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A method for correcting the tube kinking after ascending aortic replacement for acute dissection is described. Its main advantage is the no need for cardiopulmonary by-pass (CPB) and aortic clamping to solve the problem.

Pulmonary embolism is a serious complication following trauma and bed rest and it represents a challenge in the prompt diagnosis and medical or surgical therapy. We present a surgically treated patient with a massive pulmonary embolism (more than 50% of the vascular pulmonary bed) which occurred after an inferior leg trauma which required a prolonged bed immobilization. We believe surgical intervention is the treatment of choice in patients with massive pulmonary embolism who do not respond to fibrinolytic therapy. Moreover prompt surgical embolectomy is mandatory to have more chances to save the patient's life.

To evaluate risks and complications of reoperations on heart valve prostheses, we reviewed data on 183 patients who underwent reoperation because of prosthetic valve malfunction. The incremental effect of the redo procedure on hospital mortality and morbidity was studied by comparing primary and reoperative procedures and analyzing a series of possible predisposing factors. Late survival after first and second reoperations was computed, and possible determinants of late mortality were examined. Overall operative mortality was 8.7%; emergency operation (p = 0.0001), previous thromboembolism (p = 0.05), and advanced New York Heart Association functional class (p = 0.031) were the independent determinants. In a series of 1,355 patients having primary or secondary isolated valve replacement, the redo procedure was a significant risk factor in the univariate analysis (p = 0.025) but not in the multivariate analysis except for the subset of patients having mitral valve replacement (p = 0.052). The postoperative course was quite complicated, as evidenced by the long mean stay in the intensive care unit (mean stay, 3.8 days; longer than 2 days for 26% of the survivors). Nevertheless, postoperative complications were not significantly greater after a redo procedure than after a primary operation. Actuarial survival at 7 years was 57.3% +/- 8%. A comparison with a nonhomogeneous series from our institution did not demonstrate significant differences. In the subset of 16 patients having a second reoperation, late survival was 37.8% +/- 16% at 2 years. Advanced New York Heart Association class (p = 0.0001), double prosthetic valve dysfunction (p = 0.003), and any indication other than primary tissue failure (p = 0.06) were determinants of late mortality.(ABSTRACT TRUNCATED AT 250 WORDS)

This study was undertaken to evaluate the myocardial preservation obtained by adding a Ca++ channel blocker, nifedipine, to cold potassium cardioplegia (4 mcg/Kg/L) in 24 patients undergoing coronary artery surgery. They were randomly divided into a treated (N) and a control (C) group. Significant differences between the two groups were noted in the cardiac arrest time (p less than 0.001), in the mechanical recovery mode (p less than 0.01) and in the inotropic support needed (p less than 0.01). Cardiac index increased significantly in group N but decreased in group C (p less than 0.01). Peripheral delta P/delta t and endocardial viability ratio (EVR) decreased in both groups. Coronary sinus and serum CK and CK-MB release were significantly lower in the treated group. ECG ischaemic changes occurred in 8 patients in group C but only in 1 case in group N (p less than 0.001). Arrhythmias occurred in 3 cases in group C (p less than 0.05). The incidence of perioperative myocardial infarction was not significant (2 cases in group C). These data suggest that nifedipine can protect the myocardial cell from ischaemic injury without depressing myocardial contractility or AV conduction.

We studied 13 porcine bioprostheses removed from patients with endocarditis at our institute during the last 4.5 years. All bioprostheses had been removed at reoperation and were analyzed using anatomical and histological techniques. Each bioprosthesis was found to have developed rather constant lesions which were not related to the type of bioprosthesis. The stage of infection was not related to the duration of implantation. The presence of perivalvular abscesses was an ominous finding, often being the seat of persistent endocarditis. Our good clinical results of reoperation lead us to suggest that this be performed early once valvular or prosthetic malfunction is detected. Bioprostheses are, in our experience, the best choice in the surgical treatment of prosthetic valve endocarditis.

Two unusual cases of traumatic aneurysm of the aorta are described. Both presented several days after thoracic trauma sustained in a car accident. The presenting features were progressing dysphagia and displacement of the oesophagus in the first case and a coarctation-like syndrome in the second. Diagnosis was confirmed in each case by aortography and emergency resection of the aneurysm with a dacron prosthesis was carried out. Aortic rupture should be considered in all cases of thoracic trauma, especially when severe, even several days after the trauma itself. Patients should be evaluated with serial chest roentgenograms and an aortography should be performed in any suspicious case. Treatment is surgical and the operative mortality and morbidity is acceptably low.

Clinical results with porcine bioprostheses were reviewed for 990 patients who underwent heart valve replacement from January, 1974, to December, 1980. Eight hundred and seventy-four Hancock, 283 Carpentier-Edwards, and 10 Liotta bioprostheses were used. In 23 patients, 26 mechanical prostheses were implanted as well. Overall operative mortality was 60 out of 990 (6.06%): 30 out of 506 (5.9%) for mitral valve replacement (MVR), 13 out of 287 (4.5%) for aortic valve replacement (AVR), 1 out of 4 (25%) for tricuspid valve replacement, 0 out of 2 for pulmonary valve replacement, and 16 out of 191 (8.4%) for multiple valve replacement. Cumulative follow-up covered 1,793 patient-years. (Actuarial survival at 7 years was 76.6 +/- 3% for MVR. At 6 years, it was 83.2 +/- 2.8% for AVR and 55 +/- 13.5% for multiple valve replacement.) Prosthesis-related survival at 7 years was 91.7 +/- 1.9% for MVR, and at 6 years, it was 96.6 +/- 1.5% for AVR and 95.1 +/- 2.2% for multiple valve replacement. Bioprosthesis survival, considering deaths or complications that led to reoperation as final events, was 84.2 +/- 3.7% at 7 years for mitral valves and 87.7 +/- 3.8% at 6 years for aortic valves. Emboli per 100 patient-years numbered 3.2 for MVR, 0.5 for AVR, and 1.6 for multiple valve replacement. Twenty-seven patients underwent reoperation, 12 for perivalvular leak, 5 for endocarditis, 6 for valve thrombosis, and 4 for primary tissue failure (linearized rates of 0.7, 0.3, 0.3, and 0.2% per patient-year, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

This study was undertaken to evaluate the potential role of a perioperative calcium-channel blocker (Diltiazem) infusion in improving myocardial preservation. Forty consecutive CAD patients were randomly assigned to a control (C; n = 20) and a treated (D; n = 20) group. In patients in the latter group diltiazem was continuously infused at 0.5 to 2.0 mcg/kg/min i.v. from anesthesia induction until the aortic cross-clamping, and from myocardial reperfusion till the 48th postoperative hour. During the preCPB phase hypertension occurred less frequently in group D (3 vs 12 cases, p = 0.0033). In the immediate postischemic period, depression of contractility and the need for inotropic support were observed in 3 cases in group D and in 9 in group C (p = 0.0384). Postoperatively, group D patients had a lower incidence rate of hyperkinetic arrhythmias or conduction disturbances (p = 0.0218), as well as of ECG signs of ischemia (p = 0.0016). Significant CK enzyme level increase was noted in 13 patients in group C versus 4 in group D (p = 0.0040). Two perioperative myocardial infarctions were diagnosed, both in group C. These clinical data show that continuous perioperative infusion of diltiazem can effectively increase myocardial preservation during ischemic arrest, without unfavorable effects on the hemodynamics, electrical activity or mechanical performance of the heart.