Paolo Vanelli

Assessment of an aortosaphenous vein graft anastomotic device in coronary surgery: Clinical experience and early angiographic results

BACKGROUND Until now technologic evolution in coronary bypass surgery has focused on extracorporeal circulation, on operation without extracorporeal circulation, and on the exposure of the operative site. Recently a one-shot anastomotic device for the proximal anastomosis in coronary surgery was developed. We investigated whether the use of the aortic connector system (ACS) could facilitate the creation of aortosaphenous vein graft anastomoses in myocardial revascularization. METHODS From November 2000, 40 ACS devices were used in 36 consecutive patients (mean age 70.7 +/- 8.9 years); 12 patients (33.3%) underwent surgery on pump and 24 patients (66.6%) off pump; 50 distal anastomoses were performed. In all cases the connection with the ascending aorta was created before the distal anastomoses because of the necessity to slide the saphenous vein graft (SVG) over the vein transfer sheath. Intraoperative graft function was tested measuring blood flow by Doppler analysis. Postoperative evaluation of the anastomotic patency was carried out by early angiography in 34 patients (94.7%) but was excluded in 5 patients (5.3%) with extensive extracardiac vascular occlusive disease. RESULTS Of 38 AC (95%) evaluated, 36 (94.7%) functioned properly. The end-to-side proximal anastomosis without aortic clamping is instantaneous, the quality of anastomoses was highly rated, no additional stitches were required, and all coronary arteries could be reached. Intraoperative quantity flow was measured by Doppler analysis and all but one showed good flow. Early postoperative angiography demonstrated good patency of the grafts in all cases but 2 (5.3%). At 1-year follow-up, 1 patient died of stroke; all other patients remained free of symptoms and no reoperation was required. CONCLUSIONS The use of ACS makes end-to-side anastomosis rapid, effective, and reproducible while eliminating aortic cross clamping; it opens a new era in beating or nonbeating coronary surgery. Long-term results are mandatory to confirm our favorable preliminary results.

Myocardial revascularization with multiple arterial grafts: comparison between the radial artery and the right internal thoracic artery

BACKGROUND Bilateral internal thoracic artery (ITA) harvesting is significantly underused, whereas the radial artery is being used with increasing frequency. We have retrospectively analyzed perioperative and short-term outcomes of patients receiving a radial artery versus those receiving a right ITA as a second arterial graft. METHODS Between February 1999 and May 2000, 250 patients underwent coronary artery bypass grafting using the radial artery (156 patients) or the right ITA (94 patients) in combination with the left ITA and, when required, the saphenous vein. RESULTS There was a higher prevalence of risk factors in the radial artery group. More coronary artery bypass graftings (p < 0.001) were performed with the radial artery. Operative mortality was not different (p = not significant). In the right ITA group there was more bleeding (p < 0.001) and a longer hospital stay (p < 0.001). Mean follow-up was 8.1 +/- 3.9 months. The probability of survival was similar (p = not significant). CONCLUSIONS The radial artery can extend the benefits of multiple arterial grafting to those patients who are usually excluded from bilateral ITA harvesting because of multiple risk factors. Perioperative and short-term results are good.

Profile of infective endocarditis observed from 2003 - 2010 in a single center in Italy.

BackgroundThis study aimed to provide a contemporary picture of the epidemiologic, clinical, microbiologic characteristics and in-hospital outcome of infective endocarditis (IE) observed in a single center in Italy.MethodsWe performed a retrospective study of patients with definite or probable IE observed at the “L. Sacco” Hospital in Milan, Italy, from January 1, 2003 through December 31, 2010.Results189 episodes of IE in 166 patients were included. The mean number of incident IE in the study period was of 1.27 (range 0.59-1.76) cases per 1000 patients admitted. The median age of the cohort was 57 (interquartile range, 43-72) years, 63% were male and 62.5% had native valve IE. Twenty-six percent were active intravenous drug users (IVDU), 29% had a health care-associated IE and 5% chronic rheumatic disease. Twenty-nine percent of the cases occurred in patients affected by chronic liver disease and 19% in HIV positive subjects. Staphylococcus aureus was the most common pathogen (30%), followed by streptococci. The mitral (34%) and aortic (31%) valves were involved most frequently. The following complications were common: stroke (19%), non-stroke embolizations (25%), heart failure (26%) and intracardiac abscess (9%). Surgical treatment was frequently employed (52%) but in hospital mortality remained high (17%). Health care-associated IE and complications were independently associated with an increased risk of in-hospital death, while surgery was associated with decreased mortality.ConclusionS. aureus emerged as the leading causative organism of IE in a University hospital in northern Italy. Our study confirmed the high in-hospital mortality of IE, particularly if health care associated, and the protective role of surgery.

One-stage repair of aortic coarctation and ascending aortic aneurysm by extra-anatomic graft.

The best surgical approach for patients presenting with coarctation of the aorta and additional surgical cardiovascular disorders is uncertain. We describe the case of a young man with an aneurysm of the ascending aorta and a bicuspid aortic valve with a moderate insufficiency associated with a coarctation of the aorta. The patient underwent a single-stage procedure where the ascending aorta was replaced, the aortic valve repaired and the coarctation bypassed with an extra-anatomic graft. In our opinion, ascending-to-descending extra-anatomic graft is a good solution to treat these complicated cases.

Aortic valve repair: a ten-year single-centre experience

OBJECTIVES Aortic valvuloplasty could represent an alternative to valve replacement resulting in optimal haemodynamic conditions, avoiding anticoagulation and allowing, in young people, normal aortic annulus growth. We analysed our results of aortic valve repair for incompetence due to leaflets and root pathology. METHODS From January 2003 to January 2013, 235 patients affected by aortic valve regurgitation, pure or associated with aortic dilatation, were treated with a combination of the principal leaflet repair techniques and, when necessary, sparing procedures. Of these patients, 218 were considered eligible in this study. All of them were submitted to pre- and postoperative transthoracic echocardiography and pre- and post-repair transoesophageal echocardiography. Follow-up was achieved with periodic echocardiograms and clinical evaluations. RESULTS Eight patients (3.40%) died before discharge. Median clinical and echocardiographic follow-up for all patients was 2.94 (1.41-5.41) years. Mean cross-clamping time was 101.94 ± 40.22 min and mean hospital stay was 10 ± 6.69 days. Kaplan-Meier freedom from aortic regurgitation >2 and freedom from aortic valve replacement were, respectively, 92.9 ± 2.8 and 94.5 ± 2.5% at 9.24 years: 6 patients (2.75%) were reoperated on with aortic valve replacement for severe aortic regurgitation. We also observed a good effect of aortic surgery on the left ventricle: the end-diastolic volume decreased from 137.89 ± 50.23 ml in the preop to 105.17 ± 31.19 ml at follow-up. CONCLUSIONS Aortic valve leaflet repair seems to be a good and feasible option for selected patients, both alone or associated with an aortic sparing technique concerning long-term results.

Type F quadricuspid aortic valve: surgical treatment of a rare cause of aortic valve disease.

Quadricuspid aortic valve is the rarest congenital anomaly of the semilunar valves. In the past it has been frequently detected incidentally at autopsy or during cardiac surgery. Recently, the evolution of diagnostic techniques with Doppler analysis has allowed to identify preoperatively this uncommon cardiac abnormality. We report a case of quadricuspid aortic valve diagnosed during surgery.

Epidemiological trends of infective endocarditis in a single center in Italy between 2003–2015

Abstract Objective: Changes in the incidence, clinical features and microbiology of infective endocarditis (IE) observed in a single center in Italy were compared between the period 2003–2010 and 2011–2015. Methods: All cases of IE, defined as definite or possible according to the modified Duke criteria, observed at the ‘L. Sacco’ Hospital in Milan, Italy between 2003 and 2015 were retrospectively reviewed. Results: 366 episodes of IE were identified in 325 patients. The mean number of incident IE over the period 2003–2015 was 1.43 (range: 0.6–2.1) cases per 1000 admissions, with a significantly increasing trend from a mean of 1.28–1.72 cases per 1000 admissions/year in 2003–2010 and 2011–2015, respectively (+34%; p = .04). Staphylococci remain the leading pathogens causing IE (29%) with a relative increase of methicillin-resistant Staphylococcus aureus between the two periods. Streptococci and enterococci account for 26% and 18% of IE, respectively. We found an increase in the proportion of cases due to enterococci (from 14% in 2003–2010 to 22% in 2011–2015). The rate of in-hospital mortality was 19%, similar in the two periods studied. Conclusion: The incidence of IE continuously increased in our cohort over the past decade and, along with the aging of the population, a raise in the incidence of health care-associated infections and a change in the distribution of prevalent pathogens were observed. Surgery was independently associated with higher in-hospital survival (AOR, 95% CI: 0.38, 0.19–0.74; p = .005). A constant surveillance is required to guide the optimal management of the changing epidemiology of IE.

An Oral Abscess as the Entrance Leading to Endocarditis: A Sexual Behavior Role

We report a case of atypical endocarditis for which the transmission mode has long been debated among cardiac surgeons, microbiologists, and infectious disease specialists. This is the first reported case of Streptococcus agalactiae being responsible for the probable sexually transmitted case of endocarditis in a healthy, 49-year-old female. Keywords S. agalactiae; Infective endocarditis; Aortic valve

Left atrial ablation through monolateral thoracotomy

We read with interest the recent paper of Solinas et al. [1], who first described a technique to perform a left atrial (LA) ablation with bipolar irrigated radiofrequency (RF) through a single right thoracotomy. This work confirms the feasibility of pulmonary veins isolation (PVI) through the monolateral approach and therefore sustains the use of minimally invasive surgery (MIS) for the treatment of atrial fibrillation (AF). However, two questions about the treatment of AF are currently unanswered: What is the best approach? What is the best lesion set? Wolf et al. [2], using a bipolar RF device, support a full left maze with testing of the electrical block. Unfortunately, this techniqueneeds a bilateral approach, increasing invasiveness. Some authors [3,4] also described AF ablations through a monolateral approach. However, this procedure was performed ‘on pump’ and on cardioplegic arrest. From these articles, we could conclude that best approach and best lesion set are inversely related.Fromthis point of view, Solinas et al., using abipolarRFdevice, didnotchange this paradigm. In fact, their technique was only in part performed on beating heart but, itwas alwaysduring theextracorporeal circulationand for a concomitant mitral valve disease, where left atrium was opened. Solinas et al. [1] have not explained the selection criteria of patients. According to the literature, persistent and permanent AF could have a more extended lesion set. In our opinion, this treatmentmay count almost themitral isthmus to avoid supra ventricular tachycardia, like atypical flutters. Ideally, surgeons would like to develop a technique easy to perform, monolateral, off-pump, epicardial, with adequate transmural lesion set, and good clinical outcomes. Bipolar RF clamp devices that appear to be most capable of reliably producing transmural lesions are least able to be minimally invasive. Alternative sources of energy could be taken into account to solve this dilemma. Recently, we described a method for AF ablation using high-intensity focused ultrasound (HIFU) energy [5] with promising results. However, it is our opinion that a good selection of the patients should be always taken into account. In fact, even if we performed AF ablation with an HIFU device, we were not able to create a bi-atrial lesion set useful for patients with more severe and advanced states of AF. In conclusion, Solinas et al. plead a case of AF treatment moving toward a simpler and less-invasive procedure. We hope industries will respond by applying the innovative technology to the needs of new instruments capable of retaining the efficacy of the full Cox-maze procedure and really adapted for MIS. References