Carmine Minale

Controversial aspects of coronary endarterectomy

Between 1980 and 1987, 635 patients underwent coronary bypass grafting combined with coronary endarterectomy. A total of 728 vessels were endarterectomized and grafted. There were 15 early deaths (2.3%). The mortality rate was higher (7.8%) for multiple-vessel endarterectomy (p less than 0.05). The ratio of MB fraction of creatine kinase to total creatine kinase was greater than or equal to 0.10 in 48% of the cases. The first consecutive 132 survivors were followed for an average of 16 months (range, 4 months to 5 years). No late deaths occurred. Fifty-nine unselected patients underwent postoperative recatheterization at a mean interval of 18 months. An improvement in heart wall contractility could be detected in 13 patients (16.5%) and deterioration in 14 patients (17.7%). A more detailed analysis of wall contractility showed a higher rate of improvement in the posterior wall than in the anterior wall (p greater than 0.05). Furthermore, the better the contractility before operation, the greater the rate of deterioration after operation (p less than 0.05). Despite an average of 55% of all endarterectomized vessels being occluded or severely restenosed, 90% of the patients were clinically improved. A multiparametric analysis revealed that the revascularization of myocardial areas that required endarterectomy had no significant influence with respect to clinical improvement. Endarterectomy should be limited, whenever possible, to myocardial areas with already impaired contractility. Endarterectomy of multiple branches should be treated with caution because the risk of deterioration is potentiated, with a significantly higher perioperative mortality rate.

Surgical correction of coarctation in early infancy: Does surgical technique influence the result?

Between 1979 and 1988, a total of 53 infants less than 1 year of age underwent repair of coarctation. Thirty-seven patients (70%) were younger than 3 months. Median age was 0.9 month. Four different surgical techniques were used: resection with end-to-end anastomosis, patch enlargement, subclavian flap aortoplasty, and subclavian displacement aortoplasty (Meier-Mendonca technique). Hospital mortality was 7.5% and was limited to patients with additional complex intracardiac defects. Neither age nor surgical technique had an influence on the operative risk. Follow-up averaged 15 to 43 months for the four different groups. Restenosis developed in 9 (19%) of 47 patients regularly followed up, 5 (11%) of whom have had reoperation. Age at operation was not a predictor for restenosis, which occurred in 17.4% of patients less than 1 month and 20.8% of those greater than 1 month of age at operation. Patch enlargement and the subclavian displacement technique demonstrated the highest restenosis rates (42% and 43%, respectively). However, patients who underwent patch enlargement had less favorable pathological conditions. It is concluded that results of coarctation repair in early infancy do not depend as much on the operative method itself as on the specific pathological aspect, which largely determines the method of treatment. Some reservation must be made in regard to the subclavian displacement technique.

New Developments in Medical-Surgical Treatment of Acute Myocardial Infarction

Selective intracoronary thrombolysis with streptokinase was successful in 72 of 84 (86%) patients admitted to the hospital with definitive signs of acute transmural myocardial infarction due to complete occlusion of either the left anterior descending coronary artery, the right coronary artery, or the circumflex artery. The average time between onset of acute symptoms and medically induced reperfusion was 241 +/- 90 minutes (SD). Reperfusion resulted in prompt relief of pain, regression of cardiogenic shock, and normalization of electrocardiograms. Follow-up treatment was either medical or surgical. The 32 medically treated patients had a high reocclusion rate, with 6 fatal (19%) and 9 nonfatal (28%) reinfarctions. In order to the reduce the risk of reinfarction, additional simultaneous transluminal balloon angioplasty was done in a recent series of patients with stenoses accessible to this technique. The best early and long-term results were achieved in 17 patients who underwent coronary artery bypass grafting within three days after successful thrombolysis. There was no operative mortality, and subsequent bleeding has not been a problem. It is concluded that early operation is the treatment of choice in all patients suitable for such intervention who have undergone successful intracoronary thrombolysis within 4 hours after onset of acute myocardial infarction. Late coronary bypass operation should be reserved for symptomatic patients who have definitive signs of infarction in spite of successful thrombolysis.

Replacement of the entire thoracic aorta in a single stage

Aneurysms of the entire thoracic aorta are usually approached in two to three stages. From 1990 to 1992, we performed one-stage aortic replacement from the root to the diaphragm in 12 patients (7 men, 5 women; median age, 51 years; range, 49 to 73 years). There were 9 type A dissections, 5 of which were acute. Five patients underwent aortic valve reconstruction, and 5 had aortic root replacement by Bentall or Cabrol techniques. In 2 patients the innominate artery had to be replaced by a vascular graft separately, in addition to reimplantation of the supraaortic branches as an island flap into the arch prosthesis. In 5 patients a mid-sternotomy was used; in 7 a bilateral transverse thoracotomy. The procedure was performed under deep hypothermic circulatory arrest in all cases (median, 45 minutes). Two patients, both operated on for an acute dissection, died perioperatively: 1 due to a bronchopneumonia, 1 because of a thrombosed Cabrol graft to the right coronary artery. No bleeding or neurologic complications developed. At a median follow-up of 14 months (range, 1 to 33 months), all patients discharged from the hospital were still alive. Four patients underwent subsequent thoracoabdominal aortic replacement. This experience suggests that complete thoracic aortic replacement can be performed in a single session, with an operative risk comparable with that of the conventional two-stage approach. The bilateral transverse thoracotomy affords an excellent exposure. The lack of spinal cord ischemia may be the result of spinal cord protection with hypothermic circulatory arrest and the open clamp technique.

New access to facilitate endovascular repair of descending aorta aneurysms.

Coexisting arterial diseases and endoprosthesis to peripheral-vessel mismatch may impair conventional femoral access for endovascular treatment of descending aorta aneurysms. Furthermore, previous abdominal operations can make an optional aortic-iliac approach more difficult. We introduced a new minimally invasive access through the aortic arch, which completely avoids the aortic-iliac access and minimizes surgical trauma.

Transluminal Angioplasty in Patients with Unstable Angina Pectoris

Percutaneous transluminal coronary angioplasty (PTCA) has been performed in 101 patients in our department since October 1978 (Table 1). Initially we selected only patients iwith stable angina pectoris. These patients were transferred to the Department of Internal Medicine or to the Department of Surgery for considerations of bypass surgery because of their severe, medically not sufficiently treatable angina pectoris. Their clinical symptoms were stable over a period of more than 3 months. All had proximal, isolated coronary stenoses. This group represents the normal population for PTCA according to the indication initially set by Gruntzig.

Medium-Term Clinical and Hemodynamic Results after Reconstruction of the Tricuspid Valve Applying a New Technique

Between 1986 and 1988, 28 patients whose age averaged 61 years underwent tricuspid valve repair applying a new technique. Nine patients were NYHA class III and 19 class IV. There were three hospital deaths (11%) caused by respiratory failure in one case and cardiac failure in two cases. Follow-up averaged 10 months.

Combination of valve replacement and coronary bypass

The combination of valve disease and coronary artery disease (CAD) has been reported to be as high as 64% [1–5]. In 28% of these cases, CAD can be completely asymptomatic [6]. The association of the two conditions has been blamed for increased morbidity and mortality after surgical correction of valve disease [2, 3].