Search

Severe ventricular dysfunction and concomitant infection are considered absolute contraindications for major thoracic operations and immunosuppressive therapy, respectively. However, cardiac transplantation represents the first-choice treatment in advanced heart failure. We report the case of a patient with dilated cardiomyopathy and severe left ventricular dysfunction (ejection fraction = 25%), initially not considered as a potential heart transplant candidate due to the presence of a lung abscess. The patient subsequently underwent atypical pulmonary resection with intraoperative and perioperative intraaortic balloon counter-pulsation for circulatory support and was then listed for cardiac transplant. Pitfalls and intra/postoperative strategy, all of which are potentially important aspects in minimizing operative risk, are discussed.

Background: Surgical intervention for coronary artery disease (CAD) is determined by the viability of coronary artery branches. When peripheral coronary artery disease is present, conventional bypass grafting is not suitable. Research has recently been done on alternative methods such as transmyocardial laser revascularization (TMLR). TMLR works through the vascular connections that are present between the cardiac chambers and the myocardial muscle in the human heart. The creation of 1-mm transmural cardiotomies through a CO2 laser should improve myocardial perfusion., Methods: From February to June of 1996, twelve patients (9 males and 3 females with a mean age of 67.8 +/- 4.6) with CAD (mean n0 of diseased vessels 2.7), angina (mean CCS class 3.5 +/- 0.5), mean ejection fraction 47.8% and viable ischemic myocardium on scintiscan in segments without graftable coronary branches, underwent TMLR at our institute. Nine of the 12 patients also underwent associated CABG (mean number of anastomoses per patient: 2.5). Cardiopulmonary bypass was never used, since coronary anastomoses and laser cardiotomies were performed on the beating heart., Results: Perioperative mortality was 2/12 (16.6%). Postoperative inotropic support and diuretic therapy was required in most cases. At a mean follow-up period of 4.2 months, all remaining patients are still alive: 5/10 are angina-free (CCS 0), 4/10 are in CCS class 1 and 1/10 is in CCS class 2 (mean 0.6 +/- 0.7)., Conclusions: We believe that TMLR could be considered an effective mean to treat symptomatic myocardial ischemic disease in which coronary bypass grafting is not suitable. During the immediate postoperative period, contractile myocardial dysfunction occurs in a high percentage of patients treated using TMLR and consequently it would be worthwhile to invest in further research.

The authors report on a 47-years old woman with bacterial endocarditis involving both the mitral and aortic valves. At first echocardiographic examination, the mitral vegetation was small, while the aortic one was large highly mobile. Despite adequate antibiotic therapy, the aortic vegetation had become bigger and the valve regurgitation, initially mild to moderate, resulted severe and was associated with left heart failure. While awaiting surgery, the patient sustained an acute non Q wave myocardial infarction with ST segment elevation in inferior and anterolateral leads, complicated by ventricular arrhythmias. Thirty-six hours later, the patient received mitral and aortic valve replacement: at surgical view, the aortic vegetations was found to be very close to the right coronary orifice. After a period of further antibiotic therapy, the woman discharged and at a six months follow-up, she was fairly well. The authors review the mechanisms of acute coronary insufficiency in infective endocarditis and suggest an embolic pathogenesis in the case reported. Taking into account the possible life threatening embolic complications, it seems reasonable not to delay surgery when antibiotic therapy fails to reduce the size and mobility of valve vegetations.

Eighty-two consecutive patients undergoing reoperation for coronary revascularization from January 1980 to November 1990 were reviewed to determine early and late results and predictors of survival. Seventy patients were male and 12 female; age ranged from 36 to 75 years (mean 56.4 +/- 8.1). All were symptomatic for angina. The mean interval between first and second operation was 62.8 +/- 47.8 months (range 1 to 220 months). Angiographic indications for reoperation were: graft failure (34.1%), progression of atherosclerosis in the native coronary circulation (6.1%) and combination of the two (59.8%). Mean ejection fraction was 45.9 +/- 10.2 (range 11 to 67). Surgical indication was elective in 79.3%, urgent in 14.6% and emergent in 6.1%; 199 grafts were performed (2.4 +/- 1 grafts/patient). Hospital mortality was 6.1% (5 cases). Late mortality was 5.2% (4 cases). Actuarial survival rate (including hospital mortality) was 87.9% at 3, 5 and 10 years. Multivariate analysis identified left main stenosis (p = 0.00001), family history of coronary disease (p = 0.003), urgent/emergency operation (p = 0.015) as predictors of increased in-hospital mortality; postoperative myocardial infarction (p = 0.002) and preoperative heart failure (p = 0.01) as predictors of increased late mortality. Follow-up of in-hospital survivors (mean interval 42.7 +/- 25.8 months, range 3 to 120 months) documented 27 cardiac major events (other than death) in 24 patients (32.9%). Actuarial rates of freedom from major cardiac events were 70%, 52.9% and 48.1% at 3, 5 and 10 years respectively. Multivariate analysis identified preoperative ejection fraction (p = 0.01) as predictor of recurrence of angina and preoperative heart failure (p = 0.02) as predictor of occurrence of cardiac major events.

To determine the potential role of emergency surgical revascularization as treatment of acute myocardial infarction (AMI), results in 79 patients undergoing operation for myocardial revascularization during AMI from January 1986 to January 1991 were reviewed. Clinical characteristics for inclusion in the study were: 1) emergency operation; 2) persistent angina not controlled by medical therapy; 3) fixed ST segment elevation until surgical procedure, independently from magnitude of enzymatic levels. The 79 patients were divided in 2 groups: 27 with AMI or evolving AMI (Group 1); 52 with AMI due to complications during PTCA (Group 2). Twenty-eight patients had extremely severe clinical conditions. Mean interval between the beginning of AMI and operation was 4.2 +/- 6.7 hours, with a statistically significant difference between Group 1 (8.7 +/- 10.0) and Group 2 (1.9 +/- 1.0). One hundred ninety-two grafts were performed (2.4 +/- 1.1 grafts/patient). Overall hospital mortality was 10.1% (CL 6.7-13.3) (8 deaths) with a difference between Group 1 [18.5% (CL 10.7-25.3)] and Group 2 [5.8% (CL 4.7-6.6)] (p = 0.074). The incidence of perioperative myocardial infarction was 30.4% (CL 24.9-35.1) for that one in the area of ischemic muscle and 2.6% (CL 0.8-4.1) for infarction in remote muscle. Multivariate analysis for the entire series (79 patients) identified as independent predictors of increased in-hospital mortality: preoperative cardiogenic shock (p = 1.000E-4) and hyperlipidemia (p = 0.008). In Group 1 multivariate analysis identified as independent predictors of increased in-hospital mortality: the attempt of revascularization by PTCA and hyperlipidemia; in Group 2: preoperative need of mechanical ventilatory support.(ABSTRACT TRUNCATED AT 250 WORDS)

Ten consecutive patients with ventricular septal rupture complicating acute myocardial infarction were studied by means of Doppler echocardiography (including two-dimensional, conventional and color Doppler techniques) and bedside right heart catheterization using a Swan-Ganz catheter. One patient died before an operation could be performed. Seven critically ill patients underwent emergency cardiac surgery without preoperative cardiac catheterization, while in two patients it was also possible to undertake coronary angiography before surgery. Two-dimensional echocardiography diagnosed post-infarction ventricular septal rupture in 6 out of 10 patients. Color Doppler revealed the presence and the location of septal rupture in all 10 patients. The color Doppler diagnosis was confirmed either by surgery or necropsy. The estimates of pulmonary artery pressure, obtained by color Doppler-guided continuous wave Doppler beam, were very close to those measured by simultaneous right heart catheterization. In 3 patients, patch leakage occurred 3 days, 15 days and 1 year after the operation. Two-dimensional echocardiography revealed the patch leakage in only one of 3 patients while its location was visualized by color Doppler in all 3 patients. In one patient the color Doppler diagnosis was confirmed at necropsy. In the remaining 2 patients, a small left-to-right shunt was demonstrated by radionuclide studies. Color Doppler echocardiography is a highly sensitive and rapid technique in the diagnosis of postinfarction ventricular septal rupture. In critically ill patients it offers relevant information and may obviate the need for any invasive preoperate investigation.

Surgical correction of ostium secundum atrial septal defects may be performed, in most cases, without cardiac catheterization, on the ground of clinical and two-dimensional echocardiographic (2D echo) findings. Consequently it's useful to identify the reliability of 2D echo and the indications for angiography in these patients (pts). One hundred forty-five patients operated in "A. De Gasperis" Division of Cardiac Surgery in Milan from January 1982 to December 1986 are reviewed. Patients with ostium primum atrial septal defects or subjected to cardiac catheterization and angiography in other institutions are excluded. Altogether two-dimensional echocardiography was performed in 131 pts, cardiac catheterization in 78. Sixty-four pts were studied with both 2D echo and angiography. In 35 pts (with only 2D echo examination) radionuclide angiocardiography was performed. The results of the different techniques were compared with intra-operative findings, defining sensitivity and specificity in relation to detection of the site of the defect and of the pulmonary venous return. There were no statistically significative differences between echo 2D and cardiac catheterization (Figs. 1 and 2). Two-dimensional echocardiography confirms its cost effective and psychological advantages, especially in younger patients. Hemodynamic and angiographic assessment should be performed as follows: 1) when associated anomalies are suspected; 2) in cases of non-satisfying quality of the 2D echo examination; 3) when diagnostic incoherence between clinical and instrumental data is present; 4) in patients with pulmonary hypertension.

From January 1978 to December 1984, 214 patients underwent a total of 243 reoperations for repair or replacement of a prosthetic heart valve. On the basis of the number of valve reoperations in the same anatomic position within the heart, the patients were divided into three groups. Overall hospital mortality was 23.4% (CL 20.3-26.7) in Group I (214 patients), 48% (CL 36.1-60.1) in Group II (25 patients), 25% (CL 3.3-62.6) in Group III (4 patients). Hospital mortality appeared to be related to urgency of reoperation (p less than 0.001 in Group I; p = 0.037 in Group II), primary indication for reoperation (p = 0.034 in Group I; p = 0.022 in Group II), association with other cardiac surgical procedures (p = 0.00253 in Group I). Hospital mortality in Group I was significantly higher (p = 0.0056) when reoperation was performed within one year after valve replacement. No significant differences in urgency and emergency rate were noted between reoperations on mechanical heart valves and bioprostheses. No significant differences in bleeding complications were noted between reoperations and initial valve replacement. Mean follow-up is 37.4 +/- 21.8 months (range 2 to 85 months). Actuarial survival rate is 82.8 +/- 3.1% at 1 year, 78.7 +/- 3.5% at 2 years and 71.5 +/- 5.1% at 5 years; 90.9% (CL 87.4-93.6) of the followed patients are in I or II NYHA class. The results appear to suggest that when significant (on clinical or instrumental criteria) prosthetic disfunction is diagnosed, reoperation should be undertaken early to minimize operative risk. The Authors point out that surgery in such patients also ensures satisfying long-term results.

Ninety patients who underwent emergency cardiac valve surgery from January 1976 to December 1981 are reported. Patients were divided in two groups: those operated on native valves are included in group I; patients with prosthetic valves operated because of leakage or malfunction, in group II. In group I (57 patients) the aetiology was: rheumatic heart disease (34 cases); acute endocarditis (16 cases); sequelae of recent endocarditis (2 cases); luetic infection (1 case); sequelae of myocardial infarction (1 case); rupture of mitral chordae in mixomatous valve (3 cases). The emergency operation was prompted in 22 patients by cardiogenic shock, in 13 patients by intractable pulmonary edema, in 21 patients by low output syndrome, in one case by ventricular arrhythmias. In group II (33 cases) the causes of reoperation were: in 27 cases leakage (in 13 due to active endocarditis); in 6 cases variance of the occluder or thrombosis. The emergency originated in 12 cases from cardiogenic shock, in 11 cases from intractable pulmonary edema, in 9 cases from low output syndrome, in 1 case from ventricular arrhythmias. Twenty-six patients died perioperatively in group I and 17 in group II. Mean follow-up in group I was 26 months. Among 27 patients there were two deaths; 25 patients are alive and well (one has been reoperated again). Mean follow-up in group II was 21 months. Among the 15 patients observed there were 6 deaths (3 after re-reoperation); 9 patients are alive and well (one has been re-reoperated).' The Authors feel that surgery is mandatory in all such patients to ensure satisfying long term results, in spite of high perioperative mortality rate.