Alberto Molardi

Italian multicentre study on type A acute aortic dissection: a 33-year follow-up

OBJECTIVES Despite substantial progress in surgical techniques and perioperative management, the treatment and long-term follow-up of type A acute aortic dissection (AAD) still remain a major challenge. The objective of this retrospective, multicentre study was to assess in a large series of patients the early and long-term results after surgery for type A AAD. METHODS We analysed the preoperative, intraoperative and postoperative conditions of 1.148 consecutive patients surgically treated in seven large referral centres from 1981 to 2013. We applied to each patient three different multi-parameter risk profiles (preadmission risk, admission risk and post-surgery risk) in order to compare risk factors and outcome. Long-term Kaplan-Meier survival was evaluated. RESULTS The median age was 64 years and the male population was predominant (66%). Identified diagnosis of collagen disease was present in 9%, and Marfan syndrome in 5%. Bicuspid aortic valve was present in 69 patients (6%). Previous cardiac surgery was identified in 10% of the patients. During surgery, the native aortic valve was preserved in 72% of the cases, including leaflet resuspension in 23% and David operation in 1.2%. Considering aortic valve replacement (AVR: 28%), bioprosthesis implantation was performed in 14.7% of the subjects. Neurological impairment at discharge was shown in 23% of the cases among which 21% of patients had new neurological impairment versus preoperative conditions. The overall 30-day mortality rate was 25.7%. All risk profiles remained independently associated with in-hospital mortality. During the available follow-up of hospital survivors (median: 70 months, interquartile range: 34-113, maximum: 396), cardiac-related death occurred in 7.9% of the subjects. The cumulative survival rate for cardiac death was 95.3% at 5 years, 92.8% at 10 years and 52.8% at 20 years. Severe aortic regurgitation (AR) (grade 3-4) at the time of surgery showed to be a significant risk factor for reintervention during the follow-up (P < 0.001). Among risk profiles, only the preadmission risk was independently associated with late mortality after multivariate analysis. Unexpectedly, there was no difference in freedom from cardiac death between patients with and without AVR. CONCLUSIONS Although surgery for type A has remained challenging over more than three decades, there is a positive trend in terms of hospital mortality and long-term follow-up. About 90% of patients were free from reoperation in the long term, although late AR remains a critical issue, suggesting that a thorough debate on surgical options, assessment and results of a conservative approach should be considered.

The Evolution of Cardiovascular Surgery in Elderly Patient: A Review of Current Options and Outcomes

Due to the increase in average life expectancy and the higher incidence of cardiovascular disease with advancing age, more elderly patients present for cardiac surgery nowadays. Advances in pre- and postoperative care have led to the possibility that an increasing number of elderly patients can be operated on safely and with a satisfactory outcome. Currently, coronary artery bypass surgery, aortic and mitral valve surgery, and major surgery of the aorta are performed in elderly patients. The data available show that most cardiac surgical procedures can be performed in elderly patients with a satisfactory outcome. Nevertheless, the risk for these patients is only acceptable in the absence of comorbidities. In particular, renal dysfunction, cerebrovascular disease, and poor clinical state are associated with a worse outcome in elderly patients. Careful patient selection, flawless surgery, meticulous hemostasis, perfect anesthesia, and adequate myocardial protection are basic requirements for the success of cardiac surgery in elderly patients. The care of elderly cardiac surgical patients can be improved only through the strict collaboration of geriatricians, anesthesiologists, cardiologists, and cardiac surgeons, in order to obtain a tailored treatment for each individual patient.

Diagnostic value of chest ultrasound after cardiac surgery: a comparison with chest X-ray and auscultation.

OBJECTIVE Chest auscultation and chest x-ray commonly are used to detect postoperative abnormalities and complications in patients admitted to intensive care after cardiac surgery. The aim of the study was to evaluate whether chest ultrasound represents an effective alternative to bedside chest x-ray to identify early postoperative abnormalities. DESIGN Diagnostic accuracy of chest auscultation and chest ultrasound were compared in identifying individual abnormalities detected by chest x-ray, considered the reference method. SETTING Cardiac surgery intensive care unit. PARTICIPANTS One hundred fifty-one consecutive adult patients undergoing cardiac surgery. INTERVENTIONS All patients included were studied by chest auscultation, ultrasound, and x-ray upon admission to intensive care after cardiac surgery. MEASUREMENTS AND MAIN RESULTS Six lung pathologic changes and endotracheal tube malposition were found. There was a highly significant correlation between abnormalities detected by chest ultrasound and x-ray (k = 0.90), but a poor correlation between chest auscultation and x-ray abnormalities (k = 0.15). CONCLUSIONS Chest auscultation may help identify endotracheal tube misplacement and tension pneumothorax but it may miss most major abnormalities. Chest ultrasound represents a valid alternative to chest x-ray to detect most postoperative abnormalities and misplacements.

Parma tracheostomy technique: a hybrid approach to tracheostomy between classical surgical and percutaneous tracheostomies

BACKGROUND The aim of our study is to compare the classical surgical tracheostomy (TT) technique with a modified surgical technique designed and created by the cardiothoracic surgery staff of our department to reduce surgical trauma and postoperative complications. This modified technique combines features of percutaneous TT and surgical TT avoiding the use of specialized tools, which are required in percutaneous TT. METHODS From October 2008 to March 2014 we performed 67 tracheostomies using this New Modified Surgical Technique (NMST) and 56 TT with the Classical Surgical Technique (CST). We collected data about the early clinical complications, deaths TT-related, deaths due to other complications and the presence of late TTs complications were performed by a telephone follow-up. SPSS software (IMB version 21) was used for the statistical analysis. Categorical data were treated with chi-square test and continuous data were treated with t-test for independent samples. RESULTS NMST group had a significant lower number of early complications (P=0.005) compared to CST group (5 vs. 15). In-hospital mortality was significantly higher in CST group (18 deaths vs. 4 in NMST group, P=0.001) but we registered only one case of TT-related mortality in CST group (P=0.280). We did not note other differences between the two groups regarding short or mid-long term complications. CONCLUSIONS In our experience the NMST demonstrated to be easily safe and reproducible with an amount of early, mid- and long-term complications similar to the CST; furthermore the aesthetic results of the procedure appear similar to those of percutaneous TT.

Renal Doppler Resistive Index as a Marker of Oxygen Supply and Demand Mismatch in Postoperative Cardiac Surgery Patients.

Background and Objective. Renal Doppler resistive index (RDRI) is a noninvasive index considered to reflect renal vascular perfusion. The aim of this study was to identify the independent hemodynamic determinants of RDRI in mechanically ventilated patients after cardiac surgery. Methods. RDRI was determined in 61 patients by color and pulse Doppler ultrasonography of the interlobar renal arteries. Intermittent thermodilution cardiac output measurements were obtained and blood samples taken from the tip of pulmonary artery catheter to measure hemodynamics and mixed venous oxygen saturation (SvO2). Results. By univariate analysis, RDRI was significantly correlated with SvO2, oxygen extraction ratio, left ventricular stroke work index, and cardiac index, but not heart rate, central venous pressure, mean artery pressure, pulmonary capillary wedge pressure, systemic vascular resistance index, oxygen delivery index, oxygen consumption index, arterial lactate concentration, and age. However, by multivariate analysis RDRI was significantly correlated with SvO2 only. Conclusions. The present data suggests that, in mechanically ventilated patients after cardiac surgery, RDRI increases proportionally to the decrease in SvO2, thus reflecting an early vascular response to tissue hypoxia.

The use of RemoweLL oxygenator-integrated device in the prevention of the complications related to aortic valve surgery in the elderly patient: Preliminary results

Background The effects of fat microembolization due to cardiopulmonary bypass are well known in cardiac surgery. Our aim is to evaluate the use of the RemoweLL device (Eurosets, Medolla, Italy) during elective aortic valve replacement in elderly patients (>70 years old) to rate its biochemical and clinical effects. The RemoweLL device is an oxygenator-integrated reservoir which combines two strategies for fat emboli and leucocytes removal: filtration and supernatant elimination. Methods Forty-four elderly patients were enrolled and assigned randomly to a Group A (standard device) and a Group B (RemoweLL). Biochemical effects were evaluated by blood samples, which were tested for white blood cells, neutrophils, protein SP-100 and interleukin 6 besides standard lab tests. Our clinical endpoints were any type of neurological, cardiac, respiratory, gastrointestinal or renal complications, and length of stay in the intensive care unit. Statistical analysis was carried out with chi square test for non-parametric data; t test and analysis of variance for repeated measures were used for parametric data. Results Group B showed lower levels of white blood cells, neutrophils, interleukin 6 and protein SP-100 immediately and 24 hours after the operation. Group B also showed a lower amount of neurocognitive type II dysfunction even if the length of stay in the ICU did not change. Conclusions The RemoweLL system is safe and effective in reducing inflammatory response to cardiopulmonary bypass and it could be a useful tool in minimizing negative effects of cardiopulmonary bypass; however, it does not seem to have any effect on elderly patients’ hospital stay.

The role of genetic testing in the prevention of acute aortic dissection

Although much has been learned about disease of the thoracic aorta, most diagnosis of thoracic aortic aneurysm (TAA) is still incidental. The importance of the genetic aspects in thoracic aortic disease is overwhelming, and today different mutations which cause TAA or alter its natural history have been discovered. Technological advance has made available testing which detects genetic mutations linked to TAA. This article analyses the genetic aspects of TAA and describes the possible role of genetic tests in the clinical setting in preventing devastating complications of TAA.

Non-A non-B aortic dissection: a systematic review and meta-analysis

OBJECTIVES Non-A non-B aortic dissections are rare, and little is known about their natural history, indications for surgery and operative results. We aim to examine the literature to summarize what is known of the natural history of non-A non-B dissections and evaluate the outcomes of the therapeutic options available. METHODS An extensive literature search was performed using MEDLINE to find all published studies that report data on the natural history and outcomes of patients with non-A non-B aortic dissection. Data on patients treated with medical therapy were extracted to characterize the natural history. Primary end points included 30-day mortality, stroke and retrograde type A dissection. RESULTS Of the 423 studies found, 14 articles (433 patients) fulfilled the inclusion criteria for quantitative analysis. The proportion of medically treated patients ranged from 5 to 54% with a pooled rate of 36% (50/138). The 30-day mortality of patients treated with medical therapy was 14% (7/50). The overall estimated proportion of 30-day mortality for patients who underwent intervention was 3.6% [95% confidence interval (CI) 1.7-5.6%], retrograde type A dissection was 2.6% (95% CI 0.8-4.4%) and stroke was 2.8% (95% CI 1.0-4.5%). CONCLUSIONS Despite the likelihood of reporting and selection bias, patients with non-A non-B dissection often have a complicated course requiring some form of intervention. The 30-day mortality of patients treated with medical therapy seems higher than surgical or endovascular therapy. Ideally, further large prospective studies are necessary to confirm our suggestion that early intervention may be indicated in non-A non-B dissections.