Search

Idiopathic left ventricular tachycardia is a rare arrhythmia whose electrophysiological basis is not yet well-defined. We report a case of idiopathic left ventricular tachycardia caused by a reentrant circuit limited exclusively to the two fascicles of the left bundle branch.

The authors report their experience on the diagnosis, pathological findings and surgical treatment of prosthetic aortic valve thrombosis.Between January 1976 and June 1998, 1289 mechanical prostheses were implanted in aortic position at our institution: a prosthetic obstruction was found in 12 cases. Thrombolysis was performed in two cases and as a result, pathological findings were not available and the patients were excluded from the study. Ten patients underwent surgical treatment.Thrombectomy was performed in one case and prosthetic replacement was done in 9 patients. One patient died postoperatively of low-output syndrome, the others were discharged and no recurrence of thrombosis has been observed at follow-up. Primary thrombosis was found in 6 cases, and pannus formation was observed in 4 patients. All patients with primary thrombosis had a history of poor anticoagulation. Patients with pannus formation had a tilting disc prosthesis.Use of bileaflet prostheses and adequate anticoagulation can further lessen the incidence of this dreadful complication.

Many authors have shown the role of uroflowmetry in the follow-up of patients operated on for hypospadias. This technique has also been used to assess the validity of the operative technique.Sixty patients have been selected among those operated on for hypospadias from January 1990 till January 1996 at the Pediatric Surgery Department of the Second University of Naples, Italy. These patients underwent uroflowmetry with a rotating disk sensor at clinic. Postoperative time at uroflowmetry ranged between 6 months and 6 years. Flow pattern, maximum flow rate (Q max) and mean flow rate (Q ave) were measured. Results are expressed as percentiles and compared with those obtained from Toguri. Q max and Q ave greater than 25 degrees percentile were considered normal; Q max and Q ave between 25 degrees and 5 degrees percentile were considered query obstructed; Q max and Q ave below the 5 degrees percentile were considered obstructed.Forty-two patients (70%) presented values above the 25 degrees centile, 8 patients (13.4%) presented an obstructed-like flow and 10 children (16.6%) showed a query obstructed flow. Three patients from the latter group presented within three months an obstructed-like flow.Uroflowmetry is an important tool in the follow-up of patients operated on for hypospadias that are at risk for stenosis and then requiring a further treatment, either dilatation or surgery.

Bileaflet cardiac prostheses (St. Jude, CarboMedics, Duromedics, Bicarbon, Jyros) have shown a low incidence of complications and good haemodynamic performance. In the last twelve years, 783 bileaflet prostheses were implanted in 690 patients at our Institution. The population of our study comprises 591 bileaflet prostheses (418 CarboMedics, 124 St. Jude, 49 Bicarbon) implanted in the mitral (MVR) (n = 305) or aortic (AVR), (n = 286) position. The follow-up study evaluated 292 male and 295 female patients with age ranging from 13 and 79 years (mean 50.4 +/- 14.7 years). Hospital mortality was 6.6%. Follow-up was 97% complete, with 1822 +/- 33 patient/years and a mean follow-up of 37 months (range 1 to 144 months). Twelve years actuarial freedom from complication according to prosthetic site were calculated as follows (linearized rates in parentheses): late mortality AVR 97.6% +/- 0.6% (2.3%), MVR 96% +/- 0.5% (2.1%); thrombosis AVR 100%, MVR 96% +/- 0.9% (0.8%); embolism AVR 97% +/- 0.5% (1.5%), MVR 96.6% +/- 0.7% (1.8%). Global freedom from anticoagulant-related haemorrhage was 95% +/- 1.2% (2.3%) and 94.5% +/- 0.7% (2.2%) following AVR, 94 +/- 0.6% (2.1%) following MVR. The difference of the haemorrhagic risk for prosthetic site was not significant (p0.05). Functional improvement was confirmed by the low postoperative NYHA functional class. According to our results, cumulative experience with bileaflet valves has shown very good long-term results in term of low rate of complication, long-term survival and quality of life.

Prosthetic valve obstruction is caused by thrombi or fibrous tissue overgrowth, or both; thrombolysis avoids reoperation-related risks, but is effective only on clots. Hence, the study aims were to: (i) further assess our indication criteria for thrombolysis in prosthetic valve thrombosis; and (ii) evaluate treatment and follow up in a large patient population.Between January 1991 and January 1994, 20 cases of prosthetic thrombosis were treated with thrombolysis using recombinant tissue type plasminogen activator (rt-PA). Indication criteria for thrombolysis were: (i) recent onset of symptoms; (ii) transesophageal echocardiographic (TEE) evidence of clots on the valve or cardiac chambers; and (iii) a partially preserved disc excursion. All patients were fitted with mechanical valves (four caged balls, 10 tilting discs, six bileaflets), with 17 valves located in the mitral and three in the aortic position. Symptoms of obstruction comprised cardiac failure in 11 cases and/or embolism in 10.After rt-PA infusion, normal prosthetic function was restored in all patients, though one underwent successful reoperation five days later. During infusion, five patients had a transient ischemic attack and one a minor transient peripheral embolism. Recurrence of thrombosis occurred in three patients during follow up; subsequent thrombolysis was successful in two, without complication.As treatment proved satisfactory, the reliability of our indicational criteria was confirmed. Only transient complications arose during treatment with recurrent thrombosis most common in those patients who had more thrombogenic valve prostheses.

Submitral left ventricular aneurysm most commonly occurs among the black population. Nevertheless, this lesion has been described among whites. We report 2 cases of submitral left ventricular aneurysm that we treated successfully by surgery. Case 1 is that of a 52-year-old Brazilian black man with a submitral left aneurysm and mitral incompetence. Case 2 is that of a 25-year-old white man with a history of recurrent stroke; his echocardiographic study showed a small submitral left ventricular aneurysm. Due to the growing incidence of submitral left ventricular aneurysm among the white population, we emphasize the importance of a targeted echocardiographic study in all patients with a history of embolic episodes in the absence of apparent risk factors for embolism.

We report the implantation of a fresh, stentless pulmonary homograft in the mitral position as an attempt to treat the 2nd recurrence of prosthetic endocarditis in a 66-year-old man. The postoperative course was uneventful; early postoperative transesophageal echocardiography showed a competent valve with a gradient of 4.2 mmHg. Fifteen months postoperatively, transthoracic echocardiography showed a good functioning homograft with a competent valve and no recurrence of endocarditis.

Aortic dissection, especially type A, is a life-threatening condition, that requires a prompt and accurate diagnosis to ensure a rapid and precise therapeutic approach. Transesophageal echocardiography (TEE) is a highly reliable technique because of its sensitivity and specificity (near 100%; almost similar to nuclear magnetic resonance), and because it is a very low risk, rapid and easy diagnostic tool. Two hundred sixty-one patients were admitted at our institution in a 6-year period (1988-1994), because of a suspicion of aortic dissection. Two hundred forty-seven of them were submitted to TEE and the diagnosis was compared with surgical data in 124. There was only one false positive by TEE. Sensitivity of TEE vs surgery was 100%, specificity 93.7%, diagnostic accuracy 99%. Agreement between TEE and surgery in the setting of intimal tear was 69.2%. These data confirm the usefulness of TEE in the diagnostic approach to aortic dissection and the therapeutic decision, without using other methods.

The authors report the experience of 161 surgical cases operated between 1980 and 1992 because of valve endocarditis. Two hundred and two surgical procedures were performed. Patients were divided into two groups: Group I (EN) considered 117 patients with endocarditis on the native valve; Group II (EP) included 64 patients with prosthetic endocarditis. In 23 patients the prosthesis was implanted for previous endocarditis on the native valve (EP1); in 41 patients the prosthesis was implanted for other valve diseases (EP2). Each group was described according to sex, age, site of endocarditis, previous cardiac diseases, socio-economical level, hemodynamic and infective conditions at surgery, etiology of endocarditis, surgical indication, pathology report, surgical procedure and results. The results were evaluated considering surgical mortality, late mortality and recurrence of endocarditis. The main risk factors were correlated to overall survival and recurrency. Hospital mortality was 7.6% in EN, 13% in EP1, 36.5% in EP2; endocarditis recurrency was 20.3% in EN, 65% in EP1, 19.2% in EP2. Sixteen patients with prosthetic endocarditis were submitted to a second reoperation with 50% mortality; 4 patients to a third reoperation with 50% mortality; 1 patient to a fourth reoperation with no mortality. Actuarial overall survival was 40.3% at 12 years in Group EN, 33.3% at 12 years in Group EP1, 73.4% at 12 years in Group EP2. Finally the Authors report the experience of 12 stentless grafts (autologous, homologous and eterologous) implanted between March 1991 and July 1994 in patients with valve or prosthetic endocarditis with no recurrency at 42 months of follow-up.

This report shows the importance of non-invasive techniques in infective endocarditis (IE) diagnosis. ECG is quite specific in identifying perivalvular extension of infection when conduction system disease is demonstrated but has a low degree of sensitivity overall. Our casuistry (76 patients with IE) confirms the literature data about the great importance and the utility of transthoracic and transesophageal echocardiography to detect vegetation presence or complications as abscesses or valvular leaflet perforations. Therefore, these techniques are widely applied to predict major clinical events as embolism and death or to suggest a surgical therapy. Nuclear medicine studies play a minimal role. Magnetic resonance imaging appears to be an effective tool in this setting; however, because of a paucity of clinical data, its precise utility has not yet been determined.

The Jyros valve is a new bileaflet valve with the unusual feature that the hinge is expected to rotate continuously inside the housing. Nine isolated Jyros mitral prostheses were implanted from July to October 1993. All patients survived the surgical procedure and during the follow up underwent transthoracic (TTE) and transesophageal echocardiograms (TEE) for the evaluation of hinge rotation. Neither TTE nor TEE were able to show hinge rotation in any patient at any time. Five patients had prosthetic thrombosis. In the successfully treated with thrombolysis. In the remaining patient thrombolysis was contraindicated. Eight patients are alive; one died of gastro-intestinal bleeding a few months after discharge. The absence of hinge rotation may be the triggering mechanism of valve thrombosis although no explanted prostheses were available for examination. Further studies are necessary to understand the mechanism of valve thrombosis with the Jyros bileaflet prosthesis.

A homograft bank was established in 1986 at the Institute of Cardiac Surgery of the Second University of Naples. Since then 163 aortic and pulmonary homografts have been collected, and mostly used for right ventricular outflow tract reconstruction (69 at our Institution and 14 at other Italian Centers). In March 1991 free aortic homografts were first implanted in the left ventricular outflow tract in adult patients with aortic valve and/or root disease, for a total of 15 implantations with a follow-up ranging between 3 and 19 months (mean 10 months). According to the literature and our data, operative mortality for such procedure is not higher than for ordinary aortic valve replacement. With regard to mid-term failure rate and complications, homografts are to be preferred as they don't require anticoagulation. Moreover the best indication to free homograft implantation is active aortic valve endocarditis, especially when annular abscesses are present. Reinfection rate is lesser in these patients compared to those with mechanical or bioprosthetic valves because homografts have no prosthetic material, allow exclusion of abscessual cavities from blood flow and do not require the fixation of a rigid prosthetic sewing ring in an infected, friable annulus. Finally short and mid-term haemodynamic evaluations of such patients are excellent for all the aforementioned reasons as well as for the homograft non obstruction rate.

Operative mortality, recurrence and late survival were analyzed in 64 patients operated for prosthetic valve endocarditis (PVE) between 1980-1992: age, sex, drug addiction, early vs. late PVE, micro-organism, sepsis at the time of surgery, indication for surgery, prosthesis type and site were assessed as potential risk factors. PVE developed after replacement for native valve endocarditis in 23 cases (Group A) and after replacement for other valvular disease in 41 patients (Group B). The overall operative mortality was 28.1% (18/64); 16 operative survivors underwent a second reoperation with eight operative deaths (50%), four of them a third procedure with two operative deaths (50%), and one patient had a successful fourth intervention. Female sex (p = 0.015) and sepsis at the time of surgery (p = 0.013), were found statistically significant independent predictors of operative mortality. Age (p:0.002), mechanical valves (p:0.05) and mitral position (p:0.03) were significant predictors of PVE recurrence. None of the risk factors considered were significant for late survival. Twelve-year actuarial survival for all patients was 52.11 +/- 10%; it was 33.3 +/- 13% for Group A and 73.4 +/- 14% for Group B (p:0.04). Patients with mechanical valves and bioprostheses had an actuarial survival of 39.5 +/- 15% and 48.5 +/- 14% respectively with no significant difference. PVE is still a challenging complication of heart valve replacement; patients with PVE after native valve endocarditis have a very poor outcome. Prompt prosthetic replacement is recommended whenever the antibiotic treatment is unsuccessful and/or the hemodynamic status deteriorates.

Inadequate flow and limited length can be reasons for not using the internal mammary artery graft for myocardial revascularization. Several methods have been described to obviate these limitations, but each has disadvantages that contraindicate their application on a routine basis. Herein we describe what to the best of our knowledge is a new surgical technique of harvesting the internal mammary artery graft wherein the endothoracic fascia is incised longitudinally along the artery. In our experience, this surgical maneuver enables an increase in hematic flow (average, 30.6%) and in length of the graft (average, 10%) with reduced risk of damaging the arterial intima. This technique also enables the surgeon to detect the presence of atheromatous plaques and of parietal hematomas of the internal mammary artery wall. Moreover, we have observed a drastic reduction in the incidence of arterial spasms after use of this technique.

From January 1988 through August 1992, 38 cardiac transplants were performed. 385 endomyocardial biopsies (EMBs) from 32 cardiac allograft recipients were investigated. In 21 (5.45%) EMBs the specimens were inadequate for the diagnosis. In the remaining 364 EMBs the grades of acute rejection were: minimal in 213 (58.51%) EMBs, mild in 132 (36.26%), mild/moderate in 12 (3.3%) and moderate in 7 (1.93%). The most reliable histologic feature of acute rejection was the myocyte necrosis or damage in presence of pironinophilic mononuclear cell infiltrate, so our therapeutic protocol requires myocyte damage to perform an additional treatment, which was performed in 7 cases (1.93%). An intermediate grade mild/moderate, was introduced to classify the EMBs in which the myocyte necrosis was scant or not clear. In these patients another EMB was performed after 3 or 5 days. One patient died of chronic rejection 17 months after the transplant. Changes not related to acute rejection were: ischemic early or late necrosis; changes related to previous biopsy site; subendocardial infiltrate of mononuclear cells (Quilty's alteration); focal, diffuse or perimyocytic fibrosis and artefacts as contraction bands; nuclear or cytoplasmic vacuolar alterations. Some of these changes occasionally made the diagnosis hard or the specimens inadequate for the diagnosis. In spite of these diagnostic difficulties, the EMB is a safe and reliable invasive investigation which plays an important role in the management of rejection in cardiac allograft recipients.

A consecutive series of 912 surgically excised aortic valves was evaluated by means of macroscopic and histologic study. Pure aortic stenosis was diagnosed in 203 patients (p.) (22.25%), pure incompetence in 125 (13.72%) and combined dysfunction in 584 (64.03%). The diseases affecting the valves were: a) chronic rheumatic disease (593 p., 65%); b) dystrophic calcifications (214 p., 23%); c) noninflammatory aortic root disease (NIARD) and/or myxomatous infiltration of aortic cusps, floppy aortic valve (FAV) (55 p., 6%) d) infective endocarditis (50 p., 5.5%). Males outnumbered females with a ratio ranging from 2.4 (dystrophic calcific disease) to 1.6 (infective endocarditis). The mean age ranged from 37 +/- 7.5 (NIARD) to 61.2 +/- 6.3 (dystrophic calcific disease). Chronic rheumatic disease was the most frequent cause of stenoincompetence (542 p., 91.4%) while isolated stenosis was prevalently due to dystrophic calcification (172 p., 80.4%). The diseases causing isolated aortic incompetence were (in order of frequency): a) NIARD and/or FAV (55 p., 44%); b) infective endocarditis (50 p., 40%); and c) rheumatic disease (30 p., 16%). The 55 patients with NIARD and or FAV were divided into 3 groups: a) 23 p. with aortic root dilatation and normal cusps; b) 20 p. with aortic root dilatation and FAV; c) 12 p. with FAV but undilated aortic root. Aortic regurgitation was caused by cusp derangement in rheumatic disease (shortening, retraction) and infective endocarditis (perforations, erosions). Cusps diastasis and prolapse were the cause of regurgitation in aortic root dilatation.(ABSTRACT TRUNCATED AT 250 WORDS)

Matteo -IRCCS Universita degli Studi di Pavia, Pavia, Italy; Az. Osp. di Bologna Policl. S. Orsola Malpighi, Bologna, Italy; Europeen Georges Pompidou, Paris, France; Hopital Pitie Salpetriere, Paris, France; Azienda Ospedaliera di Padova Universita degli Studi, Padova, Italy; Cliniques Universitaires Saint Luc, Brussels, Belgium; UZ Gasthuisberg, Leuven, Belgium; Novartis Pharma AG, Basel, Switzerland