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AIMS Age over 75 years and logistic Euroscore over 20% have been jointly proposed by European scientific associations as the criteria for aortic valve stenosis patients to be considered 'high-risk' for surgical aortic valve replacement (AVR) and candidates for transcatheter aortic valve implantation (TAVI). We aimed to verify traditional AVR outcomes in the presence of the above criteria. METHODS Between January 2001 and January 2011, 180 patients with severe aortic valve stenosis (mean aortic valve area = 0.4±0.1 cm/m), with age range 75-88 years (mean 78.2±3), logistic Euroscore between 4.5 and 40% (mean 12.6±7.4%), underwent surgical AVR. The patient population was divided into group A (118 patients between 75 and 79 years of age), further divided into subgroups A1 (76 patients) and A2 (42 patients) with logistic Euroscore, respectively, less than 20% and at least 20%; and group B (62 patients between 80 and 88 years of age), subdivided into B1 (34 patients) and B2 (28 patients) with logistic Euroscore, respectively, less than 20% and at least 20%. Hospital outcomes were retrospectively evaluated. Univariate and multivariate analyses, including age and logistic Euroscore, were performed to individuate predictors of hospital mortality. RESULTS Overall observed/expected mortality ratio was 0.4. Hospital mortality was 5.3% in group A1, 4.8% in A2, 5.9% in B1, 3.6% in B2 (P=NS). Mortality with age over 75 and Euroscore at least 20% was 4.3%. As regards postoperative morbidity, atrio-ventricular bock indicating pacemaker implantation occurred in four patients, pneumonia in three, stroke in two, perioperative myocardial infarction in one. Age and Euroscore were not independent predictors of mortality, morbidity or composite endpoint in multivariable analysis. CONCLUSION Age and logistic Euroscore might be inadequate criteria for the identification of patients with severe aortic stenosis unsuitable for AVR and addressable to TAVI.

The need for a specific risk score system for infective endocarditis (IE) surgery has been previously claimed. In a single-center pilot study, preliminary to future multicentric development and validation, bivariate and multivariate (logistic regression) analysis of early postoperative mortality predictors in 440 native valve IE patients were performed. Mathematical procedures assigned scores to the independent predictors emerged (AUC of the ROC curve: 0.88). Overall mortality was 9.1%. Six predictors were identified and assigned scores, including age (5–13 points), renal failure (5), NYHA class IV (9), critical preoperative state (11), lack of preoperative attainment of blood culture negativity (5), perivalvular involvement (5). Four risk classes were drawn ranging from “very low risk” (≤5 points, mean predicted mortality 1%), and to “very high risk” (≥20 points, 43% mortality). IE-specific risk stratification models are both needed, as disease-specific factors (e.g., cultures, abscess), beside the generic ones (e.g., age, renal impairment) affect mortality, and feasible.

Objectives: The aim of this study was to assess the early and long-term outcomes of a previously introduced technique of reduction aortoplasty for asymmetric ascending aortic dilatation. Different indication criteria for reduction ascending aortoplasty have been previously adopted by others, thus another purpose was to identify the patient profile for whom this approach may be best suited. Methods: Between January 2001 and December 2010, reduction ascending aortoplasty with “waistcoat technique” was performed in 156 patients (mean age 62±12 years, 61% male) with asymmetric dilatation of the ascending aorta (prevailing at the convexity of the supracoronary tract). Eighty-seven patients had a tricuspid aortic valve (TAV), 69 a bicuspid aortic valve (BAV). Aortoplasty was associated to aortic valve replacement in 60% cases. Preoperative, intraoperative, early postoperative and follow-up data were analysed. Comparisons were performed between groups of valve morphology (TAV versus BAV) and subgroups of baseline valve function. In patients with a follow-up time >1 year the annual growth of the ascending tract was calculated and compared between subgroups. The independent predictors of growth velocity were assessed by multivariable linear regression analysis. Results: Mean cross-clamp and cardiopulmonary bypass times were 39 ± 18 and 69 ± 29 min, respectively. Hospital death was 1.9%. In no case, postoperative death or any early complication was causally related to the aortoplasty procedure. The mean postoperative ascending diameter was 3.1 ± 0.3 (versus preoperative 5.2 ± 0.8 cm, P< 0.001). Mean follow-up time was 4 ± 2.5 years (maximum 10 years): 7-year survival was 95 ± 2%; 7-year freedom from aortic events 94 ± 4%. Redilatation (ascending diameter exceeding 4.5 cm) occurred in two patients, acute dissection in one: all three preoperatively had significant aortic regurgitation. The mean ascending aortic diameter at last follow-up was 3.4 ± 0.5 cm; median diameter progression was 0.4 mm/year, with no significant difference between TAV and BAV and no patient reaching 0.5 cm/year. With TAV, the only determinant of aortic growth rate was normal preoperative valve function (P= 0.04); with BAV, the degree of regurgitation at preoperative echocardiography (P= 0.001). Conclusions: Waistcoat aortoplasty proved a safe and durable treatment for patients with asymmetric non-syndromic non-familial ascending aorta dilatation. The technique showed its best durability in aortic stenosis patients and in patients with normofunctional BAV.

Knowledge of the characteristics of the normal human aorta has been constrained by lack of data on fresh aortic tissue, especially from healthy individuals. In this study, the gene expression and morphological characteristics of the thoracic ascending aorta (AA) of healthy organ donors have been evaluated, with the aim of providing reference data for the analysis of pathological AAs. We analysed by RT-PCR the differential expression of mRNAs coding for myocardin, smoothelin, alpha-smooth muscle actin (alpha-SMA) and the ED-A isoform of fibronectin (ED-A FN) in AA specimens from donors, integrating the results with immunohistochemical analysis of the same targets. Morphological and morphometric characteristics of the AAs were also evaluated. In order to account for possible regional variations in wall structure, the convexity of the aortic profile was compared to the concavity. No differences in gene expression occurred for any of the target genes between the concavity and the convexity of AAs. Immunohistochemistry revealed a different distribution of total FN and of its ED-A isoform in the media and in the intima. Smoothelin is expressed by the majority of cells in the media, with some positive cells also in the intima. Alpha-SMA is expressed in all the tunicae. Immunohistochemistry also revealed in the convexity of 50% of AAs the presence of discrete areas in the subadventital media with altered structure and cell morphology and with altered gene expression, resulting positive for ED-A FN and alpha-SMA, but not for smoothelin, indicating the occurrence of early lesions also in macroscopically healthy AAs

This study aimed to evaluate our 30-year experience in the treatment of deep sternal wound infection after cardiac surgery. Between 1979 and 2009, deep sternal wound infections occurred in 200 of 22,366 (0.89%) patients who underwent sternotomy. The study population was divided into 3 groups. In group A (62 patients; 1979–1994), an initial attempt at conservative antibiotic therapy was the rule, followed by surgery in case of failure. In group B (83 patients; 1995–2002), the treatment was in 3 steps: wound debridement and closed irrigation for 10 days; in case of failure, open dressing with sugar and hyperbaric treatment; delayed healing and negative wound cultures mandated plastic reconstruction. In group C (2002–2009), the treatment was based on early surgical debridement, vacuum application, and reconstruction using pectoralis muscle flap. Hospital mortality in group A was significantly higher than that in groups B and C. Hospital stay, time for normalization of white blood cell count and C reactive protein, and time for defervescence were significantly shorter in group C. In our experience, early surgical debridement and vacuum application followed by plastic reconstruction provided a satisfactory rate of healing and a good survival rate.

Between January 2002 and January 2009, 39 patients with post-cardiotomy staphylococcal deep sternal wound infection were treated primarily by a vacuum-assisted closure method (group A). Results were compared with those of 30 patients with staphylococcal deep sternal wound infection who received closed mediastinal irrigation with antibiotics (group B). The prevalence of methicillin-resistance was similarly high in both groups (64.1% in A, 56.7% in B). One group B patient died during treatment. The median healing time was significantly shorter at 13 days in group A (mean, 13.5 ± 3.2 days) compared to 18 days (mean, 21.2 ± 16.4 days) in group B. Deep sternal wound infection did not recur after vacuum treatment, while 7 (24%) patients in group B suffered a recurrence. Hospital stay was significantly shorter in group A (median, 30.5 days; mean, 32.2 ± 11.3 days vs. median, 45 days; mean, 49.2 ± 19.3 days). The significantly shorter healing time with vacuum-assisted closure was confirmed in both methicillin-sensitive (12 vs. 17 days) and methicillin-resistant infections (14 vs. 21 days). Hospital stay remained significantly shorter in group A (35 vs. 46 days) when only methicillin-resistant deep sternal wound infection was considered.

The Starr-Edwards caged-ball prosthesis has been widely used to replace cardiac valves. The Model 6120 mitral prosthesis was introduced on the market in 1965 to reduce the high incidence of ball variance and thromboembolism of the previous model. We report the case of a Starr-Edwards Model 6120 which had been in place for 44 years and was still well functioning with no apparent structural damage.

A 19 year-old man presented with a 2-month history of fever, cough and hemoptysis that were unresponsive to broad spectrum antibiotics. He had been implanted with an epicardial pace-maker at the age of 5 for complete heart block. One year before presentation, he experienced rupture of the epicardial implant following a car accident, and underwent emergency placement of an endocardial pacemaker. He also underwent orthopedic and abdominal surgery for multiple bone fractures and mesenteric artery aneurysm, with a resultant long-lasting intensive care unit stay. On admission to our hospital, computed tomography of the chest showed bilateral pulmonary inflammatory infiltrates with multiple pulmonary artery emboli. Trans-thoracic echocardiography showed a massive, mobile structure adhering to the pace-maker lead and severe pulmonary hypertension. Multiple blood cultures grew Candida albicans. The patient remained highly febrile and septic despite full dose combination antifungal treatment with caspofungin and fluconazole.

Cardiopulmonary bypass induces a systemic inflammatory response (SIR), characterized by the activation of cellular and humoral elements, with concomitant release of neutrophil elastase and matrix-metallo proteinases. In the present study, the protease release during extracorporeal circulation in 28 patients undergoing cardiac surgical operations was monitored using casein zymography. A peak in protease activity was found in all patients at the end of cardiopulmonary bypass. Plasma samples of patients were allowed to interact with different traps obtained by immobilizing different protease inhibitors on specific carriers. α1-Antitpypsin, Bovine Pancreatic Trypsin Inhibitor, Elastatinal or Leupeptin were used as inhibitors and were covalently immobilized by diazotization or by condensation. A reduction in the proteolytic activity of the plasma samples was observed after interaction with the different traps. The most efficient traps, i.e. the ones displaying greatest power to inhibit protease activity, were those obtained by immobilizing Bovine Pancreatic Trypsin Inhibitor and Leupeptin. The biocompatibility of traps was also tested. Results show that protease activity in blood can be decreased by our protease traps.

This study aimed to assess the results of the introduction of thoracoabdominal perfusion (TAP) in the surgical strategy for aortic arch replacement with cerebral protection.Two hundred two arch procedures performed with moderate hypothermia (22 degrees to 26 degrees C) and antegrade cerebral perfusion (ACP) were the objects of retrospective investigation. Acute type A dissection was the indication in 164 patients, aortic aneurysm in 38. In 80 patients, during ACP, the thoracoabdominal aorta was perfused either in an antegrade fashion through proximal descending aorta endoluminal cannulation (in 62 dissections), or retrograde through femoral artery cannulation with proximal descending aorta endoluminal occlusion (in 18 aneurysms). Hospital mortality and morbidity rates were compared between the two treatments (group A: ACP only, 122 patients; group B: ACP plus TAP, 80 patients) and the underlying aortic disease (dissection/aneurysm) was stratified.Cerebral perfusion (p = 0.008) and cardiopulmonary bypass times (p = 0.035) were significantly longer in group B. No complication related to the TAP technique was observed in group B. Overall hospital mortality was 12.9%, without significant difference between groups. No differences were found in terms of permanent neurological dysfunction between groups A (9.3%) and B (9.1%; p = 0.58). Group B patients showed lower rates of respiratory failure (18.2% versus 30.5% in group A; p = 0.038), shorter mechanical ventilation times (18.1 +/- 26 hours versus 57.9 +/- 70.1; p0.001) and lower incidence of acute renal failure (6.5% versus 18.6%; p = 0.012). Shorter intensive care and hospital stays were observed in group B (p = 0.02).The adjunction of TAP to ACP was associated with lower rates of end-organ complications, even in more extensive and time-consuming procedures.

We investigated whether and how the severity of medial degeneration lesions varies along the circumference of the dilated intrapericardial aorta. Two groups of aortic wall specimens, respectively harvested in the convexity and concavity of ascending aorta in 72 patients undergoing surgery for dilatation of the intrapericardial aorta associated with aortic valve disease, were separately sent for pathology, morphometry, and ultrastructural examination. Cystic medial necrosis, fibrosis, and elastic fiber fragmentation were classified into three degrees of severity; their mean degree and morphometric findings in the convexity and in the concavity specimens were compared by paired t-test. Correlation between echocardiographic degree of aortic dilatation and severity of medial degeneration was assessed separately for each of the two groups of specimens. Morphologically, medial degeneration was found in all cases; a higher mean degree was found in the convexity group (2.39 ± 0.58 vs 1.44 ± 0.65 in the concavity group; P < 0.001). At morphometry normal smooth muscle cells in the convexity specimens were significantly reduced (P = 0.007); the length (P = 0.012) and number (P = 0.009) of elastic fibers reduced and increased, respectively. Moreover, in the convexity specimens a significantly smaller amount of smooth muscle cells and an increase of immunohistochemical labeling of apoptosis-associated proteins in the subintimal layer of the media was noticed. Correlation between aortic ratio and medial degeneration degree was significant in the convexity group (P < 0.001), but not in the concavity group (P = 0.249). Scanning electron microscopy analysis confirmed morphological results and allowed us to better distinguish the early pathological cavities from the microvessels, which were in the outer media in normal aorta and ubiquitous in aortitis or atherosclerosis. Electron transmission microscopy analysis showed changes in the extracellular matrix and smooth muscle cells, and these changes increased from the intima to the adventitial layer of the media. In dilated intrapericardial aorta, medial degeneration changes and expression of apoptosis-associated proteins are more marked in the ascending aorta convexity, likely due to hemodynamic stress asymmetry. Ultrastructural findings allow us to distinguish the early medial changes not yet evident on light microscopy.

Objective: Postoperative respiratory failure is a frequent and serious complication in patients with type A acute aortic dissection. Experimental evidence suggests that pulmonary artery perfusion using hypothermic protective solutions helps prevent lung injury. The aim of this pilot prospective study was to evaluate the effect of pulmonary artery flushing during selective cerebral perfusion (SCP) on lung function. Methods: Twenty patients referred for acute type A aortic dissection, who were free from preoperative respiratory dysfunction, were assigned prospectively and alternately to two treatment groups. Pulmonary flushing was performed during SCP in group P (10 patients), while conventional Kazui technique was applied in group N (10 patients). Lung perfusion consisted of single-shot hypothermic pulmonary artery flush with Celsior. Lung function was evaluated by intubation time, scoring of chest radiograms at 12 hours after CPB, and PaO 2 /FiO 2 assessed from immediately before surgery to 72 hours after termination of cardiopulmonary bypass. Results: Incidence of pre, intra and post operative determinants of lung dysfunction proved homogeneous in both groups. Lung oxygenation function showed a marked post operative decline followed by a slow improvement in both groups. Analysis of respiratory ratios did not disclose significant differences even though the flushed group had a better performance in all study patients. The incidence of prolonged ventilator support (longer than 72 hours) (30% vs 20%, p=NS) and severity of x-ray pulmonary infiltrate score were comparable (mean score 1.7±0.71 vs 1.6±0.68, p=NS). Conclusions: Pulmonary artery flushing with Celsior solution does not seem to provide an effective preservation of lung function. (Int J Artif Organs 2003; 26: 1032-8)

ContextSeveral investigations as well as prospective studies have shown a significant correlation between glucose metabolism and atherosclerosis in patients without diabetes, but differences in parameters of glucose metabolism among the various degrees of coronary disease in such patients have not been specifically evaluated.ObjectiveTo investigate glucose metabolism in patients with normal glucose tolerance (NGT) and coronary heart disease (CHD).Design, Setting, and ParticipantsCross-sectional study of 234 men (mean [SD] age, 56.2 [6.1] years) with NGT and suspected CHD who were admitted from January 1 through June 30, 2001, to an academic medical center in Italy for coronary angiography.Main Outcome MeasuresCorrelation of glucose metabolic factors and extent of atherosclerosis determined by coronary angiography. Factors included levels of fasting and postload glucose and insulin, glycosylated hemoglobin (HbA1c), and lipids, as well as insulin resistance measured by homeostasis model assessment (HOMA-IR).ResultsPatients were divided into 4 groups based on coronary angiography: no significant stenosis (n = 42), 1-vessel disease (n = 72), 2-vessel disease (n = 64), and 3-vessel disease (n = 56). Simple correlation analysis showed that the factors correlated with the extent of atherosclerosis were levels of postload glucose (r = 0.667), HbA1c (r = 0.561), postload insulin (r = 0.221), and fasting insulin (r = 0.297), as well as HOMA-IR (r = 0.278) (P

Several pathogenetic mechanisms account for the association of the ascending aorta dilation with aortic valve dysfunction. Functional aortic insufficiency can derive from medial degeneration of the aortic wall and annuloaortic ectasia; leaflet structural disease can determine root dilation by increasing aortic wall stress in case of both regurgitation and stenosis; aortic valve disease and aortic aneurysm can however coexist due to two different intrinsic etiologies. In the attempt to best tailor the surgical correction of such conditions to the underlying causative mechanism, several technical options have already been developed including composite or separate aortic valve and root replacement, valve-sparing operations, and aortoplasty techniques. The criteria for surgical indication cannot leave the underlying pathogenesis out of consideration as well. The newly acquired knowledge in the basic research on this topic is expected to affect the approach to the individual patient in the future.

A 46-year-old man with polycystic kidney disease was referred to our institution for ventricular septal defect complicating myocardial infarction. Cardiac catheterization disclosed normal coronary arteries and absence of myocardial bridging. None of the more frequent causes of thrombosis were present, and histopathology proved negative for acute myocarditis. The surgical procedure was successful and the 11-month follow-up uneventful.

Objective: Despite the achievements of third generation mechanical cardiac valve prostheses, conservative procedures are still considered the best surgical option for rheumatic mitral valve stenosis. To compare long-term results of open mitral commissurotomy (Group A) and mitral valve replacement with bileaflet prostheses (Group B) a 15-year follow-up study was carried out. Methods: From January 1981 to May 1996, 540 consecutive patients with pure isolated rheumatic mitral stenosis underwent mitral valve surgery: 300 had mitral commissurotomy and 240 valve replacement. The follow-up was 99.05% complete and ranged between 1 and 185 months in Group A and from 1 to 171 months in Group B. Results: Hospital mortality was 2% in Group A and 2.08% in Group B. Late mortality was 1% in Group A and 3% in Group B. The 10-year survival rates were 98.7% ± 1% in Group A and 93.7% ± 3% in Group B. There was a statistically significant difference of freedom from reoperation in Group B (97.7% ± 1%) versus Group A (88.1% ± 2%) (P = 0.04). In group A 14 embolic events occurred (93.7% ± 2%) and 15 (6.52%) in Group B (83.9% ± 7%). Haemorrhagic events were observed in 2 patients (0.68%) of Group A (99.3% ± 0.5%) and in 3 patients (1.3%) of Group B (98.4% ± 1%). Conclusions: Long term results of mitral commissurotomy were more satisfactory than those obtained with bileaflet valves. Reoperation rate was higher in mitral commissurotomy.

Surgical approaches to postoperative mediastinitis that imply wire removal achieve earlier infection recovery but leave the patient with sternal instability. In 10 patients after wound surgical debridement, my colleagues and I achieved sternal synthesis by using Achilles tendons retrieved from multiorgan donors and stored in glutaraldehyde. Three tendons were used in each patient; they were passed through the bone at the manubrium and parasternally at the midsternum and the lower sternum. Thirty-day computed tomographic scan results, infection recovery, and quality of life were satisfactory.

Three hundred eighty-five valve prostheses were implanted between 1974 and 1981 in patients with isolated mitral disease: 157 caged-ball valves (156 Starr-Edwards; 1 Smeloff-Cutter) (group A), 107 tilting-disc valves (44 Bjork-Shiley, 49 Sorin, 14 Lillehei-Kaster) (group B), 121 porcine bioprostheses (45 Carpentier-Edwards, 66 Liotta, 10 Hancock) (group C). Perioperative mortality was 9.5% in group A, 11.2% in group B and 6.6% in group C. The follow-up was 86% complete. Actuarial freedom from complications was calculated as follows (linearised rates in brackets) in groups A, B and C, respectively: survival: 47.01% +/- 0.11 (3% patient/yr), 53.37% +/- 0.08 (1.8% patient/yr), 61.24% +/- 0.05 (2.2% patient/yr); thromboembolism: 67.94% +/- 0.09 (1.18% patient/yr); 73.07% +/- 0.06 (1% patient/yr); 97.43% +/- 0.02 (0.02% patient/yr); anticoagulation-related hemorrhage: 84.10% +/- 0.13 (0.18% patient/yr), 97.21% +/- 0.01 (0.12% patient/yr), 100%; prosthetic valve endocarditis: 100% in groups A and B, 95.76% +/- 0.02 (0.18% patient/yr) in group C; valve-related mortality: 87.52% +/- 0.03 (0.75% patient/yr), 87.96% +/- 0.03 (0.56% patient/yr), 82.53% +/- 0.04 (0.93% patient/yr); valve failure: 81.22% +/- 0.07 (0.56% patient/yr), 63.36% +/- 0.1 (1.06% patient/yr), 14.31% +/- 0.05 (4% patient/yr); treatment failure: 78.81% +/- 0.05 (1.12% patient/yr), 76.44% +/- 0.09 (0.62% patient/yr), 80.97% +/- 0.04 (1% patient/yr); all valve-related morbidity and mortality: 40.43% +/- 0.13 (1.93% patient/yr), 57.76% +/- 0.08 (1.43% patient/yr), 14.96% +/- 0.05 (4.18% patient/yr); all valve-related morbidity and mortality at 5 years: 91.97% +/- 0.02 (7.8% patient/yr), 87.06% +/- 0.03 (3.6% patient/yr), 90.27% +/- 0.03 (2.6% patient/yr); at 10 years: 80.4% +/- 0.03 (4.6% patient/yr), 75.91% +/- 0.03 (2.6% patient/yr), 37.44% +/- 0.05 (4.18% patient/yr).(ABSTRACT TRUNCATED AT 250 WORDS)

ObjectiveLeukocytes in allogeneic blood transfusions cause several immunomodulatory events. This before-and-after cohort study evaluated clinical outcomes after adoption of prestorage leukoreduction program for blood transfusions, with particular focus on acute kidney injury.MethodsOne thousand thirty-four consecutive patients who underwent on-pump coronary artery bypass grafting between January 2004 and December 2007 were included. Propensity score analysis for transfusion was performed in the whole population; patients who were actually transfused were then divided according to leukoreduction. From these 2 groups, 147 pairs matched for propensity score were considered to evaluate with bivariate and multivariable analyses the effects of leukoreduction, with all-cause in-hospital mortality and morbidity as main outcomes.ResultsUnadjusted in-hospital mortalities were 6.6% for the entire cohort and 44.2% for those with acute kidney injury. In the matched population, after introduction of leukoreduction, mortality rates decreased to 5.4% (vs 11.4%) and acute kidney injury (RIFLE [Risk, Injury, Failure, Loss of function, End-stage renal disease] class R or greater) dropped from 51.7% to 41.5% (relative risk −20%, P

The coexistence of a coronary artery obstructive disease (CAOD) with aorto-iliac obstructive disease (AIOD) often represents a surgical problem. Because of left main coronary disease (LMCOD) the contemporary correction of AIOD should be performed with a simple non traumatic procedure. The case of a high risk patient in whom aortoiliac obstructive disease has been corrected with the implantation of a bifurcated vascular prosthesis from the ascending aorta to the bilateral common femoral arteries, and with a double aorto-coronary by-pass, is reported.

Five clinical cases were treated with the implantation of an apical-aortic conduit. Two adult patients were affected by obstructive myocardiopathy associated to subaortic membrane in one case, and three children by different forms of aortic stenosis (subaortic tunnel in one case; subaortic tunnel associated to severe coartation of the thoracic aorta in one case; aortic annulus hypoplasia in one case). A double outlet left ventricle has been created in all cases by implanting a composite prosthesis between the apex of the left ventricle and the aorta. The extracardiac conduit consisted of an apical curved connector and a valved dacron tubular prosthesis. The site of implantation was the supraceliac abdominal aorta in three cases and the ascending aorta in two cases. All patients survived the operation and one late mortality was observed for cerebral bleeding. The surviving patients have been restudied with satisfactory data.

Background Perioperative management of post-infarction left ventricular free wall rupture (LVFWR) is not clearly standardized and surgical repair is the only therapeutic option. Role of off-pump surgery and stabilization with perioperative intraaortic balloon pumping (IABP) were here analysed. Methods Seven patients underwent surgery for LVFWR between 1990 and 2002. Clinical picture included electromechanical dissociation (3 patients) and sudden hypotension (4 patients). Except in one patient who was reanimated through femoro-femoral cardiopulmonary bypass, off-pump repair through on-lay patching technique was always performed. IABP was employed in the immediate postoperative period in five cases. Results A satisfactory hemodynamic state was restored in all cases and there were no reoperations for bleeding or rerupture. Hospital survival was 100%. One patient underwent successful surgical myocardial revascularization two months after LVFWR. Two patients died at follow-up. The survivors present with good NYHA and CCS functional classes. Conclusions When the anatomy of the LVFWR is favourable, off-pump external patching repair proves a good choice. Postoperative IABP provides satisfactory hemodynamic support.

We report a case of abdominal aortic aneurysm complicated by retroperitoneal fibrosis with both duodenal and bilateral ureteral obstruction. The patient underwent successful bilateral transurethral ureteral stenting, and then he was referred for surgical treatment of the aneurysm. Massive retroperitoneal fibrosis was found at surgery, and the mass was removed along with the diseased aorta, which was replaced by a bifurcated Dacron prosthesis; duodenolysis and ureterolysis were concomitantly performed. Ureteral stents were removed on the 8th postoperative day. Follow-up assessment at 1 year showed normalization of the urinary tract structure at echography and good hemodynamic performance of the vascular prosthesis at Doppler examination. To our knowledge, no other case of duodenal and bilateral ureteral stenosis secondary to massive retroperitoneal reactive fibrosis in association with abdominal aortic aneurysm has been reported. (Tex Heart Inst J 2003;30:311–3)