Andrea Dell'Amore

Aortic valve replacement: Results and predictors of mortality from a contemporary series of 2256 patients

OBJECTIVE The studys objectives were to evaluate results and identify predictors of hospital and mid-term mortality after primary isolated aortic valve replacement; compare early and mid-term survival of patients aged more than 80 years or less than 80 years; and assess the effectiveness of the logistic European System for Cardiac Operative Risk Evaluation in predicting the risk for hospital mortality in octogenarians with a logistic European System for Cardiac Operative Risk Evaluation greater than 15% who are undergoing aortic valve replacement. METHODS Data from 2256 patients undergoing primary isolated aortic valve replacement between January 2003 and December 2007 were prospectively collected in a Regional Registry (Regione Emilia Romagna Interventi Cardiochirurgia) and analyzed to estimate hospital and mid-term results. RESULTS Overall hospital mortality was 2.2%. By multivariate analysis, New York Heart Association III and IV, Canadian Cardiovascular Society III and IV, pulmonary artery pressure greater than 60 mm Hg, dialysis, central neurologic dysfunction, and severe chronic obstructive pulmonary disease emerged as independent predictors of hospital mortality. At 3 years, the survival was 89.3%. The same predictors of hospital mortality plus ejection fraction of 30% to 50% and age more than 80 years emerged as independent risk factors for 3-year mortality. Compared with younger patients, octogenarians had a higher hospital mortality rate (3.72% vs 1.81%; P = .0143) and a reduced 3-year survival (82.3% vs 91.3%; P < .001). Three-year survival of octogenarians was comparable to the expected survival of an age- and gender-matched regional population (P = .157). The observed mortality rate in octogenarians with a logistic European System for Cardiac Operative Risk Evaluation greater than 15% (mean: 22.4%) was 7% (P < .001). CONCLUSIONS This study provides contemporary data on the characteristics and outcome of patients undergoing first-time isolated aortic valve replacement.

Early and long-term results of pulmonary resection for non-small-cell lung cancer in patients over 75 years of age: a multi-institutional study.

OBJECTIVES Older lung cancer patients with multiple morbidities are increasingly referred to thoracic surgery departments. The aim of this multicenter study was to analyse the prognostic factors for in-hospital morbidity and mortality and to elucidate the predictors of long-term survival and oncological outcomes. METHODS We identified 319 patients aged ≥ 75 years who underwent intended curative lung resection for lung cancer in three different thoracic surgery departments between January 2000 and December 2010. RESULTS Seventy-one patients underwent limited resection, 202 had lobectomy, 16 had bilobectomy and 30 had pneumonectomy. The in-hospital mortality was 6.6%. Chronic renal failure, low respiratory reserve and pneumonectomy were predictors of in-hospital mortality. The mean follow-up time was 3.9 years, ranging from 1 month to 10.4 years. The disease-free survivals at 1, 3 and 5 years were 82, 60 and 47%, respectively. The overall survivals at 1, 3 and 5 years were 86, 59 and 38%, respectively. The long-term overall survival was negatively influenced by pneumonectomy, extended resection, N(1-2) subgroups and pathological TNM stage. CONCLUSIONS Nowadays, we can consider surgery a safe and justifiable option for elderly patients. Careful preoperative work-up and selection are mandatory to gain satisfactory results. Good long-term results were achieved in elderly patients with early stage who underwent lobar or sublobar lung resection. The role of surgery or other alternative therapies, in patients with advanced stages, extensive nodal involvement and/or requiring extensive surgical resection for curative intent, is still unclear and further studies are certainly needed.

Aortic valve replacement with and without combined coronary bypass grafts in very elderly patients: early and long-term results

OBJECTIVE The number of older patients being referred for aortic valve replacement with or without combined coronary bypass grafting (CABG) is increasing. The aim of this study was to evaluate operative risk factors, early and long-term results of isolated aortic valve and aortic valve replacement combined with CABG in octogenarians and nonagenarians. METHODS In the last 10 years, 285 very elderly patients who underwent aortic valve replacement either alone or in combination with coronary artery bypass grafts were retrospectively studied. The population was divided into two groups; isolated aortic valve replacement was performed in 188 patients (group A) and 97 patients had aortic valve replacement combined with coronary surgery (group B). RESULTS The overall hospital mortality was 5.3%, without statistical difference between groups. The incidence of low-output syndrome was higher in group B (P = 0.0001). The multivariate analysis for hospital mortality showed that urgency status, ejection fraction (EF) <35%, intra-operative variables such as clamping time, need for intra aortic balloon pump and post-operative variables such as prolonged ventilation, dialysis, post-operative myocardial infarction and re-thoracotomy for bleeding were independent prognostic factors for hospital mortality. The mean follow-up time was 49.03 ± 19 months. Survival at one, three and five years was 97.1 ± 1.8%, 92.2 ± 2.2% and 82.4 ± 3.6% for group A and 97.2 ± 2.0%, 88.4 ± 2.7% and 75.6 ± 3.2% for group B (P = 0.62), respectively. Age, male gender, post-operative myocardial infarction, urgency status, dialysis, low EF, mean aortic gradient were risk factors for the impaired survival. CONCLUSIONS In our experience, a careful pre-operative evaluation has yielded good surgical results even in older patients with different comorbidities. Associated coronary grafts slightly increase the surgical risk. The role of revascularization on long-term morbidity and mortality is still not clear. It is essential to compare the results of percutaneous and trans-apical aortic valve replacement with the literature results of conventional aortic valve replacement with and without CABG before it can be used as an alternative for very older patients.

An alternative technique for anterior chest wall reconstruction: the sternal allograft transplantation.

OBJECTIVES Sternal resection is indicated for a variety of pathological conditions, mainly neoplastic or related to sternotomy complications. Resection of the sternum generally leaves a large chest-wall defect, and reconstruction is thus the most difficult part of the operation. Correct stabilization of the anterior chest wall is very important to avoid secondary complications and respiratory failure. In the last few years, different technical solutions have been used to reconstruct the sternum. We describe our technique using a sternal allograft to reconstruct the anterior chest wall after partial or complete sternal resection. METHODS Between June 2010 and February 2012, four patients underwent sternectomy followed by anterior chest wall reconstruction using sternal allograft. The sternal allograft was harvested from a multitissue donor following Italian legislation for tissue donation. Three patients had neoplastic involvement of the sternum, and one had a complete sternal defect as a complication of a cardiac operation. RESULTS We had no operative mortality. Three patients underwent partial sternal transplantation, and one underwent total sternal replacement. We had no postoperative respiratory insufficiency, infections or mechanical failure of the reconstructions. The respiratory function was preserved in all patients. The follow-up period was free from complications related to the sternal allograft implantation. CONCLUSIONS The technique of sternal allograft transplantation is simple, reproducible and provides excellent functional and cosmetic results. Further studies including a larger number of patients are needed to understand the biology of the allograft and the long-term results of this technique.

Cardiac mesothelial/monocytic-incidental-excrescence: more than an artifactual lesion?

Mesothelial/monocytic incidental cardiac excrescence (MICE) is a benign finding made up of a mixture of cuboidal mesothelial cells, histiocytes and fibrine and is mainly found incidentally during open heart surgery, commonly after cardiac catheterization. Clinical importance of this lesion has been emphasized because of its potential confusion with malignancies, especially with metastatic carcinoma. We report a case of an asymptomatic 72-year-old man with incidental finding of a pericardial effusion and a small mass attached to the left appendage.

Myocardial protection using HTK solution in minimally invasive mitral valve surgery.

BACKGROUND Minimally invasive cardiac surgery (MICS) is a safe and satisfactory approach used mainly in mitral valve surgery with excellent results in many centers. Cardioplegia administration can be still a problem, especially when an endoaortic clamp is used. We retrospectively analyzed our early results with histidine-triptophane-ketoglutarate (HTK) solution used for myocardial protection in MICS. METHODS Between February 2003 and February 2004, 8 patients underwent mitral valve surgery using an endo- cardiopulmonary bypass (CPB) system and HTK solution as myocardial protection. The mean patient age was 67.7 +/- 9.2 years, and the preoperative ejection fraction was normal in all patients. Three patients had valve repair and 5 had valve replacement. Mean CPB time was 129.2 +/- 19.4 minutes, and aortic cross-clamp duration was 88.5 +/- 15.4 minutes. RESULTS In every case HTK solution was used for only a single dose for cardioplegia at the beginning of the procedure, without any recalls. The heart restarted spontaneously at reperfusion in 6 of 8 cases (75%), and there were no significant modifications in electrocardiogram results or myocardial cytonecrosis enzymes (creatine kinase and its MB fraction) during the postoperative period. CONCLUSIONS HTK solution is a cold crystalloid cardioplegia solution that has demonstrated its utility in MICS because it provides a safe long cardioplegic arrest time and it reduces the risk of inadequate coronary perfusion due to dislodgement of the endoaortic clamp.

Allogenic sternal transplant after sternectomy for metastasis of ovarian carcinoma.

Sternal metastasis from ovarian carcinoma is extremely rare. We report a case of a young woman in whom a single metastasis at the level of the upper portion of the sternum developed. Surgical excision of the sternum was performed with replacement by a sternal allograft stabilized by titanium plates and transosseous high-tension sutures. With this simple and reproducible technique, we obtained a stable and dynamic reconstruction of the sternoclavicular joints and shoulder girdle. The use of a sternal allograft provides excellent functional and cosmetic results. The implantation technique is simple and reproducible.

Surgical results and long-term follow-up of T4-non-small cell lung cancer invading the left atrium or the intrapericardial base of the pulmonary veins

Patients with locally advanced non-small cell lung cancer infiltrating the left atrium (LA) or the intrapericardial base of the pulmonary veins (PVs) are generally not considered good candidates for surgery because of the poor long-term survival. In the last 10 years, 31 consecutive patients with non-small cell lung cancer directly invading the LA or the intrapericardial base of the PVs underwent surgery. Pneumonectomy was the operation performed most frequently. In-hospital mortality was 9.7% and overall morbidity was 52%. One-, 2- and 3-year survival rates were 64, 46 and 30%, respectively with a mean survival of 22 months. The systemic recurrence of disease was the major cause of death at follow-up. At statistical analyses, the N-factor and the type of operation were related to poor long-term survival. In these patients, surgery could be performed with an acceptable operative mortality and morbidity. Surgery should be considered whenever a complete resection is technically possible. A careful preoperative evaluation is mandatory to select good candidates for surgery.

Mini re-sternotomy for aortic valve replacement in patients with patent coronary bypass grafts.

As the population ages, an increasing number of patients with patent coronary grafts will require subsequent aortic valve replacement. Major operative problems include those associated with re-entry and, in particular, damage of the patent grafts. Between January 2007 and October 2008, 10 patients who had previous coronary bypass surgery underwent aortic valve replacement through upper j-shaped mini re-sternotomy. In all patients the previous grafts were patent. The operation was performed with normothermic cardiopulmonary bypass without dissection and temporary closure of the arterial and venous coronary bypass grafts. The mean age was 73.2+/-13.6 years. The patients had a mean of 2.8+/-0.6 bypass grafts. There were no intraoperative complications due to redo ministernotomy and at no time conversion to full re-sternotomy was necessary. No damage to the previous grafts was reported and the incidence of perioperative myocardial infarction was 0%. One patient required a pacemaker implantation for atrio-ventricular block. The in-hospital mortality was 0%. Aortic valve replacement in previous coronary bypass grafting can be performed safely with a mini re-sternotomy. This approach avoids extensive dissection, decreasing the risk of injuries to heart chambers and previous patent coronary grafts with low morbidity and mortality.

Minimally invasive coronary artery bypass grafting using the inferior J-shaped ministernotomy in high-risk patients

In the last years the population of patients referred for coronary surgery has changed toward a high-risk profile. In selected cases minimally invasive approach could be a good option to reduce mortality and morbidity. Between September 2005 and September 2007, twenty-one consecutive patients underwent minimally invasive bypass surgery using the J-shaped inferior mini-sternotomy approach. All patients had a EuroSCORE higher than 6. The operative mortality was 0%. Conversion to on-pump surgery was not necessary. The mean operation time was 89+/-18 min, the mean ventilation time was 2.4+/-2.2 h, the mean intensive care unit stay was 47.2+/-36.5 h. In four patients a hybrid approach to achieve a complete revascularization was used. After six months from the operation the graft patency was evaluated with the 64-slice computed tomography. In high-risk coronary patients the use of the minimally invasive technique appeared a good option to achieve low morbidity and mortality. Through a mini-sternotomy approach, single- or double-vessel revascularization can be performed safely off-pump even in high-risk patients without compromising the accuracy of the anastomosis. Nevertheless, a further investigation is required to evaluate the long-term results in a larger cohort of patients.