Giuseppe Tartarini

Early Results of Transmyocardial Revascularization With a Holmium Laser

BACKGROUND Transmyocardial laser revascularization (TMLR), a surgical technique designed to improve perfusion in the ischemic myocardium by creating transmural channels, has been performed thus far using a carbon dioxide laser, with apparently gratifying early results. We have investigated clinically TMLR using a holmium laser as sole therapy for patients with coronary artery disease that is not amenable to traditional treatment such as coronary artery bypass grafting or percutaneous transluminal coronary angioplasty. METHODS From November 1995 to December 1996, 16 patients underwent TMLR using a holmium laser. Their mean age was 68 +/- 6 years and 75% were men. Previous coronary artery bypass grafting or percutaneous transluminal coronary angioplasty had been performed in 81% and 31% of the patients, respectively. Before operation, their mean anginal class was 3.4 +/- 0.5 and their mean left ventricular ejection fraction was 0.49 +/- 0.06. Six patients had unstable angina. RESULTS There were no operative deaths. The mean duration of TMLR was 27 +/- 13 minutes and the mean duration of the entire operation was 120 +/- 40 minutes. There were no major postoperative complications and the mean hospital stay was 8 +/- 4 days. There were 2 late deaths, 1 that occurred 40 days after TMLR as a result of stroke and 1 that occurred 4 months after TMLR as a result of myocardial infarction. Current survivors have been followed up for a mean of 10 +/- 4 months (range, 3 to 15 months), with 7 patients followed up for 1 year. At last follow-up, the mean anginal class had decreased to 1.8 +/- 0.7 (p = 0.001) and the patients had increased exercise tolerance and a reduced number of hospitalizations. However, no statistically significant changes in the percentage of segments with fixed or reversible ischemia and no statistically significant differences in the viability scores of lased and nonlased segments were observed. CONCLUSIONS Transmyocardial laser revascularization using a holmium laser is a simple technique with low operative risk and low morbidity. Early results confirm that clinical improvement is obtained in most patients, although significant changes in myocardial perfusion are not evident in the short term.

The Edwards Prima stentless valve: hemodynamic performance at one year

BACKGROUND The Edwards Prima stentless valve (EPSV) is a porcine aortic root cylinder with resected coronary ostia, fixed in glutaraldehyde at low pressure. The purpose of this study was to evaluate the hemodynamic performance of the EPSV 1 year after aortic valve replacement. METHODS From December 1994 to February 1996, 29 patients underwent aortic valve replacement with EPSV used in the subcoronary position (group 1, n = 23) or as a root replacement (group 2, n = 6). Hemodynamic performance of EPSV was assessed by two-dimensional Doppler echocardiography at 1 week, 6 months, and 1 year by calculating peak transprosthetic velocity, peak and mean gradients, effective orifice area, degree of aortic regurgitation, and regression of left ventricular hypertrophy. RESULTS There were no operative deaths. One patient in group 2 died after 3 months at reoperation for endocarditis. In group 1 early mean gradient (25+/-5 mm Hg for 23 mm and 19+/-5 mm Hg for 25 mm) decreased at 6 months and 1 year in the 23-mm size (17+/-7 mm Hg and 15+/-4 mm Hg, p < 0.01) and at 1 year in the 25-mm size (14+/-4 mm Hg, p = 0.03) without modifications of the effective orifice area in both sizes. A significant reduction in left ventricular hypertrophy occurred at 6 months and 1 year in both sizes. In group 2 lower early gradients were recorded with subsequent improvement at follow-up; reduction in left ventricular hypertrophy occurred as well. CONCLUSIONS The EPSV used in the subcoronary position has shown high early gradients, which partially regressed at 6 months, with further improvement at 1 year. Gradients are attributed to inward folding of the Dacron cloth at the right coronary ostium, being more evident in patients with aortic stenosis without dilatation of the aortic root and coronary ostia close to the annulus. In such patients a better early hemodynamic result can be obtained by using the EPSV as a root replacement.

P‐Wave Signal‐Averaged Electrocardiogram Predicts Atrial Fibrillation After Coronary Artery Bypass Grafting

Background: AF is one of the most common complications after CABG. The aim of the study was to identify the risk factors for postoperative AF.

Performance of 21-mm size perimount aortic bioprosthesis in the elderly

BACKGROUND Aortic valve replacement in elderly patients with a small aortic annulus may pose difficult problems in terms of prosthesis selection. We have evaluated the hemodynamic performance of the 21-mm Carpentier-Edwards Perimount bioprosthesis implanted in elderly patients. METHODS From July 1996 to June 1998, 19 patients (17 women and 2 men, mean age 76+/-4 years and mean body surface area 1.73+/-0.13 m2), had aortic valve replacement with a 21-mm Carpentier-Edwards Perimount bioprosthesis. The hemodynamic performance of the valve was evaluated in 16 patients, who completed at least a 6-month follow-up interval, with transthoracic color-Doppler echocardiography with particular reference to peak and mean transprosthetic gradients, effective orifice area index, and regression of left ventricular mass index. RESULTS There were no late deaths and no major postoperative complications. At a mean follow-up of 12+/-7 months, compared to discharge, all patients showed clinical improvement with a significant reduction of peak gradient (from 23+/-4 to 21+/-6 mm Hg, p = 0.04) and left ventricular mass index (from 181+/-23 to 153+/-20 g/m2; p<0.001), whereas mean gradient (from 13+/-3 to 13+/-4 mm Hg, p = not significant) and effective orifice area index (from 1.12+/-0.34 to 1.13+/-0.28 cm2/m2, p = not significant) remained substantially unchanged. CONCLUSIONS The use of a 21-mm Carpentier-Edwards Perimount bioprosthesis is associated with low transprosthetic gradients and significant reduction in left ventricular hypertrophy after aortic valve replacement. The results of our study suggest that a 21-m Carpentier-Edwards Perimount bioprosthesis should be considered a valid option in elderly patients with aortic valve disease and a small aortic annulus.

Evaluation of pulmonary vascular pressures in cardiac patients : the role of the chest roentgenogram

In 77 patients (34 with left heart valvulopathy, 17 with dilated cardiomyopathy, and 26 with chronic coronary artery disease) pulmonary vascular pressures were estimated from the chest film by means of a new scoring system. Standard chest x-ray films taken immediately before diagnostic right and left cardiac catheterization were analyzed independently by three readers without knowledge of the hemodynamic findings. The radiographic signs were subdivided into three groups as follows, and to each one a score derived from a retrospective statistical analysis was attributed: (A) signs of interstitial edema, (B) patterns of pulmonary blood flow distribution, and (C) alterations in the pulmonary arteries. The sum of the scores of groups A and B x-ray findings correlated well with pulmonary wedge pressure, and the sum of the scores of groups A, B, and C correlated more strongly with the mean pulmonary artery pressure. These results confirm that it is possible, in patients with chronic heart disease, to assess accurately the pulmonary artery and wedge pressures by means of the noninvasive and easily performed chest roentgenogram.

Acute Hemodynamic Effects of Brescia-Cimino Arteriovenous Fistula for Hemodialysis

In ten uremic patients, who were not yet undergoing periodic hemodialysis and in whom we were creating a 1 cm, distal, side-to-side arteriovenous fistula of Brescia-Cimino type for hemodialysis, the acute hemodynamic changes of the systemic and pulmonary circulations were studied immediately after the opening of the fistula. An increase in cardiac output (Q) was observed in one patient, the other patients showing either no change or a slight reduction. In the four patients in whom the Q decreased there was a significant reduction of total blood volume (TBV) and stroke volume (SV) and an increase in systemic vascular resistance (SVR) (p less than 0.05, p less than 0.05, p less than 0.01 respectively). At the level of pulmonary circulation, in these patients a decrease in pulmonary blood volume (PBV) (mean = 20%) and a significant increase in pulmonary vascular resistance (PVR) were also observed. In five patients who had been on chronic hemodialysis and who presented the clinical picture of cardiac failure, the acute hemodynamic changes following temporary closure of the fistula (by a sphygmomanometer) were studied: a significant decrease (p less than 0.05) in Q, TBV and SV was observed. The difference between the two values of Q (i.e. fistula open and closed) was considered to indicate the magnitude of the flow across the fistula.