Michael Anelli-Monti

Cardiac myxomas: 24 years of experience in 49 patients

OBJECTIVES In this single-center study we reviewed our experience with a significant number of cardiac myxoma cases occurring over the past two decades. PATIENTS AND METHODS Cardiac myxomas represented 86% of all surgically treated cardiac tumors at our center. Specifically, there were 49 consecutive patients, each with at least one myxoma. A detailed clinical, immunological, and echocardiographic long-term examination of 37 patients revealed one recurrent myxoma. RESULTS Most myxomas originated from the left atrium (87.7%), but also much less frequently from the mitral valve (6.1%), from the right atrium (4.1%), and from the left and right atria (2.0%). The myxomas produced a prolapse into the left ventricle in 40.8% of the patients, mitral stenosis in 10.2%, and threatened left ventricular outflow tract obstruction in 2.0%. Multiple myxomas were found in 20.4% of the patients. Cardiac signs appeared in 93.9% of the patients. Preoperative embolic events had occurred in 26.5%. Immunologic alterations were present in 87.5%. For resection, a bilateral atriotomy was used. An additional aortotomy was needed to expose one mitral valve myxoma. Postoperatively, 81.1% of the patients remained without cardiac symptoms. The early mortality rate was 2.0% and the late mortality rate was 6.1%. Long-term prognosis was excellent with an actuarial survival rate of 0.74. Specific immunologic alterations were found in 71.4% of the patients. The actuarial freedom from reoperation of the myxoma was 0.96. The rate of reoperations was low with 2.0% after 24 years. CONCLUSIONS Myxomas were usually detected and operated on in symptomatic patients. A high index of suspicion seems important for early diagnosis. Immunologic findings may play an additional role in confirming the diagnosis and the recurrence of a myxoma. Immediate surgical treatment was indicated because of the high risk of embolization or of sudden cardiac death. Also, a familial genesis must be excluded in myxoma patients.

Minimally invasive versus conventional aortic valve operations: a prospective study in 120 patients

BACKGROUND Risk evaluation comparing the minimally invasive and standard aortic valve operations has not been studied. METHODS Four surgeons were randomly assigned to perform the minimally invasive (L-shaped sternotomy) (group 1) or the conventional (group 2) operation in 120 patients exclusively. RESULTS In both groups (n = 60) a CarboMedics prothesis was implanted in 90% of patients. There was no significant difference in the cross-clamping period (group 1, 60 minutes; range, 35 to 116 minutes), in the duration of extracorporal circulation (group 1, 84 minutes; range, 51 to 179 minutes) or in the time from skin-to-skin (group 1, 195 minutes; range, 145 to 466 minutes). Patients in group 1 were extubated earlier (p<0.001), the postoperative blood loss was less (p<0.001), and the need for analgesics was reduced (p<0.05). In 5 patients in group 1 a redo operation was required for bleeding (p>0.05), 3 patients in group 1 required a redo operation because of paravalvular leakage or endocarditis (p>0.05), the 30-day mortality rate was 1.6%. Overall the survival rate was 95% in group 1 and 97% in group 2 (mean follow-up, 294 days; range, 30 to 745 days). CONCLUSION The advantages of minimally invasive aortic valve operation include reduced trauma from incision and duration of ventilation, decreased blood loss and postoperative pain, the avoidance of groin cannulation, and a cosmetically attractive result. Simple equipment is used with a high degree of effectiveness and with no sacrifice of safety. Our study demonstrated the practicability and reliability of this new method.

Reducing unnecessary right ventricular pacing with the managed ventricular pacing mode in patients with sinus node disease and AV block.

Background: Frequent and unnecessary right ventricular apical pacing increases the risk of atrial fibrillation or congestive heart failure. We evaluated a new pacing algorithm, managed ventricular pacing (MVP) which automatically changes modes between AAI/R and DDD/R in patients receiving pacemakers for symptomatic bradycardia.

Left ventricular architecture after valve replacement due to critical aortic stenosis: an approach to dis-/qualify the myth of valve prosthesis–patient mismatch?

OBJECTIVES Left ventricular hypertrophy in patients with critical aortic stenosis (AS) is an adaptive process that compensates for high intracavitary pressure and reduces systolic wall stress followed by an increase in myocardial masses. In the present prospective clinical trial, we investigated long-term compensatory changes in left ventricular geometry and function after aortic valve replacement using mechanical bileaflet prostheses with the main emphasis on the small-sized aortic annulus and valve prosthesis-patient mismatch. METHODS A total of 58 patients with critical AS were assigned to the following groups according to the predictive value of prosthetic valve area index (VAI): group EXMIS: 29 patients (VAI < or =0.99), expected mismatch; group NOMIS: 29 patients (VAI < or =0.99), no mismatch. At controls T(0) (before operation/operation (OP), T(1) and T(2) (4 and 20 months after OP) the left ventricular geometry was recorded by means of Imatron electron beam tomography and the transprosthetic velocities were measured by echocardiography. RESULTS Statistical analysis showed a consistent reduction in the absolute (P=0.04) and indexed (P=0.04) left ventricular myocardial mass for both cohorts; furthermore, there was a significant difference between EXMIS and NOMIS patients concerning the factors, time and mass reduction (P=0.005), because of distinct baselines. A logistic regression report revealed preoperative cardiac output, absolute left ventricular myocardial mass, perfusion, body surface area and the native valve orifice area as predicting coefficients and factors for a minimum mass reduction of 25%. We explain a mathematical formula that turned out to be the most sensitive for correctly classified factors. CONCLUSIONS The left ventricular geometry and transprosthetic velocities resulted in the same postoperative recovery for both EXMIS and NOMIS patients. The presented data showed that valve prosthesis-patient mismatch had no influence in several stepwise logistic regression models. We conclude that modern mechanical bileaflet prostheses allow both acceptable hemodynamics and recovery of left ventricular hypertrophy, even in small aortic annuli.

Left ventricular outflow tract obstruction due to valve myxoma

A life-threatening left ventricular outflow tract obstruction developed in a 26-year-old man because of a very uncommon myxoma emerging from the ventricular side of the mitral valve. Immediate surgical treatment was indicated because of high-risk factors reported herein. After transaortic resection of a single myxoma, the progress of this patient has been excellent, especially as a familial myxoma could be excluded.

Aortic dissection due to discontinuation of beta-blocker therapy

beta-Blockers are known to protect a vulnerable aorta from acute dissection, as well as reducing the risk of recurrent dissection. This case presentation reports the history of a 60-year-old male suffering from acute aortic dissection following discontinuation of beta-blocker therapy. The patient has shown arterial hypertension for about 20 years treated solely by beta-blockers. Two days after stopping the use of metoprolol, a nonselective beta 1-blocker without ISA, the patient developed severe chest pain during exercise. Diagnosis of type I-aortic dissection according to DeBakey was achieved by transthoracal echocardiography and computed tomography. Successful surgery by replacement of the ascending aorta was performed about 1 h following admission to the intensive care unit. During the procedure, tamponade of the left ventricle occurred followed by cardiogenic shock. Postoperative management was complicated by prolonged respiratory therapy and acute gastrointestinal bleeding; 1-year follow-up showed no evidence of disease. Thus, in this case acute dissection may be the consequence of discontinuing the use of metoprolol, possibly due to uncontrolled hypertension or specific response to the beta-blocker.

A high-resolution esophageal electrocardiogram for monitoring atrial activity in the hypothermic potassium-arrested heart.

Atrial electrical activities during hypothermic, K+-induced cardioplegic arrest correlate with an increased incidence of postoperative supraventricular dysrhythmias in coronary artery bypass graft patients. Surface electrocardiogram (ECG) (S-ECG) may be insufficiently sensitive to detect such activity intraoperatively, and invasive methods are impractical and traumatic. From induction of anesthesia until the end of surgery, esophageal ECG signals were detected with a new bipolar esophageal probe and a new high-resolution preamplifier (frequency range 0.01-2000 Hz). The S-ECG and the esophageal ECG (E-ECG) were evaluated independently in 18 patients. Eight of 18 patients presented during cardioplegic arrest a mean of 483 +/- 119 high-amplitude, biphasic P components (mean amplitude 0.7 +/- 0.1 mV, range 0.35-1.15 mV) per patient (mean 36 +/- 6 [5-59] potentials/min) similar to those coinciding with the surface ECG P-waves during sinus rhythm. Six of these eight patients presented a mean of 29 +/- 11 low atrial activities (mean amplitude 0.14 +/- 0.023 mV; range 0.1-0.25 mV) per patient (mean 8.4 +/- 5.6 [2.3-48] potentials/min) in the E-ECG. In the S-ECG, one patient of these eight presented 26 P waves during cardioplegic arrest simultaneously with activities in the E-ECG. During the first 5 days, seven of eight (88%) patients with atrial activities in the E-ECG versus 3 of 10 (30%) patients without atrial activities developed supraventricular tachyarrhythmias postoperatively (P < 0.05). This new high-resolution E-ECG device detected in a beat-to-beat technique more atrial activity during cardioplegic arrest than a S-ECG and offered the advantages of artifact exclusion and better prediction of postoperative supraventricular dysrhythmias. (Anesth Analg 1997;84:484-90)

Twenty-four years' implant duration of the aortic Starr-Edwards silastic ball prosthesis: a valve of the past?

Six years after the first aortic valve replacement with the Starr-Edwards Silastic ball prosthesis at Oregon Health Sciences University, the model 1260 was implanted in a 44-year-old patient at our department. During 24 years no signs of dysfunction, thromboembolism, thrombosis, periprosthetic leaks or hemolysis were observed. Material test showed no signs of fatigue. The dimension of the Silastic poppet was found to be one millimeter less than the original specifications of these poppets and there were some lipid infiltrations. Functionally the poppet was found to be nonvariant. Histologic findings detected focal hyalinization and giant cells without signs of acute inflammation or ulceration. With regard to its reliability and durability, the Starr-Edwards valve prosthesis should not be viewed with disfavor.

Invasive Ductal Carcinoma of the Male Breast Expanding From Pacemaker Pocket Decubitus

After twenty‐five Years of therapy with different unifocal pacemaking systems, an 84‐year old male patient developed a nonseptic pacemaker decubitus. A rare incidental finding of invasive ductal carcinoma of the right mammary gland was surgically treated by a generous excision of the tumor and by consecutive modified radical mastectomy. According to published literature, the association of invasive ductal carcinoma arising from a pacemaker pocket decubitus and followed by curative treatment has not been previously reported. We do conclude that pacemaker generators in close relationship to the mammary gland should be considered with suspicion.

Minimal invasive Aortenklappenchirurgie — Die Grazer Erfahrungen an den ersten 45 Patienten

ZusammenfassungGrundlagen: Die Aortenklappenchirurgie ist bislang traditionell über eine mediane Sternotomie durchgeführt worden. Um das chirurgische Trauma zu reduzieren, bieten sich minimal invasive Therapiekonzepte an. Methodik: Nach einer 8 bis 10 cm langen Hautinzision wurde eine L-förmige, kraniale Ministernotomie bis zum 3. oder 4. Interkostalraum durchgeführt. Nach der konventionellen Kanülierung der Aorta ascendens folgte die substernale und subperikardiale venöse Kanülierung. Die extrakorporale Zirkulation wurde wie der Aorteneingriff konventionell durchgeführt. Ergebnisse: Der Eingriff wurde bei 45 Patienten (mittleres Alter 60 Jahre [18 bis 74 Jahre]) durchgeführt. In 39 Fällen wurde eine mechanische Prothese implantiert, bei 4 Patienten eine biologische Klappe, bei 2 Patienten wurde eine subvalvuläre Myektomie durchgeführt. Es kam zu keiner 30-Tage-Letalität. Die mittlere Aortenklemmzeit betrug 57 ± 2,7 min (35 bis 110 min), die gesamte Operationsdauer 205 ± 8,9 min (2,4 bis 5,1 h). Die Patienten wurden nach 7,6 ± 0,8 h (3,3 bis 25 h) extubiert. Das Drainagesystem förderte in den ersten 24 h im Mittel 168 ± 14 ml (10 bis 455 ml). Ab dem 3. postoperativen Tag benötigten 31% der Patienten Morphine. 2mal kam es zu einer Nachblutung. 1 Patient erlitt einen zerebralen Infarkt. Schlußfolgerungen: Die Vorteile der minimal invasiven gegenüber der traditionellen Methode bestehen in der Reduktion des chirurgischen Traumas, im kaudal stabil gebliebenen Thorax, in der geringen postoperativen Beatmungszeit, im geringeren Wundschmerz und im ansprechenden kosmetischen Ergebnis, ohne die Morbidität oder Letalität im Vergleich zum traditionellen Verfahren zu erhöhen.SummaryBackground: In the last 2 years there has been a rapid development in the field of minimally invasive cardiac surgery. We present our method for a minimal approach in aortic valve surgery. Methods: After an 8 to 10 cm incision an L-shaped, cranial ministernotomy reaching into the third or fourth intercostal space was performed. After cannulating the aorta the venous cannula was introduced substernally and subpericardially into the right atrium. The implantation technique of the valve itself was done as in conventional procedures. Results: We performed the procedure in 45 patients (mean 60 years [18 to 74 years]). A mechanical prostheses was implanted in 39 cases, in 4 patients a biological valve was used, in 2 patients we reconstructed the subvalvular area. There was no 30-day mortality. The mean aortic cross clamp time was 57 ± 2.7 min (35 to 110 min), the procedure from skin-to-skin lasted 205 ± 8.9 min (2.4 to 5.1 h). The patients were extubated after a mean of 7.6 ± 0.8 h (3.3 to 25 h). At the third postoperative day there was no need for morphins in 69% of the patients. Conclusions: Minimally invasive aortic valve surgery may emerge as a standard of care because in comparison to conventional procedures there is no increased morbidity or mortality with the advantage of reduced surgical trauma, reduced postoperative pain, faster mobilisation and a superior cosmetic result.