Simone Turci

Incidence, Etiology, Histologic Findings, and Course of Thoracic Inflammatory Aortopathies

BACKGROUND The aims of this study were to detect the incidence of thoracic histologically proven aortitis in a large series of 788 patients operated on for thoracic aortic disease, to describe the surgical and histologic features of inflammatory thoracic aortopathies, and to evaluate the frequency of postsurgical complications and mortality. METHODS Thirty-nine patients (4.9%) were affected by aortitis (mean age, 72.6 +/- 9.6). There were 24 women (61.5%). Thirty-four (87.2%) were operated on because of aneurysms and 5 because of dissection. In all cases the diagnosis of aortitis was incidental and was made on the basis of histopathologic findings. RESULTS Histologically, there were 30 cases of giant cell aortitis (76.9%), 3 inflammatory aneurysms (7.7%), 2 cases of aspecific lymphoplasmacellular aortitis (5.1%), 1 of Takayasu aortitis, 1 of systemic erythematosus lupus-associated aortitis, and 1 of Behçets disease-associated aortitis. The only case of infectious aortitis was a syphilitic aortitis. In 79.5% of cases, inflammatory infiltrates were moderate to severe in degree; the most widespread inflammation was seen in Takayasu aortitis, systemic erythematosus lupus-associated aortitis, and in Behçets disease. The overall in-hospital mortality was 10.3% (4 of 39 patients). Neurologic complications occurred in 4 patients (10.3%). CONCLUSIONS During surgery of the thoracic aorta, an inflammatory etiology of aneurysms is found in almost 5% of cases. The inflammatory process is in a histologically advanced phase, often with systemic development. Surgery can be associated with high morbidity and mortality.

Aortic Valve Replacement Through Right Minithoracotomy: Is it Really Biologically Minimally Invasive?

BACKGROUND Minimally invasive aortic valve replacement through a right mini-thoracotomy is a procedure developed in the past few years. Currently, the main limits of this technique are longer cardiopulmonary bypass time compared with the standard approach and the need for peripheral cannulation. METHODS From January 2010 to March 2014, 206 patients underwent an aortic valve replacement using a minimally invasive technique through a right mini-thoracotomy. Mean age was 71.4 ± 12.0 years, and 129 (62.6%) were male. In the first series of 42 patients, the vacuum-assisted venous drainage was obtained percutaneously through the groin. A totally central arterial and venous cannulation was adopted in the subsequent 164 patients. Two hundred patients (97.1%) received a bioprosthesis implanted with three 2-0 Prolene running sutures; a mechanical valve was implanted in six patients. One patient required reoperation. RESULTS Aortic valve replacement was performed through a 4-6-cm skin incision at the third intercostal space. Overall cardiopulmonary bypass was 64.8 ± 17.2 min, and aortic cross clamping was 51.8 ± 14.9 min. In-hospital mortality was 1.5% (3/206). CONCLUSIONS Our initial series confirms that aortic valve replacement performed through a right mini-thoracotomy is a safe procedure. When using running sutures, it is possible to obtain cardiopulmonary bypass and cross-clamping times comparable to those for the standard approach. A central cannulation can be performed easily to avoid groin incisions. In conclusion, we believe that this kind of surgery could really be a biologically minimally invasive approach, rather than just an aesthetic choice.

Aortopulmonary Window and Anomalous Coronary Artery: An Exceptional Association

Aortopulmonary window is rarely associated with other cardiac anomalies, such as anomalous origin of one coronary artery. This exceptional association has been reported in 15 patients, with different surgical solutions. We describe 2 patients with aortopulmonary window with anomalous origin of the right coronary artery, one of which presented with tetralogy of Fallot-pulmonary atresia. A neonatal modified Blalock-Taussig shunt and ligature of the distal pulmonary artery at the level of pulmonary bifurcation was performed in the first patient, and the second patient underwent aortopulmonary window division with anomalous coronary artery reimplantation. Both patients had an uneventful postoperative course.

Pulmonary artery banding

Pulmonary artery banding (PAB) is a simple surgical technique to reduce pulmonary overcirculation in some congenital heart disease. In the beginning, when the use of cardiopulmonary bypass was affected by many deleterious effects, this technique played a fundamental role in the treatment of patients with congenital heart defects and an intracardiac left-to-right shunt. The use of PAB has decreased during the last two decades, due to the increasing popularity of early complete intracardiac repair, which results have shown to be superior to staged repair, even in low body weight patients. Moreover, several authors have emphasized the negative effects of PAB such as pulmonary arterial branch distortion, abnormal right ventricular hypertrophy, pulmonary valve insufficiency, sub-aortic obstruction and decreased ventricular compliance in patients with univentricular heart. For all these reasons, this procedure has been placed in the dark corner of surgery, representing, between 2002 and 2005, ∼2% of the total amount of cardiac surgery procedures. In a more recent era, PAB has been performed in instances other than classic univentricular heart, as palliation in small infants with cardiac defects with a left-to-right shunt and pulmonary overcirculation, thus gaining some time prior to a planned staged repair. Recently, the role of PAB is becoming more important in selected subsets of congenital cardiac defects: L-transposition of the great arteries, D-transposition of the great arteries, hypoplastic left heart syndrome, moderately hypoplastic left ventricle (congenitally corrected transposition of the great arteries). This renewed interest in the banding procedure is spurring all surgeons and cardiologists to find new solutions for an easier banding procedure while making debanding less traumatic.

Pulmonary artery debanding

Pulmonary artery banding is a simple palliative surgical procedure for congenital heart defects with left-to-right shunt or complete mixing and pulmonary over-circulation. Even though indication for pulmonary artery banding has been sensibly reduced, since early reparative surgery has been proved superior to palliation and a staged approach, an increasing support for pulmonary banding has been raised in the last two decades by new indications such as left ventricular retraining, in the late arterial switch operation for complete transposition of the great arteries or before the double-switch operation in congenitally corrected transposition. Along with the increasing interest raised by the new indications and the consequently more diffuse use of banding, debanding has become an important surgical issue. Debanding is usually performed several months after palliation along with the repair of the cardiac malformations; otherwise, it can be done progressively or partially to further delay surgery and let the patient grow. Occasionally, after pulmonary artery banding, a spontaneous resolution of the underlying cardiac malformation can occur; however, a debanding procedure is in any case necessary.

Left main coronary artery stenosis secondary to severe pulmonary artery dilation.

A 45-year-old lady with dyspnea and occasional precordial chest pain was diagnosed with a huge sinus venosus atrial septal defect and partial anomalous pulmonary venous return. Preoperative coronary angiography disclosed severe main stem stenosis, considered secondary to compression by the dilated pulmonary trunk. Atrial septal defect closure and pulmonary artery reduction plasty were performed. The left main coronary artery appeared completely patent. The postoperative course was uneventful, and the patient was asymptomatic on follow-up.