Antonino Loforte

Cox/Maze III operation versus radiofrequency ablation for the surgical treatment of atrial fibrillation: a comparative study

BACKGROUND The purpose of this study was to evaluate the efficacy of radiofrequency (RF) ablation in the treatment of atrial fibrillation, by comparatively analyzing the outcomes of the patients who underwent RF ablation with those of patients who underwent Cox/Maze III surgery. METHODS Between April 1995 and June 2002, 70 patients underwent surgery for atrial fibrillation and open-heart surgery at the Department of Cardiovascular Surgery of the University of Bologna: 30 patients underwent the surgical Cox/Maze III procedure (group 1), and 40 patients underwent the RF ablation according to the Maze III configuration at least on the left atrium (group 2). There were 14 males and 56 females, with a mean age of 61.5 +/- 12.5 years (range 22 to 80 years old). RESULTS Groups 1 and 2 did not differ in terms of baseline characteristics. The perioperative mortality rate was not significantly different between the two groups (6.6% in group 1 vs 7.5% in group 2). The overall cumulative rates of sinus rhythm were 68.9% in group 1 and 88.5% in group 2 (not statistically significant). Biatrial contraction was assessed by transthoracic echocardiography in 70.4% of the patients in group 1 and 76.5% of the patients in group 2 (p = 0.65). CONCLUSIONS The RF ablation procedure offers as good results as the Cox/Maze III operation, allowing recovery of the sinus rhythm and atrial function in the great majority of patients with atrial fibrillation who underwent open heart surgery; it is a safe and effective means of curing atrial fibrillation with negligible technical and time requirements.

Extracorporeal membrane oxygenation for intraoperative cardiac support in children with congenital heart disease

OBJECTIVES Extracorporeal membrane oxygenation (ECMO) is commonly used in children to allow recovery from ischemic injury or cardiac surgery, to support the circulation in case of end-stage cardiomyopathy, as bridge-to-bridge therapy and as bridge to transplantation as well. It has achieved success in providing cardiac support for these kind of patients with expected mortality due to severe myocardial dysfunction. In this modern era, ECMO support should be considered an important option for children with cardiopulmonary failure refractory to medical therapy or resuscitation. We report our experience in pediatric patients supported by ECMO for intraoperative cardiac failure between November 1991 and December 2006. METHODS AND RESULTS Sixty-six patients with a mean age of 5.2+/-4 years (range: 1 day-17 years) and mean weight of 14.3+/-11 kg (range: 2.8-69 kg) had intraoperative ECMO support for failure to wean off cardiopulmonary bypass (n=46, 69.7%), low cardiac output syndrome (n=8, 12.1%), isolated right ventricular failure (n=6, 9.1%), isolated left ventricular failure (n=3, 4.5%), malignant arrhythmia (n=1, 1.5%) and pulmonary hypertension (n=2, 3.1%). Mean duration of ECMO support was 5.1+/-3 days. Overall 30 (45.4%) patients were successfully weaned off ECMO and survived to decannulation. Overall 6 (9.1%) patients were successfully bridged to heart transplantation while on ECMO support. Thirty patients died (54.4%) (16 while on ECMO and 14 after decannulation) because of multi-factorial complications, i.e. cerebral hemorrhage, pulmonary failure, consumption coagulopathy and therapy-resistant myocardial insufficiency, leding to an overall hospital mortality rate of 45.4%. Mean survival time after decannulation was 28+/-16 h. Overall survival rate on ECMO as bridge to recovery and transplantation has been 54.5% with successful hospital discharge of patients. CONCLUSIONS Our experience shows that ECMO support can be offered intraoperatively to any children after palliative or corrective surgery for congenital heart disease with potentially reversible pulmonary, cardiac or cardiopulmonary failure. In the majority of patients who did not survive late after weaning from ECMO support, significant myocardial dysfunction persisted or pulmonary hypertensive events. Nevertheless, an acceptable proportion of patients who were successfully weaned from ECMO ultimately survived to leave the hospital.

Surgery for atrial fibrillation using radiofrequency catheter ablation.

OBJECTIVE We present the results obtained in 40 patients with chronic atrial fibrillation using direct intraoperative radiofrequency to perform atrial fibrillation surgery. METHODS Between April 2001 and June 2002, 40 patients underwent surgery for atrial fibrillation using radiofrequency ablation and cardiac surgery at the Department of Cardiovascular Surgery of the University of Bologna [corrected]. There were 8 men and 32 women with a mean age of 62 +/- 11.6 years (range: 20 to 80 years). RESULTS Concomitant surgical procedures were: mitral valve replacement (n = 13), mitral valve replacement plus tricuspid valvuloplasty (n = 11), combined mitral and aortic valve replacement (n = 8), and combined mitral and aortic valve replacement plus tricuspid valvuloplasty (n = 5). Moreover, 1 patient underwent tricuspid valvuloplasty plus atrial septal defect repair, another required aortic valve replacement plus coronary artery bypass graft, and a third underwent aortic valve replacement. After the mean follow-up time of 16.5 +/- 2.5 months survival was 92.8% and the overall cumulative rate of sinus rhythm was 88.5%. CONCLUSIONS We conclude that the radiofrequency ablation procedure is a safe and effective means of curing atrial fibrillation with negligible technical and time requirements, allowing recovery of the sinus rhythm and atrial function in the great majority of patients with atrial fibrillation who underwent cardiac surgery (88.5% of our study population).

Simultaneous temporary CentriMag right ventricular assist device placement in HeartMate II left ventricular assist system recipients at high risk of right ventricular failure

An approach is reported for right ventricle temporary mechanical support in long-term axial left ventricular assist device (LVAD) patients preoperatively judged at high risk of right ventricular (RV) failure. The timing for RV assist device (RVAD) weaning and the technique for its removal through a right mini-thoracotomy are described. This strategy provides a good outcome in LVAD recipients avoiding the risk of immediate postoperative RV failure.

Complex double-outlet right ventricle repair in a neonate with complete tracheal agenesis

underline the relative greater frequency of this complication in heterotaxy syndrome when associated with anomalous pulmonary and systemic venous connections, which can make surgical repair complicated with the need to create a tortuous and potentially obstructive pathway. Despite this concern, a recent report from our institution 5 has shown excellent outcome with cavopulmonary connection in patients with heterotaxy syndrome and anomalous pulmonary venous return. This is likely due to improved surgical technique and use of extracardiac conduit in cases with complex atrial and venous anatomy (18%). None of the 3 patients had evidence of obstruction at the pulmonary venous pathway early after the Fontan procedure, as determined by 2-dimensional echocardiography. Pulmonary venous obstruction developed slowly through a period of several months to years. In patient 2, pulmonary venous obstruction developed 4 months after device closure of the fenestration, suggesting that the additional scarring from device implantation contributed to the obstruction. The obstruction was due to fibrotic tissue at either the interatrial septum or in the interatrial course of the pulmonary veins (patient 2). To prevent this complication, and to ensure a wide open pulmonary venous outflow, particularly in patients with mitral atresia or stenosis, we currently enlarge the communication between the pulmonary veins and the right atrium by unroofing the coronary sinus posteriorly into the left atrium, in addition to resection of the interatrial septum. In conclusion, late onset obstruction of pulmonary venous pathway after lateral tunnel cavopulmonary connection is a rare but serious complication that may be prevented by unroofing the coronary sinus at the time of Fontan procedure.

Thrombolysis for acute pulmonary embolism after major hepatic surgery

Acute pulmonary embolism (PE) is a serious complication of oncologic surgery,moreover,major liver surgery is often associatedwith postoperative derangements in coagulation balance [1]. In fact, the equilibrium between pro and anticoagulant factors may progressively change during the subsequent postoperative days [2], therefore, themanagement of coagulation could be more challenging in case of pulmonary embolism. A 67 years old man was scheduled to undergo a right hepatectomy plus segment 1 resection and a right hemicolectomy for an adenocarcinoma of the appendix with hepatic metastases. His comorbidities were benign prostatic hypertrophy and gastroesophageal reflux disease and he never underwent surgery before. The procedure was carried out without complications but an unexpected difficult airway (Cormack-Lehane grade 3, orotracheal intubation achieved at the third attempt) and the patient was subsequently transferred to ICU for postoperative monitoring. On POD1 weaning from mechanical ventilation was concluded and the patient was successfully extubated, however three hours later he developed a new onset atrial fibrillation with high ventricular response and profound hypotension (ABP 70/30 mmHg, HR 160 BPM). A single synchronised cardioversion at 100 J successfully restored sinus rhythm and acceptable hemodynamics. Post cardioversion ECG showed a new onset right bundle branch block, transthoracic echocardiography performed by the consultant cardiologist demonstrated a new onset abnormal motion of the interventricular septum, right heart dilatation, moderate tricuspid insufficiency and an estimated right ventricular systolic pressure of 55 mmHg. Because of the very high suspicion of acute pulmonary embolism (PE), an urgent CT pulmonary angiogramwas scheduled and the patient was sedated and reintubatedwithfibrobronchoscopic technique in consideration of the difficult airway and the potential instability during the transfer. The CT pulmonary angiogram evidenced a massive pulmonary embolism with a thrombus located in the pulmonary trunk and involving the main bilateral branches with partial sparing of the vessels for the left superior lobe and lingula (Fig. 1). Serum Troponin I values measured every three hours were 584– 2319–2540 ng/L.

Single-step surgical procedure for total replacement of the thoracic aorta in a case of Turner syndrome.

Turnersyndrome(TS)isawell-definedautosomaldominantgenetic syndrome caused by a partial or complete monosomy of the chromosome X(45,X0). Cardiovascular complications are mostly responsible forreducedlifeexpectancy.Themaincardiacabnormalitiesarebicuspid aortic valve and aortic coarctation in approximately 16% and 11% of the patients, respectively [1]. A dilatation of major vessels is also observed, above all of the aorta and of the carotid and the brachial arteries. Aortic disease in TS is characterizedbya “connective tissue disorder”similarto that seen in Marfansyndrome. Ascending aorta dilatation is observed in 33% of the cases, and the incidence of aortic dissection is much higher than for women in general, occurring in the third and fourth decades of life [2]. We present a case of TS with bicuspid aortic valve plus hypoplastic aortic arch and chronic aneurysm of the descending thoracic aorta. Informed consent was obtained by the patient. The patient, a 38-year-old woman (Body Surface Area: 1.34 m 2 ; Aortic Size Index: 2.6 cm/m 2 ) with 45,X0 karyotype diagnosed at birth, presented a bicuspid aortic valve, an aortic coarctation, a left superior vena cava and patent ductus arteriosus. At 11 months, she underwent surgical repair of isthmic coarctation and patent ductus closure. After that, she was followed by regular examinations until the age of six, when she was operated on for an excision of a supravalvular mitral stenosis. During the following years, the patient had a normal quality of life up to 38 years when an echocardiogram showed mild aortic regurgitation