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An aneurysm of a single sinus of Valsalva is rare. It is usually asymptomatic and rarely discovered, unless it compresses the adjacent cardiac structures, or it presents in association with other pathology. We herein describe a case of a male, with known ischemic heart disease, collapsing after sudden back pain. A computed tomography scan demonstrated an aneurysm of the right sinus of Valsalva. The surgical repair aimed to exclude the aneurysm, preserving and reconstructing the aortic root.

The aim of this retrospective study was to evaluate the clinical outcome of treating or not treating moderate-or-more functional tricuspid regurgitation in patients with functional mitral regurgitation undergoing mitral valve surgery.From January 1988 to March 2003, 110 patients with functional mitral regurgitation undergoing mitral valve surgery showed moderate-or-more functional tricuspid regurgitation, which was treated (group T) in 51 and untreated in 59 (group UT) patients. Propensity score was used to adjust midterm results. The tricuspid valve was always repaired using the DeVega technique. The mitral valve was repaired in 84 and replaced in 26 patients; no residual moderate-or-more functional mitral regurgitation was assessed at hospital discharge.Thirty-day mortality was 5.5% (8.5% for group UT versus 2% for group T; p= 0.245). Adjusted 5-year survival was 45.0% +/- 6.1% in group UT and 74.5% +/- 5.1% in group T (p= 0.004), whereas the possibility to be alive in New York Heart Association class I or II was 39.8% +/- 6.0% in group UT versus 60.0% +/- 6.5% in group T (p= 0.044). Proportional Cox analysis, forcing propensity score into the model, demonstrated that untreated moderate-or-more tricuspid regurgitation was a risk factor for lower midterm survival (hazard ratio, 2.7; 95% confidence interval, 1.3 to 5.4) and survival in New York Heart Association class I or II (hazard ratio, 1.9; 95% confidence interval, 1.1 to 3.4). Follow-up functional tricuspid regurgitation progression rate (3+/4+) was 5% in group T versus 40% in group UT (p0.001). The progression of functional tricuspid regurgitation grade at follow-up was a risk factor for worse survival and the possibility to be alive in New York Heart Association class I or II.Tricuspid annuloplasty is an easy and safe procedure, mandatory in case of at least moderate functional tricuspid regurgitation to achieve better mid-term outcome in patients with functional mitral regurgitation undergoing mitral valve surgery.

Mitral valve repair for degenerative mitral regurgitation is nowadays one of the most common valvular procedures. Different technical modifications were added to the original Carpentier's method, trying to maximise the stability of the results and to reduce the incidence of immediate complications and of late failure of the correction. Survival is good, even if recent reports showed that recurrence of mitral regurgitation can be higher than expected. Prolapse of the anterior leaflet remains challenging and is related to higher reintervention rates. Nevertheless, the overall success rate is high, and the increasing experience of the different surgical teams approaching this procedure will help maintain satisfactory and stable long-term results.

Objective(s): We evaluated our experience to investigate if the use of bilateral internal mammary artery (BIMA) grafting, with or without complementary saphenous vein grafts (SVGs), if compared to the use of single IMA and SVG(s), increases the quality of the results of coronary bypass grafting in patients younger than 75 years who undergo first myocardial revascularization. Methods: From September 1986 to December 1999, 1602 patients younger than 75 years underwent first myocardial revascularization using left internal mammary (LIMA) to left anterior descending (LAD) and SVG(s) ðn ¼ 576Þ or BIMA (one IMA on the LAD) with or without SVG(s) ðn ¼ 1026Þ: Propensity score analysis was used to select 1140 patients with the same preoperative and operative characteristics. Thirty day outcome was evaluated as well as 10-year freedom from death by any cause, cardiac death, acute myocardial infarction (AMI), AMI in a grafted area (GA), redo/PTCA, redo/PTCA in a GA, target cardiac events (death from cardiac cause, AMI in a GA, redo/PTCA in a GA), and any event. Follow-up ranged from 3.5 to 16.8 years (mean 7.3 ^ 4.8 years). Results: Thirty day mortality was 2.8% in Group LIMA and 2.1% in Group BIMA, P n.s.; incidence of major complications was, respectively, 7.0 versus 5.4%, P n.s. Group BIMA showed better 10-year freedom from cardiac death (96.5 ^ 0.8 versus 91.3 ^ 1.4, P ¼ 0:0288), AMI (98.0 ^ 0.6 versus 94.3 ^ 1.2, P ¼ 0:0180), AMI in a GA (98.4 ^ 0.6 versus 94.7 ^ 1.1, P ¼ 0:0057) and target cardiac events (93.9 ^ 1.1 versus 86.3 ^ 1.8, P ¼ 0:0388). Cox analysis confirmed that LIMA þ SV(s) was an independent risk factor from lower freedom from cardiac death, AMI, AMI in a GA and cardiac events. Conclusions: As freedom from cardiac events is a main target of any revascularization procedure, we think that, when a patient undergoes a first coronary surgery and is younger than 75 years, BIMA grafting should not be denied, especially if his life expectancy is higher than 10 years. q 2004 Elsevier B.V. All rights reserved.

Our purpose is to describe a technique for exclusion of anteroseptal dyskinetic or akinetic areas.From January to December 2002, 22 consecutive patients with myocardial infarction following left anterior descending artery occlusion underwent septal reshaping. All of them were admitted for dyspnea. Eight patients were referred for angina. After a 5 to 8 cm apical incision, 2 U stitches were passed from inside to join the anterior wall to the septum, as high as possible, following the border of the scars. An oval Dacron patch was then sutured from the septum (end of the direct suture through the border with the inferior septum) to the anterior wall (between the healthy and the scarred wall) up to the new apex. Purpose of the procedure is to maintain a longitudinal size as similar as possible to the normal. The incision was closed in a double layer.No patient died and only one had acute renal failure. No patients had restrictive syndrome. After a mean follow-up of 6.7 +/- 3.6 months (3 to 15), mean New York Heart Association Class improved from 2.7 +/- 1.1 to 1.2 +/- 0.3 (p0.001). Echocardiographic results showed reduction of left ventricle volumes and normalization of the stroke volume. In patients with low ejection fraction (or=35%), left ventricular volumes decreased with a concomitant ejection fraction increase and a normal stroke volume. In patients with smaller cavities, significant reduction of left ventricular cavities was also obtained, with similar changes in ejection fraction and normal stroke volume.This technique treats all the dyskinetic or akinetic areas following left anterior descending artery occlusion, when the septal involvement is higher than the anterior free wall. Clinical and morphologic results are good.

J Thorac Cardiovasc Surg 2005;129:1440-1442 Contini, Carlo Di Lorenzo, Antonio Bivona and Gerardo Liberti Gabriele Di Giammarco, Michele Di Mauro, Marco Pano, Sergio Cirmeni, MarcoGiant metastatic myxoid liposarcoma of the mediastinum: A case report http://jtcs.ctsnetjournals.org/cgi/content/full/129/6/1440 located on the World Wide Web at: The online version of this article, along with updated information and services, is

ObjectivesWe evaluated results of an echocardiographically based strategy combining mitral annuloplasty with other procedures to treat chronic ischemic mitral regurgitation.MethodsFrom March 2006 to February 2009, 147 patients underwent mitral valve surgery for chronic ischemic mitral regurgitation. Mean effective regurgitant orifice was 36 ± 11 mm2, and ejection fraction was 35% ± 9%. On the basis of echocardiographic findings, in 10 cases a prosthesis was inserted and mitral annuloplasty was performed in 137 cases, isolated in 83, associated with chordal cutting in 12 cases (in 5 anterior leaflet was augmented with pericardial patch), and with exclusion of anteroseptal (n = 35) or inferior (n = 7) scars in 42.ResultsThirty-day mortality was 4.8%; 3-year survival was 86% ± 3%. None of the 126 survivors were in New York Heart Association functional class III or IV. Among 117 survivors of mitral valve repair, after 18 ± 6 months mean effective regurgitant orifice reduced from 34.1 ± 10.2 mm2 to 2.3 ± 0.4 mm2 (P

Background: The purpose of this study was to evaluate the impact of untreated moderate-or-more functional tricuspid regurgitation (FTR) on mid-term outcome of patients with functional mitral regurgitation (FMR) undergoing mitral valve surgery (MVS). Methods: From January 1988 to April 2003, 165 patients having FMR underwent MVS with untreated FTR. Patients with organic mitral or tricuspid valve disease were excluded. The entire population was divided into two groups, group A: 102 patients (FTR 0/1+), group B: 63 patients (FTR 2+/ 3+). No statistical difference was found between two groups concerning preoperative and operative variables. MV was repaired in 137 and replaced in 28 cases; the impact of untreated moderate-or-more FTR was estimated by Cox analysis. Results: Thirty-day mortality was 6.7 (5.9% group A vs 7.9% group B, p = 0.607). Five-year actuarial survival was 73.5% (66.6—80.4%); 88.2% (83.0—93.4%) group A versus 46.0% (33.7—58.3%) group B, p < 0.001; the possibility to be alive in NYHA class I—II was 65.8% (58.4—73.2%); 78.4% (72.3—84.5%) group A versus 41.2% (29.1—53.3%) group B, p < 0.001. Cox analysis confirmed the impact of untreated moderate-or-more FTR on 5-year survival (HR = 3.1, 95% CI = 1.8—5.1, p < 0.001) and possibility to be alive in NYHA class I—II (HR = 3.0, 95% CI = 1.8—4.9, p < 0.001). After a median interval time of 28 months (IQR = 11—60), TR grade was echocardiographically assessed in 122 (79.2%) of 154 patients surviving the first month. In group A (87 patients), TR grade decreased significantly from 0.7 0.5 to 0.3 0.5 (p < 0.001) in the early postoperative period. Then, it increased again to 0.6 0.7 at follow-up (p < 0.001); no difference was found between preoperative and follow-up time (p =n s). In group B (35 cases), TR grade decreased significantly from 2.2 0.4 to 1.3 0.7 in the early postoperative period (p < 0.001), but then increased again to 2.2 0.9 (p < 0.001 vs postoperative value; p = 0.838 vs preoperative value). Cox analysis confirmed that the progression of TR grade at follow-up is a risk factor for lower survival and possibility to be alive in NYHA class I—II. Conclusions: Patients with untreated moderate-or-more FTR had survival and survival in NYHA class I—II lower than patients with untreated less-than-moderate FTR at 5-year follow-up.

Our aim was to evaluate midterm results in patients who underwent mitral valve repair (MVR) for ischermic mitral regurgitation (IMR) in our most recent experience. From March 2006 to March 2008, 105 patients underwent MVR for IMR. Mean IMR grade was 2.6 ± 1.1, with 46 patients having ≤2/4 and 59 ≥3/4. Five patients (4.8%) died within first month; Two-year freedom from death any cause was 85.5% ± 3.8, freedom from cardiac death was 88.7% ± 3.4. NYHA Class of the survivors was 1.3 ± 0.6, with 3 patients in NYHA Class III. Freedom from death any cause and NYHA Class III-IV was 78.6% ± 4.6. IMR grade decreased from 2.6 ± 1.1 to 0.1 ± 0.3 at the discharge and to 0.5 ± 0.3 after a mean of 7 ± 4 months, with no patient with IMR grade 3/4 or 4/4. MVR for IMR should be performed in patients with moderate-or-more IMR grade or when the MV is excessively dilated, to achieve good midterm results.

Objective This study was undertaken to evaluate long-term results of bilateral internal thoracic artery grafting with saphenous vein or another arterial conduit as the third conduit. Methods From September 1991 to December 2002, a total of 1015 patients underwent first isolated coronary artery bypass grafting for triple-vessel disease, with bilateral internal thoracic artery plus saphenous vein in 643 cases and bilateral internal thoracic artery plus arterial conduit in 372. A nonparsimonious regression model was built to determine propensity score, then sample matching (saphenous vein vs arterial conduit) was performed to select 885 patients (590 with saphenous vein, 295 with arterial conduit). Groups had similar preoperative and operative characteristics. Results Eight-year freedoms from cardiac death were significantly higher when saphenous vein was used (98.6% ± 0.5% with saphenous vein vs 95.3% ± 1.3% with arterial conduit, P = .009), but this difference was related exclusively to right gastroepiploic artery grafting (94.5% ± 1.6% vs saphenous vein, P = .004). This difference disappeared for radial artery grafting (97.6% ± 1.6% vs saphenous vein, P = .492). Cox analysis confirmed that supplementary gastroepiploic artery was an independent variable for lower freedoms from all-cause mortality and from cardiac death. Presence of high-degree stenosis (80%) appeared to influence this result. Conclusions In patients with triple-vessel disease undergoing first isolated coronary artery bypass grafting, supplementary venous grafts seem to provide more stability than gastroepiploic artery, which may even impair long-term outcome.

Background: Different techniques have been proposed to measure the correct length of artificial chordae. We herein describe a new simple method to measure the chordal length in complex chordal replacement. Method: Chordal replacement was used by us for two different purposes: (1) to maintain the correct chordal length for the anterior leaflet (AL) and (2) to eliminate any movement of the posterior leaflet (PL) to fix it. To reach this goal, the AL is pulled up to the maximum extent and the new chordae are tied 5 mm higher than the related border. On the contrary, in the PL the new chordae are tied at the level of the related border. Results: From March 2006 to March 2007, at the University of Catania, this technique was used in 32 patients (16 for correction of PL prolapse, 6 patients for correction of AL prolapse, and in 10 patients for correction of both leaflets prolapse). The number of chordae per patients was 8.6 for the PL and 6.8 for the AL. No patient died or had major complications. After a mean follow-up of 5 ± 2 months, two-dimensional echocardiography showed that all the patients had no or trivial mitral regurgitation (MR). The echocardiogram showed a correct movement of the new chordae. Conclusions: This technique allows to easily establish the length of the new chordae of the AL and, if necessary, of the PL in complex mitral valve repair.

Background We evaluated the impact of ischemic mitral regurgitation (IMR) on long-term outcome of patients with an ejection fraction (EF) exceeding 0.30 undergoing isolated coronary artery bypass grafting (CABG). Methods From November 1994 to December 2002, 4226 patients (EF > 0.30) underwent a first isolated CABG. Preoperative IMR was present in 1421 (33.6%, group IMR), of which 1254 had mild (1/4) and 167 had moderate (2/4). The remaining 2805 patients (66.4%, group no-IMR) showed no IMR. A nonparsimonious regression model was built to determine the propensity score. Ten-year freedom from death from any cause, cardiac death, and cardiac events was evaluated by the Kaplan-Meier method. Results of Cox analysis were adjusted by entering the propensity score as an independent variable. Results All patients had similar early mortality (2.1% no-IMR vs 2.5% IMR, p = 0.502) and morbidity (6.5% no-IMR vs 6.6% IMR, p = 0.840). In patients with EF of 0.31 to 0.40, but not in those ones with EF exceeding 0.40, IMR grade was an independent variable for worse long-term freedom from cardiac death (82.8 ± 3.2 vs 91.4 ± 2.4; Cox hazard ratio [HR], 2.1 [95% confidence interval (CI), 1.1 to 4.1]; p = 0.0324) and cardiac events (78.6 ± 3.5 vs 88.5 ± 2.7; Cox HR, 2.0 [95% CI, 1.1 to 3.7]; p = 0.0174). Conclusions Mild or moderate IMR in patients with an EF exceeding 0.30 undergoing first isolated CABG influences long-term outcome when EF is 0.31 to 0.40, but not when it exceeds 0.40.

BACKGROUND The aim of this study was to evaluate in elective patients the early and midterm results of partial clamping of the brachiocephalic trunk (BCT) for total ascending aorta replacement (TAAR) without circulatory arrest. Contraindications to the procedure were BCT/aortic arch calcifications and chronic aortic dissection. METHODS The right radial artery was cannulated to monitor the systemic pressure after the BCT was partially clamped. A specially designed clamp was applied obliquely to occlude approximately 50% of the BCT and part of the aortic arch. The distal tip of the clamp was positioned in front of the left subclavian artery. From January 2002 to October 2003, 92 patients underwent TAAR. In 62 patients (67.4%), partial clamping of the BCT was used. Twenty of these patients underwent isolated TAAR, 27 underwent aortic valve replacement and TAAR, 11 had a Bentall operation, and 2 had a Cabrol operation. The aortic valve was spared in the remaining 2 patients. The mean (+/- SD) aortic cross-clamping and cardiopulmonary bypass times were 96 +/- 31 minutes and 116 +/- 43 minutes, respectively. RESULTS Early mortality was 1.6% (1 patient). No cerebrovascular accidents occurred, demonstrating the safety of the technique. The major complications were acute respiratory insufficiency in 2 cases and acute renal failure in 5. The mean follow-up time was 9.0 +/- 6.5 months. The mean 18- month and event-free survival rate was 96.6% +/- 0.9%. CONCLUSION Partial clamping of the BCT for TAAR without circulatory arrest provides good early and midterm clinical results. Aortic arch clamping is not associated with cerebrovascular accidents.

The prospect of grafting the internal mammary artery (IMA) to the left anterior descending (LAD) artery via a thoracotomy without the aid of cardiopulmonary bypass (CPB) was first explored by Kolessov in 1967 (1), and further applied by Favaloro (2), Garrett (3), Trapp (4), and others. The early wave of enthusiasm for this technique soon wavered with the widespread availability of CPB and cardioplegia, which allowed for a motionless and bloodless operative field. The unequivocal and widespread success of conventional coronary artery bypass grafting (CABG) limited the use of unsupported bypass grafting. Two developments in the early 1990s revived the technique of myocardial revascularization without CPB: (1) the emergence of minimally invasive technology applicable to the chest, and (2) the promising results of “pumpless” bypass grafting reported by a number of authors (5–7).

We evaluated our experience to investigate if the use of bilateral internal mammary artery (BIMA) grafting, with or without complementary saphenous vein grafts (SVGs), if compared to the use of single IMA and SVG(s), increases the quality of the results of coronary bypass grafting in patients younger than 75 years who undergo first myocardial revascularization.From September 1986 to December 1999, 1602 patients younger than 75 years underwent first myocardial revascularization using left internal mammary (LIMA) to left anterior descending (LAD) and SVG(s) (n=576) or BIMA (one IMA on the LAD) with or without SVG(s) (n=1026). Propensity score analysis was used to select 1140 patients with the same preoperative and operative characteristics. Thirty day outcome was evaluated as well as 10-year freedom from death by any cause, cardiac death, acute myocardial infarction (AMI), AMI in a grafted area (GA), redo/PTCA, redo/PTCA in a GA, target cardiac events (death from cardiac cause, AMI in a GA, redo/PTCA in a GA), and any event. Follow-up ranged from 3.5 to 16.8 years (mean 7.3+/-4.8 years).Thirty day mortality was 2.8% in Group LIMA and 2.1% in Group BIMA, P n.s.; incidence of major complications was, respectively, 7.0 versus 5.4%, P n.s. Group BIMA showed better 10-year freedom from cardiac death (96.5+/-0.8 versus 91.3+/-1.4, P=0.0288), AMI (98.0+/-0.6 versus 94.3+/-1.2, P=0.0180), AMI in a GA (98.4+/-0.6 versus 94.7+/-1.1, P=0.0057) and target cardiac events (93.9+/-1.1 versus 86.3+/-1.8, P=0.0388). Cox analysis confirmed that LIMA+SV(s) was an independent risk factor from lower freedom from cardiac death, AMI, AMI in a GA and cardiac events.As freedom from cardiac events is a main target of any revascularization procedure, we think that, when a patient undergoes a first coronary surgery and is younger than 75 years, BIMA grafting should not be denied, especially if his life expectancy is higher than 10 years.

The impact of myocardial revascularization without cardiopulmonary bypass (CPB) was evaluated in a series of consecutive patients with multivessel disease.From May 21, 1997 to November 30, 2000, 1,843 consecutive patients underwent isolated myocardial revascularization. From this total, 919 patients were done without CPB (group A, 49.9%) and 924 patients were done with CPB (group B, 50.1%). Patients that converted from without CPB to with CPB were included in group A. Thirty-three variables were evaluated with univariate and multivariate analysis to identify the independent variables predictive of higher incidence of early mortality, acute myocardial infarction, cerebrovascular accident, and early major events.Early mortality was 2.2% (group A, 1.4%; group B, 3.0%; p = 0.016), acute myocardial infarction incidence was 1.8% (group A, 1.1%; group B, 2.6%; p = 0.027), cerebrovascular accident incidence was 0.9% (group A, 0.8%; group B, 1.0%; p = not significant), and early major events incidence was 6.7% (group A, 5.3%; group B, 8.2%; p0.001). Stepwise logistic regression analysis showed that CPB was an independent risk factor for higher mortality (odds ratio, 2.2; p = 0.0217), higher incidence of acute myocardial infarction (odds ratio, 2.5; p = 0.0185), and higher incidence of early major events (odds ratio, 1.8, p = 0.0034).When CPB was not used, patients experienced lower early mortality and incidences of acute myocardial infarction were less complicated, both at univariate analysis and stepwise logistic regression analysis.