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The mobility afforded by the wearable Novacor LVAS provides the possibility for the recipients to leave the hospital, with undoubted improvements in their quality of life. A staged program for discharging LVAS recipients from the hospital has been set up at the Policlinico San Matteo of Pavia together with the Rehabilitation Center of Montescano and Baxter Novacor Service support, in order to proceed smoothly towards patient's self sufficiency and to minimize any associated risk. The steps are: stay in the hospital ward, discharge to Rehabilitation Center and discharge to home. Several excursions with and without an LVAS team member are encouraged before final discharge to home. Simple criteria of eligibility must be fulfilled to move to the next step. Every move towards a reduced presence of specialized personnel includes an appropriate training of the patient and relatives and a technical checkout of the needed equipment. During the stay at the Rehabilitation Center primarily the physical training and psychological preparation are taken care of by means of tailored programs. When the patient is discharged to home, the check of patient condition is performed weekly at the Rehab Center, bloodwork and technical evaluation is assessed once every two weeks and technical inspections at home twice per year. Complications are reported as in hospital protocol. Control parameters of the LVAS are reported only in case of alarms or abnormal operation. Periodic review of patient training is performed during the check visits, mostly focused on how to address emergency situations. The hospital is responsible for providing one LVAS operator available on call (all hours). Up to date, 11 patients received an implant of LVAS, 9 of them with the wearable system. All of these 9 patients made excursions out of the hospital and 4 patients have successfully undergone the staged program, showing a satisfactory general condition and restoration to social life.

The port-access technique for cardiac surgery was recently developed at Stanford University in California as a less invasive method to perform some cardiac operations. The port-access system has been described in detail elsewhere. It is based on femoral arterial and venous access for cardiopulmonary bypass (CPB) and on the adoption of a specially designed triple-lumen catheter described originally by Peters, and subsequently modified and developed in the definitive configuration called the endoaortic clamp.

Infective acute mediastinitis is a postoperative complication reported in 0.5-1% of patients undergoing open chest operations. The treatment of choice for this life-threatening complication is still a matter of debate. The aim of this study was to retrospectively analyse the efficacy of different therapeutic approaches in the treatment of postoperative infective mediastinitis. In the 2nd Division of Cardiac Surgery, from October 1986 to May 2000, 10,234 patients underwent cardiac surgery operations. In 42 patients (0.4%) the operation was complicated by acute infective mediastinitis requiring surgical treatment. On the basis of the treatment opted for, these patients were subdivided into 5 groups: 23 patients underwent continuous iodopovidone (Betadine) mediastinal irrigation (GL) associated with surgical omentoplasty in 8 patients (GLO); 5 patients underwent isolated omentoplasty (GO), and 4 patients were treated with a pectoral muscle flap (GF). In 8 patients other different procedures were performed (GS). There were no deaths in GF and GS despite 24% and 20% mortality reported among patients who underwent mediastinal irrigation (GL) and isolated omentoplasty (GO), respectively. The mean hospital stay was 15 +/- 1 days in GF, 16 +/- 1 days in GS, 25 +/- 11 in patients who underwent omentoplasty and 27 +/- 14 in patients who underwent mediastinal irrigation. Predictors of death were low cardiac output syndrome (Por = 0.009) and respiratory insufficiency (Por = 0.032) when found before treatment. Our study suggests that surgical omentoplasty should be the treatment of choice in deep mediastinal infections, whereas wound sterilisation, associated with surgical chest wall reconstruction, seems to be a better procedure in superficial infective disease. A more extended clinical series would be needed to confirm these preliminary data.

Despite several controversies, the term "dextrocardia" usually defines a rare type of intrinsic cardiac abnormality due to a rotation disorder and resulting in a right-sided direction of the cardiac axis. According to the majority of experts, the extent of a dextrocardia associated with a situs solitus is termed "dextroversion". In such a rare condition, therefore, the relationships between the cardiac chambers and the other structures (that is superior and inferior venae cavae, liver, stomach) are modified whereas in case of dextrocardia with situs inversus, the relationships between the cardiac chambers and neighboring structures are preserved and the classical "mirror image" is shown. In 95% of cases with dextroversion, an associated cardiac abnormality has been described and, therefore, acquired heart diseases in patients with isolated dextroversion are extremely rare. To our knowledge, the present is the first case report describing a coronary artery bypass graft performed in a patient with isolated dextroversion. The technical aspects of the surgical procedure are also discussed.

To report the experience gained at our Cardiosurgical Centre with the recently introduced port-access technique.Prospective collection of data from the month of October 1997.Regional University HospitaL Patients: Adult patients undergoing coronary bypass graft or mitral valve surgery.Port-access technique makes it possible to carry out open-heart procedures through a minithoracotomy and extrathoracic cardiopulmonary bypass with a set of properly designed catheters (Heartport EndoCPB system) for cardioplegia delivery and heart venting.Transesophageal echography and pressure traces are the main monitoring tools used for the correct placement of these catheters and for the clinical management of the patient.Sixty-two cases have been performed so far. A complete description of the procedure, with monitoring aspects and problems encountered is thoroughly presented.The major differences with traditional cardiac surgery are that interruption of myocardial perfusion is not achieved through a transversal clamp but through an endovascular occlusive balloon and that thoracic access is by minithoracotomy. Unlike traditional open surgery, the surgeon has no direct vision of the position of the clamp and the anesthesiologist can not visually inspect the contractile state of the heart. The operative team has to cope with a multifaceted system of monitored variables that must be continuously integrated and interpreted. Tight cooperation and continuous communication between anaesthesiologist, surgeons and perfusionist appear to be more important than in any other cardiac operation.

Data from the initial experience of 40 patients operated on with the Port-Access technique are reported. Indication to surgery was mitral disease in 24 patients and coronary stenosis in 16 patients. Mean age was 52 years (range 32-75). Operations performed were: 8 mitral valvuloplasties, 16 valve replacements, 9 single CABG (associated with an MVR in one case), 1 double CABG, 6 triple CABG and one quadruple CABG. Coronary endarterectomy was performed in 5 patients and left atrial isolation was associated with MV surgery in 5 cases.There were no operative deaths and every patient was discharged after a mean postoperative stay of 5.5 days (range 3-30). Postoperative course was complicated in 7 patients: surgical revision was necessary in 4 patients due to bleeding (through the mini-thoracotomy incision in 3 cases), 1 pacemaker was implanted for A-V block, one retained pulmonary catheter was removed through the mini-thoracotomy without the aid of cardiopulmonary bypass and in one case, there was an emergency conversion to median sternotomy due to a ventricular fibrillation unresponsive to usual resuscitative maneuvers a few hours after surgery. Some of these complications can be ascribed to the learning phase of this new technique and should disappear as experience is increased.Port-Access surgery is a new minimally invasive technique that utilizes a cardiopulmonary bypass with femoral access and a specialized catheter system that provides endoaortic clamping, pulmonary artery venting and myocardial preservation with infusion of cardioplegic solution in the aortic bulb or in the coronary sinus. Major contraindications to this technique are iliac-femoral disease or severe dilatation of ascending aorta. The aim of the Port-Access technique is to combine the aesthetic and functional advantages of the minimally invasive surgery with the wide range of surgical options that cardiopulmonary bypass can afford (to operate on atrioventricular valves and perform all the CABG that the patient need), without the limitations characteristic of the classic minimally invasive direct coronary artery bypass (MIDCAB) technique.

The shortage of donors is responsible for the majority of patients dying while waiting for transplantation. To rescue these critically ill patients, a wide variety of devices have been proposed for circulatory assistance as bridge to heart transplantation [1,2]. Prolonged bridging is often necessary, because of donor scarcity and because of the need to allow complete patient recovery before transplantation.

Starting in January 1995, we performed heart transplantation, randomly using standard and bicaval techniques. In the latter technique, the anatomy of the right atrium is maintained, since the venae cavae are anastomosed. In 38 patients who received heart transplantation with bicaval anastomosis, 339 endomyocardial biopsies (EMB) were performed. EMB was done under echocardiographic control in 309 cases, whereas the remaining 30 were done under fluoroscopy. When EMB was echo-guided there was one major complication, namely right hemothorax in a 29-year-old man, who had had heart transplantation one week before, and this required surgical exploration. Other complications, correlated to venipuncture were: left hemothorax in a 65-year-old woman determined by arterial puncture, treated by means of chest tube drainage; pneumothorax (1 case). Echocardiographic guidance during EMB allows a better choice of biopsy site, reduces the risk of damaging cardiac structures and allows immediate monitoring of heart performance. Moreover the risk of X-ray exposure to both patient and operators is reduced. In any case, because the superior vena cava suture line is not visualized by two-dimensional echocardiography, if the bioptome cannot be introduced easily through superior vena cava, fluoroscopic control should be immediately applied, particularly in the early post-operative period when cicatrization is not complete.

We describe a 47-year-old man with a history of malignant melanoma, starting with a resection from his left thigh and followed, 4 years later, by a metastatic melanoma in the right ventricle. Within a few days, hemodynamic compromise occurred combined with evidence of an impressive intracavitary growth of the tumor causing obstruction of the right ventricular inflow and outflow tract. Echocardiography was valuable in the assessment of neoplastic cardiac involvement and was useful in detecting rapid right ventricular cavity obliteration by the expansion of the metastatic mass.

Surgical isolation of the left atrium was performed for the treatment of chronic atrial fibrillation secondary to valvular disease in 100 patients who underwent valve surgery.From May 1989 to September 1991, 62 patients underwent mitral valve surgery (Group I), 19 underwent mitral valve surgery and DeVega tricuspid annuloplasty (Group II), 15 underwent mitral and aortic surgery (Group III), and 4 patients underwent mitral and aortic surgery and DeVega tricuspid annuloplasty (Group IV). Left atrial isolation was performed prolonging the usual left paraseptal atriotomy towards the left fibrous trigone anteriorly, and the postero-medial commissure posteriorly. The incision was conducted a few millimeters apart from the mitral valve annulus, and cryolesion were placed at the edges to ensure complete electrophysiological isolation of the left atrium.Operative mortality accounted for 3 cases (3%). In 79 patients (81.4%) sinus rhythm recovered and persisted until discharge from the hospital. No differences were found between the groups (Group I: 80.7%; Group II: 68.5%; Group III 86.7%, Group IV 75% - p = N.S.). Three cases of late mortality (3.1%) were registered. long-term results showed persistence of SR in 71% of Group I, 61.2% of Group II, 85.8% of Group III, and 100% of Group IV. The unique risk factor for late recurrency of atrial fibrillation was found to be a duration of preoperative AF longer than 6 months.Due to the high success rate in recovering the sinus rhythm, we suggest left atrial isolation in patients with chronic atrial fibrillation undergoing valvular surgery.

The article deals with the modern approaches to the treatment of supraventricular tachycardia . The authors analyse the results of operations in ectopic atrial tachycardias, the Wolff-Parkinson-White syndrome, modal re-entry tachycardias, and atrial fibrillation . The last-named is of most interest because the authors possess experience in a new operation for isolation of the internodal tracts. In all conditions the authors obtained convincing evidence on the efficacy of modern surgical treatment in supraventricular tachycardias.

Iatrogenic false aneurysm of a branch of the internal mammary artery after sternal wire closure is a very rare occurrence. We describe a case which appeared in a 62 year old woman operated upon for mitral valve replacement and diagnosed after Digital Subtraction Angiography.

Four-hundred consecutive patients were operated of coronary artery bypass between July 1980 and November 1982 without any hospital mortality. Clinical and coronarographic characteristics and surgical techniques are presented. Eighteen cases were complicated by peri-operative myocardial infarction. Follow-up data, were available for 91% of the discharged patients, ranged between 5 and 33 months (mean 17,6). Two hundred and sixty-one patients were asymptomatic, 66 had improved clinical conditions, but angina was still present; 25 were unchanged while 5 had worsened. There were seven late deaths; 6 due to cardiac disease and 1 to a mesothelioma.

The authors report on the casuistry of aorto-coronary by-pass operations they performed between April 1971 and December 1974, discussing the criteria which indicate the necessity of operating, the principles of the operative techniques, and the results obtained. Out of a total of 342 operated cases, there was an operative mortality (within 30 days) of 3% in isolated by-pass cases, and 4% if one includes associated operations. In 3,5% of patients, postoperative necrosis was present. Almost the same values were found in the smaller group (66 cases) which underwent urgent by-pass operations. The authors consider that the aorto-coronary by-pass operation is a very useful treatment, both for stable and unstable angina, as long as the anatomo-functional conditions exist.

Six cases of aneurysm of the thoracic aorta, four located in the 1st segment and two in the 3rd, are reported. The four cases in the ascending aorta presented a different aetiology: a) aneurysm on aortic stenosis (case 1); b) atheromatous aneurysm (case 2); c) aortic dissection (case 5); d) aneurysm due to dystrophy of the media in a patient with Marfan's disease (case 6). 3 tubular prosthetic substitutions of the ascending aorta were made (with a valvular substitution and commissural relocation associated with right aorto-coronary venous by-pass) and one plastic intervention on the aorta with valvular substitution. The aneurysms of the descending thoracic aorta presented traumatic aetiology and were treated with resection-dacron graft, using femoral artero-venous partial CEC.

Left main coronary artery disease (LMCAD) is a particularly severe form of coronary artery disease (CAD); its frequency ranges from 5% of 7% in patients with CAD [4, 6, 7] and virtually all published reports show a grim natural history: the survival rate of medically treated patients with LMCAD ranges from 65% to 57% at 2 years [9, 16], from 49% to 46% at 5 years [3, 13], and from 13% to 31% after 10 years [19]. Coronary artery bypass grafting (CABG) is generally accepted as the treatment of choice in these patients and randomized studies of large series have shown a significantly better prognosis for the operated patients, with 88% or 86% survival at 4 years [5, 7]. The data obtained from our experience with 155 consecutive cases of LMCAD treated by CABG form the basis of this report.

Doppler characteristics of normally functioning tilting disk prostheses in aortic position were studied in 55 patients (30 Medtronic-Hall and 25 Sorin) whose valvular function was considered normal using clinical and echocardiographic evaluation. Peak gradients, mean gradients and effective orifice area were estimated for different sizes of prostheses. The peak gradient calculated from maximal aortic velocity was 27.3 +/- 11.1 mmHg in Sorin and 21.1 +/- 9.7 mmHg in Medtronic-Hall valves; the mean gradients were 12.9 +/- 6.2 mmHg and 10.8 +/- 5.7 mmHg in Sorin and Medtronic-Hall valves respectively. The effective orifice area calculated by the continuity equation was 1.4 +/- 0.5 cm2 in Sorin and 1.5 +/- 0.57 cm2 in Medtronic-Hall prostheses; the performance index calculated as the ratio between functional area and manufactured area was 0.4-0.6 for Medtronic-Hall and 0.45-0.52 for Sorin prostheses. Prosthetic regurgitation was found in 64% of Sorin valves and 80% of Medtronic-Hall valves; prosthetic regurgitation was mild in 81% and moderate in 19% of cases. Doppler echocardiography is a reliable method for the characterization of the normal function of prosthetic aortic valves and provides information similar to cardiac catheterization.

107 patients suffering from angina at rest associated with ST segment changes underwent coronary arteriography. 46 patients showed ST segment elevation during ischemic attacks (group I) while 61 patients exhibited ST segment depression during chest pain (group II). Non-significant coronary artery disease was more frequent in group I patients (group I 15%, group II 5%) as well as one vessel disease (group I 33%, group II 15%) while multivessel disease and left main involvement were more frequent in group II patients (group I 28%, group II 60%). Depression of left ventricular function was found in similar percentage of cases in both groups. During hospitalization all patients were treated with calcium antagonists (Nifedipine 10/20 mg every six hours) and/or nitrates (2% nitroglycerin ointment 2 inches every six/four hours) with one death (occurring after coronary arteriography) and eleven non-fatal myocardial infarctions. 50 patients underwent coronary bypass grafting with four perioperative deaths and six nonfatal myocardial infarctions. Most of the surgically treated patients were poorly responsive to medical treatment and had multivessel disease or left main involvement. Since these features are known to be related to a poor prognosis with medical treatment, surgical results in such patients seem satisfactory.

This report addresses the problems related to surgical treatment of post-infarction ventricular tachycardia (VT) and is based on a 5 year experience of 36 consecutive patients. In every case the arrhythmia was unresponsive to pharmacological therapy. All patients were operated on after the completion of a diagnostic protocol including preoperative endocardial, intra-operative epi-endocardial mapping, the latter performed automatically when possible. Surgical techniques were: classical Guiraudon's encircling endocardial ventriculotomy (EEV); partial EEV, endocardial resection (ER); cryoablation or a combination of these procedures. The in-hospital mortality (30 days) was 8.3% (3 patients). During the follow-up period (1-68 months), 3 patients (9%) died of cardiac but not VT related causes. Of the survivors, 92% are VT-free. We consider electrophysiologically guided surgery a safe and reliable method for the treatment of post-infarction VT and suggest its more extensive use. We stress the importance of automatic mapping in pleomorphic and non-sustained VT, and the necessity of tailoring the surgical technique to the characteristics of each case.

At present, for most patients with coronary artery disease (CAD), coronary artery bypass grafting (CABG) is the therapy which offers the best control of symptoms and, in many cases, longer survival. Although an improvement in clinical status can be achieved in most patients treated with CABG, angina may persist in operated on patients or may appear later in the postoperative course.

To determine the effects on survival of the medical and surgical treatment of variant angina, we compared the prognosis of 75 surgically treated subjects with that of 75 medically treated patients, selected from a series of 340 consecutive patients observed between January 1969 and December 1982. The patients were selected on the basis of a developed computer program to match each medically treated patient with one surgically treated patient so that each pair was similar according to the following clinical and angiographic variables: sex, age, previous myocardial infarction, severe ventricular arrhythmias during pain, site of ST elevation (anterior or inferior), coronary artery disease (single or multivessel), left ventricular function (normal or abnormal). Patients who were considered unoperable because of poor ventricular function or distal vessel disease were not included in this study. Mantel-Haenszel log-rank analysis demonstrated a significantly better prognosis in surgically treated patients, particularly in those with multivessel disease as well as in those with ST elevation in anterior leads. However survival in 63 medical patients who were treated with calcium-antagonists was not significantly different from that of their surgical matched patients. During the follow-up period, anginal symptoms were more frequently found in medically treated patients (p less than 0.05). We conclude that in patients with variant angina surgical treatment does not improve survival as compared to medical treatment with calcium blocking drugs. Coronary artery bypass surgery can be carried out at low risk and is particularly indicated in those patients with angina refractory to medical treatment.

We report a case of one patient who underwent emergency retransplantation with a highly positive donor crossmatch. Standard immunosuppression was integrated by the addition of plasma exchange during extracorporeal circulation, polyclonal IgG, and cyclophosphamide for the first 30 days. After transplantation the clinical outcome was normal; immunosuppression induced a complete disappearance of the donor-specific antibody. In spite of the heavy immunosuppression, we did not observe any infectious complications. We suggest that a greater immunosuppression established soon after the transplant and adjusted on the basis of immunological monitoring may allow a heart transplant with a positive crossmatch.

Seven patients (6 men and 1 woman), aged 45-67 years, with previous myocardial infarction and recurrent sustained ventricular tachycardia (VT), refractory to medical treatment, underwent encircling endocardial ventriculotomy, according to a modified Guiraudon's technique, associated with surgical resection of ventricular aneurysm. Before surgery all patients underwent electrophysiologic study, to evaluate the modalities of onset and interruption of VT; endocardial mapping at multiple sites was carried out in order to define the site of origin of VT and the sequence of endocardial activation: during VT in 5/5 patients the earliest activation occurred in the left ventricle at mid septum (2 cases), in the low (1 case) and high (1 case) septal regions and in the latero-basal region (1 case); the arrhythmias always originated at the border between fibrous and viable tissue. Intraoperative mapping was carried out from 18-29 points of the epicardial surface, both in sinus rhythm (7 cases) and during VT in the 6 patients in whom the arrhythmia was inducible with electrical stimulation. During sinus rhythm fragmented electrical activity of low voltage and prolonged duration was recorded from the epicardial surface of the aneurysm in all cases; during VT the site of earliest activation was localized in the low posterior (3 cases), high lateral (2 cases) and high posterior (1 case) regions of the left ventricle. Intraoperative endocardial mapping during VT confirmed the site of origin of the arrhythmia, as determined by preoperative mapping, in the 3 cases in whom it was performed. In all cases encircling endocardial ventriculotomy around the area of earliest activation or, when the origin of VT was not precisely determined, along the border zone of the aneurysm, was associated with conventional surgical procedures (aneurysmectomy: 6 cases; incision-suture: 1 case; aorto-coronary bypass: 1 case; mitral valve replacement: 1 case). One patient died in the early post-operative course with a low-output syndrome. During a follow-up of 6-35 months, one patient died two months after surgery because of intractable heart failure; the remaining patients are alive and well, with no recurrence of VT; none of them required antiarrhythmic therapy.(ABSTRACT TRUNCATED AT 400 WORDS)

From July 1981 to June 1987 160 consecutive patients underwent left ventricular (LV) septoplasty for LV aneurysm involving the septum. LV septoplasty affords reconstruction of LV septum by means of a series of stitches passed from the free edge of the aneurysm through the border of the septal scar and pulled out through the adjacent right ventricular free wall. Associated procedures included 163 (coronary artery bypass grafts) and 49 antiarrhythmic treatments. Hospital and late mortalities were 6.2% and 10% respectively: 92% of the discharged patients were followed up. Actuarial survival rates were 89.9% and 83.7% at 1 and 5 years respectively. Clinical results showed functional improvement from a mean NYHA class 2.7 to 1.5 for dyspnea and from 2.1 to 1.1 for angina. The factors that seem to affect early and late prognosis are ejection fraction and preoperative congestive heart failure alone or associated with ventricular tachycardia. Ventricular septoplasty permits an optimal reconstruction of LV shape and function by excluding akinetic or dyskinetic septum. LV septoplasty can correct a postinfarction ventricular septal defect, if present, by excluding the involved portion of the septum.