Renzo Pessotto

Heparin-coated circuits for high-risk patients: a multicenter, prospective, randomized trial

BACKGROUND Heparin-coated circuits (HCCs) in low-risk cardiac patients who have coronary revascularization have a limited impact on postoperative outcome. In this prospective, randomized investigation, we studied high-risk patients who had cardiac operations with or without HCCs. METHODS A total of 886 patients who had cardiac operations with cardiopulmonary bypass and at least one patient-related or procedure-related risk factor were enrolled in a multicenter study. They were randomly allocated to have cardiopulmonary bypass with Duraflo II HCCs (HCC group, n = 442) or conventional circuits (control group, n = 444). Postoperative outcome was investigated with respect to the occurrence of organ dysfunction. RESULTS HCCs are associated with a shorter intensive care unit and postoperative hospital stay and with a lower rate of patients having a severely impaired clinical outcome (stay in intensive care unit for more than 5 days or death) (relative risk 0.66, p = 0.045). Lung dysfunction rate was significantly lower for the patients in HCC group affected by chronic obstructive pulmonary disease or who had mitral procedure (relative risk, respectively, 0.31, p = 0.018 and 0.05, p = 0.02). Renal dysfunction rate was significantly (p = 0.05) lower for diabetics in the HCC group (relative risk 0.28). CONCLUSIONS When HCCs were used postoperative times decreased and they had a protective effect on lung and kidney function in high-risk patients.

Risk of late reoperations in patients with acute type A aortic dissection : impact of a more radical surgical approach

OBJECTIVE To evaluate the incidence and risk factors for reoperations on the pre-isthmic aorta after repair of type A acute aortic dissection. METHODS From January 1979 to December 1996, 178 patients (125 males and 53 females with a mean age of 57 +/- 9 years) underwent emergency surgery for acute type A aortic dissection with an overall operative mortality rate of 21%. One hundred and forty-one patients (100 males and 41 females, aged 58 +/- 12 years), were discharged after successful replacement of the ascending aorta in 136 cases (96%) with extension to the transverse arch in 22 (16.2%) and associated total root or aortic valve replacement in 31 (22.8%) and 6 (4.4%) cases, respectively. Intimal tear resection and direct primary anastomosis of the aorta were performed in 5 patients (4%). Total follow-up was 690 patient-years, mean 5.1 +/- 4.1 years, with an actuarial survival rate at 5,10 and 15 years of 88%, 73% and 42%, respectively. RESULTS Nineteen patients (13%), 13 males and 6 females, aged 50 +/- 10 years, required a total of 22 reoperations with an actuarial freedom from reoperation at 5, 10 and 15 years of 94%, 64% and 35%, respectively. Initial repair consisted of replacement of the ascending aorta in 16 (84%) cases, with total root replacement in 2 (12%) and isolated aortic valve replacement in 1 (6%). Three patients (16%) were treated by intimal tear resection and direct primary anastomosis of the aorta. Mean interval between initial repair and reoperation was 5.2 +/- 3.1 years and indication to re-do surgery were severe aortic regurgitation in 2 (11%), aneurysmal evolution of the false lumen in 4 (21%) or both in 13 (68%). Extensive aortic reconstruction comprising simultaneous graft replacement of the aortic root, ascending aorta and aortic arch was necessary in 13 cases (68%), isolated replacement of the ascending aorta in 3 (16%), aortic valve in 2 (11%) and aortic arch in 1 (5%). There were 1 hospital (5%) and 2 late (11%) deaths at a mean follow-up of 2.5 +/- 2.4 years, with an actuarial survival at 5 years of 88%. Retrospective analysis of our total experience revealed that the introduction of the open distal anastomosis technique since 1990, reduced the incidence of reoperation from 11/46 (24%) to 8/95 (8.4%) (P < 0.05). However, also with this strategy 8/73 (11%) patients surviving replacement limited to the ascending aorta required reoperation versus none of the 22 patients surviving repair extended to the aortic arch. Three out of 5 (60%) patients undergoing intimal tear resection and primary anastomosis of the aorta early in our experience, required reoperation. CONCLUSIONS Management of patients with acute type A aortic dissection may include one or more surgical procedures after the initial emergency repair. Reoperations carry a low operative risk with good long-term survival and their incidence is reduced by routine open distal anastomosis and aggressive replacement of the aortic arch. Intimal tear resection and primary anastomosis of the aorta appear to be associated with increased risk of reoperation.

Preservation of the aortic valve in acute type A dissection complicated by aortic regurgitation

BACKGROUND The aim of the present study was to verify the efficacy of preserving the aortic valve in patients with acute type A aortic dissection complicated by significant aortic regurgitation. METHODS From January 1979 to December 1996, 178 patients (125 males; mean age 57 +/- 9 years) underwent emergency surgery for acute type A aortic dissection, with an overall operative mortality rate of 21%. Based on a retrospective analysis of the preoperative angio- or echocardiographic findings, the 141 survivors were divided into 2 groups: Group 1 (G1) included 80 patients (57%) with no or mild aortic regurgitation, and Group 2 (G2) the remaining 61 patients with moderate-to-severe aortic regurgitation. The native aortic valve was preserved by means of a uniform technique consisting of reconstruction of the aortic root and sinotubular junction in 99 patients (70%) [68 in G1 (85%) and 31 in G2 (51%)]. Forty-two patients required aortic valve (8 patients; 6%) or total root replacement (34 patients; 24%). RESULTS At a mean follow-up of 4 +/- 3.6 years (range, 6 months to 19 years), 19 of the 99 patients with a preserved aortic valve developed moderate-to-severe aortic insufficiency [19%; 7/68 in G1 (10%) and 12/31 in G2 (39%)]. Multivariate analysis revealed that moderate-to-severe preoperative aortic valve insufficiency was a significant risk factor for development of postoperative aortic valve regurgitation (p = 0.008). Reoperation was necessary in 7 G1 patients (10%) and in 8 G2 patients (26%), with an actuarial freedom from reoperation at 5 and 10 years of 93% +/- 7% and 80% +/- 9% in G1 patients, and 81% +/- 8% and 40% +/- 15% in G2 patients (p = 0.045). CONCLUSIONS Preservation of the aortic valve and aortic root is recommended in patients with acute type A aortic dissection and absent or mild aortic insufficiency. Patients presenting with moderate-to-severe aortic regurgitation and treated conservatively present an increased risk of recurrent valvular insufficiency.

Hancock versus stentless bioprostheses for aortic valve replacement in patients older than 75 years

BACKGROUND Stented aortic bioprostheses are routinely used in elderly patients. The stent, however, is obstructive and implies several hazards. Stentless aortic valves appear to be hemodynamically advantageous. However, their implantation is longer and technically more demanding, and durability is still under investigation. METHODS Between January 1993 and December 1996, 77 patients (28 men) were prospectively randomized to undergo aortic valve replacement using the Hancock valves (group A: 40 patients, 16 men; age, 77+/-3 years; body surface area, 1.7+/-0.17 m2) or a stentless bioprostheses (group B: 37 patients, 12 men; age, 76+/-2 years; body surface area, 1.7+/-0.15 m2; Biocor, 17; Toronto SPV, 20). Preoperative variables were not significantly different between the two groups. Bypass time was 123+/-46 versus 133+/-51 minutes, and aortic cross-clamp time was 83+/-26 versus 95+/-24 minutes for group A and group B, respectively (not significant). Seven patients in group A (17.5%) and 5 in group B (13.5%) had enlargement of the aortic annulus. Valve size normalized to body surface area was 13.7+/-1.5 versus 14.1+/-1.6 mm/m2 for group A and group B, respectively (not significant). Eleven patients in group A (27.5%) and 5 in group B (13.5%) had concomitant myocardial revascularization. RESULTS Overall perioperative mortality was 5% in group A (low cardiac output in 2 patients), and 8% in group B (low cardiac output in 1; major neurologic event in 2). Follow-up is 97% complete (group A, 14.5+/-10 months; group B, 18.5+/-12 months). One patient in group B died at 28 months of myocardial infarction. Actuarial survival at 12 and 24 months is 92% versus 91% and 92% versus 81% for group A and group B, respectively. At 6 months, patients in group A showed a peak transaortic gradient of 25+/-7 versus 20+/-9 mm Hg in group B. Progressive regression of left ventricular mass expressed as a percentage of preoperative value was 10.5% and 19% for group A and group B at 1 year postoperatively (not significant). CONCLUSIONS Stentless valves represent a valuable alternative to conventional prostheses in patients older than 75 years, although no great advantages with their use emerge from this study. Continued evaluation particularly with regard to evidence of left ventricular remodeling and valve degeneration in the long term is warranted.

Primary cardiac leiomyosarcoma: seven-year survival with combined surgical and adjuvant therapy

Primary cardiac sarcomas constitute a rare entity that have been uniformly associated with poor long-term survival. A case of left atrial leiomyosarcoma involving the interatrial septum and the right atrial free wall and presenting with syncope and atrial fibrillation, is described. Two extensive surgical excisions followed by adjuvant radiation and chemotherapy improved survival with a good quality of life. This approach of combined surgical, medical and radiation therapy may offer better longterm outcome, since our patient is the longest survivor thus far reported.

Over twenty-year follow-up of the standard Hancock porcine bioprosthesis implanted in the mitral position

BACKGROUND To define the long-term results of 331 standard Hancock porcine bioprostheses implanted in the mitral position between 1973 and 1980. METHODS Of 331 patients (225 male patients, 68%), mean age 49+/-10 years (range 14 to 69 years), 88% were in New York Heart Association functional class III or IV and 77% were in atrial fibrillation. Follow-up time extended more than 20 years (mean 13.9 years, range 0.3 to 24.7 years) for a total of 4,601 patient-years. RESULTS Overall operative mortality was 6.3%. At 5, 10, 15, and 20 years, the actuarial survival rate of patients were 71%+/-2%, 46%+/-3%, 30%+/-3%, and 22%+/-2%, respectively. Actuarial estimates of freedom from structural valve deterioration were 95%+/-1%, 67%+/-3%, 32%+/-3%, and 14%+/-3%; from reoperation were 96%+/-1%, 72%+/-3%, 36%+/-4%, and 18%+/-4%; from thromboembolism were 89%+/-2%, 82%+/-3%, 74%+/-4%, and 51%+/-2%; and from anticoagulant-related hemorrhage were 98%+/-1%, 96%+/-1%, 91%+/-1%, and 86%+/-4%. Estimates of freedom from all valve-related mortality at 5, 10, 15, and 20 years were 89%+/-2%, 76%+/-3%, 64%+/-4%, and 48%+/-4%. Multivariate analysis showed younger age to be a significant risk factor for reoperation. Age at operation did not correlate with structural valve deterioration. CONCLUSIONS The long-term results with the standard Hancock bioprosthesis implanted in the mitral position appear satisfactory, particularly up to 15 years from implantation. Protection from stroke, anticoagulant hemorrhage, and endocarditis was good.

Hypoplastic left heart syndrome with restrictive atrial septal defect and congenital pulmonary lymphangiectasis.

The presence of a restrictive atrial septal defect in hypoplastic left heart syndrome represents a surgical emergency and may negatively affect survival after operation. A neonate with such a disease association, requiring septectomy upon birth developed intractable respiratory failure due to congenital pulmonary lymphangiectasis. The therapeutic implications of this rare pathologic condition are discussed.

Single aortic cross-clamp technique in coronary surgery: a prospective randomized study

OBJECTIVE To test the hypothesis of an improved myocardial and cerebral protection by combining blood cardioplegia and the single aortic cross-clamp technique, 100 patients were enrolled in a prospectively randomized study and stratified for preoperative conditions. METHODS In Group I, 55 patients underwent myocardial revascularization using crystalloid cardioplegia and the conventional partial occluding clamp technique to perform proximal anastomoses, whereas in Group II, 45 patients were operated on combining blood cardioplegia and the single aortic cross-clamp technique. Unstable angina, emergency procedures, reoperations and preoperative counterpulsation accounted for an higher risk score in group II patients (P < 0.03). Operations were performed by the same surgical team. Aortic cross-clamp time was significantly longer in group II patients (59 +/- 22 vs. 47 +/- 18 min.) (P < 0.001). Other intraoperative variables were not significant. RESULTS A 70-year-old male in group I died on post-operative day 5 as a consequence of a major neurological event. Length of ventilatory dependency, post-operative bleeding, need for blood transfusions, ICU stay, and hospital stay were similar between the two groups (P = NS). Patients in group I showed a strict correlation between the duration of surgical ischemia and post-operative myocardial necrosis. Analysis of combined mortality and morbidity events (adverse events) between the two groups, led to a significant prevalence in group I patients (P < 0.03) in spite of an higher pre-operative risk score and longer ischemic times in group II patients. Neurological lesions remained confined to group I patients. CONCLUSIONS The combined use of blood cardioplegia, delivered via the antegrade and retrograde routes, and the single-clamp technique to perform myocardial revascularization, might enhance myocardial and cerebral protection when compared to conventional methods. Larger groups of patients are needed to support this trend.

Surgical treatment of an aortopulmonary artery fistula complicating a syphilitic aortic aneurysm

Spontaneous rupture of an aortic aneurysm into the pulmonary artery is unusual and is rarely reported in the literature. The case of a patient with a syphilitic aneurysm of the ascending aorta perforated into the pulmonary artery is presented. In an attempt to define the best surgical treatment for this complication the literature has been comprehensively reviewed.

Accelerated aortic allograft fibrocalcification after right ventricular outflow tract reconstruction in pediatric patients : report of two cases

Two cases are presented of accelerated aortic allograft fibrocalcification after right ventricular outflow tract (RVOT) reconstruction occurring within 2 months after surgery in a 5-year-old and 22-month-old. Potential determinants of early calcification, clinical management after implantation and surgical alternatives are discussed.