Pino Fundarò

Improvement of cardiac function by allopurinol in patients undergoing cardiac surgery

Allopurinol reduces formation of cytotoxic free radicals during myocardial ischemia/reperfusion in animals. To evaluate the effect of allopurinol on cardiac performance and metabolism after coronary bypass in humans, we divided 33 patients into two groups: 15 patients (controls) received no allopurinol and 18 patients received 200 mg allopurinol intravenously (i.v.) 1 h preop-eratively. Hemodynamic measurements were made with a triple-lumen thermodilution pulmonary artery catheter before cardiopulmonary bypass (CPB), 30 min after completion of CPB and 6 h later in the intensive care unit (ICU). A catheter placed into the coronary sinus was used for blood sampling for measurement of lactate and creatine phosphokinase MB. Peripheral blood was obtained for measurement of xanthine oxidase activity (XO), uric acid, and thiol groups. A myocardial biopsy was taken for measurement of thiol group content and XO before CPB and after heparin neutralization with prota-min (a few minutes after CPB). Treated patients had better recovery of cardiac output (CO) and left ventricular stroke work (LVSW) 30 min and 6 h after completion of CPB than did controls. Allopurinol significantly reduced plasma XO. Plasma concentrations of uric acid increased significantly in both groups 30 min after completion of CPB, but the increase in controls was greater (p < 0.02) than with allopurinol. Thiol group levels increased (p < 0.05) only in controls. Our results demonstrate improvement of cardiac function in coronary artery bypass surgery with allopurinol that is related to its metabolic effects consistent with protection against XO catalyzed free radical-mediated injury.

Mitral Valve Remodeling: Long-Term Results With Posterior Pericardial Annuloplasty

BACKGROUND We studied the long-term results of a technique of mitral annuloplasty using autologous pericardium. METHODS Between June 1989 and December 1994, 113 mitral valvuloplasties were performed for myxomatous degenerative disease. Repair of isolated anterior leaflet prolapse was performed in 26 patients (23%), posterior leaflet prolapse in 38 (33.6%), and prolapse of both leaflets in 49 (43.4%). Posterior pericardial annuloplasty was performed in all patients. In 20 patients, the pericardial graft was marked with metal clips for postoperative cinefluoroscopic assessment of annulus motion. RESULTS The operative mortality rate was 2.7% (3/113). One patient died of myocardial infarction and 2 of low cardiac output syndrome. One patient required replacement of the mitral valve 2 days after operation because of dehiscence of the annular plication. Follow-up (average length, 32.41 +/- 20.09 months; range 1 to 71 months) was 97% complete and revealed good clinical and functional results: 95 patients (84.1%) were in New York Heart Association class I and had no regurgitation or only mild residual regurgitation. Postoperative transmitral flow indices were almost normal (mitral valve area = 3.7 +/- 0.4 cm2; peak flow velocity = 1.06 +/- 0.2 m/s). Only 3 patients had reoperation within 3 years (actuarial 5-year reoperation-free rate, 89.7%) and event-free survival at 5 years was 91%. In patients with metal clips marking autologous pericardium, planimetry of the area derived by fluoroscopic examination showed systolic narrowing of annulus size (8.5% +/- 6.4%; p < 0.01) and a slight systolic fall in the anteroposterior diameter of the annulus contour (5.9% +/- 3.8%; p < 0.01). CONCLUSIONS Posterior pericardial annuloplasty seems to be a safe, effective and easily performed technique and a more physiologic correction that preserves mitral annulus motion.

Surgical treatment of left ventricular post-infarction aneurysm with endoventriculoplasty: late clinical and functional results

OBJECTIVE The temporal response to endoventriculoplasty (EVP) has not been well defined. We have evaluated the long-term clinical and functional results of this technique. METHODS From 1988 to 1997, 121 patients underwent aneurysmectomy by EVP associated with myocardial revascularization for anteroapical left ventricular postinfarction aneurysm. Among these, 39 patients (43%) underwent early post-operative cardiac catheterization (within 3 months maximum), and were available to be revaluated after a mean follow-up time of 56+/-28 months, by means of a new hemodynamic study. Left ventricular silhouettes were analyzed by means of a special software. RESULTS The mean New York Heart Association functional class decreased from 2.5+/-0.9 to 1.6+/-0.8 (P<0.001) late postoperatively. The global ejection fraction improved early postoperatively from 43+/-13 to 61+/-13% (P<0.001), and late postoperatively slightly decreased to 42+/-13% (ns) versus preoperative values. Left ventricular end diastolic pressure early postoperatively fell from 16.8+/-7 to 15.7+/-6.7 (ns), and late postoperatively increased to 21.6+/-8.8 (ns) versus preoperative values. Pulmonary artery pressure rose early postoperatively from 31.5+/-6.4 to 32.1+/-6.7 (ns), and late postoperatively to 34.9+/-8.9 (ns). The global contractility score decreased early postoperatively from 42.3+/-9.6 to 28.4+/-13.6 (P<0.001); the global late postoperative contractily was 35+/-14 (ns) versus preoperative values. Patients who benefit most from the operation were those with a normal postoperative contraction pattern, where ejection fraction improved respectively early postoperatively from 43+/-13 to 63+/-11% (P<0.001), and late postoperatively to 49+/-10% (P<0.001) versus preoperative values. Occlusion or critical stenosis of bypass grafts occurred in 10 patients (25.6%). There were no significant differences in hemodynamic data and hypokinesis score changes between patients with patent or occluded bypass graft, and between patients with mono or multivessel disease. The operative mortality was 6.3%, and 8.8% needed intraaortic balloon counterpulsation. The actuarial survival rates at 5 and 7 years were 73+/-6 and 61+/-6%. The mean follow-up period was 68 months (with 112 months maximum). CONCLUSIONS We conclude that, in our patients group, EVP of left ventricular aneurysm associated with coronary grafting improves clinical status after operation. We registered a trend for a mild hemodynamic worsening, irrespective of coronary artery disease except in those patients who had shown a normal postoperative contraction pattern.

Severe diastolic dysfunction after endoventriculoplasty

Endoventriculoplasty with pericardial patch has been advocated to repair anteroseptal ventricular aneurysm, but not studies have reported the influence of this technique on diastolic left ventricular function. We have evaluated the changes on ventricular filling by means of pulsed Doppler recording of diastolic transmitral flow. Doppler analysis reveals three distinct spectral patterns: (1) normal, (2) inverted, and (3) restrictive. We have found an abrupt change from a preoperative normal to postoperative restrictive pattern in a significant minority of patients (8%) who underwent endoventriculoplasty. These patients had clinical and hemodynamic signs (New York Heart Association class, time from anterior myocardial infarction, left ventricular end-diastolic pressure, pulmonary hypertension, and mitral regurgitation) of severe impairment but no differences were found in ejection fraction, aneurysmal extension, or remote myocardial function. Moreover, after operation they had a satisfactory ejection fraction, a low end-diastolic volume, and an apex-base length shorter than the predicted value for a normal population. The presence of a postoperative restrictive pattern of diastolic filling is a strong predictor of 3-month mortality and makes the medical treatment difficult. Caution must be taken to perform endoventriculoplasty in patients who are severely ill, especially those recently affected by myocardial infarction. When the clinical conditions dictate the operation, a nonenthusiastic volume reduction seems to be a prudent option.

Mitral Valve Repair: Is There Still a Place for Suture Annuloplasty?

Prosthetic ring annuloplasty is considered the gold standard technique for mitral valve repair, but it has been associated with some drawbacks. Suture annuloplasty is less expensive and may have some physiopathologic advantages. We reviewed the literature to assess clinical results of mitral suture annuloplasty. Thirteen series, each reporting more than 50 patients and published in the last 10 years, were included in the analysis. They comprised 1,648 patients with cumulative follow-up of 5,607 patient-years. Our review suggests that suture annuloplasty is a safe procedure, but a trend toward recurrence of annular dilatation with time was reported. In selected cases, suture annuloplasty is effective, and its mid-term clinical results are encouraging and compare well with those of prosthetic ring repair series. The quality of the results varies according to the particular annuloplasty technique used and to the mitral valve pathology treated. Recent technical modifications have been found to decrease the incidence of repair failure and promise to improve the reproducibility of the procedure. Further investigations are warranted to better assess the long-term results of suture annuloplasty, and to determine whether its theoretical functional advantages translate into a real clinical benefit.

Free Edge Suture Plication and Remodeling: A Technique for Anterior Mitral Leaflet Prolapse Repair

This is a selected series of 28 patients with myxomatous mitral regurgitation that underwent correction of the anterior leaflet prolapse caused by chordal elongation by means of a running suture involving the chordal-cusp junction. Postoperative echocardiograms showed correction of anterior leaflet prolapse and mitral regurgitation in all patients. This technique is effective and easy to perform, and increases the number of options for restoring mitral valvular function.

A new multipurpose aortic root cannula for open-heart surgery

Cold cardioplegic infusion is widely and successfully used today for myocardial protection. Cardioplegic solution is administered using a variety of means and techniques. This paper introduces a newly developed double-lumen cannula that allows the delivery of cardioplegic solution via the aortic root with simultaneous air aspiration, thus preventing coronary artery embolization. The featured double- lumen is useful for the removal of air from the aortic root after the releasing of the aortic cross-clamp. This aortic cannula also features an additional port that provides monitoring of the infusion pressure in the aortic root. This cannula has been used safely, effectively and without complications in 200 cases and we think it is a valid aid in open-heart surgery.

Transposition of Chordae in “Floppy” Mitral Valve Repair

Between January 1985 and July 1987, 31 patients underwent reconstructive surgery for mitral regurgitation secondary to a floppy valve. In 11 patients chordal transposition with posterior annulovalvuloplasty was performed. In all patients a significant anterior leaflet prolapse (ALP) was present. In four patients both leaflets were involved. The ALP was caused by chordal rupture in six patients and chordal elongation in the other five patients. The mitral valve was repaired by quadrangular excision of the mural leaflet, transposition of chordae from the mural cusp to the prolapsed part of the anterior leaflet, and posterior annuloplasty performed by insertion of a polytetrafluoroethylene (PTFE) graft. After operation all patients recovered promptly and uneventfully. Subsequent follow-up revealed good functional and clinical results. All patients are alive, in NYHA class I or II (two patients) and none required reoperation. Echocardiographic studies revealed mild to trivial regurgitation in five patients. The experience suggests that surgical repair of a mitral floppy valve provides good and stable results. A much wider use of this technique seems indicated.

Open Endarterectomy with Vein-Patch Coronary Reconstruction and Internal Mammary Artery Implant

A series of 18 patients are described who underwent open coronary endarterectomy (EA) combined with vein-patch reconstruction and internal mammary artery (IMA) grafting. Patients selected for this operation had disabling angina and severe and diffuse coronary atherosclerosis that prevented revascularization using conventional means. Open EA was performed on the left anterior descending artery (LAD) in 13 patients and on the right coronary artery (RCA) in 5. Additional grafts to other coronary arteries were performed in all cases (average, 2.6 bypass grafts per patient). There was no operative mortality and a perioperative myocardial infarction, not related to a open EA, occurred in one patient. Postoperative graft and coronary angiography performed in 16 patients showed that only one of the grafts to endarterectomized artery was occluded. With a mean follow-up of 8.7 months all patients but one were angina-free. No late deaths occurred. Although long-term clinical results and graft patency are undocumented, early results encourage us to continue use of this technique in patients with a diffusely diseased coronary artery that is inoperable using conventional means.

Left Ventricular Volume Reduction for End‐Stage Heart Disease

Abstract Partial left ventriculectomy (PLV) was recently introduced for end‐stage dilated cardiomyopathy to improve ventricular function. Since November 1996 we have performed PLV in 14 patients; preoperatively 4 patients had idiopathic dilated cardiomyopathy and 10 had ischemic dilated cardiomyopathy. 57.1% of patients were in New York Heart Association functional Class IV. The mitral valve was replaced in 11 patients. Postoperative echocardiography showed a reduction of left end‐diastolic diameter (55.4 ± 5.4 mm) and an increase in forward ejection (cardiac index from 2.19 ± 0.571 min/m2 to 2.67 ± 0.931/min/m2). The 30‐day mortality was 28.6% and 20‐month survival was 57.2%. Only one patient was not in NYHA functional class due to postoperative progressive mitral incompetence. Prognostic factors should be identified to avoid early failure. However, even if the mortality rate for PLV high, this operation is a valid choice for the treatment of end‐stage dilated cardiomyopathy.