Piero Proietti

Should Mild‐to‐Moderate and Moderate Ischemic Mitral Regurgitation Be Corrected in Patients with Impaired Left Ventricular Function Undergoing Simultaneous Coronary Revascularization?

Introduction: Mitral valve regurgitation (MR) occurring as a result of myocardial ischemia and global left ventricular (LV) dysfunction predicts poor outcome. This study assessed the feasibility of mitral valve (MV) surgery concomitant with coronary artery bypass grafting (CABG) in patients with mild‐to‐moderate and moderate ischemic MR and impaired LV function. Materials and Method: From January 1996 to July 2000, 49 patients (group 1) and 50 patients (group 2) with grade II and grade III ischemic MR and LV ejection fraction (EF) between 17% and 30% underwent combined MV surgery and CABG (group 1) or isolated CABG (group 2). LVEF (%), LV end‐diastolic diameter (EDD) (mm), LV end‐diastolic pressure (EDP) (mmHg), and LV end‐systolic diameter (ESD) (mm) were 27.5 ± 5, 67.7 ± 7, 27.7 ± 4, and 51.4 ± 7, respectively in group 1 versus 27.8 ± 4, 67.5 ± 6, 27.5 ± 5, and 51.2 ± 6, respectively in group 2. Groups 1 and 2 were divided into Groups 1A and 2A with mild‐to‐moderate MR (22 [45%] and 28 [56%] patients, respectively) and groups 1B and 2B with moderate MR (27 [55%] and 22 [46%], respectively). In group 1, MV repair was performed in 43 (88%) patients and MV replacement in 6 (12%) patients. Results: Preoperative data analysis did not reveal any difference between groups. Five (10%) patients in group 1 died versus 6 (12%) in group 2 (p = ns). Within 6 months after surgery, LV function and its geometry improved significantly in group 1 versus group 2 (LVEF, p < 0.001; LVEDD, p = 0.002; LVESD, p = 0.003; and LVEDP (p < 0.001) improved significantly in group 1 instead of a mild improvement in Group 2). The regurgitation fraction decreased significantly in group 1 patients after surgery (p < 0.001). There was an inverse strong correlation between postoperative forward cardiac output and regurgitation fraction (p < 0.001). LVEF and LVESD improved significantly in group versus group 2 patients (p = 0.04 and p = 0.02, respectively). The cardiac index increased significantly in group 1 and 2 (p < 0.001 and p = 0.03, respectively). LV function and geometry improved significantly postoperatively in group 1B versus group 2B (LVEDD, p = 0.027; LVESD, p = 0.014; LVEDP, p = 0.034; and LVEF, p = 0.02), instead of a mild improvement in group 1A versus group 2A (LVESD, p = 0.015; LVEF, p = 0.046; and LVEDD and LVEDP, p = 0.05). At follow‐up, 4 (67%) of 6 patients undergoing MV replacement died versus 5 (11.59/0) of patients undergoing MV repair in group 1 (p = 0.007). The overall survival at 3 years in Group 2 was significantly lower than group 1 (p < 0.009). Conclusion: MV repair and replace‐ ment‐preserving subvalvular apparatus in patients with impaired LV function offered acceptable outcomes in terms of morbidity and survival. Surgical correction of mild‐to‐moderate and moderate MR in patients with impaired LV function should be taken into consideration since yields better survival and improved LV function.

Early and long-term outcome in patients undergoing aortic root replacement with composite graft according to the Bentall's technique

OBJECTIVE The aims of this study were: (i) to evaluate the early and long-term outcome in patients undergoing aortic root replacement (ARR) with a composite graft; (ii) to identify the predictors for poor overall survival in this pool of patients. MATERIAL AND METHODS Between January 1989 and December 2000, 212 patients underwent ARR with a CG. Mean age was 56+/-14 years, ranging from 16 to 77. Annuloaortic ectasia was the most frequent cause of aortic disease in this series, 81 (38%) patients, followed by atherosclerotic aneurysm 57 (27%) and type A acute aortic dissection 52 (24.5%). Marfans syndrome was present in 37 (17.5%) patients. Duration of follow-up ranged from 1 to 120 months, mean 59+/-35 months. RESULTS The overall hospital mortality was 16 (7.5%) patients. Eight of them had aortic dissection and four Marfan syndrome. The most frequently found complication resulted to be renal failure in 22 (10%) patients and low cardiac output in 15 (7%) patients. The incidence of perioperative myocardial infarction, neurological complications, respiratory complications, renal failure and coagulopathy incidence were significantly higher in patients with cardiopulmonary bypass (CPB) time >170 min, CA >40 min, and total aortic arch replacement. The actuarial survival at 1, 3 and 5 years resulted to be 91.8, 86 and 81.5%, instead the actuarial survival without re-operation resulted to be 89, 82 and 78%. The actuarial survival in patients with aortic dissection was significantly lower versus non-dissection (P=0.022). The multivariate analysis revealed the aortic dissection (P=0.03), age >65 years (P=0.014), associated coronary artery disease (P=0.002), NYHA functional class>/=3 (P=0.027), LVEF <35% (P=0.002) and total arch reconstruction (P=0.003) as strong predictors for poor overall survival in patients undergoing ARR. CONCLUSIONS The ARR with a CG offers acceptable early and long-term outcome. The predictors for poor overall survival in patients undergoing ARR seems to be preoperative aortic dissection extended into the aortic arch, older age, depressed left ventricular function and associated coronary artery disease.

Cardinal vein isomerism An embryological hypothesis to explain a persistent left superior vena cava draining into the roof of the left atrium in the absence of coronary sinus and atrial septal defect

BACKGROUND A persistent left superior vena cava (PLSVC) is a relatively frequent systemic venous anomaly associated with congenital heart defects. This anomaly has been explained with the persistence of the left superior cardinal vein. PLSVC usually drains into the right atrium, via coronary sinus, but it joins the left atrium in approximately 8% of the cases either directly in the setting of atrial isomerism, or via an unroofed coronary sinus, or through a coronary sinus type atrial septal defect. CASE REPORT We describe a case of an adult patient with atria in the situs solitus, PLSVC draining into the left atrium, atresia of coronary sinus without atrial septal defect, and with additional cardiac anomalies (ventricular septal defect and discrete subaortic stenosis). CONCLUSION A possible embryological explanation to this case rises from a right partial isomerism of the superior cardinal veins, which gives reason for both the coexistence of the PLSVC draining into the left atrium and the absence of coronary sinus, atrial septal defect, or coronary sinus ostium.

Does On-Pump/Beating-Heart Coronary Artery Bypass Grafting Offer Better Outcome in End-Stage Coronary Artery Disease Patients?

Abstract  Objectives: The purpose of our study was to evaluate in a cohort of end‐stage coronary artery disease (ESCAD) patients the effects of on‐pump/beating‐heart versus conventional coronary artery bypass grafting (CABG) requiring cardioplegic arrest. We report early and midterm survival, morbidity, and improvement of left ventricular (LV) function. Methods: Between January 1992 and October 1999,107 (Group I) ESCAD patients underwent on‐pump/beating‐heart surgery and 191 (Group II) ESCAD patients underwent conventional CABG requiring cardioplegic arrest. Mean age in Group I was 65.8 ± 6.5 years (58–79 years); New York Heart Association (NYHA) and Canadian Cardiovascular Society (CCS) classifications were 3.2 ± 0.4 and 3.3 ± 0.5, respectively. LV ejection fraction (LVEF) was 24.8% ± 4%, LV end diastolic pressure (LVEDP) was 28.2 ± 3.8 mmHg, and LV end diastolic diameter (LVEDD) was 69.6 ± 4.6 mm. Mean age in Group II was 64.1 ± 5 years (57–76 years), NYHA class was 3 ± 0.6, CCS class was 3.4 ± 0.4, LVEF was 26.2% ± 4.3%, LVEDP was 27.2 ± 3.4 mmHg, and LVED was 68 ± 4.2 mm. Results: Preoperatively, Group I patients versus Group II patients had a markedly depressed LV function (LVEF, p = 0.006; LVEDP, p = 0.02; LVEDD, p = 0.003; and NYHA class, p = 0.002), older age (p = 0.012), and higher incidences of multiple acute myocardial infarction (AMI; p = 0.004), cardiovascular disease (CVD; p = 0.008), and chronic renal failure (CRH, p = 0.002). Cardiopulmonary bypass (CPB) time was longer in Group II patients (p = 0.028). The mean distal anastomosis per patient was similar between groups (p = NS). Operative mortality between Groups I and II was 7 (6.5%) and 19 (10%), respectively (p = NS). Perioperative AMI (p = 0.034), low cardiac output syndrome (LCOS; p = 0.011), necessity for ultrafiltration (p = 0.017), and bleeding (p = 0.012) were higher in Group II. Improvement of LV function within 3 months after the surgical procedure was markedly higher in Group I, demonstrated by increased LVEF (p = 0.035), lower LVEDP (p = 0.027), and LVEDD (p = 0.001) versus the preoperative data in Group II. The actuarial survivals at 1, 3, and 5 years were 95%, 86%, and 73% in Group I and 95%, 84%, and 72% in Group II (p = NS). Conclusions: ESCAD patients with bypassable vessels to two or more regions of reversible ischemia can undergo safe CABG with acceptable hospital survival and mortality and morbidity. In higher risk ESCAD patients, who may poorly tolerate cardioplegic arrest, on‐pump/beating‐heart CABG may be an acceptable alternative associated with lower postoperative mortality and morbidity. Such a technique offers better myocardial and renal protection associated with lower postoperative complications.

Growth factor production by arterial and vein grafts : Relevance to coronary artery bypass grafting

BACKGROUND Occlusion caused by myointimal hyperplasia, atherosclerosis, or both is the main reason for late failure of saphenous vein coronary artery bypass grafts. On the other hand, internal mammary artery grafts are usually spared from atherosclerosis. Evidence exists that platelet-derived growth factor (PDGF) and basic fibroblast growth factor (bFGF) are involved in the genesis of myointimal hyperplasia and atherosclerosis. The aim of this study was to assess the production of PDGF and bFGF by arterial and vein grafts. METHODS In 20 inbred Lewis rats alpha 1 cm long segment of arterial graft was interposed at the level of the abdominal aorta. In a control group of 20 Lewis rats alpha 1 cm long segment of vein graft was implanted at the level of the abdominal aorta. Animals were killed 4 weeks after operation, and the grafts were studied in serum-free organ culture to assess the production of PDGF and bFGF. RESULTS. Arterial grafts produced a smaller quantity of PDGF and bFGF than vein grafts (p < 0.01) Higher mitogenic activity was present in the conditioned media from vein grafts than in the conditioned media from arterial grafts (p < 0.001). A large amount of myointimal hyperplasia was present in all vein grafts. CONCLUSIONS This phenomenon could explain the rarity of atherosclerotic changes in internal mammary coronary bypass grafts.

λ graft with the radial artery or free left internal mammary artery anastomosed to the right internal mammary artery: flow dynamics

BACKGROUND The aim of this study was to evaluate the outcome and flow dynamics of the lambda graft configuration, relative to a second arterial graft. METHODS From 1998 to 2000, 47 patients (mean age 55.5 +/- 4.7 years) with triple-vessel disease underwent arterial revascularization using the lambda graft. The in situ left internal mammary artery (LIMA) and right internal mammary artery (RIMA) were anastomosed to the left anterior descending (LAD) and obtuse marginal arteries, respectively. In 21 patients (group I) presenting proximal or middle-third LAD or right coronary (RC) arterial stenoses, the lambda graft was constructed by anastomosing the distal LIMA, as a free LIMA graft, to the RC and proximally to the in situ RIMA. In the other 26 patients (group II) presenting with middle-distal third LAD or RC arterial stenoses, the radial artery (RA) was used to construct the lambda graft. All patients underwent transthoracic echo color Doppler before and after an adenosine test at 1 week and 3 months after operation. RESULTS There were no hospital deaths. Overall, 47 lambda grafts were constructed. There was no difference between baseline and maximal flows and coronary flow reserve (CFR) between groups. CFR at IMA stems increased in both groups within 3 months versus 1 week [(LIMA)CFR = 2 +/- 0.3 vs 2.3 +/- 0.3 (p = 0.002) and (RIMA)CFR = 2.2 +/- 0.4 vs 2.5 +/- 0.3 (p = 0.009) in group I, and (LIMA)CFR = 2.12 +/- 0.33 vs 2.4 +/- 0.35 (p = 0.005) and (RIMA)CFR = 2.17 +/- 0.32 vs 2.52 +/- 0.26 (p = 0.001) in group II]. At 3 months versus 1 week, the (RIMA)diameter(i) (mm) at rest was 1.69 +/- 0.32 versus 1.48 +/- 0.2 (p = 0.015) in group I and 1.66 +/- 0.3 versus 1.47 + 0.2 (p = 0.01) in group II. At 6 +/- 2.4 months, all patients were free of angina. CONCLUSIONS These data, almost identical for free LIMA and RA to RIMA using the lambda graft, demonstrate that RIMA flow reserve is adequate for multiple coronary anastomoses irrespective of the second arterial graft.

Beating heart myocardial revascularization on extracorporeal circulation in patients with end-stage coronary artery disease.

OBJECTIVES To evaluate in a cohort of ESCAD patients (pts) the effects of on-pump/beating-heart versus conventional CABG in terms of early and mid-term survival and morbidity and LV function improvement. METHODS Between January 1993 and December 2000, 78 (Group I) ESCAD pts underwent on-pump/beating-heart surgery. Mean age in Group I was 66.2+/-6 (58-79), NYHA and CCS class were 3.2+/-0.6 and 3.3+/-0.4 respectively, Myocardial viability index 0.69+/-0.1 (%), LVEF (%) 24.8+/-4, LVEDP (mmHg) 28.1+/-5.8 and LVEDD(mm) 69.5+/-6. Group II consisted in 78 ESCAD patients undergoing conventional CABG selected in a randomized fashion from an age, sex, and LVEF corrected group of patients. Mean age in Group II was 65.7+/-5 (57-78), NYHA 3.1+/-0.7, CCS 3.4+/-0.8, LVEF(%) 25+/-5, LVEDP(mmHg) 27.9+/-4.4 and LVEDD(mm) 69.2+/-7.2. RESULTS Postoperatively, 5(7.7%) patients died in Group I versus 7(11.5%) patients in Group II (P>0.1). CPB time resulted to be in Group II patients (P=0.001) and the mean distal anastomoses per patient was similar between groups (P=Ns). Perioperative AMI (P=0.039), LCOS (P=0.002), necessity for ultrafiltration (P=0.018) and bleeding>1000 ml (P=0.029) were significantly higher in Group II. None of the Group I patients underwent surgical revision for bleeding versus 8(10.3%) patients in Group II (P=0.011). At 6 months after surgery, the LV function improved significantly in Group I patients, demonstrated by an increased LVEF=27.2+/-4(%)(P=0.001), lower LVEDP=26.4+/-3(mmHg)(P=0.029) and LVEDD=67+/-4(mm) (P=0.004) instead of a lower LVEDD=66.8+/-6(mm)(P=0.032) versus the preoperative data in Group II. The actuarial survival at 1, 3 and 5 yr were 90, 82 and 71% in Group I and 89, 83 and 74% in Group II (P=Ns). CONCLUSION In ESCAD patients who may poorly tolerate cardioplegic arrest, on-pump/beating-heart CABG may be an acceptable alternative associated with lower postoperative mortality and morbidity. Such a technique offers a better myocardial and renal protection associated with lower postoperative complications due to intraoperative hypoperfusion.

Growth factors and myointimal hyperplasia in experimental aortic allografts

OBJECTIVES To analyse the role of growth factors (platelet derived growth factor, PDGF; basic fibroblast growth factor, bFGF; interleukin 1, IL-1) in the genesis of myointimal hyperplasia in arterial allografts. MATERIALS Two groups of experiments were performed: isografts and allografts. The isograft group consisted of 15 inbred Lewis rats in which a 1 cm long segment of aorta was inserted as an abdominal aortic interposition graft. The aortic segments were obtained from syngenic Lewis rats. The allograft group consisted of 15 inbred Lewis rats, in which a 1 cm long segment of aorta was interposed at the abdominal aorta level. The aortic segments were obtained from allogenic Brown-Norway rats. CHIEF OUTCOME MEASURES The animals were killed 4 weeks after surgery and were analysed by morphometric analysis (n = 3 for each group). In addition, production of PDGF, bFGF and IL-1 by aortic segments (n = 12 for each group) in organ culture was assessed. MAIN RESULTS Allografts had more myointimal hyperplasia, than isografts (p < 0.05). PDGF and bFGF production, generally considered to be the cause of myointimal hyperplasia, was not increased in allografts. IL-1 production was higher in allografts (p < 0.001). MAIN CONCLUSIONS Myointimal hyperplasia in aortic allografts is dependent on growth factors produced by the graft itself. These growth factors are different from PDGF and bFGF that generally have been implicated in the genesis of naturally occurring myointimal hyperplasia and atherosclerosis. IL-1 may have a principal role in the genesis of myointimal hyperplasia in arterial allografts.

Myocardial revascularization in chronic renal failure: 10-year experience

From January 1989 to June 1999, 244 patients with chronic renal failure underwent myocardial revascularization, of whom 56 were undergoing hemodialysis (group 1) and 188 (group 2) did not require hemodialysis. Mean age was 63.4 ± 6.5 years in group 1 and 65.4 ± 7 years in group 2. Hospital mortality was 7% overall; 6 (10.7%) patients died in group 1 versus 11 (5.9%) in group 2 (p > 0.05). Post-operative complications were significantly higher in group 1 versus group 2. Multivariate analysis revealed cerebrovascular disease, myocardial infarction, left ventricular ejection fraction < 35%, and duration of renal failure as strong predictors of poor survival in non-dialysis patients. Left ventricular ejection fraction < 35% and duration of hemodialysis were predictors of late mortality in group 1. The 1-, 3-, and 5-year survival rates were 90%, 76%, and 68% in group 1, and 95.5%, 86%, and 80.7% in group 2 (p < 0.004), respectively. Myocardial revascularization can be carried out in patients with chronic renal failure with acceptable early and late mortality and morbidity, but those undergoing hemodialysis are at substantial risk of major morbid events and poor long-term survival.

Type A Chronic Aortic Dissection in 40- Years Old Smeloff-Cutter Aortic Valve

We report the case of a 60-year-old man undergone an aortic valve replacement with a SmeloffCutter prosthesis 40 years ago. The patient underwent a redo aortic valve and ascending aorta replacement for ascending aorta aneurysm that intraoperatively appeared as a chronic Type A aortic dissection. The Smeloff-Cutter prosthesis looked intact and functionally normal. The ascending portion of the aorta appeared dissected two centimeters above the sino-tubular junction, between the non-coronary and the left coronary valsalva sinuses: we speculate that Smeloff-Cutter prosthesis may contribute, due to its rheology and features, to the determinism of aortic dilatation and subsequently dissection.