Davide Passolunghi

TachoSil® for postinfarction ventricular free wall rupture

Despite a decline in the last three decades, postinfarction ventricular free wall rupture still complicates more than 3% of acute ST-elevation myocardial infarctions and remains a surgical challenge. TachoSil (Nycomed, Zurich, Switzerland) is an equine collagen patch coated with human fibrinogen and human thrombin, which has recently been used for haemostasis in cardiovascular surgery, but its potential usefulness in free wall rupture has not been reported. Initial clinical experience with an on-pump sutureless technique without cardioplegia, using wide TachoSil patching to achieve free wall rupture repair, has been described.

Predictors of adverse events after surgical ventricular restoration for advanced ischaemic cardiomyopathy

OBJECTIVE Post-infarction ventricular remodelling has been graded (I-III) according to the loss of systolic left ventricular silhouette curvature changes. Although surgical ventricular restoration (SVR) has been extended to type III ischaemic cardiomyopathy, the results are less satisfactory. We sought to identify geometric and functional predictors of late outcome after SVR. METHODS Among 144 patients who underwent SVR since 1998, a subgroup of 31 patients (age: 65.2+/-7.6 years) was analysed. Inclusion criteria were: type III cardiomyopathy, no associated procedure except coronary artery bypass grafting, prior anterior infarction, absent-to-2+ mitral regurgitation, elective operation, follow-up > or =18 months (mean: 44+/-26; longest: 96 months). Probability of events was estimated with the Kaplan-Meier method. A Cox multivariable regression model was constructed selecting eight potential predictors of four adverse events: death, cardiac death, recurrent heart failure (New York Heart Association class III or IV) and left ventricular re-remodelling, defined as a 25% increase of end-systolic volume index after SVR, or an end-systolic volume index > or =50 ml.m(-2). RESULTS Early and late mortality were zero and 6% (2/31 patients, one cardiac-related death). NYHA class and all echocardiographic functional variables significantly improved early after SVR. Freedom (+/-standard error (SE)) from heart failure was 97%+/-3%, 93%+/-5%, 77%+/-11% and 64%+/-15%, whereas freedom from left ventricular re-remodelling was 97%+/-3%, 80%+/-8%, 60%+/-12% and 39%+/-15%, respectively, 1, 3, 5 and 7 years after SVR. Multivariable analysis identified baseline mitral regurgitation degree and sphericity index as independent predictors of recurrent heart failure (p=0.025; hazard ratio (HR)=7.80 (95% confidence intervals (CIs): 1.29-47.19)) and left ventricular re-remodelling (p=0.047; HR=2.84 (95% CIs: 1.01-7.95)). Both predictors also correlated with a higher recurrence of end-systolic volume index > or =50 ml.m(-2) at late follow-up. CONCLUSIONS Despite advanced cardiomyopathy, SVR determines left ventricular volume reduction and improved systolic function. Baseline absent-to-moderate mitral regurgitation and a more spherical left ventricular geometry predict a less favourable clinical and functional outcome, suggesting a possible rationale for wider indications for combined correction of 2+ mitral regurgitation and undersizing of the mitral annulus, particularly in patients with sphericity index > or =0.75.

Baseline left ventricular function and surgical annular stiffening to predict outcome and reverse left ventricular remodeling after undersized annuloplasty for intermediate-degree ischemic mitral regurgitation

OBJECTIVE We sought to identify determinants of clinical and functional outcome after myocardial revascularization and associated undersized annuloplasty in patients with intermediate-degree ischemic mitral regurgitation. METHODS Fifty-seven patients with 2+ or 3+ ischemic mitral regurgitation underwent coronary bypass surgery and implantation of undersized semirigid or flexible complete ring or autologous pericardial band and were followed up to 8.6 years. RESULTS Operative mortality was 5%. Baseline left ventricular end-systolic volume index, the strongest multivariable predictor of early postoperative outcome, was correlated with end-systolic volume index (P < .001, R(2) = 0.67) and ejection fraction (P < .001, R(2) = 0.40) after repair. More compromised ejection fraction and end-systolic volume index predicted comparatively greater early functional improvement but higher residual postoperative end-systolic volume index (P < .01). Cox multivariable analysis identified wall motion as the best baseline predictor of late death and heart failure and regional inferoposterior wall motion as the strongest predictor of recurrent mitral regurgitation (P < or = .01). More rigid annuloplasty carried a higher probability of functional recovery in terms of ejection fraction, wall motion, and the occurrence and earlier timing of left ventricular reverse remodeling, expressed by different degrees of end-systolic volume index reduction (P < .001, hazard ratio >6). CONCLUSIONS Combination of undersized mitral annuloplasty and coronary revascularization presents low operative mortality and determines left ventricular unloading in patients with intermediate-degree ischemic mitral regurgitation. Global and regional wall motion are powerful predictors of late outcome. Stiffer mitral annular repair promotes functional recovery and predicts higher probability and earlier timing of reverse remodeling.

Recovery of severe neurological dysfunction after restoration of cerebral blood flow in acute aortic dissection

Emergency repair has been successfully performed in acute type A aortic dissection complicated by cerebral malperfusion. Despite the lack of criteria to define irreversible brain damage, immediate surgery is often denied in case of stroke or coma. We report two patients presenting with coma and altered brainstem reflexes shortly after onset of aortic dissection, in whom aortic repair was successfully undertaken.

Fulminant prosthetic valve endocarditis caused by Listeria monocytogenes

1010-7940/

A free-floating left atrial mass

— see front matter # 2009 European Association for Cardio-Thoracic doi:10.1016/j.ejcts.2009.06.036 Listerial endocarditis is uncommon, but potentially destructive. Fifteen years after mitral valve replacement, a 67-year-old male without co-morbidities developed hyperacute shock (white blood cell count = 38.750 ml ) following a mildly febrile period with normal echocardiograms. Trans-oesophageal echocardiography showed a flail prosthesis (Fig. 1). Surgery consisted of valve re-replacement and pericardial annular reinforcement.

Femoro-axillary cardiopulmonary bypass for giant abdominal aortic aneurysm repair prior to staged cardiac operation for ischaemic cardiomyopathy

A 78-year-old woman was transferred to our stroke unit 10 days after cerebral infarction. Her left hemisphere was aff ected, resulting in residual aphasia and mild right hemiparesis. Medical history included coronary artery bypass grafting 18 years before, and atrial fi brillation. Longstanding warfarin therapy had been temporarily suspended, and subcutaneous nadroparin initiated in advance of recent orthopaedic surgery. Twodimensional and three-dimensional transoesophageal echocardio graphy (fi gure A, B; see also webvideo 1) showed a 6 cm diameter free-fl oating left atrial mass, suggesting embolisation was the cause of the stroke. The mass had no mural attachment and could not cross the mitral valve orifi ce (fi gure C; see also webvideo 2). Nadroparin was immediately switched to an intravenous unfractioned heparin infusion. Cardiac surgery was deferred until 15 days after stroke onset, during which time the heparin infusion was continued and intracranial haemorrhage was excluded by CT. At surgery, the mass was successfully removed and was consistent with a left atrial ball thrombus.

Letter by Pocar et al Regarding Article, “No Major Differences in 30-Day Outcomes in High-Risk Patients Randomized to Off-Pump Versus On-Pump Coronary Bypass Surgery: The Best Bypass Surgery Trial”

The optimal surgical management of simultaneous abdominal aortic aneurysm and cardiac disease remains a major challenge in case of larger aneurysms and severe cardiac disease. In case of symptomatic aneurysms or impending rupture, a single-stage combined operation is the most widely accepted procedure. We report the successful use of closed-chest cardiopulmonary bypass, with femoral venous and axillary arterial peripheral cannulation, to support cardiac function on the beating heart during resection of a giant abdominal aortic aneurysm and ischaemic cardiomyopathy. One month later, the patient underwent a second-stage deferred cardiac operation, consisting of triple coronary bypass grafting, undersized mitral annuloplasty and epicardial left ventricular lead implantation for cardiac resynchronisation therapy.

Modified Coronary Reimplantation for Small Aortic Root Replacement Mismatch

To the Editor: We congratulate Moller et al for outlining no major differences in short-term outcomes after off-pump versus conventional coronary bypass surgery in patients with European System for Cardiac Operative Risk Evaluation (EuroSCORE) ≥5.1 Mean additive EuroSCORE was 6.9, but no patient with ejection fraction <30% was enrolled, suggesting the prevalence of extracardiac risk factors in determining a higher risk profile. Although the …

Transcatheter CoreValve implantation for aortic regurgitation in a Jehovah's witness with prior aortic dissection

Coronary reimplantation is a key step of aortic root replacement and may present special challenges under specific circumstances. Particularly in reoperations, mobilization of the coronary ostia can be hazardous and reattachment may require one or more interposition grafts to avoid tension, as originally described by Cabrol. We report a modified reimplantation technique of the coronary arteries that allows the creation of wide neo-ostia with minimal prosthetic material in case of a small aortic root.