Michele Triggiani

Thromboangiitis obliterans of coronary and internal thoracic arteries in a young woman

Coronary artery disease may rarely be due to vasculitis. Angina pectoris and acute myocardial infarction have been reported in patients with Takayasus disease, polyarteritis nodosa, and thromboangiitis obliterans. TM In this article we report a case of Buergers disease localized to coronary and internal thoracic arteries (ITAs) in a young nonsmoking woman. The diagnosis was made by histologic examination of the ITAs that were discarded at the time of bypass surgery. A 39-year-old woman had a 2-year history of epigasmc pain of unknown origin and sporadic episodes of typical angina for the past 8 months. Because of worsening of symptoms she underwent a treadmill exercise test. which showed signs of myocardial ischemia. The patient appeared to be otherwise in good health, without evidence of risk factors including diabetes mellitus, hypercholesterolemia, hypertension, obesity, or family history of isch-

Surgical treatment for life-threatening acute myocardial infarction: a prospective protocol.

OBJECTIVE In this paper we describe the preliminary results of a prospective operative protocol designed in order to define the role of emergent myocardial revascularization in extensive acute myocardial infarction and in post-infarction cardiogenic shock. METHODS Entry criteria are: age < 75 years; anterior acute myocardial infarction with ST segment elevation > 4 leads, infero-postero-lateral or inferior and right ventricular within 6 h from onset of chest pain; post-infarction cardiogenic shock within 3 h from onset of shock. From November 1994 to July 1995, after emergency coronary arteriography, 23 patients were treated by coronary artery bypass grafting. Fifteen were operated for extensive acute myocardial infarction (group A, mean age 54.1 +/- 9.4 years) and eight for post-infarction cardiogenic shock (group B mean age 65.0 +/- 8.7 years). Mean time from onset was 4.4 +/- 1.3 h in group A and 2.2 +/- 0.8 h in group B. Mean left ventricular ejection fraction was 39.3 +/- 12.7% in group A and 22.6 +/- 3.5% in group B. Six out of eight group B patients needed intraaortic balloon counterpulsation preoperatively, and 2/8 cardiopulmonary resuscitation. RESULTS Myocardial revascularization consisted in 3.4 +/- 1.1 grafts in group A (vein grafts, except for 8 patients who also received a left internal thoracic artery graft) and 3.3 +/- 1.1 vein grafts in group B. All patients in group B and 3/15 (20%) in group A underwent intraaortic balloon counterpulsation. In-hospital death occurred in 1/15 (6.7%) patients of group A and in 4/8 (50%) patients of group B. At a mean follow-up of 4.1 +/- 3.4 months for group A and 3.9 +/- 2.2 months for group B left ventricular ejection fraction was 43.4 +/- 9.0% in group A and 35.7 +/- 13.1% in group B. CONCLUSIONS Experience of 9 months with this prospective protocol showed its effectiveness in the management of critically ill patients with acute coronary occlusion leading to low mortality rate in acute myocardial infarction and improved survival rate in post-infarction cardiogenic shock.

Chordal plication and free edge remodeling for mitral anterior leaflet prolapse repair: 8-year follow-up

BACKGROUND Chordal suture plication and free edge remodeling represent a personal technique for the repair of anterior leaflet prolapse. We report the results of an 8-year experience. METHODS Sixty-one patients with degenerative mitral regurgitation caused by prolapse of the anterior leaflet (11) or both leaflets (50) underwent anterior leaflet prolapse repair. Twenty patients who had associated cardiac procedures are included. RESULTS There were two perioperative deaths. Postoperative mitral regurgitation fell to 0.4 +/- 0.7 versus 3.7 +/- 0.4 preoperative (p < 0.0001). Mean follow-up was 40.5 months. There were 3 late deaths and 3 mitral reoperations (1 of 3 repairs, 2 of 3 replacements). Thromboembolism and endocarditis occurred in 1 patient each. Actuarial overall survival, freedom from cardiac death, and freedom from mitral reoperation at 92 months were 85.1% +/- 7.9%, 88.9% +/- 7.7%, and 94.6% +/- 3.0%, respectively. CONCLUSIONS Our technique of anterior leaflet prolapse repair appears effective, safe, and durable at mid- to long-term follow-up, and may be used in the presence of extensive disease of both leaflets.

Measurement of Cardiac Troponin T and Myosin to Detect Perioperative Myocardial Damage during Coronary Surgery

This study evaluated the use of monitoring blood levels of the isoenzyme of creatine Phosphokinase, troponin T (tnT) and myosin in the detection of perioperative myocardial damage after coronary artery surgery. Serial blood samples were collected in 24 patients undergoing myocardial revascularization. The patients were retrospectively divided into three groups: group A with no changes in their electrocardiogram; group B showing non-specific signs of perioperative myocardial infarction such as deep and permanent T wave inversion; and group C with definite electrocardiographic signs of perioperative myocardial infarction (new persistent Q-waves and loss of R-waves). Group A (n= 17) demonstrated a mean(s.d.) troponin T peak blood level of 0.64(0.35) ng/ml at 12 −24 h after surgery, a myosin peak of 1030(670) μunits/l at 3−6 days afterwards, and a creatine Phosphokinase isoenzyme peak of 25.8(10.6) units/l. In group B (n = 5), mean(s.d.) troponin T levels were elevated to a peak of 4.8(3.9) ng/ml 24 h after intervention, while myosin rose to 2074(340) μunits/l 3−6 days after surgery and creatine Phosphokinase isoenzyme reached 57.8(38) units/l. Group C(n = 2)had a mean(s.d.) troponin T peak of 4.8(2.6) ng/ml, a myosin peak of 2404(392) μunit/l and a creatine Phosphokinase isoenzyme peak of 88.5(20) units/l. Peak values of troponin T and myosin in groups B and C were statistically different from those in group A (P< 0.001). These results suggest that troponin T and myosin are reliable indicators of perioperative myocardial damage. In particular, troponin T may allow the differentiation of reversible from irreversible myocardial injury.

Advantages of delayed sternal closure in cardiac-compromised adult patients.

Severe hemodynamic dysfunction may follow closure of the median sternotomy in patients with myocardial edema, cardiac dilatation, postcardiotomy shock, or raised endexpiratory alveolar pressure. Open sternotomy and delayed sternal closure (DSC) is a well described adjunct in complicated cardiac operations, which is more widely applied in neonates. In this article we report our results in using open sternotomy in eight adult patients from January 1994 to February 1995 (excluding patients who needed ventricular assistance devices [VADs]). Three patients died in hospital: 1 case of multiorgan failure; 1 case of refractory low cardiac output syndrome; and 1 case of respiratory distress syndrome. Our experience confirms that DSC is an effective means of dealing with postoperative hemodynamic impairment. Furthermore, this technique may represent an intermediate step between intra‐aortic balloon counterpulsation and VADs and should be given a role in the prophylaxis of low postoperative cardiac output and multiorgan failure, particularly when contraindications to VAD exist.

Inferior epigastric artery as a conduit for myocardial revascularization: a two-year clinical and angiographic follow-up

The inferior epigastric artery has been proposed as a suitable conduit for myocardial revascularization but its mid-term patency rate has not been assessed. A prospective clinical and angiographic study on the use of the inferior epigastric artery as an additional arterial conduit together with bilateral internal thoracic artery grafting was conducted in 38 patients. No deaths or major postoperative complications occurred. Twenty-three patients underwent repeat angiography after an average of 21.2 months. The left and right internal thoracic artery grafts patency rate was 95.6% (44/46), while inferior epigastric artery patency rate was 52.2% (12/23). By relating patency to the grafted coronary branch, the following results were obtained: 100% for the left anterior descending (3/3), right coronary (1/1) and ramus medianus (1/1); 40% (4/10) and 37.5% (3/8) for diagonals and obtuse marginals respectively. The low patency rates observed when the inferior epigastric artery is used on diagonals and obtuse marginals indicate that this vessel cannot be considered a suitable conduit for extensive application of arterial revascularization. We suggest that the inferior epigastric artery should only be used in patients presenting with contraindications to bilateral internal thoracic artery or right gastroepiploic artery grafting, or exhibiting unsuitable saphenous veins.

Mitral valve prosthetic endocarditis: development of left ventricular-coronary sinus fistula following replacement

We report the history and course of a patient in whom a left ventricular-coronary sinus fistula developed following mitral valve replacement due to prosthetic endocarditis. Six months after the intervention the patient suddenly presented with deterioration of her symptoms, holosystolic murmur and signs of congestive heart failure. Transesophageal echocardiography showed a left-to-right shunt but did not show its exact location. At surgery, exploration of the right atrium revealed a left ventricular-coronary sinus communication due to discontinuation of the left ventricular free wall next to the coronary sinus; repair of the defect was successfully performed by direct suture. The postoperative course was uneventful and the patient recovered quickly. This case is reported to stress that debridement of the mitral annulus and removal of an old prosthesis must be very carefully performed and to facilitate the diagnosis of this rare but severe complication of repeated mitral valve replacement.

Surgery of cavo-atrial renal carcinoma employing circulatory arrest: immediate and mid-term results

From 1990 to 1995, 12 patients with cavo-atrial renal cell carcinoma underwent resection of the tumor. Circulatory arrest was employed in 11/12 cases. The neoplasm extended to the inferior vena cava in two patients and to the intrahepatic veins or right atrium in five cases. Two severely cardiac compromised patients died perioperatively. Of five patients who showed preoperative suspicion of isolated metastases, 3 patients died postoperatively because of relapsing disease after a mean period of 10.8 months. Five patients are alive and doing well after a mean follow-up of 14.8 months. In our experience myocardial dysfunction determined poor immediate survival. Mid-term survival was influenced by preoperative metastases and lymph-node involvement, but not by intracaval extension. Circulatory arrest appears to be a relatively safe technique to remove renal carcinoma with cavo-atrial extension and should be indicated whenever there are no metastases.

Warm heart surgery in cold haemagglutinin disease

Continuous warm retrograde blood cardioplegia and systemic normothermia are a promising method for heart surgery in patients with cold autoimmune disorders in order to avoid the adverse effects of both systemic and coronary hypothermia during cardiac arrest and cardiopulmonary bypass. A 59-year-old white man with cold haemagglutinin disease who underwent coronary surgery using continuous retrograde normothermic blood cardioplegia and systemic normothermia is reported.

Usefulness of transcranial color Doppler ultrasonography in aortic arch surgery.

Background Hypothermia in combination with selective cerebral perfusion is a well-documented technique for cerebral protection during aortic arch surgery. However, such complex surgery is still accompanied by a considerable incidence of neurological events. Aim This study describes the advantages of transcranial color Doppler ultrasound (TCDU) as a noninvasive real-time method for intraoperative monitoring of cerebral blood flow. Method Between 1 January 2010 and 31 December 2011, 29 consecutive patients underwent transcranial echo color Doppler (TCDU) monitoring during hypothermic circulatory arrest. Results and conclusions TCDU was easily applied and provided continuous information on cerebral perfusion in all patients studied. Early detection of perfusion abnormalities during selective cerebral perfusion guided surgeon and anesthesiologist to research for causes and correct them, avoiding severe neurological consequences. Moreover, transcranial echo color Doppler allowed us to optimize anterograde and retrograde cerebral perfusion rate, avoiding hyper-perfusion or hypo-perfusion phenomena during cardiac arrest.