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OBJECTIVES Management of resternotomy is often a difficult challenge in patients with congenital diseases who have undergone multiple sternotomies. Our goal was to report our single-centre experience with carotid cannulation using a graft interposed during redo sternotomy in complex cardiac reintervention procedures. METHODS We performed a retrospective review of all patients who had undergone complex redo sternotomies between January 2019 and May 2020 utilizing a cervical cannulation technique with a Gore-Tex graft interposed on the carotid artery. We classified our population study on the basis of the primary diagnosis and the type of surgery. The primary outcomes of our analysis were the evaluation of the safety of the procedure in terms of survival and freedom from neurological events. RESULTS We analysed 22 patients who had undergone previous complex operations. The median age and weight at the time of reintervention were 130.35 (range 0.46–435) months and 31.5 (range 2.2–85) kg, respectively. Composite graft carotid cannulation provided adequate arterial flow in all patients with a median arterial flow of 3.5 l/min/m2 (range 0.6–6). One major cardiac injury occurred during sternotomy when emergency cardiopulmonary bypass (CPB) was initiated. Moreover, during their hospital stays, all patients had an uneventful recovery without neurological or vascular complications and no cervical wound infections. CONCLUSIONS Carotid cannulation using interposition of a side graft on the common carotid artery for arterial inflow is a reliable and safe method for initiation of CPB in complex redo surgeries in patients with congenital disease. Complications directly associated with this type of cannulation are uncommon and allow surgical re-entry with overall low risks.

OBJECTIVES The aim of this study was to identify the predictors of death and of reintervention after mitral valve replacement (MVR) in children. METHODS A single-centre retrospective study was performed including 115 patients under the age of 18 undergoing MVR between 1982 and 2019. For all patients, the ratio of prosthetic valve size (diameter in mm) to weight (kg) at surgery was calculated and long-term result was assessed. The primary outcome was freedom from mitral valve (MV) re-replacement. The composite secondary outcome was freedom from death or transplant. RESULTS Fifty-four patients had a previous surgical attempt to MV repair. The median age at surgery was 5.5 years (interquartile range 1.21–9.87). Death/transplant-free survival was 77 ± 4% at 5 years and 72 ± 5% at 10 years. Univariate analysis showed a size/weight ratio higher than 2 and age CONCLUSIONS MVR is a viable strategy in children with unrepairable MV disease. Mortality can be predicted based on size/weight ratio and age

Previous studies have showed that people living in Bastogi - a segregated and deprived peripheral area of Rome- have difficulties in accessing and relating to health services. Our aim was to analyze the health perception, health-related behaviors, and the interaction between healthcare professionals and the census population living in Bastogi, compared to the population living in the area of the same local health unit, ASL Roma 1 (hereafter ASL). The PASSI survey (from the Italian Surveillance System) was administered by phone and through door-to-door interviews to a sample of 210 residents of Bastogi. Data were analyzed and compared to the ones of the ASL collected in 2017-2018. Descriptive and univariate analysis were performed with STATA 13. P-values ≤ 0.05 were considered statistically significant. The socio-economic indicators, acknowledged determinants of health inequalities, showed a worse condition for the inhabitants of Bastogi. There was a significantly higher proportion of foreign and unemployed residents in Bastogi, with a lower educational level compared to the ASL. 58.1 % of the Bastogi group claimed their health to be good/very good (ASL: 71.6%; p = 0.000). 56.2% of the respondents from Bastogi were current smokers (ASL: 25.8%; p = 0.000). Risk factors for and prevalence of chronic diseases were significantly higher in Bastogi. The proportion of respondents who stated they had not had any recent contact with health professionals was significantly higher, and mammogram screening uptake was lower (75.3%; ASL: 90.4%; p = 0.001). Despite their lower help-seeking behavior, our study pointed out that the respondents from Bastogi who had had a contact with a health professional reported a higher perceived interest about their health than in the ASL. Further studies are needed to investigate whether this attention is attributable to the higher prevalence of chronic diseases or to the health professional's awareness of vulnerability of a hard-to-reach group. Key messages The population from Bastogi is marginalized and hard-to-reach: we found a worse overall self- reported health condition, a worse help-seeking behavior and a lack of reliance on health professionals. The PASSI survey administration has led to a greater involvement of the competent health institution, which resulted in the introduction of a community nurse and a Single Access Point.

Evolving reconstructive techniques have progressively become the preferred approach for treatment of pediatric mitral valve regurgitation. We present our experience in a cohort of patients undergoing surgical correction for severe mitral regurgitation. Fifty-five patients (age 1 month–18 years; median 5 years) were included in the present analysis. Different surgical techniques were used (posterior leaflet augmentation in 25, isolated cleft closure in 12, Alfieri-type procedure in 10, annuloplasty in 5, with artificial chordae in 2, and quadrangular resection with chordal transposition in 1). Follow-up time ranged from 1 to 192 months (median 38[IQR 12–54] months). Operative and follow-up mortality was 0%. Reintervention in the whole population occurred in 31% of patients. However, when first surgery was performed under 2 years of age (no = 17), reintervention reached nearly 50%. The degree of residual mitral regurgitation at follow-up remained stable after surgery, while a significant increase in mean transmitral gradient was observed over time (paired t test = 0.03). In multivariable Cox-regression analysis, post-surgical transmitral gradient was the only independent predictor for reintervention (p = 0.017; HR 2.4; 95%CI 1.2–5.1), after correcting for differences in age at surgery, type of reintervention, mitral annulus dimension, and BSA at the first surgery. ROC curve demonstrated that a post-surgical transmitral mean gradient value > 5 mmHg, was predictive for reintervention (AUC = 0.89; Youden index = 0.44). Our study suggests that the use of conservative technique strategy achieves satisfactory functional results in infants and children with severe MR, although the rate of reoperation in younger patients remains substantial. Post-operative moderate mitral stenosis was the strongest predictor for reoperation.

Background and Aims: Disease progression in children with primary sclerosing cholangitis (PSC) is variable. Prognostic and risk-stratification tools exist for adult-onset PSC, but not for children. We aimed to create a tool that accounts for the biochemical and phenotypic features and early disease stage of pediatric PSC. Approach and Results: We used retrospective data from the Pediatric PSC Consortium. The training cohort contained 1,012 patients from 40 centers. We generated a multivariate risk index (Sclerosing Cholangitis Outcomes in Pediatrics [SCOPE] index) that contained total bilirubin, albumin, platelet count, gamma glutamyltransferase, and cholangiography to predict a primary outcome of liver transplantation or death (TD) and a broader secondary outcome that included portal hypertensive, biliary, and cancer complications termed hepatobiliary complications (HBCs). The model stratified patients as low, medium, or high risk based on progression to TD at rates of

Anomalous origin of the pulmonary arteries from the ascending aorta is a rare, but severe clinical entity necessitating a scrupulous evaluation. Either the right or the left pulmonary arteries can arise directly from the ascending aorta while the other pulmonary artery retains its origin from the right ventricular outflow tract. Such a finding can be isolated or can coexist with several congenital heart lesions. Direct intrapericardial aortic origin, however, must be distinguished with origin through a persistently patent arterial duct. In the current era, clinical manifestations usually become evident in the newborn rather than during infancy, as used to be the case. They include respiratory distress or congestive heart failure due to increased pulmonary flow and poor feeding. The rate of survival has now increased due to early diagnosis and prompt surgical repair, should now be expected to be at least 95%. We have treated four neonates with this lesion over the past 7 years, all of whom survived surgical repair. Right ventricular systolic pressure was significantly decreased at follow-up. Our choice of treatment was to translocate the anomalous pulmonary artery in end-to-side fashion to the pulmonary trunk. Our aim in this report is to update an Italian experience in the diagnosis and treatment of anomalous direct origin of one pulmonary artery from the aorta, adding considerations on the lessons learned from our most recent review of the salient literature.

Heart failure is an important cause of late morbidity and mortality in children, adolescents, and young adults with congenital heart disease. Heart failure is the first cause of mortality in adult congenital heart disease population accounting for 30% to 50% of death while the incidence related to ventricular arrhythmias accounts for another 20%. Symptomatic heart failure requiring hospitalization is associated with 3% to 5% mortality during hospital stay and a 25% incidence of death within the first year after admission. Patients at highest risk for death as a result of heart failure are those with single-ventricle physiology or systemic right ventricular anatomy; however, patients with left-sided obstruction or chronic volume overloaded right ventricle are also at a higher risk than the general population. Medical therapy is scarcely effective in most cases of congenital heart disease related heart failure in children, adolescents and young adults. Lack of donors limits access to heart transplantation and results in adult congenital heart disease population are worse than those in other cardiac populations with heart failure.

Background Heterotaxy syndrome (HS) is a group of congenital disorders characterized by abnormal arrangement of thoraco-abdominal organs across the left-right axis of the body, classified as right (RAI) and left atrial isomerism (LAI)·We investigated the long-term survival and phenotypic spectrum in our HS cohort. Results are compared to literature data. Methods This is a single centre, observational, both retro and prospective study. Cardiac features, surgical management and abdominal ultrasound (US) of all HS patients were reviewed or investigated if missing. We evaluated all anatomical data and their clinical impact on survival, arrhythmias, infections, and heart transplant (HT). Results 136 patients were classified as RAI (81) and LAI (55). Long-term survival and freedom from HT reached 69.8% and 87.8% at 40 years in RAI and LAI, respectively. Multivariate analysis showed that LAI is an independent predictor for pacemaker implantation (p = 0.019). Splenic status varied in both groups: in RAI, abdominal US showed asplenia, polysplenia and normal spleen in 48%, 4% and 32% of patients, respectively, whereas in LAI polysplenia, asplenia and normal spleen occurred in 64%, 4% and 16% of cases, respectively. Conclusions Mortality was significantly lower (9%) compared to literature (50%). Although patients with RAI experienced a higher mortality, no independent predictors were found. We demonstrated that the obsolete cardiac definition of "asplenia" and "polysplenia" instead of RAI and LAI is misleading, because of the high variability of the splenic phenotype among patients of both groups.

AimsThe aim of this study was to describe atrial septal defect morphology in hypoplastic left heart syndrome, to report the incidence of restrictiveness and its relationship with defect morphology, to correlate restriction with midterm outcome, and to describe our interventional approach to restrictive defect.Methods and resultsFrom 2011 to 2015, 31 neonates with hypoplastic left heart syndrome underwent hybrid procedure with pulmonary artery banding and ductal stenting at our Institution. Restrictive physiology of the atrial septal defect was based on Doppler gradient >6 mmHg through the defect and on clinical signs of pulmonary hypertension. The mean gradient was then measured invasively. Restrictive defect occurred in 11/27 patients (40%). The restrictive group showed three ostium secundum defects (27%) and eight complex morphologies (73%). Conversely, in the non-restrictive group, we observed 11 ostium secundum defects (69%) and five complex morphologies (31%). Early balloon atrioseptostomy was required in three cases. Late restriction occurred in eight patients and was dealt with balloon dilation, stenting, or atrioseptectomy. There was no significant difference between restrictive and non-restrictive groups in terms of early or 12-month survival.ConclusionsComplex morphologies were more frequently related to restrictiveness. Stenting technique has a crucial role, as the procedure carries a significant risk for stent migration. Effective treatment of restrictive atrial septal defect is related to a better outcome, as it leads to equalisation of survival between patients with and those without restrictive atrial septal defect.

Assessment of cardiac function is crucial in pediatric patients undergoing cardiovascular surgery, monitoring cardiac output and changing hemodynamic conditions during surgery accordingly is important to improve post-surgical outcome. We aimed to measure cardiac index (CI) and maximal rate of the increase of left ventricular pressure dp/dt(max) with the pressure recording analytic method (PRAM, MostCare®) and compared it with transthoracic echocardiographic cardiac index estimation in infants with transposition of the great arteries (TGA) undergoing surgical correction. We enrolled 74 infants with TGA consecutively into this study. CI and dp/dt(max) were measured with PRAM and echocardiography at 0, 4, 8, 12, 24 and 48 h postoperatively. Blood brain natriuretic peptide (BNP) and blood lactate (Lac) were measured at baseline and after operation. The median age at surgery was 13 days (range 1–25 days) with an average weight of 3.24 kg (range 2.31–4.17 kg). CI estimated by PRAM was 1.11 ± 0.12 L/min/m2 (range 0.69–1.36) and by Doppler echocardiography was 1.13 ± 0.13 L/min/m2 (range 0.76–1.40). dp/dt(max) estimated by PRAM was 1.31 ± 0.03 mmHg/s (range 1.23–1.43) and by Doppler echocardiography was 1.31 ± 0.04 L/min/m2 (range 1.25–1.47). CI (r = 0.817, P

Atrioventricular Septal Defect (AVSD) is a rare congenital heart defect (CHD) often associated with genetic syndromes, most commonly Down syndrome (DS). Over the last four decades, surgical repair has increased survival and improved quality of life in these patients. The prevalence of bradyarrhythmias namely, atrioventricular block (AVB) and sinus node dysfunction (SND) in AVSD is partially known. 522 cases with both partial and complete AVSD (38.7% with DS), undergoing intracardiac repair from 1982 to 2016 at our institution, were reviewed from our system database. 38 (7.3%) patients received permanent PM implantation for AVB (early or late) or SND. On one hand, AVB requiring PM was found in 26 (4.98%). This was further subdivided into early-onset 14 (2.6%) and late-onset AVB 12 (2.2%) (median 4 [IQR 1-7] years). On the other hand, 12 (2.3%) experienced late SND requiring PM (median 11 [IQR 3.5-15.2] years). Early and late AVB were independent from the type of AVSD (partial or complete), whereas the late SND was remarkably observed in complete AVSD compared to partial AVSD (p = 0.017). We classified the cohort into two main categories: DS (202, 38.7%) and non-DS (320, 61.3%). At Kaplan-Meier survival analysis, DS was significantly associated with late-onset bradyarrhythmias (p = 0.024). At Cox regression analysis, we identified DS as an independent predictor of PM implantation (HR 2.17). In conclusion, about 7% of repaired AVSD patients need PM implantation during follow-up. There are no differences in early and late AVB occurrence according to the type of AVSD. There is a higher incidence of late SND in repaired complete AVSD, with a later timing onset in patients with associated DS. Moreover, DS seems to be an independent predictor of PM implantation.

BackgroundThe reported incidence of necrotising enterocolitis in neonates with complex CHD with ductus-dependent systemic circulation ranges from 6.8 to 13% despite surgical treatment; the overall mortality is between 25 and 97%. The incidence of gastrointestinal complications after hybrid palliation for neonates with ductus-dependent systemic circulation still has to be defined, but seems comparable with that following the Norwood procedure.MethodsWe reviewed the incidence of gastrointestinal complications in a series of 42 consecutive neonates with ductus-dependent systemic circulation, who received early hybrid palliation associated with a standardised feeding protocol.ResultsThe median age and birth weight at the time of surgery were 3 days (with a range from 1 to 10 days) and 3.07 kg (with a range from 1.5 to 4.5 kg), respectively. The median ICU length of stay was 7 days (1–70 days), and the median hospital length of stay was 16 days (6–70 days). The median duration of mechanical ventilation was 3 days. Hospital mortality was 16% (7/42). In the postoperative period, 26% of patients were subjected to early extubation, and all of them received treatment with systemic vasodilatory agents. Feeding was started 6 hours after extubation according to a dedicated feeding protocol. After treatment, none of our patients experienced any grade of necrotising enterocolitis or major gastrointestinal adverse events.ConclusionsOur experience indicates that the combination of an “early hybrid approach”, systemic vasodilator therapy, and dedicated feeding protocol adherence could reduce the incidence of gastrointestinal complications in this group of neonates. Fast weaning from ventilatory support, which represents a part of our treatment strategy, could be associated with low incidence of necrotising enterocolitis.

Background Acute failure of the Fontan circulation is rare but remains associated with high morbidity and mortality rates. Little is known about the long-term outcome of patients who underwent Fontan takedown to an intermediate palliative circulation and their potential candidacy for redo Fontan completion. Methods Patients followed up at a single institution who underwent takedown of a Fontan circulation to an intermediate palliative circulation within 2 months of extracardiac Fontan completion were reviewed. Results Between October 1990 and December 2015, 18 patients underwent Fontan takedown to a superior cavopulmonary connection (with or without an additional shunt) at a median age of 3.3 years (range, 1.8 to 8.0) and median weight of 13.8 kg (range, 8.0 to 27.0 kg). Takedown was required during the Fontan procedure itself in 2 patients, and within the first 2 postoperative months in 16 patients (median time to takedown, 3 days). Seventeen patients survived the post–takedown period and 3 ultimately underwent successful redo Fontan. Four patients required heart transplantation, with 2 deaths. In patients with extended intermediate palliation, median arterial oxygen saturation was 84% (range, 76% to 92%) at a median follow-up of 6.3 years (range, 0.7 to 25.9). Conclusions Takedown to a superior cavopulmonary connection is an effective treatment option and, in some patients, acts as a bridge to subsequent redo Fontan completion or heart transplantation. An extended intermediate palliative circulation is tolerated for several years with reasonable oxygen saturation levels at rest. In our experience, an early takedown strategy to a superior cavopulmonary connection is the treatment of choice for acute Fontan failure.

The aim of the study is to compare mid-term results of Bentall aortic root replacement with composite mechanical valved conduit and aortic valve reimplantation procedure using the Valsalva graft for the treatment of aortic root aneurysm in patients with Marfan syndrome.We retrospectively compared data of 23 patients (mean age 38 + or - 14 years) who had undergone the Bentall procedure (group B) to those of 24 patients (mean age 36 + or - 12 years) who had undergone aortic valve reimplantation (group R) during a 14-year period. Follow-up (mean duration 65 + or - 44 months) was 100% complete.There were no operative deaths in either group. In group B, as compared with group R, preoperative aortic insufficiency (3.2 + or - 1.1/4 vs. 1.7 + or - 1.4/4, P0.001), ascending aorta diameter (55.8 + or - 4.9 vs. 44.1 + or - 8.7 mm, P = 0.001) were prevailing; cardiopulmonary bypass (107 + or - 51 vs. 145 + or - 32 min, P0.05) and aortic cross-clamp (77 + or - 17 vs. 116 + or - 30 min, P = 0.005) times were shorter. Eight-year survival and freedom from cardiac death and reoperation were 91 + or - 6, 96 + or - 4 and 100% in group B and 100, 100 and 91 + or - 6% in group R, respectively (P = NS for all comparisons). At follow-up, echocardiography showed significant improvement of left ventricular ejection fraction (0.60 + or - 0.10 vs. 0.52 + or - 0.09 preoperatively, P = 0.01) and end-systolic diameter (34 + or - 5 vs. 47 + or - 14 mm, P = 0.001) in group B and significant reduction of preoperative aortic insufficiency (0.7 + or - 1.0/4 vs. 1.7 + or - 1.4/4, P = 0.01) and aortic annulus (24 + or - 2.4 vs. 33 + or - 5 mm, P = 0.01) in group R.In Marfan patients, the Bentall procedure is associated with excellent mid-term outcome. The reimplantation technique, adopted for less dilated aortas, provides similarly satisfactory results. The Valsalva graft seems, with time, to allow a stable aortic valve function.

BACKGROUND: The Ross operation has been applied to various aortic valve pathologies, particularly when somatic growth is an issue. However, associated cardiac disease and technical problems may limit its use with regard to associated procedures and issues of right ventricular outflow reconstruction. MATERIALS AND METHODS: From December 1992 to March 1998, 24 patients underwent aortic pulmonary autograft implantation. There were 14 males and 10 females, 15+/-10 years of age (mean +/- SD) (range 1 to 50 years), weighing 42.8+/-20 kg (mean +/- SD) (range 8 to 78 kg). Aortic insufficiency was present in 15 (62.5%) patients, stenosis in 8 (33.3%) patients, and valvar stenosis associated with left ventricular outflow tract obstruction in 1 (4.1%) patient. Etiology was rheumatic in 17 patients and congenital in 7. The Ross procedure was accompanied by a partial-Konno left ventricular outflow enlargement in one patient, and mitral valve annuloplasty, mitral commissurotomy, and tricuspid valve replacement in three other patients, respectively. The right ventricular outflow was reconstructed with a valved pulmonary homograft in 14 patients and with a Shelhigh No-React porcine pulmonary conduit in 10 patients. Evaluation was done by New York Heart Association (NYHA) Class and by echocardiography at a follow-up of 22.8+/-24 months (mean +/- SD) (range 3 to 63 months). RESULTS: There were no operative mortalities and no postoperative arrhythmias. One (4.1%) patient required intra-aortic balloon pump (IABP) support for 3 days, one (4.1%) patient died 2 years later of probable arrhythmia, and one (4.1%) patient required mechanical aortic valve replacement 2 years later for severe autograft insufficiency. Left ventricular ejection fraction was unchanged (preoperative 62.4%+/-30%, postoperative 64.2%+/-30% [mean +/- SD], [p = NS]) and no significant gradient was documented by echocardiographic Doppler in the right and left ventricular outflow tracts. The aortic insufficiency scale decreased from a mean of 3.9+/-0.2 to a mean of 1+/-0 (p < 0.01). NYHA Class decreased to I in all patients, from III (10) and II (14). CONCLUSIONS: The pulmonary autograft in the aortic position is suitable for aortic valve replacement in pediatric and adult patients with good medium-term results and in patients with rheumatic etiology, and it provides a desirable solution in the presence of associated pathologies, such as left ventricular tract obstruction or associated multivalvular disease. The development of new means of right ventricular outflow reconstruction must parallel the progress achieved for the left side.

OBJECTIVE: Surgical ventricular restoration (SVR) for postinfarction left ventricular anterior aneurysm improves left ventricular function. The aim of this study was to evaluate whether concomitant multivessel coronary artery disease (MVCAD) can affect long-term outcome. Thus, long-term results of SVR associated with multiple coronary artery bypass grafting (CABG) for MVCAD (group 1) were compared with SVR with or without CABG to left anterior descending artery and/or its diagonal branch for single-vessel coronary artery disease (group 2). METHODS: Data from 104 consecutive patients (age 64 +/- 8 years) with left ventricular anterior aneurysm, subjected to SVR from January 1994 to December 2004 and divided into group 1 (n = 79) and group 2 (n = 25), were analyzed. RESULTS: In group 1 vs. group 2, number of grafts/patient (2.7 +/- 0.9 vs. 0.6 +/- 0.6, P < 0.0001) was higher, cardiopulmonary bypass (109 +/- 30 vs. 65 +/- 28 min, P < 0.0001) and aortic cross-clamp times (65 +/- 18 vs. 44 +/- 23 min, P < 0.0001) were longer, resected aneurysmatic area (12 +/- 8 vs. 17 +/- 11 cm2, P < 0.05) was smaller. Operative mortality was 3.7 vs. 4% (P = not significant). At 12 years, survival (85 +/- 5 vs. 80 +/- 16%) and freedom from cardiac events (70 +/- 7 vs. 75 +/- 16%) were not statistically different in both groups. Follow-up echocardiography showed significant left ventricular ejection fraction improvement in group 1 (0.45 +/- 0.07 vs. 0.34 +/- 0.10 preoperatively, P < 0.0001) and group 2 (0.47 +/- 0.09 vs. 0.36 +/- 0.12, P = 0.001). Independent predictors of late death were preoperative history of ventricular arrhythmias (P < 0.001) and hypo/akinesia of proximal myocardial anterior wall (P < 0.05). CONCLUSION: Late survival and freedom from cardiac events are excellent after SVR, also when concomitant MVCAD requires complete revascularization. Ventricular arrhythmias and impaired left ventricular anterior wall function are predictors of worse outcome.

Background Supraventricular arrhythmias complicate operated and unoperated congenital heart disease, especially when atrial dilatation coexists. Methods We evaluated the results of intraoperative ablation in a group of 23 patients with chronic supraventricular tachyarrhythmias (mostly intraatrial reentry) that were unresponsive to conventional medical therapy. All procedures were performed consecutively between September 1999 and November 2001. Ablation was done during redo operations (Fontan conversion to total cavopulmonary connection in 16 patients) in 18 patients and during primary surgical correction in 5 patients. The mean age at operation was 25 ± 12 years (2 to 50 years). Cryoablation was done in 10 patients and radiofrequency ablation in 13 patients. Nineteen patients had ablation in one atrium and 4 had ablation in both atria. A generous atrial reduction was always performed at the end of the operation. Results The operative mortality rate was 13% (3 patients) from causes unrelated to ablation. In 20 survivors, the ablation was effective immediately. Eight patients required a permanent pacemaker. During a mean follow-up of 22 ± 4 months, atrial arrhythmias recurred in 25% (5 patients) and were controlled with medical therapy, whereas 1 patient required pacemaker implantation. Conclusions Intraoperative treatment of unresponsive atrial tachyarrhythmias associated with operated or unoperated congenital heart disease is feasible and the midterm results are encouraging.

Partendo dalla definizione di "Acquisti pubblici verdi" l'articolo evidenzia luci ed ombre dell'attività di integrazione dei criteri ambientali in tutte le fasi del processo di acquisto ponendo in risalto la dicotomia esistente tra la riduzione della spesa pubblica voluta dalla spendi review ed il concetto di ecologia evidenziato anche dalla Corte di Giustizia della Comunità Europea.

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: Conversion to total extracardiac cavopulmonary anastomosis is an option for managing patients with dysfunction of a prior Fontan connection. Methods: Thirty-one patients (19.9 ± 8.8 years) underwent revision of a previous Fontan connection to total extracardiac cavopulmonary anastomosis at four institutions. Complications of the previous Fontan connection included atrial tachyarrhythmias (n = 20), progressive heart failure (n = 17), Fontan pathway obstruction (n = 10), effusions (n = 10), pulmonary venous obstruction by an enlarged right atrium (n = 6), protein-losing enteropathy (n = 3), right atrial thrombus (n = 2), subaortic stenosis (n = 1), atrioventricular valve regurgitation (n = 3), and Fontan baffle leak (n = 5). Conversion to an extracardiac cavopulmonary connection was performed with a nonvalved conduit from the inferior vena cava to the right pulmonary artery, with additional procedures as necessary. Results: There have been 3 deaths. Two patients died in the perioperative period of heart failure and massive effusions. The third patient died suddenly 8 months after the operation. All surviving patients were in New York Heart Association class I (n = 20) or II (n = 7), except for 1 patient who underwent heart transplantation. Early postoperative arrhythmias occurred in 10 patients: 4 required pacemakers, and medical therapy was sufficient in 6. In 15 patients, pre-revision arrhythmias were improved. Effusions resolved in all but 1 of the patients in whom they were present before revision. The condition of 2 patients with protein-losing enteropathy improved within 30 days. Conclusions: Conversion of a failing Fontan connection to extracardiac cavopulmonary connection can be achieved with low morbidity and mortality. Optimally, revision should be undertaken early in symptomatic patients before irreversible ventricular failure ensues. (J Thorac Cardiovasc Surg 2000;119:340-6)

Background. An important subgroup of patients with partial atrioventricular canal require an operation in the first year of life because of refractory congestive heart failure. Methods. From June 1982 to April 1995, of 128 patients with partial atrioventricular canal, 35 patients (27%) underwent surgical treatment at less than 1 year of life. Associated cardiac anomalies were present in 22 patients. Only 7 patients (20%) had Down's syndrome. Five patients with left ventricular hypoplasia underwent aortic coarctectomy (3 patients) or Norwood operation (2 patients). The other 30 patients underwent anatomic repair in 24 cases and aortic coarctectomy in 6. The surgical results of patients submitted for anatomic repair were retrospectively correlated with the echocardiographic mitral valve diameter. Results. There were 7 deaths (29%) after anatomic repair, 2 (22%) after aortic coarctectomy, and 2 (100%) after Norwood operation. Infants with a mitral valve diameter less than 2.5 × 10 −2 m/m 2 died at repair. In a mean follow-up of 73.5 months there were five secondary mitral valve plasties and three repairs after aortic coarctectomy. Conclusions. Among patients with partial atrioventricular canal, there is an important subgroup with clinical signs of heart failure in the first year of life. Left-sided obstructive lesions and complex mitral valve anomalies seem to play a fundamental role in the clinical evolution and prognosis of these patients. The echocardiographic mitral valve diameter may be useful for determining the correct surgical indication.

A measurement is presented of the charged hadron multiplicity in hadronic PbPb collisions, as a function of pseudorapidity and centrality, at a collision energy of 2.76 TeV per nucleon pair. The data sample is collected using the CMS detector and a minimum-bias trigger, with the CMS solenoid off. The number of charged hadrons is measured both by counting the number of reconstructed particle hits and by forming hit doublets of pairs of layers in the pixel detector. The two methods give consistent results. The charged hadron multiplicity density, dN(ch)/d eta vertical bar(eta=0), for head-on collisions is found to be 1612 +/- 55, where the uncertainty is dominated by systematic effects. Comparisons of these results to previous measurements and to various models are also presented.

Non-penetrating cardiac trauma resulting in mitral valve rupture is uncommon, requiring a high degree of suspicion for diagnosis. Sudden and severe mitral regurgitation, unless surgically corrected rapidly lead to congestive heart failure and death. We report a patient with traumatic rupture of the antero-lateral papillary muscle of the mitral valve and pericardial injury, after a lateral blunt chest trauma, who successfully underwent emergency mitral valve replacement.

Aims: For purpose of service planning for dementia, an Italian version was developed from an original German instrument and its psychometric characteristics were checked. Than, it was applied to detect which patient and/or of the carer 'characteristics influencing answers profiles. Methods: Two independent raters allowed to detect both inter-rater and rest-retest reliability, for content validity professionals and carers were required to rate the relevance of each problem area and intervention on a four point scale. Dementia patients and their carers were assessed to define levels of cognitive performance and disability, and levels of burden and care-network . These data were related to perceived needs. Results: The original psychometrics characteristic are preserved in the Italian version. The levels of patient' disability and carer' burden resulted to significantly influence CNAD total score. Conclusions: CNAD allows not only comparative study on services for dementia but also an improvement of the local process of allocation of resources and their management.

Of 353 children who underwent surgical repair of a congenital heart defect, including closure of a ventricular septal defect (VSD), 12 patients (four with tetralogy of Fallot, five with a VSD, and three with a double-outlet right ventricle) developed subaortic stenosis, which was diagnosed one to six years after the surgical procedure. Five patients required surgical treatment of the subaortic stenosis, and one required percutaneous balloon angioplasty. Postsurgical subaortic stenosis appears to be an uncommon progressive acquired disease.