Ricardo Gallo

Aortic valve replacement with freehand autologous pericardium

Fifty-one patients with a mean age of 31.2 years underwent aortic valve replacement with glutaraldehyde-treated autologous pericardium. Pure aortic regurgitation was present in 28 (54.9%), stenosis in 9, and mixed disease in 14. Simultaneous mitral valve repair was done in 17 patients and replacement in 1. There were no hospital and two late deaths. Three patients required reoperation because of failure of the pericardial valve as a result of infective endocarditis in two (5 and 31 months after operation) and commissural tear at 8 months in another. One patient underwent reoperation at 24 months because of failure of the mitral valve repair. The pericardial aortic valve, which had 2+ regurgitation since the first operation, was also replaced. Macroscopic and microscopic examination findings in the excised pericardium were excellent. No thromboembolic events have been detected and no patient received anticoagulation therapy except one after mitral valve reoperation and replacement with a mechanical valve. The actuarial survival was 84.53% +/- 12.29% at 60 months, freedom from failure of the aortic reconstruction 83.83% +/- 8.59%, and freedom from any event 72.59% +/- 12.79%. Doppler echocardiographic study at most recent follow-up showed a mean gradient of 12.56 +/- 8.10 mm Hg and mean regurgitation on a scale from 0 to 4+ of 0.80 +/- 0.66. Although the maximum follow-up is only 5 years, the results obtained so far encourage us to continue replacing the aortic valve with stentless autologous pericardium.

From aortic cusp extension to valve replacement with stentless pericardium

Between 1988 and 1994, 82 consecutive patients (median age 24 years) underwent reconstruction of the aortic valve with glutaraldehyde-treated pericardium. Simultaneously, 29 of 30 mitral valves were repaired. The first 27 patients underwent resection of the free edges and suture of a single strip of bovine pericardium. Transient ischemic changes suggested the need for a change in technique. The subsequent 55 patients underwent total valve reconstruction with an autologous pericardium fixed with glutaraldehyde in the appropriate shape and size according to the patients aortic annulus. There were one in-hospital and three late deaths. No patient received anticoagulation, and no embolic events were detected. Nine patients required reoperation as a result of failure of mitral valve repair in 4 and severe aortic regurgitation in 5 (endocarditis [n = 2], commissural tear [n = 1], root dilation [n = 1], calcification of one bovine cusp [n = 1] at 58 months). There were no reoperative deaths. Complete linear echocardiographic follow-up of these patients showed low gradients, valve competence, and no progressive deterioration. No difference between techniques was detected.

Papillary fibroelastoma of mitral valve chorda

Abstract A case of papillary fibroelastoma arising from a mitral valve chorda, presenting with right-sided hemiparesis, that was successfully treated by chordal excision is herein reported.

Pulmonary autograft for aortic valve replacement in rheumatic disease: A caveat

Pulmonary autograft replacement of the aortic valve offers an attractive option in the younger patient with growth potential and long-term survival. In our institution between January 1990 and August 1994, 78 patients have undergone this procedure. The mean age was 18.6 +/- 7.36 years (range, 1 to 41 years). The etiology was rheumatic in 63 patients (80.7%). Aortic regurgitation was the predominant lesion in 60 patients (76.9%). Significant mitral regurgitation requiring operation was present in 22 patients (28.2%). All patients underwent pulmonary autograft replacement of the diseased aortic valve and the mitral valve was repaired in 22 patients. There were no hospital mortality, endocarditis, or thromboembolism in the series up to date. There have been two late non-cardiac deaths. Five patients (6.4%) required reoperation, one for mitral repair failure and four for autograft failure. Acute rheumatic valvulitis was demonstrated in one of the reoperated patients. Echocardiography of 68 patients followed up more than 2 months show progression of aortic regurgitation more than 2/4+ in 12 patients (15.4%). Four of these patients have been reoperated without mortality. In conclusion, although the Ross procedure remains a safe and attractive alternative in aortic valve operation, the progression of aortic regurgitation, especially in the younger patient with rheumatic etiology, remains a concern.

A new expandable intracoronary tantalum (Strecker) stent: early experimental results and follow-up to twelve months.

A new radiopaque balloon expandable tantalum stent was tested in the coronary arteries of sheep. A total of 28 stents with a diameter of 2.0 to 3.8 mm were successfully deployed. The stent to coronary artery diameter ratio was 1.1-1.2:1. The animals were heparinized with 100 U/kg of heparin but did not receive antiplatelet drugs. Coronary angiography that was performed 10 minutes after stent implantation showed 100% patency with no side-branch occlusion. Four sheep died within 2 hours of stent implantation, and pathologic studies showed thrombosis of the smaller sized stents: 2 mm (n = 2), 2.8 mm (n = 1), and 3.2 mm (n = 1); three fourths of the sheep had two stents implanted. An oversized stent caused coronary rupture and cardiac tamponade in one other sheep. Follow-up study protocol included coronary angiography before animal sacrifice and pathologic studies within 48 hours (n = 11), 2 weeks (n = 1), 3 months (n = 2), 5 months (n = 1), 10 months (n = 7), and 12 months (n = 1). At 3 to 12 months of follow-up the coronary stent was completely covered with a layer of neointima, and there was no angiographic evidence of coronary stenosis and patent side branches. According to histologic examination, the neointima had nonuniform thickness (20 to 330 microns) and consisted of smooth muscle cells and some collagen. At 7 months of follow-up one of seven stents had angiographic (20%) and pathologic evidence of stenosis, which was secondary to thrombus. The tantalum device is easily deployed technically and notable for its excellent fluoroscopic visibility and flexibility. Thrombosis with a tantalum stent remains a problem, and therefore the larger diameter stents > or = 3.2 mm, antiplatelet drugs, and anticoagulation therapy are indicated for human studies. Implantation of multiple coronary stents increases the risk of stent thrombosis. The long-term, mild neointimal thickness and the patency of the stent and side branches are encouraging.

Rheumatic involvement of all four heart valves : preoperative echocardiographic diagnosis and successful surgical management

Rheumatic disease of all four heart valves is rare. We report on a patient with quadrivalvar involvement by rheumatic disease, diagnosed preoperatively by echocardiography, who underwent successful surgical correction. The implications of organic involvement of the pulmonary valve by rheumatic process is discussed.

Unstented semilunar homograft replacement of tricuspid valve in Ebstein's malformation

Tricuspid valve pathology in Ebsteins malformation requires replacement when it is not possible to repair or reconstruct this valve. In smaller children, in whom the right-sided atrioventricular valve is severely dysplastic and right ventricular volume is prohibitive, prosthetic replacement is not always possible. We report here on 3 patients who underwent stentless semilunar homograft replacement (top-hat procedure) of tricuspid valve for Ebsteins anomaly with good short-term outcome. This provides an attractive alternative in the management of a certain difficult subset of patients, avoids long term anticoagulation and probably is more durable.

Cor triatriatum with persistent levoatrial cardinal vein late presented as severe mitral stenosis

Cor triatriatum is a rare congenital cardiac anomaly that usually becomes symptomatic in the first years of life. We present a 28-year-old pregnant female patient presented with shortness of breath, palpitations and decreased exercise tolerance. Transthoracic (TTE) and transesophageal (TEE) echocardiography showed cor triatriatum, features of severe mitral stenosis and atrial septal defect (ASD). The patient underwent successful surgical correction with an uneventful postoperative course.

Spontaneous bleeding from liver after open heart surgery

INTRODUCTION Intra-abdominal hemorrhage after open heart surgery is very uncommon in routine clinical practice. There are case reports of having bleeding from spleen or liver after starting low molecular weight heparin (LMWH) postoperatively. PRESENTATION OF CASE Our patient is a 58-year-old man with mitral valve regurgitation, who underwent mitral valve repair and developed intra-abdominal hemorrhage 8h after open heart surgery. The exploratory laparotomy revealed the source of bleeding from ruptured sub-capsular liver hematoma and oozing from raw areas of the liver surface. Liver packing was done to control the bleeding. DISCUSSION The gastrointestinal complications after open heart surgery are rare and spontaneous bleeding from spleen has been reported. This is the first case from our hospital to have intra-abdominal hemorrhage after open heart surgery. CONCLUSION Spontaneous bleeding from liver is a possible complication after open heart surgery. We submit the case for the academic interest and to discuss the possible cause of hemorrhage.

Tratamiento quirúrgico de aneurisma coronario gigante

Varon de 60 anos ingresado con angor reciente. El electrocardiograma revelo cambios isquemicos en el territorio de la arteria coronaria derecha (ACD). La coronariografia demostro visualizacion de la ACD proximal con desaparicion del contraste en una cavidad (Fig. 1 A). Una tomografia computarizada mostro el segmento proximal de la ACD con continuidad en un saco oval, ubicado en la cara anterosuperior de la auricula derecha (Fig. 2 A). No se visualizo la parte distal de la ACD. se realizo reseccion quirurgica del aneurisma e interposicion de un segmento de vena safena para reconstruir la ACD (Figs. 1 B y C).