Paolo Masiello

Surgical results of aortic valve replacement via partial upper sternotomy: comparison with median sternotomy

BACKGROUND the theoretical advantages of mini-invasive cardiac surgery are shorter hospitalisation, better surgical results and costs reduction. In November 1997 we started a non-coronary mini-invasive surgery program using a partial upper median sternotomy. This study has been conceived to retrospectively compare two groups of patients who underwent isolate aortic valve replacement using the conventional and the mini-invasive technique. MATERIAL AND METHODS in Group A 100 patients (mean age 62+/-12 years; 58 male) underwent isolated aortic valve replacement through a partial upper median sternotomy. Group B was composed by the last 100 patients (mean age 63+/-8 years; 56 male) who underwent the same operation through a conventional median sternotomy. For both groups we recorded the ECC and ischaemic times, postoperative intubation time, total postoperative bleeding, intensive care unit length of stay and total hospitalisation time. Major and minor complications were reported. RESULTS operating times, were significantly longer in Group A (p<0.001). Mechanical ventilation time, ICU and total hospital stay, and total postoperative bleeding showed no significant difference. Adjunctive statistical evidenced the absence of learning curve. Mortality and other complications failed to reveal any significant difference between the two groups. CONCLUSIONS in our experience, partial upper median sternotomy does not increase surgical risks but failed to demonstrate clear advantages. Apart for an increase in operating times, the surgical results are similar to those of a conventional median sternotomy with only improvement in the aesthetical aspect. In our opinion, this supports the conviction that this approach can be proposed to selected patients, to obtain a better cosmethical result for the same given risk.

Corrected Transposition of the Great Arteries with Isolated Aortic Coarctation: In Utero Echocardiographic Diagnosis

AbstractPhysiologically corrected transposition of the great arteries (cTGA), defined by discordant atrioventricular and ventriculoarterial connections, is an uncommon congenital cardiac malformation. It rarely exists without associated cardiac anomalies, the most common of which are ventricular septal defect, pulmonary outflow obstruction, tricuspid valve (systemic) deformity, and rhythm disturbances. Conversely, hypoplasia of the systemic ventricle and systemic inflow or outflow obstructions have seldom been reported, although their recognition may significantly influence surgical repair and the patient’s prognosis. We report a case of cTGA with complete heart block, moderate hypoplasia of the systemic ventricle, and severe aortic coarctation that was echocardiographically diagnosed in utero at 30 weeks’ gestation because of fetal growth retardation and persistent fetal bradycardia. After delivery the patient underwent epimyocardial pacemaker implantation and aortic coarctation repair at 2 weeks of age. Unfortunately, the patient died on the seventh postoperative day because of systemic ventricular hypertrophy. Although it is well known that fetal echocardiography may reliably diagnose uncommon congenital cardiac malformations, to the best of our knowledge, this paper represents the first reported case of antenatal diagnosis of this complex anomaly.

Giant Left Atrial Myxoma: An Unusual Cause of Acute Pulmonary Edema

We report a case of a huge left atrial myxoma with an unusual clinical presentation characterized by acute pulmonary edema. The possible pathophysiologic mechanism has been discussed.

Type B Aortic Dissection Involving an Isolated Right-Sided Aortic Arch

We report a case of a 48-year-old man in whom type B aortic dissection in the right aortic arch and right descending aorta was diagnosed by transesophageal echocardiography and computed tomographic scan. Angiography was necessary to define the anatomy of the branching vessels. The patient was successfully treated by interposition of a Vascutek 24-mm Dacron woven tube with a right posterolateral thoracotomy approach. Circulatory arrest in profound hypothermia and cerebral retroperfusion were used.

Fibrous tissue ring : an uncommon cause of severe prosthetic valve stenosis

We describe here the case of a patient in whom severe mitral stenosis and periprosthetic leak developed 5 years after mitral valve replacement with a Medtronic Hall prosthesis (Medtronic, Inc., Minrie.apolis, Minn.). Mitral valve stenosis was attributed to the~formation of concentric dense fibrous tissue around the atrial side of the anulus. A 45-year-old woman underwent open mitral commissurotomy in 1979 for rheumatic mitral stenosis. Ten years later she underwent mitral valve replacement with a Medtronic Hall 27 mm prosthesis. In 1993 she had a fever of unknown origin. Subsequently her clinical status progressively worsened, with the onset of exertional dyspnea and fatigue. In March 1994 she was referred to us. On admission severe peripheral edema and jugular vein distention were present. The liver was palpable 6 cm below the costal border. A 2/6 to 3/6 soft holosystolic murmur was audible on the apex radiating to the axilla. Blood pressure was 130/80 mm Hg. The electrocardiogram showed sinus rhythm with a heart rate of 96 beats/min and signs of moderate right ventricular hypertrophy. The chest x-ray film revealed a slightly enlarged cardiac shadow and pulmonary congestion. A transthoracic two-dimensional and Doppler echocardiogram showed left atrial dilatation, normal opening of the prosthesis, reduction of diastolic flow through the prosthesis, and a mild periprosthetic leak. High pulmonary artery pressures were calculated and then confirmed by preoperative insertion of a thermodilution catheter (90/45 mm Hg, mean 60 mm Hg). A transesophageal echocardiogram revealed a periprosthetic leak and confirmed the transthoracic data. Mild aortic stenosis was present. The patient was operated on 2 days later and the mitral prosthesis was replaced through a vertical transseptal approach with a 27 mm CarboMedics prosthesis (CarboMedics, Inc., Austin, Tex.). The aortic valve was explored and subsequently a commissurotomy was made. The postoperative course was uneventful and the patient was discharged to her home on the ninth postoperative day. Postoperative transthoracic two-dimensional and Doppler echocardiography showed a dramatic drop in pulmonary artery pressure and a well-functioning prosthesis. Examination of the explanted valve revealed a ring of fibrosclerotic tissue, containing many inflammatory cells, surrounding the anulus on the atrial side. The movement of the disc was unimpeded but the fibrous tissue strongly reduced the valvular area, simulating mitral stenosis (Fig. 1, A and B).

Spontaneous coronary artery rupture presenting as an acute coronary syndrome evolved in pseudoaneurysm and cardiac tamponade: Case report and literature review:

Spontaneous coronary artery rupture is a rare disorder that may develop early into a sudden death due to the abrupt evolution of the associated cardiac tamponade. In some cases the rupture is contained and a false aneurysm develops with slower evolution of clinical signs. The correct diagnosis of spontaneous coronary artery rupture deserves a high level of suspicion; frequently it may be missed because the time window of its evolution seems to be very short or signs of acute coronary syndrome sometimes can prevail, leading to delays in diagnosis or to misdiagnosis. We report the case of a patient presenting a giant pseudoaneurysm of the right coronary artery due to spontaneous coronary artery rupture without any underlying disease. Moreover we present a review of the few cases in the literature, offering a pathophysiological hypothesis linking the site of rupture and clinical presentation.

Isolated atrial inversion in situs inversus: A rare anatomic arrangement

Isolated atrial inversion in situs inversus is a rare congenital cardiac malformation. Its physiology resembles transposition of great vessels, and the best option for its surgical treatment is the atrial switch operation. In this article, we present a case of isolated atrial inversion in concordance with visceral situs inversus diagnosed at birth by echocardiography and cardiac catheterization, which was successfully treated at 8 months of age by a Senning procedure.

Transesophageal Echocardiographic Diagnosis of a Dehisced Carpentier Mitral Ring

We describe an unusual case of gross dehiscence of a Carpentier mitral ring, not due to bacterial endocarditis, causing severe mitral valve insufficiency and cardiac failure. Diagnosis was made by transesophageal echocardiography (TEE). Mitral valve replacement was then performed.