Michele di Summa

Early and late risk factors in surgical treatment of acute type A aortic dissection

BACKGROUND Morbidity and mortality of emergency repair of type A dissecting aneurysms of the aorta are high. This is an attempt to investigate the risk determinants of early and late results. METHODS A series of preoperative and operative variables were retrospectively collected from the clinical records of 291 patients operated on between January 1, 1979, and December 31, 1995. Risk factors for surgical death were investigated with univariate analysis and stepwise logistic regression. Follow-up was conducted between December 1995 and February 1996. Analysis of late results was conducted by means of actuarial survival curves (life method). After removing the surgical deaths, risk factors for late deaths were analyzed by a Cox model. RESULTS The in-hospital mortality rate was 36.1%. Significant independent determinants of operative or early death were preoperative shock, preoperative neurologic impairment, operation before 1986, perioperative bleeding, and prolonged clamping time. The 10-year survival rate was 36.9% +/- 4.4%. Twenty-six patients required repeat operation. The long-term prognosis was significantly worse in patients who needed reoperation. CONCLUSIONS Growing awareness of this disease and quicker diagnosis have increased the number of patients with acute dissection of the ascending aorta who are taken early to operation. This new challenge must be met by better preoperative support and intraoperative monitoring, and by surgical techniques that focus on lowering the rate of late complications, for which lifelong follow-up must be provided.

Reoperations on heart valve prostheses : an analysis of operative risks and late results

To evaluate risks and complications of reoperations on heart valve prostheses, we reviewed data on 183 patients who underwent reoperation because of prosthetic valve malfunction. The incremental effect of the redo procedure on hospital mortality and morbidity was studied by comparing primary and reoperative procedures and analyzing a series of possible predisposing factors. Late survival after first and second reoperations was computed, and possible determinants of late mortality were examined. Overall operative mortality was 8.7%; emergency operation (p = 0.0001), previous thromboembolism (p = 0.05), and advanced New York Heart Association functional class (p = 0.031) were the independent determinants. In a series of 1,355 patients having primary or secondary isolated valve replacement, the redo procedure was a significant risk factor in the univariate analysis (p = 0.025) but not in the multivariate analysis except for the subset of patients having mitral valve replacement (p = 0.052). The postoperative course was quite complicated, as evidenced by the long mean stay in the intensive care unit (mean stay, 3.8 days; longer than 2 days for 26% of the survivors). Nevertheless, postoperative complications were not significantly greater after a redo procedure than after a primary operation. Actuarial survival at 7 years was 57.3% +/- 8%. A comparison with a nonhomogeneous series from our institution did not demonstrate significant differences. In the subset of 16 patients having a second reoperation, late survival was 37.8% +/- 16% at 2 years. Advanced New York Heart Association class (p = 0.0001), double prosthetic valve dysfunction (p = 0.003), and any indication other than primary tissue failure (p = 0.06) were determinants of late mortality.(ABSTRACT TRUNCATED AT 250 WORDS)

Stenless porcine and pericardial valve in aortic position

Fifty-seven patients underwent aortic valve replacement with a stentless glutaraldehyde-fixed bioprosthesis; 27 received a porcine aortic valve and 30 had a bovine pericardial valve. Two groups of 30 patients each who had aortic valve replacement with a tilting-disc mechanical valve or a stented porcine bioprosthesis served as controls. There were no differences in sex, body surface area, valve lesion, and valve size among the four groups. Results were assessed on a Doppler-based determination of maximum velocity across the valve, aortic valve area, and degree of valve regurgitation. Velocity across the valve was significantly less with stentless pericardial valves than with stentless porcine valves, stented bioprostheses, and mechanical valves. Stentless valves had a significantly larger aortic valve area when compared with stented valves. Mild central aortic insufficiency was detected more often with stentless pericardial than with stentless porcine bioprostheses (p = 0.04). Stentless valves showed a higher incidence of complete atrioventricular block when compared with stented valves (p = 0.04). Long-term studies are now warranted to assess the durability of both types of stentless valves.

Sternal closure using semirigid fixation with thermoreactive clips

Sternomy represents the standard approach to the heart and great vessels in most cardiothoracic procedures. Closure of this incision is simple; however, healing complications such as dehiscence, osteomyelitis, mediastinitis, and superficial wound infection or fistula may occur. We describe an alternative technique for sternal closure using semirigid fixation with thermoreactive clips.

Porcine Cardiac Bioprostheses: Evaluation of Long-term Results in 990 Patients

Clinical results with porcine bioprostheses were reviewed for 990 patients who underwent heart valve replacement from January, 1974, to December, 1980. Eight hundred and seventy-four Hancock, 283 Carpentier-Edwards, and 10 Liotta bioprostheses were used. In 23 patients, 26 mechanical prostheses were implanted as well. Overall operative mortality was 60 out of 990 (6.06%): 30 out of 506 (5.9%) for mitral valve replacement (MVR), 13 out of 287 (4.5%) for aortic valve replacement (AVR), 1 out of 4 (25%) for tricuspid valve replacement, 0 out of 2 for pulmonary valve replacement, and 16 out of 191 (8.4%) for multiple valve replacement. Cumulative follow-up covered 1,793 patient-years. (Actuarial survival at 7 years was 76.6 +/- 3% for MVR. At 6 years, it was 83.2 +/- 2.8% for AVR and 55 +/- 13.5% for multiple valve replacement.) Prosthesis-related survival at 7 years was 91.7 +/- 1.9% for MVR, and at 6 years, it was 96.6 +/- 1.5% for AVR and 95.1 +/- 2.2% for multiple valve replacement. Bioprosthesis survival, considering deaths or complications that led to reoperation as final events, was 84.2 +/- 3.7% at 7 years for mitral valves and 87.7 +/- 3.8% at 6 years for aortic valves. Emboli per 100 patient-years numbered 3.2 for MVR, 0.5 for AVR, and 1.6 for multiple valve replacement. Twenty-seven patients underwent reoperation, 12 for perivalvular leak, 5 for endocarditis, 6 for valve thrombosis, and 4 for primary tissue failure (linearized rates of 0.7, 0.3, 0.3, and 0.2% per patient-year, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Successful orthotopic transplantation of a fresh tricuspid valve homograft in a human

We report a successful transplantation of a human tricuspid valve in a human. We used a fresh tricuspid homograft with its chordae tendineae and papillary muscles, harvested 5 days earlier under sterile conditions from a multiorgan donor a few minutes after cardiectomy (the heart was not suitable for cardiac transplantation) and immediately stored at 4 degrees C. We elected to implant the homograft in a young heroin addict. Our experience demonstrates that the implantation of an atrioventricular homograft in the orthotopic position is technically feasible and can achieve good results, at least in the short term.

Endocarditis in patients with bioprostheses: pathology and clinical correlations

We studied 13 porcine bioprostheses removed from patients with endocarditis at our institute during the last 4.5 years. All bioprostheses had been removed at reoperation and were analyzed using anatomical and histological techniques. Each bioprosthesis was found to have developed rather constant lesions which were not related to the type of bioprosthesis. The stage of infection was not related to the duration of implantation. The presence of perivalvular abscesses was an ominous finding, often being the seat of persistent endocarditis. Our good clinical results of reoperation lead us to suggest that this be performed early once valvular or prosthetic malfunction is detected. Bioprostheses are, in our experience, the best choice in the surgical treatment of prosthetic valve endocarditis.

Simultaneous operation for cardiac disease and lung cancer

Concomitant lesions of the heart and lung have been increasing and the issue of performing simultaneous pulmonary resection and cardiac surgery remains controversial. We report a retrospective study of 11 patients (ten male, one female) who underwent simultaneous lung resection and cardiac operation. In all cases the lung resection was performed before heparinization and cardiopulmonary bypass. All patients were discharged in 10 days. We did not have postoperative complications. Follow up mean was 41.2 months/patients. A combined procedure, when possible, avoids other thoracic procedure, permits to improve outcomes and provides economic benefit.

Too large resection of pectus excavatum in young patients: A reason to worry?

We read with great interest the report by Dr Haller regarding the repair of chest deformity as pectus excavatum (PE) at an early age [1], and we desire to contribute to this subject our experience. In a recent review of our patients, operated on for PE with one surgical technique (Fig 1 ) during a long period (1958 to 1991), we found results worthy of consideration regarding the indications and the correct timing for operation [2]. The patient population features and clinical operative and postoperative conditions are reported in Table 1 .

Vascular complications associated with a large cardiac fibroma

A case is reported of a 30-year-old patient with an intrapericardial tumour with heart failure. After the diagnostic protocol, surgery was performed initially without extra-corporeal circulation (ECC). Due to the location, size and to the large connection with the most important vascular structures, the ascending aorta ruptured accidentally during resection and was replaced after using ECC in emergency. The post-surgical course was regular and the tumour was identified histologically as a fibroma.