Dionisio F. Colella

Long-Term Outcome of Coronary Artery Bypass Grafting in Patients With Left Ventricular Dysfunction

BACKGROUND Coronary artery bypass grafting (CABG) is a well-accepted therapeutic strategy for patients with multivessel coronary artery disease and left ventricular dysfunction. The aim of the study was to evaluate long-term results after CABG in patients with preoperative left ventricular ejection fraction (LVEF) of 0.35 or less. METHODS Data from 302 consecutive patients (mean age, 62 +/- 8.7 years) with LVEF of 0.35 or less who had undergone CABG were analyzed. Epinephrine and enoximone with or without norepinephrine were used to increase cardiac index. Intra-aortic balloon pump or left ventricular assist devices, or both, were used in case of postoperative low output syndrome. RESULTS Complete revascularization was achieved in 298 of 302 patients (98.7%); internal thoracic artery was used in 294 (97.4%). Operative mortality was 5.3%; independent predictors of operative mortality were emergency CABG (p = 0.005), history of ventricular arrhythmias (p = 0.007), and previous anterior myocardial infarction (p = 0.05). At follow-up, all-cause mortality was 30.8%, and 10-year survival was 63% +/- 4%; independent predictors of late all-cause mortality were history of ventricular arrhythmias (p < 0.0001), chronic renal dysfunction (p = 0.0004), and diabetes mellitus (p = 0.04). Cardiac death was 20.4%, and 10-year freedom from cardiac death was 73% +/- 3.3%; independent predictors of cardiac death were history of ventricular arrhythmias (p = 0.004), chronic renal dysfunction (p = 0.03), and more than one previous anterior myocardial infarction (p = 0.004). At 80 +/- 44 months of follow-up, echocardiography showed significant LVEF improvement (0.43 +/- 0.09 versus 0.28 +/- 0.06, p < 0.0001). Ten-year freedom from myocardial infarction was 87% +/- 3%. CONCLUSIONS Excellent long-term results after CABG can be expected for patients with LVEF of 0.35 or less. Complete revascularization and internal thoracic artery grafting are associated with high freedom from myocardial infarction. Careful treatment of arrhythmias, diabetes, and renal dysfunction is necessary to improve long-term survival.

Monitoring prohemostatic treatment in bleeding patients.

Acutely bleeding patients are commonly found in the trauma and major surgery scenarios. They require prompt and effective treatment to restore an adequate hemostatic pattern, to avoid serious and sometimes life-threatening complications.Different prohemostatic treatments are available, including allogeneic blood derivatives (fresh frozen plasma, platelet concentrates, and cryoprecipitates), prothrombin complex concentrates, specific coagulation factors (fibrinogen, recombinant factor XIII, recombinant activated factor VII), and drugs (protamine for patients under heparin treatment, desmopressin, antifibrinolytics).For decades, prohemostatic treatment of the acutely bleeding patient was based on empirical strategies and clinical judgment, both in terms of a correct diagnosis of the mechanism(s) leading to bleeding, and of an assessment of the effects of the treatment. This empirical strategy may lead to excessive or unnecessary use of allogeneic blood products, as well as to an incorrect, inefficacious, or even dangerous treatment. Different monitoring devices are nowadays available for guiding the diagnostic and therapeutic decision-making process in an acutely bleeding patient. This review addresses the available tools for monitoring prohemostatic treatment of the bleeding patient, with a specific respect for point-of-care tests (thromboelastography, thromboelastometry, platelet function tests, and heparin monitoring systems) at the light of the existing evidence.

Paravalvular leak of a mechanical mitral valve prosthesis associated with Burkholderia cepacia subacute endocarditis: a rare case successfully treated by multidisciplinary approach

Prosthetic valve endocarditis (PVE) represents an uncommon and very serious complication after heart valve surgery. Prosthetic valve endocarditis occurs in 1% to 6% of patients with valve prostheses and affects both mechanical and biological valves [1]. Up to 34% of all cases of infective endocarditis involve prosthetic heart valves. Prosthetic valve endocarditis represents a nosographic entity independent from native valve endocarditis (NVE) because of its specific clinical features, epidemiology, and microbiological findings; its management is complex and requires a multidisciplinary approach [2]. Anatomical signs of infective endocarditis in the mitral position include valve dysfunction, paravalvular leaks, and annular abscesses. In particular, the incidence of paravalvular leaks (PVL) is estimated at 2–17%: they can be asymptomatic conditions that do not always require treatment or can cause hemolysis and heart failure [2]. Burkholderia cepacia is a Gram-negative bacillus that represents an important nosocomial pathogen, especially in patients affected by cystic fibrosis and chronic granulomatous diseases [3]. It is rarely responsible for endocarditis in community settings, but sporadic cases have been described among intravenous heroin users and patients with prosthetic valves. According to the clinical data, most patients are treated by administration of trimethoprim-sulfamethoxazole even if the microorganism is actually characterized by multidrug resistance [4]. We present the case of a female patient who was submitted to redo cardiac surgery due to echocardiographic evidence of a paravalvular prosthetic mitral valve leak causing severe regurgitation; intraoperative evaluation revealed anatomical signs of previously undetected endocarditis, while cultures from the prosthetic valve indicated the presence of a very rare microorganism: Burkholderia cepacia. A 75-year-old woman with history of previous mitral valve replacement with a mechanical prosthesis (St. Jude 31-mm valve in 2001) was admitted to our department with the diagnosis of prosthesis dysfunction due to a paravalvular leak and critical stenosis of the left anterior descending coronary artery. The patient was in atrial fibrillation; her medical history featured a previous stroke (2 years before). In May 2016, the patient presented with fever and dyspnea and was admitted to the Internal Medicine Ward of one of our referral hospitals with the diagnosis of bronchopneumonia. After a thoracic computed tomography (CT) scan, an empiric antibiotic therapy with ceftriaxone and clarithromycin was administered. Due to a new onset of systolic murmur, the patient underwent transthoracic and transesophageal echocardiography (TTE and TEE), which demonstrated mitral valve prosthesis dysfunc-

Cold crystalloid versus warm blood cardioplegia in patients undergoing aortic valve replacement

Background Myocardial protection techniques during cardiac arrest have been extensively investigated in the clinical setting of coronary revascularization. Fewer studies have been carried out of patients affected by left ventricular hypertrophy, where the choice of type and temperature of cardioplegia remain controversial. We have retrospectively investigated myocardial injury and short-term outcome in patients undergoing aortic valve replacement plus or minus coronary artery bypass grafting with using cold crystalloid cardioplegia (CCC) or warm blood cardioplegia (WBC). Methods From January 2015 to October 2016, 191 consecutive patients underwent aortic valve replacement plus or minus coronary artery bypass grafting in normothermic cardiopulmonary bypass. Cardiac arrest was obtained with use of intermittent antegrade CCC group (n=32) or WBC group (n=159), according with the choice of the surgeon. Results As compared with WBC group, in CCC group creatine-kinase-MB (CK-MB), cardiac troponin I (cTnI), aspartate aminotransferase (AST) release, and their peak levels, were lower during each time points of evaluation, with the greater statistically significant difference at time 0 (P<0.05, for all comparisons). A time 0, CK-MB/CK ratio >10% was 5.9% in CCC group versus 7.8% in WBC group (P<0.0001). At time 0 CK-MB/CK ratio >10% in patients undergoing isolated aortic valve replacement was 6.0% in CCC group versus 8.0% in WBC group (P<0.01). No any difference was found in perioperative myocardial infarction (0% versus 3.8%), postoperative (PO) major complications (15.6% versus 16.4%), in-hospital mortality (3.1% versus 1.3%). Conclusions In aortic valve surgery a significant decrease of myocardial enzymes release is observed in favor of CCC, but this difference does not translate into different clinical outcome. However, this study suggests that in presence of cardiac surgical conditions associated with significant left ventricular hypertrophy, i.e., the aortic valve disease, a better myocardial protection can be achieved with the use of a cold rather than a warm cardioplegia. Therefore, CCC can be still safely used.

Neurologic Dysfunction after Aortic Dissection Surgery: Different Cerebral Hypothermic Antegrade Perfusion Techniques

Introduction: Neurologic dysfunction remains one of the most disabling complications of emergency aortic arch surgery. Many cerebral protection techniques are described, but their comparison has always been hampered by the wide spectrum of preoperative conditions, pathologic anatomies, complications, and surgical procedures. The aim of our study was to evaluate the incidence of early permanent neurologic injury and in-hospital mortality after emergency aortic arch surgery splitted by different antegrade cerebral perfusion techniques combined with hypothermic circulatory arrest (HCA). Methods: Between January 2005 and December 2015, 249 patients underwent emergent surgery for acute, type A aortic dissection. Of these, 112 (45%) (Mean age 63.8 ± 12.8 years, 82 males) received cerebral protection through antegrade perfusion of the supra-aortic vessels. Unilateral perfusion (UACP) was performed in 55 (49.1%) patients, while bilateral perfusion (BACP) was achieved via right axillary artery cannulation alone in 25 (22.3%) cases or with the Kazui technique in 32 (28.6%). Permanent neurologic injury was defined as the post-operative onset of focal stroke or lethal coma. Results: In-hospital mortality was 17.9% (UACP 20% vs. BACP 15.8%; p=0.56). The global rate of the early permanent neurologic injury was 12.3% (UACP 10.9% vs. BACP 15.8%; p=0.45). Conclusion: There is no evidence that BACP combined with HCA is superior to UACP combined with HCA for emergency aortic arch surgery in preventing early permanent neurologic injury and in-hospital mortality.

In-hospital and mid-term outcomes of patients operated on for type A acute aortic dissection complicated by postoperative malperfusion

Aims: To evaluate the effect of postoperative malperfusion (PM) on operative mortality and on late survival in patients who underwent surgery for acute type A aortic dissection in a referred center for aortic emergency surgery. Patients and Methods: From January 2005 to September 2015, 237 patients were referred for aortic emergency surgery at our center. We examined complete data available on 214 patients (mean age 62.5±12.6 years, 156 males). At presentation, various types of preoperative malperfusion (cerebral, renal, mesenteric) were observed in 119 patients (55.6%). Arterial access for cardiopulmonary bypass was via femoral artery (n = 99), via axillary artery (n = 99), or into the ascending aorta (n = 22). Aortic repair was performed using an open technique in 124 patients (58%). Results: Fifty-five patients (25.7%) presented PM; operative mortality was 29% (62/214): 47.3% in PM patients vs. 22.6% in non-PM patients (P 75 years at the time of operation (OR: 1.1, P = 0.0004) and renal PM (OR: 53.5, P = 0.0027). Five-year survival was 79±7% in PM vs. 94±3% in non-PM patients (P = 0.002). Independent predictors for reduced survival were age >75 years (OR: 375, P = 0.05) and renal PM (OR: 28.6, P = 0.01). All types of PM and the location of intimal tear distal to the ascending aorta were found as risk factors for survival in the univariate analysis only (P < 0.05). Conclusions: Surgery for acute aortic dissection is effective in reducing preoperative malperfusion by about 50%. Renal PM is associated with higher operative mortality, whereas all types of PM, in particular renal PM, negatively affected late survival. Surgical techniques, site of arterial cannulation, and more complex interventions requiring an open technique did not appear to be predictors of increased risk.

Essential Physics of Ultrasound and Use of the Ultrasound Machine

Understanding the basis of ultrasound physics is fundamental to using the echocardiography machine and recognizing pathologic findings from physiological variability or artifacts. Increasing resolution is useful to make the correct diagnosis. Setting the color Doppler scale in the wrong way can lead to an overestimated diagnosis. This chapter also deals with the basics of ultrasonograph regulation to obtain good images and reliable Doppler interrogation of blood flow. The main artifacts are also briefly described.