus restraining its huge potentialities in single-cell analysis and diagnostics. Remarkable results in introducing specificity are obtained through artificial intelligence (AI), but only for adherent cells. However, accessing the 3D fluorescence ground truth and obtaining accurate voxel-level co-registration of image pairs for AI training is not viable for high-throughput cytometry. The recent statistical inference approach is a significant step forward for label-free specificity but remains limited to cells' nuclei. Here, a generalized computational strategy based on a self-consistent statistical inference to achieve intracellular multi-specificity is shown. Various subcellular compartments (i.e., nuclei, cytoplasmic vacuoles, the peri-vacuolar membrane area, cytoplasm, vacuole-nucleus contact site) can be identified and characterized quantitatively at different phases of the cells life cycle by using yeast cells as a biological model. Moreover, for the first time, virtual reality is introduced for handling the information content of multi-specificity in single cells. Full fruition is proofed for exploring and interacting with 3D quantitative biophysical parameters of the identified compartments on demand, thus opening the route to a metaverse for 3D microscopy., (© 2023 The Authors. Small Methods published by Wiley-VCH GmbH.)

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., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

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.

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.

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.

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.

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.

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.

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.

Background: Coronary artery reoperation represents about 20% of coronary artery operations. In this study we compared mortality and morbidity of first intervention and redo operation., Experimental Design: a retrospective study., Settings: patients who underwent coronary artery reoperations in a University Cardiac Surgery Division in 1991-1994., Patients: our clinical survey was composed of two groups: group A included 44 consecutive patients (mean age 60+/-7 years, males/females=41/3) who underwent a coronary artery reoperation in the years 1991-1994 at the University Cardiac Surgery Division of Turin; group B included 344 patients (mean age 58+/-8 years, males/females=289/55) randomly selected among those who underwent a first coronary operation in the above indicated period of time and centre. All patients had angina pectoris refractory to maximal medical therapy., Interventions: all patients underwent a coronary artery operation in extracorporeal circulation (ECC), under mild hypothermia (30-32 degrees C), during a single aortic clamp period, with antegrade cold crystalloid cardioplegia (St. Thomas)., Measures: comparison of clinical preoperative features, risk factors and postoperative mortality and morbidity between the two groups., Results: In reoperated patients we observed a greater mean akinesis score (p<0.001) and severe left ventricular dysfunction presence (p=0.014). Reoperation mortality was 11.4% against first operation mortality of 3.2% (p=0.03). Female gender (p=0.03), intra-aortic balloon counterpulsation need (p=0.002), adrenaline use (p=0.004) and low cardiac output syndrome (p=0.007) were all perioperative risk factors in group A., Conclusions: Coronary artery reoperation involves a higher mortality and morbidity compared to the first operation, especially related to the reduced left ventricular function which characterises the population that undergoes reoperation.

Objective: Hemodynamic and clinical performances of 21-mm and 23-mm St Jude Medical Hemodynamic Plus aortic valves (St Jude Medical, Inc, St Paul, Minn) were compared with those of 21-mm and 23-mm St Jude Medical standard cuff aortic valves in the first such multicenter, prospective, randomized study. Hemodynamic Plus valves are mechanical, bileaflet prostheses suitable for the small aortic anulus., Methods: Patients with 21-mm and 23-mm anulus diameters were randomized to receive either a Hemodynamic Plus or a standard cuff valve. Postoperatively and at 6 months after the operation, patients underwent 2-dimensional Doppler echocardiography. Ejection fraction, cardiac output, peak gradient, mean gradient, effective orifice area, effective area index, and performance index were calculated. Postoperative and 6-month echocardiographic measurements and their variations across observation times were analyzed statistically., Results: Of the 140 patients enrolled, 5 died at operation and 1 died of aortic dissection during the follow-up period. Eight patients were lost to follow-up. A total of 125 patients completed the study. In 1 patient a sewing cuff escaped intraoperatively. At 6 months the 21-mm and 23-mm Hemodynamic Plus valves showed significantly lower peak gradients and mean gradients than those of the 21-mm and 23-mm standard cuff valves. The 21-mm Hemodynamic Plus valves had gradients similar to those of the 23-mm Hemodynamic Plus valves. The effective orifice area did not differ significantly between the Hemodynamic Plus and standard cuff valves at either measurement. No valve mismatch was found in the 4 groups of patients. A more enhanced decrease of peak gradients and mean gradients and a more enhanced increase of effective orifice areas, effective area indices, and performance indices were found across observation times for patients with Hemodynamic Plus valves compared with those with standard cuff valves., Conclusions: Clinical hemodynamic performances of 21-mm and 23-mm St Jude Medical Hemodynamic Plus valves correspond closely with those of standard cuff valves, and gradients are substantially better than those of standard cuff valves of the same diameter. Therefore, use of this valve may minimize the need for aortic anulus enlargement. Early follow-up results with the Hemodynamic Plus valves were excellent, although more time is required to confirm this outcome.

A case is reported of a 30-year-old patient with an intrapericardial tumour with heart failure. After the diagnostic protocol, surgery was performed initially without extra-corporeal circulation (ECC). Due to the location, size and to the large connection with the most important vascular structures, the ascending aorta ruptured accidentally during resection and was replaced after using ECC in emergency. The post-surgical course was regular and the tumour was identified histologically as a fibroma.

Background: Cardiac myxomas have varying clinical presentation, uncertain histogenesis, and debatable immunohistochemical profile. A few malignant cases have been previously reported., Methods: Fifty-three consecutive cardiac myxomas were histologically investigated and results compared with clinical data. The main goal of the study was to investigate the immunohistochemical differentiation and the clinicopathologic correlations., Results: Stromal cells were characterized by the expression of the von Willebrand factor endothelial marker (12 of 53 cases) and diffuse cytoplasmic neuropeptides such as protein gene product 9.5 (50 of 53 cases), S100 protein (47 of 53) and neuron-specific enolase (30 of 53), all of which were expressed in 30 (57%) of 53 tumors. Stromal cells did not show endocrine granules, epithelial, or smooth muscle immunoreactivity. Non-cardiac-related symptoms were observed in 7 of 53 patients and promptly disappeared after tumor excision; median values and percentages of total immunoreactivity scores for neuropeptides were higher in these 7 cases, but data analysis showed no statistical significance. Glands were detected in 2 myxomas, and they showed epithelial (cytokeratins and carcinoembryonic antigen), protein S100, and neuron-specific enolase immunoreactivity; this pattern has been previously detected in human gut. All tumors showed benign behavior, and no mitosis was detected., Conclusions: The results of this study support the hypothesis that stromal cells originate from multipotent mesenchyme capable of neural and endothelial differentiation; rare myxoma glands would represent entrapped foregut rests. A correlation could exist between neuroendocrine differentiation and non-cardiac-related symptoms.

Although rare, aortobronchial fistula complicates thoracic aortic surgery. Correct diagnosis and the infectious nature of the lesion are the most important conditions to define, for the following best therapy. We presented a case of non-infectious postsurgical aortobronchial fistula, revealed by computed-tomographic scan and angiography procedure, treated with prosthetic graft replacement and broad spectrum antibiotic therapy. In the case of infection our policy is homograft replacement. Computed tomography, being able to make diagnosis, should be performed as the initial technique.

Background: Between March 1980 and September 1997, 91 patients underwent evaluation and treatment for primary cardiac neoplasms., Methods: Tumors were grouped into three categories: atrial myxomas, benign nonmyxomas, and malignant tumors. Survivors were contacted; no one was lost to follow-up. The mean follow-up for this series is 7 +/- 5 years., Results: Eighty-three patients were diagnosed with atrial myxomas (Male/Female: 29/54), average age 55 +/- 13 years. The hospital mortality was 3.6% (3/83), the late mortality was 6.5% (5/80). No recurrent myxomas have been identified clinically or by echocardiography in any patient. Three patients were diagnosed with benign nonmyxoma tumors. (Male/Female: 2/1), average age 64 +/- 8 years. There were no perioperative deaths and 1 patient died 4 years postoperatively from fibroma, with no linked causes. No recurrent tumors have been identified. Five patients were diagnosed with malignant tumors. (M/F: 1/4), average age 53 +/- 16 years. The hospital mortality was 20% (1/5); in 3 patients a redo-operation was necessary after 8, 11, and 12 months because of tumor recurrence. All patients died within 3 years of the first operation (mean 13 +/- 14 months)., Conclusions: Surgical resection, when possible, is the treatment of choice for all primary cardiac tumors. Patients with benign tumors are probably cured by resection and in our experience there was no known tumor recurrence. Effective palliation is possible with resection of malignant tumors, but more effective adjuvant therapy will be necessary to improve long-term prognosis.

Background: The pericardial bovine prosthesis Pericarbon should offer some advantages in comparison with the former generations, because its development is focused on solving previous problems and resulted in the variation of the pericardial fixation method, of valve structure and of stent coating. This hypothesis was evaluated through a retrospective follow-up., Methods: Between 1985 and 1989, 78 Pericarbon prostheses O 29 were implanted in mitral position by the same surgeon. All patients received warfarin for the first three months to maintain an International Normalized Ratio between 2.5 and 3.5; after which they received antiaggregant therapy indefinitely. With an average follow-up period of 7.34 years for a total of 573 patient-years, we evaluated perioperative and late mortality, late morbidity (thromboembolic and haemorrhagic events, reoperations, primary tissue failures, endocarditic events) and patient clinical conditions., Results: Perioperative mortality was 1.28% (1/78), late mortality was 11.6% (9/77) with 5 valve-related deaths. 5-year survival was 93% and 10-year survival 97%. Fifteen patients required reoperation for prosthetic replacement, fourteen for primary tissue failure. There were ten minor thromboembolic events, one major event, one haemorrhage and one prosthetic endocarditis (the last two with patient exitus). After 10 years (75% of patients were in New York Heart Association class I-II., Conclusions: Besides the known better haemodynamic performance, Pericarbon bioprosthesis seems to present a survival and redofreedom curve comparable to the best porcine prosthesis, with less incidence of endocarditis, thromboembolic events and prosthesis leakage.

In this article, we report a 65-year-old man with a large atrial myxoma arising from the posterior wall and from the base of the right inferior pulmonary vein. The big neoplastic mass showed a large implant site. A rare atrial myxoma neovascularity arising from the atrial circumflex artery was very clearly visualized by selective coronary arteriography. The surgical approach used to resect this tumor was an isolated left atriotomy that provided excellent exposure and safe excision.

Background: The Bjork-Shiley convexo-concave (BS-CC) heart valves represent the improved model of the standard valve first introduced with a different design of the disc valve to ameliorate hemodynamic performances and reduce thromboembolic complications. About 86,000 BS-CC were implanted during 1979-1986 and of them a small number developed an intrinsic dysfunction resulting in sudden death., Methods: From 1979 to 1986 we implanted in 117 patients (48 males, 69 females, mean age 46.35+/-12.47, range 8-65 years) 125 BS-CC. In 38.5% (45/117) of the cases heart valve replacement represented the second cardiac procedure after a previous closed heart digital commissurotomy. The mean size of the implanted prosthesis was 25.6+/-2.8 for aortic valve and 29.5+/-1.2 for mitral valve., Results: Hospital mortality was 4.27% (5/117) and survival rate at 10 years is 71.4% and at 17 years 54.7% (Kaplan-Meier). At follow-up causes of death proved valve related in most of the patients but with no evidence of valve fracture. We had 1 case of sudden death in patients at high risk (largest size, aortic position) and 30 cases of death by unknown causes but they did not have an autopsy to confirm the cause of death., Conclusions: We conclude that in our population with BS-CC at the moment there is no indication for prophylactic replacement because of the higher risks of a reoperation (third or fourth in the 35.4% of our patients) than a strut fracture. Nevertheless we believe an autopsy mandatory in all these patients at risk, when sudden death occurs.

Background: The aim of this study was to analyse long term results of mitral valve repair of degenerative mitral regurgitation compared to valve replacement., Methods: A hundred-twenty-five consecutive patients with severe mitral valve insufficiency who underwent cardiac surgery from January 1987 to December 1995 were included in the study. Mean age was 55+/-16 years (77 males, 48 females). Mitral repair was performed in 62 patients and mitral valve was replaced in 63 patients. Mean follow-up was 5 years. The repair procedures were based on quadrangular resection of the posterior leaflet, chordal replacement and transposition. Annuloplasty was performed in 100% of cases. The technique of valve replacement was conventional with complete excision of the valve in the majority of cases., Results: Operative mortality following valve repair was 1.6%, no death occurred in the prosthesic group. In the repair group overall survival and re-operation rate were respectively 95.2% and 6.5%, while in the replacement group were 93.7% and 7.9%. No endocarditis and thromboembolic accidents were observed following valvuloplasty, while in the prostheses 6.3% of patients had endocarditis and 1.6% had a thromboembolic event. Mild or moderate left ventricular dysfunction was present in 5 patients after valvuloplasty and in 9 patients with prostheses., Conclusions: Considering these results we conclude that, in patients with severe degenerative mitral insufficiency, mitral valve repair is warranted whenever it is possible. The advantages given by maintaining the native valve suggest that surgery should be considered in asymptomatic patients before the occurrence of the left ventricular dysfunction.

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.

Background: Morbidity and mortality of emergency repair of type A dissecting aneurysms of the aorta are high. This is an attempt to investigate the risk determinants of early and late results., Methods: A series of preoperative and operative variables were retrospectively collected from the clinical records of 291 patients operated on between January 1, 1979, and December 31, 1995. Risk factors for surgical death were investigated with univariate analysis and stepwise logistic regression. Follow-up was conducted between December 1995 and February 1996. Analysis of late results was conducted by means of actuarial survival curves (life method). After removing the surgical deaths, risk factors for late deaths were analyzed by a Cox model., Results: The in-hospital mortality rate was 36.1%. Significant independent determinants of operative or early death were preoperative shock, preoperative neurologic impairment, operation before 1986, perioperative bleeding, and prolonged clamping time. The 10-year survival rate was 36.9% +/- 4.4%. Twenty-six patients required repeat operation. The long-term prognosis was significantly worse in patients who needed reoperation., Conclusions: Growing awareness of this disease and quicker diagnosis have increased the number of patients with acute dissection of the ascending aorta who are taken early to operation. This new challenge must be met by better preoperative support and intraoperative monitoring, and by surgical techniques that focus on lowering the rate of late complications, for which lifelong follow-up must be provided.

Background and Aims of the Study: The aim of this study was to evaluate the long-term follow up of the Pericarbon pericardial bioprosthesis implanted in the mitral position., Methods: Between January 1985 and January 1991, 78 patients (26 males, 52 females; mean age 56.9 +/- 7.8 years) underwent isolated mitral valve replacement with a Pericarbon valve. All bioprostheses were size 29 mm and implanted by the same surgeon., Results: Total follow up was 663.2 pt-years and it was 97% complete. Early mortality was 1.3% (1/78); two minor cerebral embolisms were observed as early complications. At 12 years the overall survival rate was 85.0 +/- and valve-related survival 93.1 +/- 3.0%; freedom from embolic events was 83.0 +/- 4.5% and from endocarditis 98.7 +/- 1.3%. Freedom from primary tissue failure was 56.8 +/- 6.6%; it was 86.3 +/- 7.5% in patients aged > 60 years and 36.8 +/- 8.2% in younger patients. There were 27 reoperations, 26 for primary tissue failure, one for endocarditis. Comparison between basal and follow up echocardiographic studies showed a significant stenotic deterioration of the bioprosthesis and a negligible incidence of regurgitation. Morphological findings of explanted bioprostheses were characterized by stenotic and diffuse microcalcification, but no tissue tear was observed., Conclusions: These results confirm that the Pericarbon bioprosthesis is structurally safe and free from the fatigue problems which afflicted the first and second generation of pericardial valves. As with other tissue valves, the rate of calcification is age-dependent, suggesting preferential use of the Pericarbon prosthesis in elderly people.

Total aorta replacement is a major and increasingly successful surgical procedure. The paper describes a patient whose progressive aneursymatic disease spread from the ascending segment to the bifurcation over a three-years period during which time after three separate operations, the aorta was totally replaced. The paper describes the diagnostic and surgical procedures deployed and shows the results of angiographic and CT scans. Credit for the success of the replacement is also given to the highly skilled anaesthetists and nurses involved.

From 1979 to 1993, 139 patients had reduction of left ventricular aneurysm (LVA) by plication (PL) (25 cases) linear repair (74 cases) or ventricular reconstruction (VR) (40 cases). Coronary bypass grafting was performed in 89 patients. We retrospectively reviewed our experience in order to identify predictore of early and late outcome and determine whether ventricular reconstruction (VR) can improve postoperative and late prognosis. Operative mortality (OM) was 7.2%. Among 129 hospital survivors, 48 died during FU (LM). OM was related to a more recent myocardial infarction (p=0.0001), a higher residual score (RS) (p=0.02), a lower EF (p=0.038), a higher left ventricular score (p=0.059), a three-system disease (TSD) (p=0.09) and a right coronary disease (RCD) (p=0.13). At Multivariate Analysis (Stepwise Logistic Regression) TSD (p=0.001), RCD (p=0.008) and RS (p=0.04) are independent risk factors. Actuarial survival rate at 15 years is 33.5+/-6.9% (OM included). According to the comparison of the Actuarial Curves (Tests of Mantel and Breslow, OM excluded) the most significant risk factors were: non use of left internal mammary artery (LIMA) (p=0.004), VR (p=0.01), TSD (p=0.03) and higher NYHA class (p=0.019). Multivariate Analysis (Co Model) confirms that late prognosis is influenced by non use of LIMA (p=0.03) and TSD (p=0.04); outcome is also affected by preoperative arrhythmias (p=0.022). Five-year survival after VR is 87.5+/-5.7% vs 64.9+/-5.5% after simple linear closure or PL (p=0.1075 and p=0.2252). Our results confirm that OM and LM are influenced by extent of myocardial ischemic damage; in agreement with the majority of Authors we advocate a complete revascularization using IMA, when appropriate, on left anterior descending artery. Our limited experience with VR fails to demonstrate this technique as an independent factor of late survival.

Background: Stent deformation seems to be effective in the long term performances of bioprostheses., Methods: The Inward Banding Angle (IBA) of three different models of bioprostheses explanted during the period 1991-1992 at our Division of Cardiac Surgery in 45 different patients (26 males; 9 females; mean age 59.71 +/- 10.74, range 26-75) has been measured. Explanted valves were as follow: Hancock, (H = 13); Carpentier-Edwards (C = 14) e Xenomedica (X = 18). Primary tissue failure was the most common cause of re-operation (n = 30; 66.7%) but also endocarditis (n = 6; 13.3%) and paraprothetic leak (n = 10; 22.2%). A semi-quantitative score (0-4) was used to assess calcifications (1.51 +/- 1.56); tears (0.41 +/- 0.98); vegetation's (0.51 +/- 0.99) and fibrosis (2.7 +/- 1.27). The mean follow-up was 7.77 +/- 3.79 years (range 1.5 +/- 16 years). The mean IBA evaluated after explantation was 3.34 +/- 2.29 degrees., Results: Statistical analysis showed a significance in term of IBA in the Hancock group vs Carpentier (P < 0.02); a less duration in the Xenomedica group vs H and C (p < 0.001) and an increased susceptibility to vegetation's and fibrosis in the Xvs C (p < 0.01) and H (p < 0.05) respectively. A suggestive correlation between IBA and time and between IBA and diameter was found but no statistical significance was observed., Conclusions: In conclusions, it is suggested that all materials tends to deform during time and a possible explanation of stent deformation can be the different material used in the stent fabrication. Moreover, mechanical stress and compression around the ring can be another mechanism of creep.

Background: Ventricular septal defect (VSD) represents a serious complication after acute myocardial infarction (AMI) with an incidence of 1-2%. Surgical treatment is often mandatory in the early period after AMI because of the worsening of the hemodynamic and clinical conditions., Methods: We reviewed 34 patients complicating AMI who underwent surgical treatment at our Institution from January 1988 to December 1994 (23 males, 11 females, mean age 64.2+/-7.96, range 45-78). The localization of the AMI was anterior in 47.05% but inferior in 52.95% of the patients (p=NS). The mean time between AMI and VSD was 5.24+/-9.31 days. The preoperative NYHA functional class was III-IV in 93% of the patients. QP/QS ratio was 2.7+/-0.65 and the diameter of VSD ranged from 1 to 8 (mean 2.5+/-0.35). In 26 patients (76.4%) an intraortic balloon pump (IABP) was inserted before surgery. Surgical treatment was done after 10+/-17.7 days after VSD appearance through a left ventriculotomy. Ten patients received a concomitant myocardial revascularization., Results: Overall surgical mortality was significantly higher (p<0.05) in patients operated on in the early period after AMI (1+/-1.4 days) and with VSD complicating an inferior AMI. A complete follow-up was possible in all the survivors with a cumulative FU of 1453 month/patients. Two patients received a redo procedure after 30 and 40 days after the first correction because of a residual shunt. We observed 3 late deaths for re-AMI and one for complications after bronchial pneumonia. The actuarial survival rate is 70% at 1 year, 68% at 2 years and 65% at 7 years. NYHA functional class after operation is 1-11 in 91% of the patients., Conclusions: The major determinant of hospital survival in VSD after AMI in our patient population was the anatomical localization and the early timing of the operation. We believe that a prompt diagnosis and immediate cardiac support (IABP or ventricular assist device) is recommended to obtain a hemodynamic stabilization and to achieve the shaping of stronger cicatricial tissue before surgery. Nevertheless surgical repair of VSD is mandatory when clinical and hemodynamic condition becomes unacceptable. The results in the long term assessment are very satisfying.

To assess if female sex is an independent risk factor for perioperatory mortality and morbidity, we have evaluated 971 consecutive patients (16% women) undergoing coronary artery bypass graft surgery at the Cardiovascular Disease Institution of the University of Turin from 1988 to 1990. In this study at baseline women were older and more likely to have diabetes, lower ventricular score and body surface area than men. As compared to men, women underwent surgery with delay: the surgical mortality rate and prevalence of arrhythmias were higher, and the size of the left anterior descending was smaller. At univariate analysis perioperative risk factors were as follows: age, diabetes, clinical instability, low body surface area, perioperatory infarction, postoperative infections, extracorporeal circulation time and left coronary size. At multivariate analysis only diabetes, left ventricular score, left anterior descending coronary size and emergency surgery were independent risk factors while sex, age and body surface area were not predictors of perioperatory mortality and morbidity. It is concluded that gender is not the cause of worse outcome in women.

To settle long-term outcome after surgery for supravalvular aortic stenosis in the Williams-Beuren syndrome, we reviewed the records of 6 patients who had repair of the localized form (n = 5) or diffuse form (n = 1) at our Institution from 1965 to 1971. Four patients were females and 2 males, ages at operation ranged from 9 to 16 years (mean = 13 +/- 2.37 years). In all the patients was present the typical elfin facies with mental retardation and reduced I.Q. Preoperative omeral pressure was different between left and right arm (89 +/- 7/67 +/- 8 vs 105 +/- 8/77 +/- 4). Chest X-ray showed and enlargement of the cardia silhouette in all the patients. Cardiac catheterization, performed in all the patients, allowed diagnosis of supravalvular aortic stenosis and, in one case of subaortic stenosis associated. Intraoperatively a coronary tree enlargement was found in all cases with particular involvement of the right coronary in two patients. The mean diameter of the ascending aorta was 5.67 +/- 1.97 mm but the smallest (3 mm) was in the diffuse group. In group with localized stenosis the aortic root was enlarged with a teardrop patch in Dacron (n = 4) or a simple transverse suture after a longitudinal incision (n = 1). A pantaloon-shaped patch was necessary in the diffuse form case. There were no operative deaths and all the patients were discharged from the hospital after 2 weeks. A clinical follow-up was possible in all the patients (10%) extended from 25 to 30 years (mean = 27.7 +/- 2.19 years); there were no late deaths and at presents time the mean age of the patient is 40 +/- 3 years. All patients were in functional class I or II. There was no significant difference between patients with a teardrop-shaped or pantaloon-shaped patch in terms of late gradient, survival, or aortic insufficiency studied by Echocardiography and color-Doppler. Of six patients two are living with parents or relatives but four are in a farm-college for disable people working and having some responsibility. We conclude that surgery for the correction of supravalvular aortic stenosis in Williams-Beuren syndrome is mandatory and both the procedures with patch techniques provide excellent long-term results of gradients and aortic valve competence. Moreover the patients after the operation can have a normal activity with a satisfactory style and expectation of life.

Optimal mitral valve repair or replacement requires an excellent exposure. We used a transeptal approach since 1975 at our Institution to obtain adequate exposure of mitral valve in 135 patients (48 males, 87 females, mean age 47.4 +/- 11.8, range 12-68). A mechanical valve (Bjork = 120; Sorin = 15) was implanted in mitral position. Associated procedures were performed in the 66% of the patients and most of them were tricuspid repair. About half of the patients were at the second or third cardiac operation after a previous closed heart mitral commissurotomy 15.15 +/- 5.6 years before. Exposure was excellent in the 95% of the cases. Hospital mortality was 12.6% and significantly major in patients at redo operation. Three patients with a concomitant aortic valve replacement required a definitive pace-marker implantation. A complete follow-up was possible in all patients who survived at operation. Actuarial survival rate at 10 years in 83% and at 20 years is 70%. Freedom from all events valve related at 10 years is 86% and at 20 years is 74%. None of the patients at echocardiographic follow-up revealed complications related to the transeptal approach to the mitral valve. In conclusion we suggest the use of transeptal approach to the mitral valve in case of redo-operations, concomitant tricuspid repair, small left atrium and in case of mitral valve repair because of the good exposure and the less inherent complications.

Background: Traumatic rupture of thoracic aorta caused by blunt trauma has been observed more frequently in recent years. The aim of this study was to evaluate the state of the art of diagnostic methods used to identify this injury and the surgical techniques used to repair it., Methods: The study was performed in 29 patients undergoing surgery for traumatic rupture of thoracic aorta from November 1979 to July 1995., Results: All patients presented multiple blunt traumatic injuries. The suspicion of traumatic aortic rupture always arose when evidence of an enlarged mediastinal shadow was found on the chest X-ray, subsequently confirmed in 27 cases using aortography. During the period 1993-1995 11 patients underwent CT scan before aortography, which resulted false negative in 3 cases (27.2%). The decision to perform surgery was based on well defined priorities: abdominal injuries took priority over the aortic injury, and in stable patients with intracerebral injuries, head CT scan and neurosurgery were performed first. Eight patients died (overall mortality was 27.5%)., Conclusions: CT scan should not be used for the diagnosis of aortic traumatic rupture because it is a waste of time (all patients have to undergo aortography before surgery) and the false negative rate is too high.

Reoperation after a surgical procedure for prosthetic valve endocarditis (PVE) is often required due to the existence of either septic recurrence or sterile para-prosthetic leak (PL). The aim of this study was to assess the risk to patients of undergoing a second operation after PVE. Thirty-six patients underwent operation for active PVE at our institution. The operative mortality rate was 11.2%. Among the 32 patients discharged, six underwent a second operation (in two cases due to persisting sepsis) and two underwent a third procedure. Multivariate analysis demonstrated increased probability of further operation for: inability to identify the infecting organism (p = 0.005); drug addiction (p = 0.007); existence of annular abscess (p = 0.016); and early occurrence of PVE (p = 0.018). In the case of mechanical prostheses, PVE was not an independent risk factor (p = 0.206). Nonetheless, 58.3% of patients with mechanical prostheses compared with 5.3% of those with bioprostheses showed annular abscesses, while 41.7% of the former versus 5.6% of the latter suffered one or more recurrences.

From March 1990 to July 1991, 110 patients (44 males, 66 females; mean age 54.44 +/- 8.8 years) underwent hearth valve replacement with a CarboMedics bileaflet prosthesis (CarboMedics Inc, Texas, USA). Preoperative pathophysiologic conditions were: aortic stenosis in 32 patients, aortic regurgitation in 22 patients; mitral stenosis in 27 patients and mitral regurgitation in 14 patients. Mitroaortic disease was present in 14 patients but 1 had triple valve disease. NYHA class was III or IV in 91 patients (83%). Operative mortality rate was 0.91% (1 patients). Actuarial survival rate is 95% at 58 months. Actuarial freedom from thromboembolic events in 95% at 58 months. Actuarial freedom from hemorrhage is 100%. Endocarditis befell in 2 patients; actuarial freedom from this complication at 58 months is 95%. Actuarial freedom from reoperation in 99%. We conclude that the low incidence of valve related events and the low mortality supports the use of the bileaflet valve CarboMedics.

Host factors might influence the fate of tissue prostheses. We have analyzed the tissue failure phenomenon in mitral and aortic porcine bioprostheses explanted from the same patient so as to avoid the bias of host factors. The 50 bioprostheses of this study were explanted from 25 patients reoperated on because of malfunctioning due to primary tissue failure. Bioprostheses explanted were photographed, radiographed and observed in polarizing light. All lesions analyzed received a score on the basis of morphological criteria. No difference was observed in the occurrence of pannus, tears or cells infiltrates. Calcifications occurred more extensively in mitral position (p=0.0031). Creep of the stent was significantly greater in mitral position (p=0.0324). Since the model of our study removed other individual factors, we may conclude that there is evidence for an earlier and more extensive calcific degeneration in the mitral than in the aortic position.

We report a case of myxoid leiomyosarcoma originating from the interventricular septum in the outflow tract of the right ventricle. Although the gross features suggested a benign myxoma, histologic examination demonstrated features of a smooth muscle tumor, which was characterized by low mitotic index and a bland degree of atypia with few cells immunoreactive for cell cycle-associated Ki-67 antigen. The tumor relapsed twice, and the patient (a 61-year-old woman) died 18 months after the first diagnosis. This case demonstrates that myxoid leiomyomatous proliferations of the heart must be considered potentially malignant, even when the gross features and degree of cellular atypia seem to suggest otherwise.