Background
Mitral valve repair (MVR) is well established and shows significant advantage over ... more Background Mitral valve repair (MVR) is well established and shows significant advantage over valve replacement for acute and chronic valve endocarditis. For the pregnant women is even more important to avoid the anticoagulant therapy with their teratogenic effects. Another choice before mechanical or biological mitral valve replacement,could be the homograft mitral valve. Material and method. We presented a 33 years old, pregnant female, which developed on the plenty of health an acute native mitral valve endocarditis due to Streptococcus aureus, with massive vegetation and mitral annular destruction. She underwent for an emergently operation performing a mitral valve repair with pericardial patch and annular reinforcement using a 30 mm annulus ring. Result. The mitral valve repair competence was tested with saline injection on left ventricle showing only a slight trace of mitral insufficiency which have been confirmed by intraoperative transesophagian echocardiography. Staphylococcus aureus founded on blood culture was also confirmed from the vegetation sample examination. Postoperative evolution was good with extubation on the first day and continuing of the parenteral antibiotic therapy for the next 6 weeks The foetus remained alive. Conclusion. Mitral valve repair should the golden standard whenever is possible in active infective endocarditis of the mitral valve. Moreover, on the young women which are pregnant or wish to get pregnant when cannot take oral anticoagulants because of their teratogenic effects.
Background. The autograft operation introduced in 1967 by D. Ross, as a scalloped subcoronary im... more Background. The autograft operation introduced in 1967 by D. Ross, as a scalloped subcoronary implantat, a better alternative for aortic valve replacement in young patients, have been recently modified to a complete aortic root technique. We introduced this operation two years ago and the aim of our study is to assess operative technique, early complication, patient-related factors of survival, autograft and homograft function over time. Material and method. From May 2000 through September 2002, 25 consecutive patients (means age, 26 years; range 3 to 49 years) underwent replacement their pathologic aortic valve by a pulmonary autograft, receiving a cryopreserved homograft in pulmonary position, using complete aortic root replacement technique exclusively and Bioglue® application. Transesophagian echocardiography was the method used for all the patients, preoperatively, intraoperative and serial after operation (at discharge, 3, 6, 12 and 24 months) with the purpose of measuring aortic and pulmonary annulus, evaluating transvalvular gradient and both valve function, evolution of muscular mass regression and studying the LV function. Results. There was no deaths early or late after operation, no bleeding or another major complications. The patients remained in mean 24 hours in intensive care unit and were discharged after mean six days. Early postoperative TEE, shown no regurgitation or minimal incompetence of autograft in some cases. The result remained stable after 6 months with recovery of LV function approximately 10% and the muscular mass reduction has been decreased. Conclusion. The Ross operation is a very appealing choose in young patients avoiding mechanical valve with their burdens and gives excellent early and mid-term results, no mortality (or low) and no morbidity. However, we are looking for the autograft and homograft function over time, in special dilatation of autograft and homograft stenosis
Abstract.
Background. The best surgical procedures in case of ascending aortic aneurysm and disse... more Abstract. Background. The best surgical procedures in case of ascending aortic aneurysm and dissection associate with aortic valve incompetence, but normal morphologic leaflets are still debate. Aortic root replacement using a conduit mechanical or biological, Bentall-DeBono operation, has proved her fesability. However, for the young patient to avoid anticoagulation therapy we try to reconstruct the aortic valve inside of graft-tube, the operation proposed some years ago by T. David and M. Yacoub. The main concern in this reconstruction remain the long term durability. In order to improve the results, a new sinus Valsalva prosthesis have been developed for more anatomical aortic root reconstruction and better leaflets protection. Our study is coming to give some technical consideration in this regard after an initial surgical experience. Material and method. Between 1986 to September 2002, 77 patients were operated for aortic aneurysm and/or dissection on Cardiac Surgery Department of Innsbruck. A total of 67 Bental and from 1998, 10 patients underwent T. David all using a normal Dacron tube but one new sinus Valsalva Prosthesis. 30 patients (44.8%) underwent emergency procedures. Results. Overall hospital mortality was 9/67 patients in Bentall group (13.4%). From this 28/67 patients had an acute aortic dissection type A, and the hospital mortality in this group was 6/28 (21.4%). No mortality in aortic root reconstruction group (10 patients) but one cerebral stroke, (patient had also before operation). He recovered after. Also we had good aortic valve competence at discharge and later one. Overall survival including hospital deaths was 85% at one year, 78% at 3 years, 75% at 5 years, and 71% at 7 years. Survival excluding hospital deaths was 96% at one year, 90% at 3 years, 90% at 5 years, and 85% at 7 years. Conclusion. The Bental operation elective or emergently give a mortality under 15% and good long-term results. The sparing-valve procedures are also a valid surgical option for the patients with ascending aorta and/or the aortic root aneurysms and dissection associate with aortic insufficiency, when the aortic valve leaflets anatomy are normal. Using the new sinus valsalva Vascutek prosthesis, seems to give better recreation of aortic root anatomy and consequently function and long term results. However, more clinical study are requiring until to prove superiority over simple tube-graft reconstruction or still aortic root replacement.
Median sternotomy in case of the redo operation and in specific situation of ascending aortic an... more Median sternotomy in case of the redo operation and in specific situation of ascending aortic aneurysm in close relation with sternum is very risky manoeuvre and should be done for safety under deep hypothermic circulatory arrest. To avoid a catastrophic bleeding the installation of the cardiopulmonary bypass (CPB) can be approach through axillary artery cannulation in conjunction with femoral vena cannulation for deep cooling (18°) and circulatory arrest of the patient before the opening of sternum. We describe a patient 24 years old male with congenital aortic stenosis and two subsequent operations, aortic valve plastic repair and later a mechanical aortic valve, which developed in time a huge (9 cm) ascending aortic aneurysm and chronic aortic dissection type A.
Introducere. Anevrismele radacinii aortei si disectiile acute cu implicarea radacinii aortei se i... more Introducere. Anevrismele radacinii aortei si disectiile acute cu implicarea radacinii aortei se insotesc, in majoritatea cazurilor, de insuficienta aortica. In unele din aceste situatii cuspele valvei aortice au un aspect normal. Conduita clasica in astfel de situatii, operatia Bentall-DeBono, are dezavantajul necesitatii unui tratament anticoagulant cronic. Pentru a evita aceasta situatie, mai ales la pacientii tineri, folosim cu succes in departamentul nostru tehnica Tirone-David sau tehnica M. Yacoub de reparare a valvei aortice. Aceste tehnici insa, pe termen lung ridica probleme de durabilitate, datorita stresului continu impus cuspelor aortice de absenta sinusurilor Valsalva. Pentru a corecta acest dezavantaj, o noua proteza aortica tip sinus Valsalva a fost introdusa de firma “Sulzer Vascutek”, proteza “Gelweave Valsalva”. Prezentam in continuare, rezultatele clinicii noastre cu acest nou tip de proteza. Material and metoda. In perioada 1986 - 2002, 77 pacienti au fost operati in Departamentul de Chirurgie Cardiaca din Innsbruck, pentru anevrism aortic sau disectie acuta de aorta toracica. Dintre acestia, 67 pacienti au beneficiat de interventia Bentall-DeBono, 10 au beneficiat de operatia Tirone David, dintre care 9 cu un tub simplu, iar unul cu noul tip de proteza sinus Valsalva. Rezultate. Mortalitatea generala in grupul Bentall (grupul A) a fost de 9/67 pacienti (13.4 %). Dintre acestia, 28/67 au avut o disectia acuta tip A, iar mortalitatea intraspitaliceasca in acest grup a fost de 6/28 (21.4 %). Grupul B de pacienti, care au beneficiat de conservarea valvei aortice, 10 pacienti, nu a avut mortalitate intraspitaliceasca, iar complicatiile postoperatorii au fost absente, cu exceptia unui soc cerebral remis ulterior. Competenta valvei aortice a fost buna, atit la externare cit si la controalele ulterioare. Supravietuirea generala a fost de 85% la un an, 78% la 3 ani, 75% la 5 ani si 71% la 7 ani. Excluzind mortalitatea intraspitaliceasca, supravietuirea a fost, respectiv, de 96% la un an, 90% la 3 ani si 85% la 7 ani. Concluzii. Operatia Bentall-De Bono, efectuata electiv sau de urgenta, are o mortalitate sub 15 % si rezultate bunepe termen lung. Procedeele de conservare a valvei aortice sant insa o optiune in cazurile de anevrism al radacinii aortei sau de disectie acuta ce implica radacina aortei. Folosirea noului tip de proteza pare sa duca la reconstructie anatomica mai fiziologica a radacinii aortei si deci, la rezultate superioare pe termen lung.
Abstract.
Background: Cerebral complication during coronary artery bypass surgery (CABG), still... more Abstract. Background: Cerebral complication during coronary artery bypass surgery (CABG), still occurs in spite of cardiopulmonary bypass (CPB) technology advances. Our study sought to assess the role of epiaortic ultrasound (EAS) and intraoperative transesophagial ecocardiography (TEE) in detection of patients with atherosclerosis of the thoracic aorta and high risk for cerebral embolisation. Consequently our surgical strategies modification for a better cerebral preotection. Methods: Our lot study comprise 352 patients undergoing EAS and TEE, during CABG. EAS was performed before opening of the pericardium using a 7,5 MHz ultrasonic probe packed in a sterile bag. In the presence of moderate aortic atherosclerosis (maximum aortic wall thickness of 3mm ) primarily single aortic cross-clamping and choose of aortic cannulation place was carried out. In cases of severe aortic atheroma (maximum aortic wall thickness > 5 mm or mobile plaque), aortic no touch technique, off-pump were used .From 34 patients with severe ascending aortic atherosclerosis 22 of these patients ( 18 male, 4 female, age 72(57-79), Parsonet Score 11(0-8), Euroscore 8(2-13), McSPI Stroke Risk Index 6 (1-30%) were managed on “no touch technique”, Off-pump. All patients received at least one leaft internal mammary artery (LIMA) in situ graft and aditional extraanatomical bypass conduits: venous Y-graft from IMA (n=14), arterial Y-graft from LIMA (n=3), vein graft from axillary artery (n=3), vein graft from the RIMA stump (n=3).. Median operative time was 240 (115-435) min. Results- We found a mild aortic atherosclerosis in 151 patients (43%), moderate in 167 (47%) and severe in 34 patients (8,8%).. Operative mortality was 2/22 in a group with high risk index, from another cause than cerebral stroke. No cerebral stroke occurred. The rate of perioperative myocardial infarction(CKMB>50U/l) was 5/22. Median stay in ICU, 54 hours (15-1245 hours). After a median follow up period of 8 months one death occurred from cerebral stroke and no myocardial infarction. Conclusion. Accurate detection of atheroma on ascending aorta and aortic arch by a combination between EAS and TEE and in special surgical technique modification using off-pump revascularization and extraanatomical bypass for the management of a heavily calcified aorta can result in a very low stroke rate despite a considerable stroke risk. The hospital mortality and morbidity can be lower than predicted by Euroscore and Parsonet Score.
Tromboza venoasa profunda (TVP), este una dintre cele mai comune si mai devastatoare tulburari al... more Tromboza venoasa profunda (TVP), este una dintre cele mai comune si mai devastatoare tulburari ale sistemului circulator. Reprezinta o complicatie in 20% din procedurile chirurgicale majore, iar ca o consecinta embolismul pulmonar este responsabil de mii de decese anual. Datorita riscului mare al mortalitatii, profilaxia TVP, a castigat un rol important. Evolutia TVP illio-femurale, chiar tratata cu doze adecvate de anticoagulant este nefavorabila, cu implicatii socio-economice semnificative. In ultimii ani s-au facut mari progrese in abordarea pacientilor cu TVP extensiva a extremitatilor inferioare, ca de exemplu tromboliza directa cu cateter percutan. Revascularizarea segmentului venos ilio-cav este una dintre cele mai provocatoare si dificile operatii vasculare. Prezentam cazul unui pacient tanar, B.J, 30 de ani, care in urma unui accident de masina si al unei leziuni spinale minime a fost tratat prin imobilizare la pat 10 zile, dezvoltand ulterior TVP ilio- femurala stanga. Dupa doi ani, in urma simptomatologiei, a examinarii Doppler si flebografice s-a pus diagnosticul de sindrom posttrombotic, ocluzie venoasa ilio-femurala cronica. Chirurgical s-a efectuat operatia Palma modificata, bypass femuro-iliac controlateral folosind o xenogrefa bovina, artera carotida. Rezultatul a fost bun, cu ameliorare clinica si patenta graftului, la un an verificata Doppler.
Purpose:
The information obtained by intraoperative graft angiography in off pump coronary arter... more Purpose: The information obtained by intraoperative graft angiography in off pump coronary artery bypass grafting remains a matter of debate despite the fact that anastomotic revision rates in the range of 10% after intraoperative grafting Intraoperative angiography are reported in the literature. We present our initial experience with intraoperative angiographic evaluation of grafts performed on the beating heart. Methods: 29 coronary artery bypass grafts were investigated in 23 patients (20 male, 3 female), age 61 (44-74). Transfemoral angiography was performed before (n=8) or after sternotomy closure (n=15) using an OEC 9800 mobile C-arm. Examination times were 25 (8-80) min and fluoroscopy times were 469 (6-1337) sec. 150 (50-470) ml of contrast agent were needed to visualize the grafts. Results: No technical complications specific for angiography occurred. Except for 3 aortocoronary vein grafts all bypass vessels could be visualized. Spasm of the graft and/or target vessel was present in 11/29 grafts, which responded well to intraluminal nitroglycerine in 9 of these. 2 grafts were severely stenosed requiring surgical revision. In addition 2 proximal target vessel occlusions were noted, which were left because of lacking intraoperative ischemic signs. There was no hospital mortality and no perioperative myocardial ischemic event. Conclusion: This experience suggests that despite being a time consuming examination technique intraoperative angiography can reveal valuable information that may demand surgical consequences.
Background.The purpose of our study was a retrospective analysis of the patients undergoing assis... more Background.The purpose of our study was a retrospective analysis of the patients undergoing assist devices in the cardiac transplantation program The outcome, complications, system related problems and initial experience with Berlin Heart Assist Device for children support were assessed.
Material and Methods The lot of study comprise 31 patients on assist device between January 1994 and June 2002, from 164 cardiac transplantation procedures at Cardiac Surgery Department Innsbruck. Group A, “Bridge to Transplantation” 21 patients, group B “Bridge to recovery or transplantation”, 5 patients, group C “ Cardiac arrested after resuscitation. Systems used; ECMO(Biomedicus), LVAD(Thoratec) and BVAD (Thoratec, Berlin Heart).
Results. In group A, “Bridge to Transplantation” which included 21 patients, age 10 to 65, 3 died and 18 were transplanted; group B “Bridge to recovery or transplantation”, of the 5 patients, 3 recovered and explanted, 2 died; group C,”Resuscitation after cardiac arrest”, all 5 patients died after 5 to 82 days. Mean time on assist device; 34,2+/-43,7 days (median 16 days, range 1-169). Complications under assist device; bleeding 2 (13,3%), hematoma 1(6,6%), pericardial effusion 1(6,6%), neurologic disorders 2 (13,3%).
Conclusion.The experience with long term cardiac support, “Bridge to transplantation or bridge to recovery, brigde to bridge, is very encouraging in adult, and now, the “Berlin Heart” assist device has proved to be a highly reliable ventricular support for children as well as adults.
Abstract
Acute–fulminant myocarditis is a disease with unclear pathophysiology and etiology, dif... more Abstract
Acute–fulminant myocarditis is a disease with unclear pathophysiology and etiology, difficult diagnosis anf very large spectrum of clinical presentation. Very rare is presentation with hemodynamic instability or franc acute cardiogenic shock. Such patients if the diagnosis is not giant cell myocarditis, have an excellent prognosis for complete long term recovery if they are supported aggressively. An aggressive approach to the use of mechanical support is strongly recommended. Survival,either by bridge to transplantation or recovery, should approach 70%. Transplantation should and can offten be avoided. We present a young, 24 years female, with acute-fulminant myocarditis with chlamidia pneumoniae and Parvovirus B19, acute cardiogenic shock, which was first supported by ECMO for 48 hours and then Thoratec bi-ventricular assist device, to support her hemodynamic. After two weeks, she recovered with normal cardiac function and was weaned from mechanical circulatory support. This case report, show that full cardiac recovery is possible and even likely despite fulminant and catastophic presentation, avoiding a cardiac transplantation whit his implication.
Background. Acute complications of PTCA, requering emergency surgical intervention are between ... more Background. Acute complications of PTCA, requering emergency surgical intervention are between 3-7%.Thrombotic or dissection occlusion of a coronary vessels during PTCA, is a well accepted indication for acute CABG. However, heart transplantation after failure of PTCA and CABG, is very rare and burden by cardiac allograft vasculopathy. After eight yeas of free evolution we should proceeded to retransplantation. Material and method.. A 45 years old male was retransplanted eight years later for the allograft diffuse coronaropathy (Nov 19.2002). His history started in 1994, with angina pectoris and positive exercice test, was referred to angiography. He had high lipid level and smoking. Angiography shown, LAD, tandem stenosis 90% and 60% and the patient PTCA was performed Nov.23, 1994, 8,15 am. After insertion of Atherocath, dissection of Left Main occurred and the patient became unresponsive with respiratory arrest and ventricular fibrillation(VF). Cardioplulmonary resuscitation (CRS) started immediately, but the patient remained in VF. Extracorporeal membrane oxygenation (ECMO), 31 minute from beginning of the dissection was instituted. Operative teather (126 min later under CPB), and CABG x 2 venae bypass performed for LAD and Cx. Weaning from CPB was not possible and ECMO restarted. In intensive care unit, bleeding, unstable. Emergency listing for cardiac transplantation (7 pm). At 11,25 pm Eurotransplant offerted an organ. Some hours later, at 6,51 am, orthotopic cardiac transplantation was succesfully performed. Results. The patient was extubated on the first postoperative day. Heart specimen examination shown massive LV myocardial infarction with hemorrhage and LAD dissection and thrombosis. However, in spite of eight years of free evolution, the burdens of immunosupresion resulted in coronary angiopathy, with relisting the patient for cardiac retransplantation and successful performed on Nov.19, 2002. Conclusion. PTCA can fail in a disastrous dissection and occlusion of the left main, menacing the life of the patient. Surgical standby with all the technical arsenal, CABG, ECMO, assist device and cardiac transplantation program should be considered for such high risk lesions. Emergency cardiac transplantation seems to be a realistic option. However, long term outcome will be burden by the immunosuppression complication and retransplantation should re reconsidered with another mortality rate and long results.
Abstract.
Tumorile cardiace primare, sunt entitati rare si reprezinta doar 5-10% din toate neopla... more Abstract. Tumorile cardiace primare, sunt entitati rare si reprezinta doar 5-10% din toate neoplasmele . Aproximativ 80% sunt tumori benigne, iar din acestea mai mult de jumatate sunt reprezentante de mixoamele cardiace. Diagnosticul de mixom cardiac este foarte rar pus pe baza datelor clinice si in majoritatea cazurilor mimeaza alte boli cardiovasculare, infectioase sau de colagen. Suspiciunea clinica este esentiala pentru diagnosticul de mixom, dealtfel simplu prin ecocardiografie. Prezentam cazul unei paciente H.I de 47 ani a care-i simptomatologie cu dureri toracice nespecifice, lichid pleural, dispnee, tahicardie, scadere in greutate a orientat investigatiile initiale (Rx toracic, Bronhoscopie, CTscan) spre un neoplasm pulmonar si a intarziat diagnosticul si interventia chirurgicala a unui mixon de atriu stang de 4/6 cm. Tratamentul chirurgical de excizie este simplu si prognosticul acestor pacienti operati la timp (inaintea unor complicatii ce pot fi fatale, embolie, moarte subita ), excelent. In concluzie cazul prezentat, aduce un argument in plus la paleta larga de simptome si semne pe care o pot prezenta mixoamele cardiace.
PURPOSE: The best methods for cerebral and visceral protection during complex repairs of aortic ... more PURPOSE: The best methods for cerebral and visceral protection during complex repairs of aortic arch in case of dissection and aneurysms is still not clear. The purpose of our study was to evaluate and compare the advantages and complications of axillary, providing antegrade flow and femoral artery cannulation, providing retrograde perfusion, in specific cases of acute dissection. METHODS. We started, in January 2000, to use the axillary artery cannulation, in our practice, achieving full cardiopulmonary bypass. Between January 1991 and September 2001, we operated 67 patients for acute aortic dissection type A. All the patients had acute aortic dissection operated in emergency using deep hypothermia and circulatory arrest. Axillary cannulation was used in 14 (21%) patients, by femoral artery 52 (77%), and ascending aorta 1 (2%). The parameters which we followed were; age, gender, cardiac tamponad, preoprative insult, hypertension, Marfan syndrome. During operation we checked CPB time, total circulatory arrest time, aortic clamp time, duration of operation, perfusion parameters. Postoperative the most important variables were; hospital mortality, ICU stay, postoperative bleeding and revision, low cardiac syndrome output, MSOF, sepsis, renal failure and neurological insults. RESULTS: Hospital mortality 8/52 (15%) in femoral cannulation group and 1/14 (7,7%) . Also we didn’t have postoperative new neurologic insult, postoperative bleeding and revision and more reduce incidence of sepsis, low output syndrome, in axillary artery cannulation group comparing with, 7,5% new neurologic events, 23% MSOF, 17% sepsis, 28% bleeding, 26 % postoperative renal failure,in femoral patients. CONCLUSION. Our first results conclude that axillary cannulation is a reproductible method, providing antegrade perfusion and better cerebral and visceral protection during aortic dissection repair.
Se realizo angioplastia directa del infarto agudo de miocardio en 168 pacientes consecutivos, con... more Se realizo angioplastia directa del infarto agudo de miocardio en 168 pacientes consecutivos, con edad media de 60,2 anos. 82,7% eran varones y 17,3% mujeres. El tiempo desde el comienzo de los sfntomas fue de 3,67 hs. Las localizaciones de las lesiones fueron: descendente anterior 78 (46,4%), coronaria derecha 55 (32,7%), circu .nfleja 32 (19%) y puentes venosos 3 (1,9%) . Presentaban lesion de multiples vasos 55 pacientes (32,7%) . Se realizo angioplastia convencional en 135 casos (80,4%), con balon de perfusion en 20 (11,8%), Rotablator en 6 (3,6%) y stent en 2 (1,2%) . Se use balon de contrapulsacion, por presentar shock, en 19 pacientes (11,3%) . Hubo exito en el 94% de los casos, resultado parcial en el 2% y fracaso en el 4% . El seguimiento medio fue de 15 meses (3-42 meses) . En el 39,6% se realizo angiografia a los 3-6 meses y el 60,4% se controlo clfnicamente. Fallecieron 6 pacientes (3,6%), todos con shock cardiogenico. Hubo 3 fibrilaciones ventriculares (1,8%), diseccion no oclusiva en 6 (3,5%) y oclusion aguda en 5 (3%). De los 162 sobrevivientes (96,4%), 38 presentaron reisquemia (23,5%), siendo redilatados 23 (14,2%) y operados 15 (9,2%). Hubo 8 casos (4,9%) de reinfarto y 4 fallecimientos (2,5%) en el seguimiento . Conclusiones En la serie analizada, la angioplastia directa del infarto tuvo una elevada tasa de reperfusion (94%), con mortalidad aceptable en los casos con shock cardiogenico (31,6%), necesidad de revascularizacion en el seguimiento del 23,5%, :mortalidad alejada del 2,5% y 4,9% de reinfarto . Rev Arg Cardiol 1995; 63 (1) : 37-45.
Abstract
Spontaneous aortic rupture, without any history of previous thoracic trauma, infection o... more Abstract Spontaneous aortic rupture, without any history of previous thoracic trauma, infection or acute thoracic pain is an extremely rare and potentially life-threatening event. Its diagnosis, in the absence of acute symptoms, is usually delayed and relies on secondary signs. While the etiology is atherosclerotic in most cases, the exact mechanisms of rupture have only recently been uncovered. Treatment may be surgical, endovascular or by a combined procedure, according to the anatomy, location and expertise of the medical team. 2007 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.
ABSTRACT
Background: The Bentall operation is considered the standard in the surgical treatment f... more ABSTRACT Background: The Bentall operation is considered the standard in the surgical treatment for aortic root aneurysm, with low mortality and very good long results. Technical modifications have been added to the original description, regarding the coronary arteries reimplantation. Our purpose was to determine the mortality, morbidity and long time events after composite graft replacement of the aortic root and to evaluate the risk factors associated with this procedure. Material and Method: Between 1986 and 2002, at the University Cardiac Surgery Innsbruck, 67 patients underwent aortic root and/or the aortic arch replacement. From 67 patients, 57 were males and 30 patients (44.8%) underwent emergency procedures. Twenty eight patients (41.8%) presented with acute aortic dissection type A, 2 patients had chronic aortic dissection, 28 patients (41.8%) had an ascending aortic aneurysm combined with aortic regurgitation, and 7 (10.5%) had an extension of the aneurysm into the aortic arch. All operations were performed using the coronary-button-method. Deep hypothermic circulatory arrest (DHCA) was necessary in 36 patients (53.7%). Results: Overall hospital mortality was 9/67 patients (13.4%). The factors associated with early mortality: aortic dissection, CPB time, aortic cross clamp time, DHCA, postoperative low cardiac output syndrome, postoperative renal failure requiring hemofiltration, multiorgan failure. Survival excluding hospital deaths was96%at 1 year,90%at 3 years, 90% at 5 years and 85% at 7 years. Conclusion: Aortic root and ascending aorta replacement using a mechanically valved composite graft is an operation with low hospital mortality especially in elective, nondissecting cases. The long-term survival rates are good and the majority of patients are event-free after the operation
Background
Mitral valve repair (MVR) is well established and shows significant advantage over ... more Background Mitral valve repair (MVR) is well established and shows significant advantage over valve replacement for acute and chronic valve endocarditis. For the pregnant women is even more important to avoid the anticoagulant therapy with their teratogenic effects. Another choice before mechanical or biological mitral valve replacement,could be the homograft mitral valve. Material and method. We presented a 33 years old, pregnant female, which developed on the plenty of health an acute native mitral valve endocarditis due to Streptococcus aureus, with massive vegetation and mitral annular destruction. She underwent for an emergently operation performing a mitral valve repair with pericardial patch and annular reinforcement using a 30 mm annulus ring. Result. The mitral valve repair competence was tested with saline injection on left ventricle showing only a slight trace of mitral insufficiency which have been confirmed by intraoperative transesophagian echocardiography. Staphylococcus aureus founded on blood culture was also confirmed from the vegetation sample examination. Postoperative evolution was good with extubation on the first day and continuing of the parenteral antibiotic therapy for the next 6 weeks The foetus remained alive. Conclusion. Mitral valve repair should the golden standard whenever is possible in active infective endocarditis of the mitral valve. Moreover, on the young women which are pregnant or wish to get pregnant when cannot take oral anticoagulants because of their teratogenic effects.
Background. The autograft operation introduced in 1967 by D. Ross, as a scalloped subcoronary im... more Background. The autograft operation introduced in 1967 by D. Ross, as a scalloped subcoronary implantat, a better alternative for aortic valve replacement in young patients, have been recently modified to a complete aortic root technique. We introduced this operation two years ago and the aim of our study is to assess operative technique, early complication, patient-related factors of survival, autograft and homograft function over time. Material and method. From May 2000 through September 2002, 25 consecutive patients (means age, 26 years; range 3 to 49 years) underwent replacement their pathologic aortic valve by a pulmonary autograft, receiving a cryopreserved homograft in pulmonary position, using complete aortic root replacement technique exclusively and Bioglue® application. Transesophagian echocardiography was the method used for all the patients, preoperatively, intraoperative and serial after operation (at discharge, 3, 6, 12 and 24 months) with the purpose of measuring aortic and pulmonary annulus, evaluating transvalvular gradient and both valve function, evolution of muscular mass regression and studying the LV function. Results. There was no deaths early or late after operation, no bleeding or another major complications. The patients remained in mean 24 hours in intensive care unit and were discharged after mean six days. Early postoperative TEE, shown no regurgitation or minimal incompetence of autograft in some cases. The result remained stable after 6 months with recovery of LV function approximately 10% and the muscular mass reduction has been decreased. Conclusion. The Ross operation is a very appealing choose in young patients avoiding mechanical valve with their burdens and gives excellent early and mid-term results, no mortality (or low) and no morbidity. However, we are looking for the autograft and homograft function over time, in special dilatation of autograft and homograft stenosis
Abstract.
Background. The best surgical procedures in case of ascending aortic aneurysm and disse... more Abstract. Background. The best surgical procedures in case of ascending aortic aneurysm and dissection associate with aortic valve incompetence, but normal morphologic leaflets are still debate. Aortic root replacement using a conduit mechanical or biological, Bentall-DeBono operation, has proved her fesability. However, for the young patient to avoid anticoagulation therapy we try to reconstruct the aortic valve inside of graft-tube, the operation proposed some years ago by T. David and M. Yacoub. The main concern in this reconstruction remain the long term durability. In order to improve the results, a new sinus Valsalva prosthesis have been developed for more anatomical aortic root reconstruction and better leaflets protection. Our study is coming to give some technical consideration in this regard after an initial surgical experience. Material and method. Between 1986 to September 2002, 77 patients were operated for aortic aneurysm and/or dissection on Cardiac Surgery Department of Innsbruck. A total of 67 Bental and from 1998, 10 patients underwent T. David all using a normal Dacron tube but one new sinus Valsalva Prosthesis. 30 patients (44.8%) underwent emergency procedures. Results. Overall hospital mortality was 9/67 patients in Bentall group (13.4%). From this 28/67 patients had an acute aortic dissection type A, and the hospital mortality in this group was 6/28 (21.4%). No mortality in aortic root reconstruction group (10 patients) but one cerebral stroke, (patient had also before operation). He recovered after. Also we had good aortic valve competence at discharge and later one. Overall survival including hospital deaths was 85% at one year, 78% at 3 years, 75% at 5 years, and 71% at 7 years. Survival excluding hospital deaths was 96% at one year, 90% at 3 years, 90% at 5 years, and 85% at 7 years. Conclusion. The Bental operation elective or emergently give a mortality under 15% and good long-term results. The sparing-valve procedures are also a valid surgical option for the patients with ascending aorta and/or the aortic root aneurysms and dissection associate with aortic insufficiency, when the aortic valve leaflets anatomy are normal. Using the new sinus valsalva Vascutek prosthesis, seems to give better recreation of aortic root anatomy and consequently function and long term results. However, more clinical study are requiring until to prove superiority over simple tube-graft reconstruction or still aortic root replacement.
Median sternotomy in case of the redo operation and in specific situation of ascending aortic an... more Median sternotomy in case of the redo operation and in specific situation of ascending aortic aneurysm in close relation with sternum is very risky manoeuvre and should be done for safety under deep hypothermic circulatory arrest. To avoid a catastrophic bleeding the installation of the cardiopulmonary bypass (CPB) can be approach through axillary artery cannulation in conjunction with femoral vena cannulation for deep cooling (18°) and circulatory arrest of the patient before the opening of sternum. We describe a patient 24 years old male with congenital aortic stenosis and two subsequent operations, aortic valve plastic repair and later a mechanical aortic valve, which developed in time a huge (9 cm) ascending aortic aneurysm and chronic aortic dissection type A.
Introducere. Anevrismele radacinii aortei si disectiile acute cu implicarea radacinii aortei se i... more Introducere. Anevrismele radacinii aortei si disectiile acute cu implicarea radacinii aortei se insotesc, in majoritatea cazurilor, de insuficienta aortica. In unele din aceste situatii cuspele valvei aortice au un aspect normal. Conduita clasica in astfel de situatii, operatia Bentall-DeBono, are dezavantajul necesitatii unui tratament anticoagulant cronic. Pentru a evita aceasta situatie, mai ales la pacientii tineri, folosim cu succes in departamentul nostru tehnica Tirone-David sau tehnica M. Yacoub de reparare a valvei aortice. Aceste tehnici insa, pe termen lung ridica probleme de durabilitate, datorita stresului continu impus cuspelor aortice de absenta sinusurilor Valsalva. Pentru a corecta acest dezavantaj, o noua proteza aortica tip sinus Valsalva a fost introdusa de firma “Sulzer Vascutek”, proteza “Gelweave Valsalva”. Prezentam in continuare, rezultatele clinicii noastre cu acest nou tip de proteza. Material and metoda. In perioada 1986 - 2002, 77 pacienti au fost operati in Departamentul de Chirurgie Cardiaca din Innsbruck, pentru anevrism aortic sau disectie acuta de aorta toracica. Dintre acestia, 67 pacienti au beneficiat de interventia Bentall-DeBono, 10 au beneficiat de operatia Tirone David, dintre care 9 cu un tub simplu, iar unul cu noul tip de proteza sinus Valsalva. Rezultate. Mortalitatea generala in grupul Bentall (grupul A) a fost de 9/67 pacienti (13.4 %). Dintre acestia, 28/67 au avut o disectia acuta tip A, iar mortalitatea intraspitaliceasca in acest grup a fost de 6/28 (21.4 %). Grupul B de pacienti, care au beneficiat de conservarea valvei aortice, 10 pacienti, nu a avut mortalitate intraspitaliceasca, iar complicatiile postoperatorii au fost absente, cu exceptia unui soc cerebral remis ulterior. Competenta valvei aortice a fost buna, atit la externare cit si la controalele ulterioare. Supravietuirea generala a fost de 85% la un an, 78% la 3 ani, 75% la 5 ani si 71% la 7 ani. Excluzind mortalitatea intraspitaliceasca, supravietuirea a fost, respectiv, de 96% la un an, 90% la 3 ani si 85% la 7 ani. Concluzii. Operatia Bentall-De Bono, efectuata electiv sau de urgenta, are o mortalitate sub 15 % si rezultate bunepe termen lung. Procedeele de conservare a valvei aortice sant insa o optiune in cazurile de anevrism al radacinii aortei sau de disectie acuta ce implica radacina aortei. Folosirea noului tip de proteza pare sa duca la reconstructie anatomica mai fiziologica a radacinii aortei si deci, la rezultate superioare pe termen lung.
Abstract.
Background: Cerebral complication during coronary artery bypass surgery (CABG), still... more Abstract. Background: Cerebral complication during coronary artery bypass surgery (CABG), still occurs in spite of cardiopulmonary bypass (CPB) technology advances. Our study sought to assess the role of epiaortic ultrasound (EAS) and intraoperative transesophagial ecocardiography (TEE) in detection of patients with atherosclerosis of the thoracic aorta and high risk for cerebral embolisation. Consequently our surgical strategies modification for a better cerebral preotection. Methods: Our lot study comprise 352 patients undergoing EAS and TEE, during CABG. EAS was performed before opening of the pericardium using a 7,5 MHz ultrasonic probe packed in a sterile bag. In the presence of moderate aortic atherosclerosis (maximum aortic wall thickness of 3mm ) primarily single aortic cross-clamping and choose of aortic cannulation place was carried out. In cases of severe aortic atheroma (maximum aortic wall thickness > 5 mm or mobile plaque), aortic no touch technique, off-pump were used .From 34 patients with severe ascending aortic atherosclerosis 22 of these patients ( 18 male, 4 female, age 72(57-79), Parsonet Score 11(0-8), Euroscore 8(2-13), McSPI Stroke Risk Index 6 (1-30%) were managed on “no touch technique”, Off-pump. All patients received at least one leaft internal mammary artery (LIMA) in situ graft and aditional extraanatomical bypass conduits: venous Y-graft from IMA (n=14), arterial Y-graft from LIMA (n=3), vein graft from axillary artery (n=3), vein graft from the RIMA stump (n=3).. Median operative time was 240 (115-435) min. Results- We found a mild aortic atherosclerosis in 151 patients (43%), moderate in 167 (47%) and severe in 34 patients (8,8%).. Operative mortality was 2/22 in a group with high risk index, from another cause than cerebral stroke. No cerebral stroke occurred. The rate of perioperative myocardial infarction(CKMB>50U/l) was 5/22. Median stay in ICU, 54 hours (15-1245 hours). After a median follow up period of 8 months one death occurred from cerebral stroke and no myocardial infarction. Conclusion. Accurate detection of atheroma on ascending aorta and aortic arch by a combination between EAS and TEE and in special surgical technique modification using off-pump revascularization and extraanatomical bypass for the management of a heavily calcified aorta can result in a very low stroke rate despite a considerable stroke risk. The hospital mortality and morbidity can be lower than predicted by Euroscore and Parsonet Score.
Tromboza venoasa profunda (TVP), este una dintre cele mai comune si mai devastatoare tulburari al... more Tromboza venoasa profunda (TVP), este una dintre cele mai comune si mai devastatoare tulburari ale sistemului circulator. Reprezinta o complicatie in 20% din procedurile chirurgicale majore, iar ca o consecinta embolismul pulmonar este responsabil de mii de decese anual. Datorita riscului mare al mortalitatii, profilaxia TVP, a castigat un rol important. Evolutia TVP illio-femurale, chiar tratata cu doze adecvate de anticoagulant este nefavorabila, cu implicatii socio-economice semnificative. In ultimii ani s-au facut mari progrese in abordarea pacientilor cu TVP extensiva a extremitatilor inferioare, ca de exemplu tromboliza directa cu cateter percutan. Revascularizarea segmentului venos ilio-cav este una dintre cele mai provocatoare si dificile operatii vasculare. Prezentam cazul unui pacient tanar, B.J, 30 de ani, care in urma unui accident de masina si al unei leziuni spinale minime a fost tratat prin imobilizare la pat 10 zile, dezvoltand ulterior TVP ilio- femurala stanga. Dupa doi ani, in urma simptomatologiei, a examinarii Doppler si flebografice s-a pus diagnosticul de sindrom posttrombotic, ocluzie venoasa ilio-femurala cronica. Chirurgical s-a efectuat operatia Palma modificata, bypass femuro-iliac controlateral folosind o xenogrefa bovina, artera carotida. Rezultatul a fost bun, cu ameliorare clinica si patenta graftului, la un an verificata Doppler.
Purpose:
The information obtained by intraoperative graft angiography in off pump coronary arter... more Purpose: The information obtained by intraoperative graft angiography in off pump coronary artery bypass grafting remains a matter of debate despite the fact that anastomotic revision rates in the range of 10% after intraoperative grafting Intraoperative angiography are reported in the literature. We present our initial experience with intraoperative angiographic evaluation of grafts performed on the beating heart. Methods: 29 coronary artery bypass grafts were investigated in 23 patients (20 male, 3 female), age 61 (44-74). Transfemoral angiography was performed before (n=8) or after sternotomy closure (n=15) using an OEC 9800 mobile C-arm. Examination times were 25 (8-80) min and fluoroscopy times were 469 (6-1337) sec. 150 (50-470) ml of contrast agent were needed to visualize the grafts. Results: No technical complications specific for angiography occurred. Except for 3 aortocoronary vein grafts all bypass vessels could be visualized. Spasm of the graft and/or target vessel was present in 11/29 grafts, which responded well to intraluminal nitroglycerine in 9 of these. 2 grafts were severely stenosed requiring surgical revision. In addition 2 proximal target vessel occlusions were noted, which were left because of lacking intraoperative ischemic signs. There was no hospital mortality and no perioperative myocardial ischemic event. Conclusion: This experience suggests that despite being a time consuming examination technique intraoperative angiography can reveal valuable information that may demand surgical consequences.
Background.The purpose of our study was a retrospective analysis of the patients undergoing assis... more Background.The purpose of our study was a retrospective analysis of the patients undergoing assist devices in the cardiac transplantation program The outcome, complications, system related problems and initial experience with Berlin Heart Assist Device for children support were assessed.
Material and Methods The lot of study comprise 31 patients on assist device between January 1994 and June 2002, from 164 cardiac transplantation procedures at Cardiac Surgery Department Innsbruck. Group A, “Bridge to Transplantation” 21 patients, group B “Bridge to recovery or transplantation”, 5 patients, group C “ Cardiac arrested after resuscitation. Systems used; ECMO(Biomedicus), LVAD(Thoratec) and BVAD (Thoratec, Berlin Heart).
Results. In group A, “Bridge to Transplantation” which included 21 patients, age 10 to 65, 3 died and 18 were transplanted; group B “Bridge to recovery or transplantation”, of the 5 patients, 3 recovered and explanted, 2 died; group C,”Resuscitation after cardiac arrest”, all 5 patients died after 5 to 82 days. Mean time on assist device; 34,2+/-43,7 days (median 16 days, range 1-169). Complications under assist device; bleeding 2 (13,3%), hematoma 1(6,6%), pericardial effusion 1(6,6%), neurologic disorders 2 (13,3%).
Conclusion.The experience with long term cardiac support, “Bridge to transplantation or bridge to recovery, brigde to bridge, is very encouraging in adult, and now, the “Berlin Heart” assist device has proved to be a highly reliable ventricular support for children as well as adults.
Abstract
Acute–fulminant myocarditis is a disease with unclear pathophysiology and etiology, dif... more Abstract
Acute–fulminant myocarditis is a disease with unclear pathophysiology and etiology, difficult diagnosis anf very large spectrum of clinical presentation. Very rare is presentation with hemodynamic instability or franc acute cardiogenic shock. Such patients if the diagnosis is not giant cell myocarditis, have an excellent prognosis for complete long term recovery if they are supported aggressively. An aggressive approach to the use of mechanical support is strongly recommended. Survival,either by bridge to transplantation or recovery, should approach 70%. Transplantation should and can offten be avoided. We present a young, 24 years female, with acute-fulminant myocarditis with chlamidia pneumoniae and Parvovirus B19, acute cardiogenic shock, which was first supported by ECMO for 48 hours and then Thoratec bi-ventricular assist device, to support her hemodynamic. After two weeks, she recovered with normal cardiac function and was weaned from mechanical circulatory support. This case report, show that full cardiac recovery is possible and even likely despite fulminant and catastophic presentation, avoiding a cardiac transplantation whit his implication.
Background. Acute complications of PTCA, requering emergency surgical intervention are between ... more Background. Acute complications of PTCA, requering emergency surgical intervention are between 3-7%.Thrombotic or dissection occlusion of a coronary vessels during PTCA, is a well accepted indication for acute CABG. However, heart transplantation after failure of PTCA and CABG, is very rare and burden by cardiac allograft vasculopathy. After eight yeas of free evolution we should proceeded to retransplantation. Material and method.. A 45 years old male was retransplanted eight years later for the allograft diffuse coronaropathy (Nov 19.2002). His history started in 1994, with angina pectoris and positive exercice test, was referred to angiography. He had high lipid level and smoking. Angiography shown, LAD, tandem stenosis 90% and 60% and the patient PTCA was performed Nov.23, 1994, 8,15 am. After insertion of Atherocath, dissection of Left Main occurred and the patient became unresponsive with respiratory arrest and ventricular fibrillation(VF). Cardioplulmonary resuscitation (CRS) started immediately, but the patient remained in VF. Extracorporeal membrane oxygenation (ECMO), 31 minute from beginning of the dissection was instituted. Operative teather (126 min later under CPB), and CABG x 2 venae bypass performed for LAD and Cx. Weaning from CPB was not possible and ECMO restarted. In intensive care unit, bleeding, unstable. Emergency listing for cardiac transplantation (7 pm). At 11,25 pm Eurotransplant offerted an organ. Some hours later, at 6,51 am, orthotopic cardiac transplantation was succesfully performed. Results. The patient was extubated on the first postoperative day. Heart specimen examination shown massive LV myocardial infarction with hemorrhage and LAD dissection and thrombosis. However, in spite of eight years of free evolution, the burdens of immunosupresion resulted in coronary angiopathy, with relisting the patient for cardiac retransplantation and successful performed on Nov.19, 2002. Conclusion. PTCA can fail in a disastrous dissection and occlusion of the left main, menacing the life of the patient. Surgical standby with all the technical arsenal, CABG, ECMO, assist device and cardiac transplantation program should be considered for such high risk lesions. Emergency cardiac transplantation seems to be a realistic option. However, long term outcome will be burden by the immunosuppression complication and retransplantation should re reconsidered with another mortality rate and long results.
Abstract.
Tumorile cardiace primare, sunt entitati rare si reprezinta doar 5-10% din toate neopla... more Abstract. Tumorile cardiace primare, sunt entitati rare si reprezinta doar 5-10% din toate neoplasmele . Aproximativ 80% sunt tumori benigne, iar din acestea mai mult de jumatate sunt reprezentante de mixoamele cardiace. Diagnosticul de mixom cardiac este foarte rar pus pe baza datelor clinice si in majoritatea cazurilor mimeaza alte boli cardiovasculare, infectioase sau de colagen. Suspiciunea clinica este esentiala pentru diagnosticul de mixom, dealtfel simplu prin ecocardiografie. Prezentam cazul unei paciente H.I de 47 ani a care-i simptomatologie cu dureri toracice nespecifice, lichid pleural, dispnee, tahicardie, scadere in greutate a orientat investigatiile initiale (Rx toracic, Bronhoscopie, CTscan) spre un neoplasm pulmonar si a intarziat diagnosticul si interventia chirurgicala a unui mixon de atriu stang de 4/6 cm. Tratamentul chirurgical de excizie este simplu si prognosticul acestor pacienti operati la timp (inaintea unor complicatii ce pot fi fatale, embolie, moarte subita ), excelent. In concluzie cazul prezentat, aduce un argument in plus la paleta larga de simptome si semne pe care o pot prezenta mixoamele cardiace.
PURPOSE: The best methods for cerebral and visceral protection during complex repairs of aortic ... more PURPOSE: The best methods for cerebral and visceral protection during complex repairs of aortic arch in case of dissection and aneurysms is still not clear. The purpose of our study was to evaluate and compare the advantages and complications of axillary, providing antegrade flow and femoral artery cannulation, providing retrograde perfusion, in specific cases of acute dissection. METHODS. We started, in January 2000, to use the axillary artery cannulation, in our practice, achieving full cardiopulmonary bypass. Between January 1991 and September 2001, we operated 67 patients for acute aortic dissection type A. All the patients had acute aortic dissection operated in emergency using deep hypothermia and circulatory arrest. Axillary cannulation was used in 14 (21%) patients, by femoral artery 52 (77%), and ascending aorta 1 (2%). The parameters which we followed were; age, gender, cardiac tamponad, preoprative insult, hypertension, Marfan syndrome. During operation we checked CPB time, total circulatory arrest time, aortic clamp time, duration of operation, perfusion parameters. Postoperative the most important variables were; hospital mortality, ICU stay, postoperative bleeding and revision, low cardiac syndrome output, MSOF, sepsis, renal failure and neurological insults. RESULTS: Hospital mortality 8/52 (15%) in femoral cannulation group and 1/14 (7,7%) . Also we didn’t have postoperative new neurologic insult, postoperative bleeding and revision and more reduce incidence of sepsis, low output syndrome, in axillary artery cannulation group comparing with, 7,5% new neurologic events, 23% MSOF, 17% sepsis, 28% bleeding, 26 % postoperative renal failure,in femoral patients. CONCLUSION. Our first results conclude that axillary cannulation is a reproductible method, providing antegrade perfusion and better cerebral and visceral protection during aortic dissection repair.
Se realizo angioplastia directa del infarto agudo de miocardio en 168 pacientes consecutivos, con... more Se realizo angioplastia directa del infarto agudo de miocardio en 168 pacientes consecutivos, con edad media de 60,2 anos. 82,7% eran varones y 17,3% mujeres. El tiempo desde el comienzo de los sfntomas fue de 3,67 hs. Las localizaciones de las lesiones fueron: descendente anterior 78 (46,4%), coronaria derecha 55 (32,7%), circu .nfleja 32 (19%) y puentes venosos 3 (1,9%) . Presentaban lesion de multiples vasos 55 pacientes (32,7%) . Se realizo angioplastia convencional en 135 casos (80,4%), con balon de perfusion en 20 (11,8%), Rotablator en 6 (3,6%) y stent en 2 (1,2%) . Se use balon de contrapulsacion, por presentar shock, en 19 pacientes (11,3%) . Hubo exito en el 94% de los casos, resultado parcial en el 2% y fracaso en el 4% . El seguimiento medio fue de 15 meses (3-42 meses) . En el 39,6% se realizo angiografia a los 3-6 meses y el 60,4% se controlo clfnicamente. Fallecieron 6 pacientes (3,6%), todos con shock cardiogenico. Hubo 3 fibrilaciones ventriculares (1,8%), diseccion no oclusiva en 6 (3,5%) y oclusion aguda en 5 (3%). De los 162 sobrevivientes (96,4%), 38 presentaron reisquemia (23,5%), siendo redilatados 23 (14,2%) y operados 15 (9,2%). Hubo 8 casos (4,9%) de reinfarto y 4 fallecimientos (2,5%) en el seguimiento . Conclusiones En la serie analizada, la angioplastia directa del infarto tuvo una elevada tasa de reperfusion (94%), con mortalidad aceptable en los casos con shock cardiogenico (31,6%), necesidad de revascularizacion en el seguimiento del 23,5%, :mortalidad alejada del 2,5% y 4,9% de reinfarto . Rev Arg Cardiol 1995; 63 (1) : 37-45.
Abstract
Spontaneous aortic rupture, without any history of previous thoracic trauma, infection o... more Abstract Spontaneous aortic rupture, without any history of previous thoracic trauma, infection or acute thoracic pain is an extremely rare and potentially life-threatening event. Its diagnosis, in the absence of acute symptoms, is usually delayed and relies on secondary signs. While the etiology is atherosclerotic in most cases, the exact mechanisms of rupture have only recently been uncovered. Treatment may be surgical, endovascular or by a combined procedure, according to the anatomy, location and expertise of the medical team. 2007 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.
ABSTRACT
Background: The Bentall operation is considered the standard in the surgical treatment f... more ABSTRACT Background: The Bentall operation is considered the standard in the surgical treatment for aortic root aneurysm, with low mortality and very good long results. Technical modifications have been added to the original description, regarding the coronary arteries reimplantation. Our purpose was to determine the mortality, morbidity and long time events after composite graft replacement of the aortic root and to evaluate the risk factors associated with this procedure. Material and Method: Between 1986 and 2002, at the University Cardiac Surgery Innsbruck, 67 patients underwent aortic root and/or the aortic arch replacement. From 67 patients, 57 were males and 30 patients (44.8%) underwent emergency procedures. Twenty eight patients (41.8%) presented with acute aortic dissection type A, 2 patients had chronic aortic dissection, 28 patients (41.8%) had an ascending aortic aneurysm combined with aortic regurgitation, and 7 (10.5%) had an extension of the aneurysm into the aortic arch. All operations were performed using the coronary-button-method. Deep hypothermic circulatory arrest (DHCA) was necessary in 36 patients (53.7%). Results: Overall hospital mortality was 9/67 patients (13.4%). The factors associated with early mortality: aortic dissection, CPB time, aortic cross clamp time, DHCA, postoperative low cardiac output syndrome, postoperative renal failure requiring hemofiltration, multiorgan failure. Survival excluding hospital deaths was96%at 1 year,90%at 3 years, 90% at 5 years and 85% at 7 years. Conclusion: Aortic root and ascending aorta replacement using a mechanically valved composite graft is an operation with low hospital mortality especially in elective, nondissecting cases. The long-term survival rates are good and the majority of patients are event-free after the operation
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Papers by Marian Gaspar
Mitral valve repair (MVR) is well established and shows significant advantage over valve replacement for acute and chronic valve endocarditis. For the pregnant women is even more important to avoid the anticoagulant therapy with their teratogenic effects. Another choice before mechanical or biological mitral valve replacement,could be the homograft mitral valve.
Material and method. We presented a 33 years old, pregnant female, which developed on the plenty of health an acute native mitral valve endocarditis due to Streptococcus aureus, with massive vegetation and mitral annular destruction. She underwent for an emergently operation performing a mitral valve repair with pericardial patch and annular reinforcement using a 30 mm annulus ring.
Result. The mitral valve repair competence was tested with saline injection on left ventricle showing only a slight trace of mitral insufficiency which have been confirmed by intraoperative transesophagian echocardiography. Staphylococcus aureus founded on blood culture was also confirmed from the vegetation sample examination. Postoperative evolution was good with extubation on the first day and continuing of the parenteral antibiotic therapy for the next 6 weeks The foetus remained alive.
Conclusion. Mitral valve repair should the golden standard whenever is possible in active infective endocarditis of the mitral valve. Moreover, on the young women which are pregnant or wish to get pregnant when cannot take oral anticoagulants because of their teratogenic effects.
Material and method. From May 2000 through September 2002, 25 consecutive patients (means age, 26 years; range 3 to 49 years) underwent replacement their pathologic aortic valve by a pulmonary autograft, receiving a cryopreserved homograft in pulmonary position, using complete aortic root replacement technique exclusively and Bioglue® application.
Transesophagian echocardiography was the method used for all the patients, preoperatively, intraoperative and serial after operation (at discharge, 3, 6, 12 and 24 months) with the purpose of measuring aortic and pulmonary annulus, evaluating transvalvular gradient and both valve function, evolution of muscular mass regression and studying the LV function.
Results. There was no deaths early or late after operation, no bleeding or another major complications. The patients remained in mean 24 hours in intensive care unit and were discharged after mean six days. Early postoperative TEE, shown no regurgitation or minimal incompetence of autograft in some cases. The result remained stable after 6 months with recovery of LV function approximately 10% and the muscular mass reduction has been decreased.
Conclusion. The Ross operation is a very appealing choose in young patients avoiding mechanical valve with their burdens and gives excellent early and mid-term results, no mortality (or low) and no morbidity. However, we are looking for the autograft and homograft function over time, in special dilatation of autograft and homograft stenosis
Background. The best surgical procedures in case of ascending aortic aneurysm and dissection associate with aortic valve incompetence, but normal morphologic leaflets are still debate. Aortic root replacement using a conduit mechanical or biological, Bentall-DeBono operation, has proved her fesability. However, for the young patient to avoid anticoagulation therapy we try to reconstruct the aortic valve inside of graft-tube, the operation proposed some years ago by T. David and M. Yacoub. The main concern in this reconstruction remain the long term durability. In order to improve the results, a new sinus Valsalva prosthesis have been developed for more anatomical aortic root reconstruction and better leaflets protection. Our study is coming to give some technical consideration in this regard after an initial surgical experience.
Material and method. Between 1986 to September 2002, 77 patients were operated for aortic aneurysm and/or dissection on Cardiac Surgery Department of Innsbruck. A total of 67 Bental and from 1998, 10 patients underwent T. David all using a normal Dacron tube but one new sinus Valsalva Prosthesis. 30 patients (44.8%) underwent emergency procedures.
Results. Overall hospital mortality was 9/67 patients in Bentall group (13.4%). From this 28/67 patients had an acute aortic dissection type A, and the hospital mortality in this group was 6/28 (21.4%). No mortality in aortic root reconstruction group (10 patients) but one cerebral stroke, (patient had also before operation). He recovered after. Also we had good aortic valve competence at discharge and later one. Overall survival including hospital deaths was 85% at one year, 78% at 3 years, 75% at 5 years, and 71% at 7 years. Survival excluding hospital deaths was 96% at one year, 90% at 3 years, 90% at 5 years, and 85% at 7 years.
Conclusion. The Bental operation elective or emergently give a mortality under 15% and good long-term results. The sparing-valve procedures are also a valid surgical option for the patients with ascending aorta and/or the aortic root aneurysms and dissection associate with aortic insufficiency, when the aortic valve leaflets anatomy are normal. Using the new sinus valsalva Vascutek prosthesis, seems to give better recreation of aortic root anatomy and consequently function and long term results. However, more clinical study are requiring until to prove superiority over simple tube-graft reconstruction or still aortic root replacement.
To avoid a catastrophic bleeding the installation of the cardiopulmonary bypass (CPB) can be approach through axillary artery cannulation in conjunction with femoral vena cannulation for deep cooling (18°) and circulatory arrest of the patient before the opening of sternum. We describe a patient 24 years old male with congenital aortic stenosis and two subsequent operations, aortic valve plastic repair and later a mechanical aortic valve, which developed in time a huge (9 cm) ascending aortic aneurysm and chronic aortic dissection type A.
Material and metoda. In perioada 1986 - 2002, 77 pacienti au fost operati in Departamentul de Chirurgie Cardiaca din Innsbruck, pentru anevrism aortic sau disectie acuta de aorta toracica. Dintre acestia, 67 pacienti au beneficiat de interventia Bentall-DeBono, 10 au beneficiat de operatia Tirone David, dintre care 9 cu un tub simplu, iar unul cu noul tip de proteza sinus Valsalva.
Rezultate. Mortalitatea generala in grupul Bentall (grupul A) a fost de 9/67 pacienti (13.4 %). Dintre acestia, 28/67 au avut o disectia acuta tip A, iar mortalitatea intraspitaliceasca in acest grup a fost de 6/28 (21.4 %). Grupul B de pacienti, care au beneficiat de conservarea valvei aortice, 10 pacienti, nu a avut mortalitate intraspitaliceasca, iar complicatiile postoperatorii au fost absente, cu exceptia unui soc cerebral remis ulterior. Competenta valvei aortice a fost buna, atit la externare cit si la controalele ulterioare. Supravietuirea generala a fost de 85% la un an, 78% la 3 ani, 75% la 5 ani si 71% la 7 ani. Excluzind mortalitatea intraspitaliceasca, supravietuirea a fost, respectiv, de 96% la un an, 90% la 3 ani si 85% la 7 ani.
Concluzii. Operatia Bentall-De Bono, efectuata electiv sau de urgenta, are o mortalitate sub 15 % si rezultate bunepe termen lung. Procedeele de conservare a valvei aortice sant insa o optiune in cazurile de anevrism al radacinii aortei sau de disectie acuta ce implica radacina aortei. Folosirea noului tip de proteza pare sa duca la reconstructie anatomica mai fiziologica a radacinii aortei si deci, la rezultate superioare pe termen lung.
Background: Cerebral complication during coronary artery bypass surgery (CABG), still occurs in spite of cardiopulmonary bypass (CPB) technology advances. Our study sought to assess the role of epiaortic ultrasound (EAS) and intraoperative transesophagial ecocardiography (TEE) in detection of patients with atherosclerosis of the thoracic aorta and high risk for cerebral embolisation. Consequently our surgical strategies modification for a better cerebral preotection.
Methods: Our lot study comprise 352 patients undergoing EAS and TEE, during CABG.
EAS was performed before opening of the pericardium using a 7,5 MHz ultrasonic probe packed in a sterile bag. In the presence of moderate aortic atherosclerosis (maximum aortic wall thickness of 3mm ) primarily single aortic cross-clamping and choose of aortic cannulation place was carried out. In cases of severe aortic atheroma (maximum aortic wall thickness > 5 mm or mobile plaque), aortic no touch technique, off-pump were used .From 34 patients with severe ascending aortic atherosclerosis 22 of these patients ( 18 male, 4 female, age 72(57-79), Parsonet Score 11(0-8), Euroscore 8(2-13), McSPI Stroke Risk Index 6 (1-30%) were managed on “no touch technique”, Off-pump. All patients received at least one leaft internal mammary artery (LIMA) in situ graft and aditional extraanatomical bypass conduits: venous Y-graft from IMA (n=14), arterial Y-graft from LIMA (n=3), vein graft from axillary artery (n=3), vein graft from the RIMA stump (n=3).. Median operative time was 240 (115-435) min.
Results- We found a mild aortic atherosclerosis in 151 patients (43%), moderate in 167 (47%) and severe in 34 patients (8,8%).. Operative mortality was 2/22 in a group with high risk index, from another cause than cerebral stroke. No cerebral stroke occurred. The rate of perioperative myocardial infarction(CKMB>50U/l) was 5/22. Median stay in ICU, 54 hours
(15-1245 hours). After a median follow up period of 8 months one death occurred from cerebral stroke and no myocardial infarction.
Conclusion. Accurate detection of atheroma on ascending aorta and aortic arch by a combination between EAS and TEE and in special surgical technique modification using off-pump revascularization and extraanatomical bypass for the management of a heavily calcified aorta can result in a very low stroke rate despite a considerable stroke risk.
The hospital mortality and morbidity can be lower than predicted by Euroscore and Parsonet Score.
In ultimii ani s-au facut mari progrese in abordarea pacientilor cu TVP extensiva a extremitatilor inferioare, ca de exemplu tromboliza directa cu cateter percutan. Revascularizarea segmentului venos ilio-cav este una dintre cele mai provocatoare si dificile operatii vasculare.
Prezentam cazul unui pacient tanar, B.J, 30 de ani, care in urma unui accident de masina si al unei leziuni spinale minime a fost tratat prin imobilizare la pat 10 zile, dezvoltand ulterior TVP ilio- femurala stanga. Dupa doi ani, in urma simptomatologiei, a examinarii Doppler si flebografice s-a pus diagnosticul de sindrom posttrombotic, ocluzie venoasa ilio-femurala cronica.
Chirurgical s-a efectuat operatia Palma modificata, bypass femuro-iliac controlateral folosind o xenogrefa bovina, artera carotida. Rezultatul a fost bun, cu ameliorare clinica si patenta graftului, la un an verificata Doppler.
The information obtained by intraoperative graft angiography in off pump coronary artery bypass grafting remains a matter of debate despite the fact that anastomotic revision rates in the range of 10% after intraoperative grafting
Intraoperative angiography are reported in the literature. We present our initial experience with intraoperative angiographic evaluation of grafts performed on the beating heart.
Methods:
29 coronary artery bypass grafts were investigated in 23 patients (20 male, 3 female), age 61 (44-74). Transfemoral angiography was performed before (n=8) or after sternotomy closure (n=15) using an OEC 9800 mobile C-arm. Examination times were 25 (8-80) min and fluoroscopy times were 469 (6-1337) sec. 150 (50-470) ml of contrast agent were needed to visualize the grafts.
Results:
No technical complications specific for angiography occurred. Except for 3 aortocoronary vein grafts all bypass vessels could be visualized. Spasm of the graft and/or target vessel was present in 11/29 grafts, which responded well to intraluminal nitroglycerine in 9 of these. 2 grafts were severely stenosed requiring surgical revision. In addition 2 proximal target vessel occlusions were noted, which were left because of lacking intraoperative ischemic signs. There was no hospital mortality and no perioperative myocardial ischemic event.
Conclusion:
This experience suggests that despite being a time consuming examination technique intraoperative angiography can reveal valuable information that may demand surgical consequences.
Material and Methods The lot of study comprise 31 patients on assist device between January 1994 and June 2002, from 164 cardiac transplantation procedures at Cardiac Surgery Department Innsbruck. Group A, “Bridge to Transplantation” 21 patients, group B “Bridge to recovery or transplantation”, 5 patients, group C “ Cardiac arrested after resuscitation. Systems used; ECMO(Biomedicus), LVAD(Thoratec) and BVAD (Thoratec, Berlin Heart).
Results. In group A, “Bridge to Transplantation” which included 21 patients, age 10 to 65, 3 died and 18 were transplanted; group B “Bridge to recovery or transplantation”, of the 5 patients, 3 recovered and explanted, 2 died; group C,”Resuscitation after cardiac arrest”, all 5 patients died after 5 to 82 days. Mean time on assist device; 34,2+/-43,7 days (median 16 days, range 1-169). Complications under assist device; bleeding 2 (13,3%), hematoma 1(6,6%), pericardial effusion 1(6,6%), neurologic disorders 2 (13,3%).
Conclusion.The experience with long term cardiac support, “Bridge to transplantation or bridge to recovery, brigde to bridge, is very encouraging in adult, and now, the “Berlin Heart” assist device has proved to be a highly reliable ventricular support for children as well as adults.
Acute–fulminant myocarditis is a disease with unclear pathophysiology and etiology, difficult diagnosis anf very large spectrum of clinical presentation. Very rare is presentation with hemodynamic instability or franc acute cardiogenic shock. Such patients if the diagnosis is not giant cell myocarditis, have an excellent prognosis for complete long term recovery if they are supported aggressively. An aggressive approach to the use of mechanical support is strongly recommended. Survival,either by bridge to transplantation or recovery, should approach 70%. Transplantation should and can offten be avoided. We present a young, 24 years female, with acute-fulminant myocarditis with chlamidia pneumoniae and Parvovirus B19, acute cardiogenic shock, which was first supported by ECMO for 48 hours and then Thoratec bi-ventricular assist device, to support her hemodynamic. After two weeks, she recovered with normal cardiac function and was weaned from mechanical circulatory support. This case report, show that full cardiac recovery is possible and even likely despite fulminant and catastophic presentation, avoiding a cardiac transplantation whit his implication.
Material and method.. A 45 years old male was retransplanted eight years later for the allograft diffuse coronaropathy (Nov 19.2002). His history started in 1994, with angina pectoris and positive exercice test, was referred to angiography. He had high lipid level and smoking. Angiography shown, LAD, tandem stenosis 90% and 60% and the patient PTCA was performed Nov.23, 1994, 8,15 am. After insertion of Atherocath, dissection of Left Main occurred and the patient became unresponsive with respiratory arrest and ventricular fibrillation(VF). Cardioplulmonary resuscitation (CRS) started immediately, but the patient remained in VF. Extracorporeal membrane oxygenation (ECMO), 31 minute from beginning of the dissection was instituted. Operative teather (126 min later under CPB), and CABG x 2 venae bypass performed for LAD and Cx. Weaning from CPB was not possible and ECMO restarted. In intensive care unit, bleeding, unstable. Emergency listing for cardiac transplantation (7 pm). At 11,25 pm Eurotransplant offerted an organ. Some hours later, at 6,51 am, orthotopic cardiac transplantation was succesfully performed.
Results. The patient was extubated on the first postoperative day. Heart specimen examination shown massive LV myocardial infarction with hemorrhage and LAD dissection and thrombosis. However, in spite of eight years of free evolution, the burdens of immunosupresion resulted in coronary angiopathy, with relisting the patient for cardiac retransplantation and successful performed on Nov.19, 2002.
Conclusion. PTCA can fail in a disastrous dissection and occlusion of the left main, menacing the life of the patient. Surgical standby with all the technical arsenal, CABG, ECMO, assist device and cardiac transplantation program should be considered for such high risk lesions. Emergency cardiac transplantation seems to be a realistic option. However, long term outcome will be burden by the immunosuppression complication and retransplantation should re reconsidered with another mortality rate and long results.
Tumorile cardiace primare, sunt entitati rare si reprezinta doar 5-10% din toate neoplasmele . Aproximativ 80% sunt tumori benigne, iar din acestea mai mult de jumatate sunt reprezentante de mixoamele cardiace. Diagnosticul de mixom cardiac este foarte rar pus pe baza datelor clinice si in majoritatea cazurilor mimeaza alte boli cardiovasculare, infectioase sau de colagen. Suspiciunea clinica este esentiala pentru diagnosticul de mixom, dealtfel simplu prin ecocardiografie. Prezentam cazul unei paciente H.I de 47 ani a care-i simptomatologie cu dureri toracice nespecifice, lichid pleural, dispnee, tahicardie, scadere in greutate a orientat investigatiile initiale (Rx toracic, Bronhoscopie, CTscan) spre un neoplasm pulmonar si a intarziat diagnosticul si interventia chirurgicala a unui mixon de atriu stang de 4/6 cm. Tratamentul chirurgical de excizie este simplu si prognosticul acestor pacienti operati la timp (inaintea unor complicatii ce pot fi fatale, embolie, moarte subita ), excelent. In concluzie cazul prezentat, aduce un argument in plus la paleta larga de simptome si semne pe care o pot prezenta mixoamele cardiace.
METHODS. We started, in January 2000, to use the axillary artery cannulation, in our practice, achieving full cardiopulmonary bypass.
Between January 1991 and September 2001, we operated 67 patients for acute aortic dissection type A. All the patients had acute aortic dissection operated in emergency using deep hypothermia and circulatory arrest. Axillary cannulation was used in 14 (21%) patients, by femoral artery 52 (77%), and ascending aorta 1 (2%). The parameters which we followed were; age, gender, cardiac tamponad, preoprative insult, hypertension, Marfan syndrome. During operation we checked CPB time, total circulatory arrest time, aortic clamp time, duration of operation, perfusion parameters. Postoperative the most important variables were; hospital mortality, ICU stay, postoperative bleeding and revision, low cardiac syndrome output, MSOF, sepsis, renal failure and neurological insults.
RESULTS: Hospital mortality 8/52 (15%) in femoral cannulation group and 1/14 (7,7%) . Also we didn’t have postoperative new neurologic insult, postoperative bleeding and revision and more reduce incidence of sepsis, low output syndrome, in axillary artery cannulation group comparing with, 7,5% new neurologic events, 23% MSOF, 17% sepsis, 28% bleeding, 26 % postoperative renal failure,in femoral patients.
CONCLUSION. Our first results conclude that axillary cannulation is a reproductible method, providing antegrade perfusion and better cerebral and visceral protection during aortic dissection repair.
edad media de 60,2 anos. 82,7% eran varones y 17,3% mujeres. El tiempo desde el comienzo de
los sfntomas fue de 3,67 hs. Las localizaciones de las lesiones fueron: descendente anterior 78
(46,4%), coronaria derecha 55 (32,7%), circu .nfleja 32 (19%) y puentes venosos 3 (1,9%) . Presentaban
lesion de multiples vasos 55 pacientes (32,7%) . Se realizo angioplastia convencional en 135
casos (80,4%), con balon de perfusion en 20 (11,8%), Rotablator en 6 (3,6%) y stent en 2 (1,2%) . Se
use balon de contrapulsacion, por presentar shock, en 19 pacientes (11,3%) . Hubo exito en el 94%
de los casos, resultado parcial en el 2% y fracaso en el 4% . El seguimiento medio fue de 15 meses
(3-42 meses) . En el 39,6% se realizo angiografia a los 3-6 meses y el 60,4% se controlo clfnicamente.
Fallecieron 6 pacientes (3,6%), todos con shock cardiogenico. Hubo 3 fibrilaciones ventriculares
(1,8%), diseccion no oclusiva en 6 (3,5%) y oclusion aguda en 5 (3%). De los 162 sobrevivientes
(96,4%), 38 presentaron reisquemia (23,5%), siendo redilatados 23 (14,2%) y operados 15 (9,2%).
Hubo 8 casos (4,9%) de reinfarto y 4 fallecimientos (2,5%) en el seguimiento .
Conclusiones
En la serie analizada, la angioplastia directa del infarto tuvo una elevada tasa de reperfusion
(94%), con mortalidad aceptable en los casos con shock cardiogenico (31,6%), necesidad de revascularizacion
en el seguimiento del 23,5%, :mortalidad alejada del 2,5% y 4,9% de reinfarto . Rev
Arg Cardiol 1995; 63 (1) : 37-45.
Spontaneous aortic rupture, without any history of previous thoracic trauma, infection or acute thoracic pain is an extremely rare and
potentially life-threatening event. Its diagnosis, in the absence of acute symptoms, is usually delayed and relies on secondary signs. While
the etiology is atherosclerotic in most cases, the exact mechanisms of rupture have only recently been uncovered. Treatment may be
surgical, endovascular or by a combined procedure, according to the anatomy, location and expertise of the medical team.
2007 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.
Background: The Bentall operation is considered the standard in the surgical treatment for aortic root aneurysm, with low mortality and very good long results. Technical
modifications have been added to the original description, regarding the coronary arteries reimplantation. Our purpose was to determine the mortality, morbidity and long time
events after composite graft replacement of the aortic root and to evaluate the risk factors associated with this procedure.
Material and Method: Between 1986 and 2002, at the University Cardiac Surgery Innsbruck, 67 patients underwent aortic root and/or the aortic arch replacement. From
67 patients, 57 were males and 30 patients (44.8%) underwent emergency procedures. Twenty eight patients (41.8%) presented with acute aortic dissection type A, 2 patients
had chronic aortic dissection, 28 patients (41.8%) had an ascending aortic aneurysm combined with aortic regurgitation, and 7 (10.5%) had an extension of the aneurysm into
the aortic arch. All operations were performed using the coronary-button-method. Deep hypothermic circulatory arrest (DHCA) was necessary in 36 patients (53.7%).
Results: Overall hospital mortality was 9/67 patients (13.4%). The factors associated with early mortality: aortic dissection, CPB time, aortic cross clamp time, DHCA, postoperative
low cardiac output syndrome, postoperative renal failure requiring hemofiltration, multiorgan failure. Survival excluding hospital deaths was96%at 1 year,90%at 3 years,
90% at 5 years and 85% at 7 years.
Conclusion: Aortic root and ascending aorta replacement using a mechanically valved composite graft is an operation with low hospital mortality especially in elective, nondissecting
cases. The long-term survival rates are good and the majority of patients are event-free after the operation
Mitral valve repair (MVR) is well established and shows significant advantage over valve replacement for acute and chronic valve endocarditis. For the pregnant women is even more important to avoid the anticoagulant therapy with their teratogenic effects. Another choice before mechanical or biological mitral valve replacement,could be the homograft mitral valve.
Material and method. We presented a 33 years old, pregnant female, which developed on the plenty of health an acute native mitral valve endocarditis due to Streptococcus aureus, with massive vegetation and mitral annular destruction. She underwent for an emergently operation performing a mitral valve repair with pericardial patch and annular reinforcement using a 30 mm annulus ring.
Result. The mitral valve repair competence was tested with saline injection on left ventricle showing only a slight trace of mitral insufficiency which have been confirmed by intraoperative transesophagian echocardiography. Staphylococcus aureus founded on blood culture was also confirmed from the vegetation sample examination. Postoperative evolution was good with extubation on the first day and continuing of the parenteral antibiotic therapy for the next 6 weeks The foetus remained alive.
Conclusion. Mitral valve repair should the golden standard whenever is possible in active infective endocarditis of the mitral valve. Moreover, on the young women which are pregnant or wish to get pregnant when cannot take oral anticoagulants because of their teratogenic effects.
Material and method. From May 2000 through September 2002, 25 consecutive patients (means age, 26 years; range 3 to 49 years) underwent replacement their pathologic aortic valve by a pulmonary autograft, receiving a cryopreserved homograft in pulmonary position, using complete aortic root replacement technique exclusively and Bioglue® application.
Transesophagian echocardiography was the method used for all the patients, preoperatively, intraoperative and serial after operation (at discharge, 3, 6, 12 and 24 months) with the purpose of measuring aortic and pulmonary annulus, evaluating transvalvular gradient and both valve function, evolution of muscular mass regression and studying the LV function.
Results. There was no deaths early or late after operation, no bleeding or another major complications. The patients remained in mean 24 hours in intensive care unit and were discharged after mean six days. Early postoperative TEE, shown no regurgitation or minimal incompetence of autograft in some cases. The result remained stable after 6 months with recovery of LV function approximately 10% and the muscular mass reduction has been decreased.
Conclusion. The Ross operation is a very appealing choose in young patients avoiding mechanical valve with their burdens and gives excellent early and mid-term results, no mortality (or low) and no morbidity. However, we are looking for the autograft and homograft function over time, in special dilatation of autograft and homograft stenosis
Background. The best surgical procedures in case of ascending aortic aneurysm and dissection associate with aortic valve incompetence, but normal morphologic leaflets are still debate. Aortic root replacement using a conduit mechanical or biological, Bentall-DeBono operation, has proved her fesability. However, for the young patient to avoid anticoagulation therapy we try to reconstruct the aortic valve inside of graft-tube, the operation proposed some years ago by T. David and M. Yacoub. The main concern in this reconstruction remain the long term durability. In order to improve the results, a new sinus Valsalva prosthesis have been developed for more anatomical aortic root reconstruction and better leaflets protection. Our study is coming to give some technical consideration in this regard after an initial surgical experience.
Material and method. Between 1986 to September 2002, 77 patients were operated for aortic aneurysm and/or dissection on Cardiac Surgery Department of Innsbruck. A total of 67 Bental and from 1998, 10 patients underwent T. David all using a normal Dacron tube but one new sinus Valsalva Prosthesis. 30 patients (44.8%) underwent emergency procedures.
Results. Overall hospital mortality was 9/67 patients in Bentall group (13.4%). From this 28/67 patients had an acute aortic dissection type A, and the hospital mortality in this group was 6/28 (21.4%). No mortality in aortic root reconstruction group (10 patients) but one cerebral stroke, (patient had also before operation). He recovered after. Also we had good aortic valve competence at discharge and later one. Overall survival including hospital deaths was 85% at one year, 78% at 3 years, 75% at 5 years, and 71% at 7 years. Survival excluding hospital deaths was 96% at one year, 90% at 3 years, 90% at 5 years, and 85% at 7 years.
Conclusion. The Bental operation elective or emergently give a mortality under 15% and good long-term results. The sparing-valve procedures are also a valid surgical option for the patients with ascending aorta and/or the aortic root aneurysms and dissection associate with aortic insufficiency, when the aortic valve leaflets anatomy are normal. Using the new sinus valsalva Vascutek prosthesis, seems to give better recreation of aortic root anatomy and consequently function and long term results. However, more clinical study are requiring until to prove superiority over simple tube-graft reconstruction or still aortic root replacement.
To avoid a catastrophic bleeding the installation of the cardiopulmonary bypass (CPB) can be approach through axillary artery cannulation in conjunction with femoral vena cannulation for deep cooling (18°) and circulatory arrest of the patient before the opening of sternum. We describe a patient 24 years old male with congenital aortic stenosis and two subsequent operations, aortic valve plastic repair and later a mechanical aortic valve, which developed in time a huge (9 cm) ascending aortic aneurysm and chronic aortic dissection type A.
Material and metoda. In perioada 1986 - 2002, 77 pacienti au fost operati in Departamentul de Chirurgie Cardiaca din Innsbruck, pentru anevrism aortic sau disectie acuta de aorta toracica. Dintre acestia, 67 pacienti au beneficiat de interventia Bentall-DeBono, 10 au beneficiat de operatia Tirone David, dintre care 9 cu un tub simplu, iar unul cu noul tip de proteza sinus Valsalva.
Rezultate. Mortalitatea generala in grupul Bentall (grupul A) a fost de 9/67 pacienti (13.4 %). Dintre acestia, 28/67 au avut o disectia acuta tip A, iar mortalitatea intraspitaliceasca in acest grup a fost de 6/28 (21.4 %). Grupul B de pacienti, care au beneficiat de conservarea valvei aortice, 10 pacienti, nu a avut mortalitate intraspitaliceasca, iar complicatiile postoperatorii au fost absente, cu exceptia unui soc cerebral remis ulterior. Competenta valvei aortice a fost buna, atit la externare cit si la controalele ulterioare. Supravietuirea generala a fost de 85% la un an, 78% la 3 ani, 75% la 5 ani si 71% la 7 ani. Excluzind mortalitatea intraspitaliceasca, supravietuirea a fost, respectiv, de 96% la un an, 90% la 3 ani si 85% la 7 ani.
Concluzii. Operatia Bentall-De Bono, efectuata electiv sau de urgenta, are o mortalitate sub 15 % si rezultate bunepe termen lung. Procedeele de conservare a valvei aortice sant insa o optiune in cazurile de anevrism al radacinii aortei sau de disectie acuta ce implica radacina aortei. Folosirea noului tip de proteza pare sa duca la reconstructie anatomica mai fiziologica a radacinii aortei si deci, la rezultate superioare pe termen lung.
Background: Cerebral complication during coronary artery bypass surgery (CABG), still occurs in spite of cardiopulmonary bypass (CPB) technology advances. Our study sought to assess the role of epiaortic ultrasound (EAS) and intraoperative transesophagial ecocardiography (TEE) in detection of patients with atherosclerosis of the thoracic aorta and high risk for cerebral embolisation. Consequently our surgical strategies modification for a better cerebral preotection.
Methods: Our lot study comprise 352 patients undergoing EAS and TEE, during CABG.
EAS was performed before opening of the pericardium using a 7,5 MHz ultrasonic probe packed in a sterile bag. In the presence of moderate aortic atherosclerosis (maximum aortic wall thickness of 3mm ) primarily single aortic cross-clamping and choose of aortic cannulation place was carried out. In cases of severe aortic atheroma (maximum aortic wall thickness > 5 mm or mobile plaque), aortic no touch technique, off-pump were used .From 34 patients with severe ascending aortic atherosclerosis 22 of these patients ( 18 male, 4 female, age 72(57-79), Parsonet Score 11(0-8), Euroscore 8(2-13), McSPI Stroke Risk Index 6 (1-30%) were managed on “no touch technique”, Off-pump. All patients received at least one leaft internal mammary artery (LIMA) in situ graft and aditional extraanatomical bypass conduits: venous Y-graft from IMA (n=14), arterial Y-graft from LIMA (n=3), vein graft from axillary artery (n=3), vein graft from the RIMA stump (n=3).. Median operative time was 240 (115-435) min.
Results- We found a mild aortic atherosclerosis in 151 patients (43%), moderate in 167 (47%) and severe in 34 patients (8,8%).. Operative mortality was 2/22 in a group with high risk index, from another cause than cerebral stroke. No cerebral stroke occurred. The rate of perioperative myocardial infarction(CKMB>50U/l) was 5/22. Median stay in ICU, 54 hours
(15-1245 hours). After a median follow up period of 8 months one death occurred from cerebral stroke and no myocardial infarction.
Conclusion. Accurate detection of atheroma on ascending aorta and aortic arch by a combination between EAS and TEE and in special surgical technique modification using off-pump revascularization and extraanatomical bypass for the management of a heavily calcified aorta can result in a very low stroke rate despite a considerable stroke risk.
The hospital mortality and morbidity can be lower than predicted by Euroscore and Parsonet Score.
In ultimii ani s-au facut mari progrese in abordarea pacientilor cu TVP extensiva a extremitatilor inferioare, ca de exemplu tromboliza directa cu cateter percutan. Revascularizarea segmentului venos ilio-cav este una dintre cele mai provocatoare si dificile operatii vasculare.
Prezentam cazul unui pacient tanar, B.J, 30 de ani, care in urma unui accident de masina si al unei leziuni spinale minime a fost tratat prin imobilizare la pat 10 zile, dezvoltand ulterior TVP ilio- femurala stanga. Dupa doi ani, in urma simptomatologiei, a examinarii Doppler si flebografice s-a pus diagnosticul de sindrom posttrombotic, ocluzie venoasa ilio-femurala cronica.
Chirurgical s-a efectuat operatia Palma modificata, bypass femuro-iliac controlateral folosind o xenogrefa bovina, artera carotida. Rezultatul a fost bun, cu ameliorare clinica si patenta graftului, la un an verificata Doppler.
The information obtained by intraoperative graft angiography in off pump coronary artery bypass grafting remains a matter of debate despite the fact that anastomotic revision rates in the range of 10% after intraoperative grafting
Intraoperative angiography are reported in the literature. We present our initial experience with intraoperative angiographic evaluation of grafts performed on the beating heart.
Methods:
29 coronary artery bypass grafts were investigated in 23 patients (20 male, 3 female), age 61 (44-74). Transfemoral angiography was performed before (n=8) or after sternotomy closure (n=15) using an OEC 9800 mobile C-arm. Examination times were 25 (8-80) min and fluoroscopy times were 469 (6-1337) sec. 150 (50-470) ml of contrast agent were needed to visualize the grafts.
Results:
No technical complications specific for angiography occurred. Except for 3 aortocoronary vein grafts all bypass vessels could be visualized. Spasm of the graft and/or target vessel was present in 11/29 grafts, which responded well to intraluminal nitroglycerine in 9 of these. 2 grafts were severely stenosed requiring surgical revision. In addition 2 proximal target vessel occlusions were noted, which were left because of lacking intraoperative ischemic signs. There was no hospital mortality and no perioperative myocardial ischemic event.
Conclusion:
This experience suggests that despite being a time consuming examination technique intraoperative angiography can reveal valuable information that may demand surgical consequences.
Material and Methods The lot of study comprise 31 patients on assist device between January 1994 and June 2002, from 164 cardiac transplantation procedures at Cardiac Surgery Department Innsbruck. Group A, “Bridge to Transplantation” 21 patients, group B “Bridge to recovery or transplantation”, 5 patients, group C “ Cardiac arrested after resuscitation. Systems used; ECMO(Biomedicus), LVAD(Thoratec) and BVAD (Thoratec, Berlin Heart).
Results. In group A, “Bridge to Transplantation” which included 21 patients, age 10 to 65, 3 died and 18 were transplanted; group B “Bridge to recovery or transplantation”, of the 5 patients, 3 recovered and explanted, 2 died; group C,”Resuscitation after cardiac arrest”, all 5 patients died after 5 to 82 days. Mean time on assist device; 34,2+/-43,7 days (median 16 days, range 1-169). Complications under assist device; bleeding 2 (13,3%), hematoma 1(6,6%), pericardial effusion 1(6,6%), neurologic disorders 2 (13,3%).
Conclusion.The experience with long term cardiac support, “Bridge to transplantation or bridge to recovery, brigde to bridge, is very encouraging in adult, and now, the “Berlin Heart” assist device has proved to be a highly reliable ventricular support for children as well as adults.
Acute–fulminant myocarditis is a disease with unclear pathophysiology and etiology, difficult diagnosis anf very large spectrum of clinical presentation. Very rare is presentation with hemodynamic instability or franc acute cardiogenic shock. Such patients if the diagnosis is not giant cell myocarditis, have an excellent prognosis for complete long term recovery if they are supported aggressively. An aggressive approach to the use of mechanical support is strongly recommended. Survival,either by bridge to transplantation or recovery, should approach 70%. Transplantation should and can offten be avoided. We present a young, 24 years female, with acute-fulminant myocarditis with chlamidia pneumoniae and Parvovirus B19, acute cardiogenic shock, which was first supported by ECMO for 48 hours and then Thoratec bi-ventricular assist device, to support her hemodynamic. After two weeks, she recovered with normal cardiac function and was weaned from mechanical circulatory support. This case report, show that full cardiac recovery is possible and even likely despite fulminant and catastophic presentation, avoiding a cardiac transplantation whit his implication.
Material and method.. A 45 years old male was retransplanted eight years later for the allograft diffuse coronaropathy (Nov 19.2002). His history started in 1994, with angina pectoris and positive exercice test, was referred to angiography. He had high lipid level and smoking. Angiography shown, LAD, tandem stenosis 90% and 60% and the patient PTCA was performed Nov.23, 1994, 8,15 am. After insertion of Atherocath, dissection of Left Main occurred and the patient became unresponsive with respiratory arrest and ventricular fibrillation(VF). Cardioplulmonary resuscitation (CRS) started immediately, but the patient remained in VF. Extracorporeal membrane oxygenation (ECMO), 31 minute from beginning of the dissection was instituted. Operative teather (126 min later under CPB), and CABG x 2 venae bypass performed for LAD and Cx. Weaning from CPB was not possible and ECMO restarted. In intensive care unit, bleeding, unstable. Emergency listing for cardiac transplantation (7 pm). At 11,25 pm Eurotransplant offerted an organ. Some hours later, at 6,51 am, orthotopic cardiac transplantation was succesfully performed.
Results. The patient was extubated on the first postoperative day. Heart specimen examination shown massive LV myocardial infarction with hemorrhage and LAD dissection and thrombosis. However, in spite of eight years of free evolution, the burdens of immunosupresion resulted in coronary angiopathy, with relisting the patient for cardiac retransplantation and successful performed on Nov.19, 2002.
Conclusion. PTCA can fail in a disastrous dissection and occlusion of the left main, menacing the life of the patient. Surgical standby with all the technical arsenal, CABG, ECMO, assist device and cardiac transplantation program should be considered for such high risk lesions. Emergency cardiac transplantation seems to be a realistic option. However, long term outcome will be burden by the immunosuppression complication and retransplantation should re reconsidered with another mortality rate and long results.
Tumorile cardiace primare, sunt entitati rare si reprezinta doar 5-10% din toate neoplasmele . Aproximativ 80% sunt tumori benigne, iar din acestea mai mult de jumatate sunt reprezentante de mixoamele cardiace. Diagnosticul de mixom cardiac este foarte rar pus pe baza datelor clinice si in majoritatea cazurilor mimeaza alte boli cardiovasculare, infectioase sau de colagen. Suspiciunea clinica este esentiala pentru diagnosticul de mixom, dealtfel simplu prin ecocardiografie. Prezentam cazul unei paciente H.I de 47 ani a care-i simptomatologie cu dureri toracice nespecifice, lichid pleural, dispnee, tahicardie, scadere in greutate a orientat investigatiile initiale (Rx toracic, Bronhoscopie, CTscan) spre un neoplasm pulmonar si a intarziat diagnosticul si interventia chirurgicala a unui mixon de atriu stang de 4/6 cm. Tratamentul chirurgical de excizie este simplu si prognosticul acestor pacienti operati la timp (inaintea unor complicatii ce pot fi fatale, embolie, moarte subita ), excelent. In concluzie cazul prezentat, aduce un argument in plus la paleta larga de simptome si semne pe care o pot prezenta mixoamele cardiace.
METHODS. We started, in January 2000, to use the axillary artery cannulation, in our practice, achieving full cardiopulmonary bypass.
Between January 1991 and September 2001, we operated 67 patients for acute aortic dissection type A. All the patients had acute aortic dissection operated in emergency using deep hypothermia and circulatory arrest. Axillary cannulation was used in 14 (21%) patients, by femoral artery 52 (77%), and ascending aorta 1 (2%). The parameters which we followed were; age, gender, cardiac tamponad, preoprative insult, hypertension, Marfan syndrome. During operation we checked CPB time, total circulatory arrest time, aortic clamp time, duration of operation, perfusion parameters. Postoperative the most important variables were; hospital mortality, ICU stay, postoperative bleeding and revision, low cardiac syndrome output, MSOF, sepsis, renal failure and neurological insults.
RESULTS: Hospital mortality 8/52 (15%) in femoral cannulation group and 1/14 (7,7%) . Also we didn’t have postoperative new neurologic insult, postoperative bleeding and revision and more reduce incidence of sepsis, low output syndrome, in axillary artery cannulation group comparing with, 7,5% new neurologic events, 23% MSOF, 17% sepsis, 28% bleeding, 26 % postoperative renal failure,in femoral patients.
CONCLUSION. Our first results conclude that axillary cannulation is a reproductible method, providing antegrade perfusion and better cerebral and visceral protection during aortic dissection repair.
edad media de 60,2 anos. 82,7% eran varones y 17,3% mujeres. El tiempo desde el comienzo de
los sfntomas fue de 3,67 hs. Las localizaciones de las lesiones fueron: descendente anterior 78
(46,4%), coronaria derecha 55 (32,7%), circu .nfleja 32 (19%) y puentes venosos 3 (1,9%) . Presentaban
lesion de multiples vasos 55 pacientes (32,7%) . Se realizo angioplastia convencional en 135
casos (80,4%), con balon de perfusion en 20 (11,8%), Rotablator en 6 (3,6%) y stent en 2 (1,2%) . Se
use balon de contrapulsacion, por presentar shock, en 19 pacientes (11,3%) . Hubo exito en el 94%
de los casos, resultado parcial en el 2% y fracaso en el 4% . El seguimiento medio fue de 15 meses
(3-42 meses) . En el 39,6% se realizo angiografia a los 3-6 meses y el 60,4% se controlo clfnicamente.
Fallecieron 6 pacientes (3,6%), todos con shock cardiogenico. Hubo 3 fibrilaciones ventriculares
(1,8%), diseccion no oclusiva en 6 (3,5%) y oclusion aguda en 5 (3%). De los 162 sobrevivientes
(96,4%), 38 presentaron reisquemia (23,5%), siendo redilatados 23 (14,2%) y operados 15 (9,2%).
Hubo 8 casos (4,9%) de reinfarto y 4 fallecimientos (2,5%) en el seguimiento .
Conclusiones
En la serie analizada, la angioplastia directa del infarto tuvo una elevada tasa de reperfusion
(94%), con mortalidad aceptable en los casos con shock cardiogenico (31,6%), necesidad de revascularizacion
en el seguimiento del 23,5%, :mortalidad alejada del 2,5% y 4,9% de reinfarto . Rev
Arg Cardiol 1995; 63 (1) : 37-45.
Spontaneous aortic rupture, without any history of previous thoracic trauma, infection or acute thoracic pain is an extremely rare and
potentially life-threatening event. Its diagnosis, in the absence of acute symptoms, is usually delayed and relies on secondary signs. While
the etiology is atherosclerotic in most cases, the exact mechanisms of rupture have only recently been uncovered. Treatment may be
surgical, endovascular or by a combined procedure, according to the anatomy, location and expertise of the medical team.
2007 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.
Background: The Bentall operation is considered the standard in the surgical treatment for aortic root aneurysm, with low mortality and very good long results. Technical
modifications have been added to the original description, regarding the coronary arteries reimplantation. Our purpose was to determine the mortality, morbidity and long time
events after composite graft replacement of the aortic root and to evaluate the risk factors associated with this procedure.
Material and Method: Between 1986 and 2002, at the University Cardiac Surgery Innsbruck, 67 patients underwent aortic root and/or the aortic arch replacement. From
67 patients, 57 were males and 30 patients (44.8%) underwent emergency procedures. Twenty eight patients (41.8%) presented with acute aortic dissection type A, 2 patients
had chronic aortic dissection, 28 patients (41.8%) had an ascending aortic aneurysm combined with aortic regurgitation, and 7 (10.5%) had an extension of the aneurysm into
the aortic arch. All operations were performed using the coronary-button-method. Deep hypothermic circulatory arrest (DHCA) was necessary in 36 patients (53.7%).
Results: Overall hospital mortality was 9/67 patients (13.4%). The factors associated with early mortality: aortic dissection, CPB time, aortic cross clamp time, DHCA, postoperative
low cardiac output syndrome, postoperative renal failure requiring hemofiltration, multiorgan failure. Survival excluding hospital deaths was96%at 1 year,90%at 3 years,
90% at 5 years and 85% at 7 years.
Conclusion: Aortic root and ascending aorta replacement using a mechanically valved composite graft is an operation with low hospital mortality especially in elective, nondissecting
cases. The long-term survival rates are good and the majority of patients are event-free after the operation