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Background and aim: We present our experience in the use of right gastroepiploic artery (rGEA). Long-term clinical results are reported. Methods: From April 1994 to June 2005, 271 patients (257 males, mean age 56.2 +/- 7.1) underwent coronary artery bypass grafting with the use of rGEA. Preoperative, perioperative, and postoperative data were retrospectively collected and clinical results and survival were examined. The end points of follow-up were death and recurrence of cardiac events such as angina and myocardial infarction (MI). The mean follow-up was 8.2 +/- 2.9 years. Results: Left ventricular ejection fraction ranged from 0.20 to 0.68 (mean 0.55 +/- 0.7). The mean cardiopulmonary bypass time was 96.8 +/- 15.8 minutes and the mean cross-clamping time was 69.7 +/- 14.2 minutes. The mean number of distal anastomosis was 3.3 +/- 0.7 (range 2 to 5). Early mortality was 2.6% and postoperative MI occurred in three patients. There were 21 (7.9%) late deaths and three of them (1.2%) were cardiac related. Actuarial 10-year-survival of all deaths, including in-hospital death, was 70.8%+/- 9.9%. No abdominal complications occurred during or after rGEA harvesting. Seven patients have been suffering of recurrence of angina. Angiography was performed only on those patients with recurrent angina. Conclusion: The rGEA can be considered as a valid arterial conduit, relatively easy to harvest, safe to use with low perioperative risks, and good mid- and long-term results. The low early and late rate mortality and the satisfactory clinical results are good reasons for using routinely this conduit in selected patients. [ABSTRACT FROM AUTHOR]

Adult patients supported on extracorporeal membrane oxygenation (ECMO) are very sick and many complications are often present in each single patient; therefore, it is not always easy to find some risk factors that can predict the early outcome. This retrospective study reports our experience in ECMO support treatment in adult cardiac patients suffering from cardiac failure (CF) in which one or more predictive factors of 30-day mortality were analyzed. Between January 2002 and August 2009, 42 consecutive adult cardiac patients with cardiogenic shock (mean age 64.3+/-11.3 years) were supported on ECMO for >2 days. They were divided into patients who had a survival <30 days (n=20) and patients who survived >30 days (n=22). Twenty-nine patients (69%) survived on ECMO. Sixteen patients were discharged with a survival rate of 38.1%. The overall mean ECMO duration was 7.9+/-5.3 days. The following variables were significantly different between the two groups: number of platelets and packed red blood cells (PRBCs) transfused per day during ECMO (P=0.002 and P=0.003), blood lactate levels 48 h and 72 h after the initiation of ECMO (P=0.01 and P=0.04), indexed blood flow after 48 h and 72 h (P=0.01 and P<0.0001), liver failure (P=0.001) and multiorgan failure (P=0.002). Stepwise logistic regression identified that blood lactate levels at 48 h and number of PRBCs transfused were associated with 30-day mortality [P=0.019, odds ratio (OR) =2.16; 95% confidence interval (CI)=1.13-4.14 and P=0.008, OR=1.08; 95% CI=1.02-1.14, respectively]. The predicted probability of mortality would be 52% when blood lactate levels are >3 mmol/l after 48 h. The blood lactate level at 48 h and PRBCs transfused per day can be considered as important parameters to predict the mortality in adult cardiac patients supported by ECMO for CF., (2010 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objective: A trigone-to-trigone semirigid annuloplasty band (C-G Future Band, Medtronic, Inc., Minneapolis, Minnesota, USA) was introduced in 2001 for mitral valve repair. We report our early clinical and echocardiographic results with this new device to correct ischemic mitral regurgitation., Methods: Between January 2002 and December 2004, among 216 patients operated on for mitral regurgitation, 107 patients had a C-G Future Band annuloplasty and 85 consecutive patients (72.6% male; mean age 66.9 +/- 8.6 years) received this annuloplasty band to correct ischemic mitral regurgitation. Mean follow-up was 14.3 +/- 9.8 months (range 0.2-37 months). Clinical and echocardiographic assessment was accomplished preoperatively, postoperatively, at 6 and 12 months, and at two years., Results: Perioperative mortality was 3.7% (three in-hospital deaths), whereas overall survival at two years was 88.7 +/- 4.2%. Immediately after repair, echocardiographic mitral regurgitation was dramatically reduced (2.5 +/- 0.6 vs. 0.9 +/- 0.6; P < 0.0001); ejection fraction increased from 43.8 +/- 11% preoperatively to 44.8 +/- 12% postoperatively (P = 0.007). At the time of follow-up, New York Heart Association (NYHA) functional class was significantly improved (mean preoperative NYHA class 2.04 +/- 0.9 vs. mean postoperative NYHA class 1.25 +/- 0.6; P < 0.0001). No patient experienced thromboembolic events and no late mitral valve reoperation occurred., Conclusions: Early and mid-term mitral valve function is satisfactory with trigone-to-trigone semirigid band annuloplasty, with excellent repair durability immediately after the operation and at two years. Moreover, after annuloplasty repair, an improvement in clinical functional status is obtained. A wider use of this semirigid annuloplasty band can be recommended.

Background: Recently, L-arginine has been added to cardioplegia to limit myocardial ischemic damage. The mechanism of action is related to the production of nitric oxide, with vasodilatation and reduction of endothelial dysfunction. Our prospective randomized study on coronary artery bypass patients investigates the effect of L-arginine on myocardial stress as expressed by myocardial cytokines release and myocardial ischemia in terms of troponin T concentration., Methods: Coronary artery surgery patients were randomly assigned to receive 7.5 g L-arginine in 500 mL of cardioplegic solution (group A). Group B was used as control. Cold blood 4:1 anterograde and retrograde cardioplegia with warm induction was administered. Blood samples were collected from the retrograde coronary sinus catheter to determine interleukin-2 receptor, interleukin-6, and tumor necrosis factor levels. Serum samples at different time points were also analyzed to measure myocardial ischemia markers. Hemodynamic and echocardiographic evaluations were obtained perioperatively., Results: Sixty-five patients were enrolled (group A, treated with L-arginine, n = 33; group B, control, n = 32). Wedge pressure and intensive care unit stay were significantly reduced in group A (p = 0.023 and p = 0.03, respectively). Cytokines levels were lower in group A, with a significance for interleukin-6 (p = 0.026); troponin T was reduced in treated patients (0.33 versus 0.57 ng/mL at 18 hours: p = 0.009)., Conclusions: Coronary artery surgery patients benefit from L-arginine cardioplegia supplementation in terms of reduced inflammatory reaction, limitation of myocardial ischemia, and better hemodynamic performance. Moreover, a clinical advantage is evident in terms of a shorter intensive care unit stay in patients treated with L-arginine.

Background: Arterial spasm is described as an event occurring after left internal thoracic artery (LITA) harvesting. Many vasodilators have been used to treat or prevent LITA spasm. The aim of this study is to compare the effects between glyceril-trinitrate/verapamil (GV) solution and papaverine to treat LITA spasm and to determine the best delivery method., Methods: One hundred consecutive ischemic patients were randomly assigned to three groups: group GV (n = 34, GV solution), group P (n = 33, papaverine), or group C (n = 33, normal saline). In each patient, pedicled LITA was harvested, thereafter sprayed with the randomized solution, and covered with a sponge. Fifteen minutes after heparin administration, LITA was distally divided; flow per minute was calculated after measuring the free flow for over 15 seconds; this is named "topical free flow." Then, the vasodilator was injected intraluminally and free flow per minute was measured; this is called "intraluminal free flow.", Results: Analysis of variance was applied to detect differences among groups; paired-sample t test was used for LITA topical free flow versus intraluminal free flow within single groups. Mean LITA free flows were as follows: group GV, topical free flow = 38.6 +/- 25.2 mL/min versus intraluminal free flow = 58.8 +/- 29 mL/min (p < 0.0001); group P, topical free flow = 45.4 +/- 38.9 mL/min versus intraluminal free flow mL/min (p < 0.0001); group C, topical free flow = 31.6 +/- 19.9 mL/min versus intraluminal free flow = 34 +/- 19.8 mL/min (p = 0.14). Topical free flow difference among the three groups was not statistically significant (p = 0.1); intraluminal free flow difference was statistically significant (p = 0.001). Intraluminal free flow in group GV and in group P were higher than intraluminal free flow in group C (p = 0.004 and 0.001, respectively). Intraluminal free flow of group P was higher than that of group GV; this difference did not reach statistical significance (p = 1.00)., Conclusions: Glyceril-trinitrate/verapamil solution and papaverine are able to treat the spasm and increase the flow of the LITA, when they are used intraluminally. When used topically, these vasodilator agents do not ensure an optimal free flow.

Background: Many studies confirm that beating heart surgery is an alternative to on-pump myocardial revascularization. However, the clinical conditions of patients are currently considered as a major landmark in the indication for beating heart surgery. This retrospective non-randomized study was carried out to evaluate the efficacy and the advantages of this surgical technique when anatomical criteria are used to choose the surgical strategy., Methods: From February to December 2003, 222 consecutive patients underwent isolated myocardial revascularization: 76 (34%) with an off-pump coronary artery bypass (OPCAB) and 146 (66%) with an on-pump coronary artery bypass (ONCAB) procedure. Selection for surgical treatment was based on coronary anatomy. All patients were stratified for mortality risk class according to the EuroSCORE system. Operative and postoperative data were analyzed., Results: Morbidity and mortality did not differ significantly between the two groups but the release of creatine kinase-MB fraction was significantly higher in the ONCAB group (48.7 +/- 55.3 vs 20.8 +/- 16.6 U/ml, p < 0.001). Patients at high surgical risk were dealt with a more complicated clinical outcome; logistic regression analysis showed that this class was an independent risk factor for postoperative complications in both groups., Conclusions: We did not find any statistical difference in hospital mortality and morbidity either using ONCAB or OPCAB; however a lower release of creatine kinase-MB in beating heart revascularization group suggests that OPCAB reduces myocardial injury and preserves cardiac function when anatomical criteria are considered for patient selection.

Background: Controversies still exist over the optimal temperature for blood cardioplegia and systemic perfusion. This study investigates the effect of temperature of blood cardioplegia and systemic perfusion on the release of troponin I and other biochemical markers., Methods: One hundred and fifty-four consecutive patients were randomly assigned to one of two cardioplegic and systemic perfusion strategies of cold blood cardioplegia with moderate systemic hypothermia (27 degrees C) or tepid blood cardioplegia with mild systemic hypothermia (33 degrees C). Cardiac troponin I and other biochemical markers were measured at baseline, at the end of surgery, at 12 hours and daily thereafter. A two-way ANCOVA for repeated measure was performed to test the effect of cardioplegia on enzyme release independently of variables that were different between the two groups., Results: The time course of dismission of troponin I, creatine kinase MB, and lactate dehydrogenase were significantly lower with tepid blood cardioplegia and mild systemic perfusion independently of the number of distal anastomoses, CPB time, cross clamp time or total volume of cardioplegia. There were no differences between the two groups in the release of total creatine kinase, aspartate transaminase and alanine transferase., Conclusions: Both strategies of myocardial protection and systemic perfusion guarantee subclinical minor myocardial damage. The strategy of tepid whole blood cardioplegia and mild systemic hypothermia seems to preserve myocardium better than whole blood cold cardioplegia.

The increasing number of coronary operations performed on a beating heart has prompted the development of new techniques and instruments to expose the coronary arteries without major hemodynamic derangements. We describe an expandable surgical pad combined with a series of tapes that help to control rotations and positioning of the heart. The empty surgical pad is fixed at the bottom of the pericardial cavity. After injection of warm saline, the pad elevates and displaces the heart, and the tapes rotate and immobilize the heart in the desired position. Easy access to all coronary arteries with minimal effect on hemodynamics is possible.

This report describes the different clinical and instrumental manifestations of coronary ischemia in a patient with left main coronary artery atresia. Exercise test and thallium-201 perfusion scintigraphy during isometric exercise test were negative for angina and electrocardiographic changes. Conversely, dipyridamole infusion caused severe angina, marked ST-segment changes and diffuse thallium-201 uptake abnormalities. This peculiar anatomical condition offers the opportunity of high-lighting the role played by the microcirculation in determining myocardial ischemia.

We report the case of a 23-year-old man who was admitted to our Division with the diagnosis of pericardial lipoma. Chest X-ray, echocardiography and magnetic resonance imaging failed to reveal an anterior diaphragmatic hernia containing a small part of the stomach with a big prehernial lipoma that were found at surgery. We believe that in all cases of suspected pericardial lipoma a diaphragmatic hernia should be expected.

Background: The Fogarty thromboembolectomy (TE) has been considered for a long time the best treatment for acute peripheral arterial occlusion. However, recently new therapeutic options like thrombolytic agents (local or systemic) have been introduced., Methods: A total of 66 patients who underwent Fogarty TE for acute thromboembolic limb ischemia has been retrospectively studied. Patients with documented atherosclerotic pathology who were treated with other revascularization procedures were excluded. Patients were divided into four groups: 1) upper limb embolism, 2) lower limb embolism, 3) thrombosis on atherosclerotic plaque or on a graft, 4) post-traumatic thrombosis. Twelve patients underwent Fogarty TE for upper limb thromboembolic ischemia and 54 for lower limb; 57.5% of patients had atrial fibrillation., Results: Procedures were successful in 59 patients (89.4%). Further surgical procedures (bypass, arterioplasty, further embolectomy) were performed in 35.1% (19/54) of patients of groups 2 and 3 with acute lower limb ischemia. Results were very good in group 1 and 4. Seven of the 54 patients treated for lower limb ischemia underwent limb amputation (12.9%), while hospital mortality was similar for lower and upper limb (31.4 and 33.3% respectively)., Conclusions: The Fogarty TE is still a good option to revascularize acute ischemic peripheral arteries with good results in a high number of patients and should be particularly used where it is possible to perform additional techniques in case of failure.

Background: Many novel techniques have been described for "minimally invasive" congenital cardiac operations to achieve an improved cosmetic result. There is little information on incorporation of such techniques into fast-track congenital heart operations., Methods: We have developed an approach to fast-track congenital heart operations, which includes a cosmetic approach for repair of congenital heart defects without sacrificing adequate exposure or requiring specialized equipment, along with a simple approach to intraoperative anesthetic management that allows extubation in the operating room. The heart is exposed through a short midline skin incision and a full median sternotomy. The conventional technique of cannulation is performed. Between October 1997 and January 1999, 88 patients were operated on with this method. Cardiac anomalies included simple and complex ostium secundum atrial septal defect, sinus venous atrial septal defect, partial atrioventricular septal defect, simple and complex ventricular septal defect, and bicuspid aortic valve stenosis., Results: There were no operative or late deaths. The majority of patients were extubated in the operating room or within 2 hours of operation. No patient underwent reoperation and the mean length of hospital stay was 3.9 days. Sternal instability or wound infection were not observed., Conclusions: We believe that our approach to fast-track congenital heart operation is safe and effective. The surgical technique provides good exposure and has excellent cosmetic results. Moreover, it is easy to learn and, if necessary, the surgeon can quickly gain direct access to the heart. The anesthetic management facilitates early tracheal extubation and a shorter duration of postoperative stay.

Background: The incidence of coronary artery disease in patients with dextrocardia associated with situs inversus is similar to that of the general population: Nevertheless, there are few papers regarding surgical myocardial revascularization in these patients., Methods: We report two patients with dextrocardia and situs inversus who underwent myocardial revascularization by means of coronary artery bypass grafting, with the right internal mammary artery to the left anterior descending coronary artery in one case and with the left internal mammary artery as a free graft to the left anterior descending coronary artery associated with the repair of an aneurysm of the right coronary sinus of Valsalva in the second patient., Results: There were no surgical complications; the patients were discharged on the 4th and 7th postoperative days, respectively. They are alive and well after 24 and 60 months of follow-up respectively., Conclusions: This report suggests that durable myocardial revascularization in dextrocardia with situs inversus can be successfully achieved with right or left mammary artery bypass grafting to the left anterior descending coronary artery. The advantage of using an in situ mammary artery is discussed.

Background: Experimental studies indicate that isoflurane, a commonly used volatile anesthetic, mimics the cardioprotective effects of ischemic preconditioning, probably through ATP-sensitive K+ (KATP) channel activation. The aim of this study was to evaluate the impact of isoflurane during coronary bypass surgery (CABG) on troponin I release., Material and Methods: Forty consecutive patients with chronic stable angina and multivessel disease undergoing isolated CABG were randomized to a control (16 men and 4 women, aged 51 to 73 years, mean 62) or isoflurane (15 men and 5 women, aged 51 to 77 years, mean 65) group before aortic cross-clamping and cardioplegia. Serum levels of troponin I and creatine kinase (CK)-MB, as markers of ischemic injury, were obtained at 24 hours after CABG. Regional wall motion score and left ventricular ejection fraction (LVEF) at transthoracic echocardiography were assessed 5 days postoperatively. Comparisons between groups were performed in the entire population and, subsequently, in those patients with preoperative LVEF < 50%., Results: There were no significant differences between isoflurane-treated patients and controls in cross-clamp time (49 +/- 14 vs 51 +/- 13 min, p = ns), peak values of troponin I (0.9 +/- 0.7 vs 1.4 +/- 1.3 ng/ml, p = ns) and CK-MB (62 +/- 27 vs 64 +/- 27 U/l, p = ns), or postoperative echocardiographic score (26 +/- 7 vs 22 +/- 5, p = ns) and LVEF (53 +/- 10 vs 55 +/- 7%, p = ns). When the comparisons were restricted to those patients with preoperative LVEF < 50%, at 24 hours the isoflurane-treated patients exhibited a smaller release of troponin I and of CK-MB than controls (1.1 +/- 0.7 vs 2.3 +/- 1.3 ng/ml, p = 0.03, and 39 +/- 10 vs 57 +/- 22 U/l, p = 0.04, respectively)., Conclusions: Isoflurane reduces myocardial injury in patients with impaired left ventricular function undergoing CABG; thus, it can be safely used as an additional cardioprotective tool during routine CABG in high-risk patients with poor left ventricular function.

We report a case of cardiac echinococcosis in a patient who had sustained an acute myocardial infarction 1 month previously. The coronary angiographic study revealed an isolated complete intrinsic obstruction of the left anterior descending coronary artery in the area of the cyst. The cyst was surgically removed. Coronary artery bypass grafting was not performed because of distal myocardial scarring. Coronary arteriography should routinely be performed in all patients with cardiac echinococcosis.

The presence of coronary artery disease (CAD) evaluated with coronary angiography and eventual correction of CAD in abdominal aortic aneurysm (AAA) patients has been considered the main determinant of early and late outcome after AAA repair. This study reports our experience in CAD and AAA patients in terms of diagnosis and therapy of CAD. In a population of 126 patients (122 males, 4 females, mean age 67.5 years, range 37-81) who were candidates to elective repair for AAA with a diameter > or = 5 centimeters, we included coronary arteriography in 1) patients who were symptomatic for angina (15.9%); 2) patients with previous myocardial infarction (33.3%); 3) patients with previous coronary artery bypass (4%). We identified a group of 45 patients (35.7%) with significant CAD who had been treated before AAA surgery by coronary artery bypass grafting (CABG) in 37 cases or percutaneous coronary angioplasty (PTCA) in 8 cases. AAA repair was performed during the same hospital stay or at a later date. We did not report any morbidity and mortality related to cardiac or vascular procedures. We believe that among patients reporting cardiac symptoms (previous myocardial infarction, angina) the incidence of surgically-correctable CAD is not negligible (45/67, 67.2%). Therefore, invasive coronary study is strongly suggested in such cases to reveal and treat an eventual coronary artery stenosis prior to AAA repair. The absence of cardiac morbidity and mortality related to cardiac and vascular procedures supports this approach.

Background and Aims: Carotid endarterectomy (CEA) is often carried out to prevent cerebrovascular strokes. It is obviously important that neurological morbidity of the procedure is contained within acceptable limits (< 2%)., Methods: Between January 1991 and December 1997 a total of 239 CEA were performed in 216 patients (169 males and 47 females, mean age 66.6 +/- 14.2 years; range 43-81). Angioplasty was carried out using a precoagulated Dacron patch, except in cases in which the residual diameter of the internal carotid artery was greater than 5 mm. A Javid shunt was used selectively if stump pressure < 50 mmHg., Results: No major neurological complications were observed. A reversible focal neurological deficit was reported in 3 cases (1.2%). Neurological morbidity correlated to peripheral arterial occlusive disease appears to be correlated mainly with technical reasons or cerebral ischemia following clamping., Conclusions: The extensive use of angioplasty with patch and the selective use of a protective shunt improve the technical success rate of surgery, significantly helping to limit morbidity.

Background: Intracoronary stenting, conventional coronary artery bypass with cardiopulmonary bypass and minimally invasive direct coronary artery bypass without extracorporeal circulation are the three accepted options for revascularizing the left anterior descending coronary artery. We compare the effects of these three procedures in terms of minor myocardial damage and systemic inflammatory response., Methods: Ninety patients undergoing left anterior descending coronary artery revascularization with these three different techniques (thirty patients per group) were considered. Blood samples were collected preoperatively and immediately postoperatively, and then 24, 48 and 72 hours after the procedures to measure troponin I, creatine kinase, its MB fraction and C-reactive protein levels., Results: Postoperative levels of troponin I and MB-creatine kinase were significantly higher in conventional coronary grafting group than in PTCA-stent and in the minimally invasive surgery groups (p < 0.0003), while in both surgery groups there were higher post-operative levels of total creatine kinase and C-reactive protein (p = 0.0001)., Conclusions: Minimally invasive direct coronary artery bypass surgery and PTCA-stent are similar in terms of virtual absence of minor myocardial damage. Skeletal muscle damage and inflammatory reaction are comparable in surgical patients, but they do not appear to have any clinical relevance.

We report the case of a woman, age 65 years, who was admitted to our hospital for intense abdominal pain. Hemoglobin was 9.7 g/100 ml and computed tomography (CT) confirmed the hemorrhagic state showing intraperitoneal blood. After laparotomy a ruptured aneurysm of the left gastroepiploic artery was diagnosed. Ligation of the artery was performed with good results. This case is reported because the situs of this aneurysm is very rare.