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Biomedical subjects

A Mazzucco

Publications and source records attributed to A Mazzucco.

At least 55 records · Page 3Linked to original sources
PubMed1998

Fatal primary multidrug-resistant tuberculosis in a heart transplant recipient.

The incidence of tuberculosis (TB) worldwide is currently on the rise, not only in the general population but also quite notably among immunosuppressed patients. Its incidence among patients undergoing antirejection therapy is considerably higher than in the general population, and heart transplant recipients have been found to carry the highest risk of TB. There are no reported data, however, on primary TB caused by multidrug-resistant (MDR) Mycobacterium tuberculosis (M. tuberculosis) in heart transplant recipients. We describe the case of a patient who developed active primary MDR TB following the reactivation of a latent tuberculous infection 6 months after transplantation. The patient was most likely infected by M. tuberculosis during a period of time he spent in prison 10 years before undergoing transplantation, but he never developed active tuberculosis, nor did he ever receive antituberculous medication prior to transplantation. Because of the atypical clinical presentation, establishment of the diagnosis was postponed, and the resistance pattern of the isolate grown from bronchoalveolar lavage (BAL) specimens (resistant to isoniazid and rifampicin) led to treatment failure and a fatal outcome. The adoption of the most rapid diagnostic tools for the identification of M. tuberculosis and for a quick screening of drug-resistant isolates is urgently needed in those centers where organ transplantation is carried out.

Fatal Outcome↗
PubMed1998

Mitral valve replacement associated with massive left atrial calcification.

Massive calcification of the atrial walls is a rare condition that entails important implications for mitral valve operations. Endoatriectomy is the procedure of choice in this situation. A technique of total replacement of the left atrium and mitral valve by means of a valved, T-shaped graft is presented as a possible alternative when a more conventional approach is not feasible.

Aortic Valve↗
PubMed1998

Aortic valve replacement with the Biocor PSB stentless xenograft.

BACKGROUND: The midterm clinical results after aortic valve replacement with the Biocor PSB stentless xenograft on all patients operated between October 1992 and October 1996 were reviewed. METHODS: One hundred six patients, aged 70+/-6 years, had aortic valve replacement for aortic stenosis (67%), regurgitation (11%), or both (22%). Associated procedures were done in 49 patients (46%), including coronary artery bypass in 30 patients, mitral valve repair/replacement in 16, and ascending aorta replacement in 5 patients. Aortic cross-clamp and cardiopulmonary bypass times were 96+/-24 and 129+/-31 minutes, respectively. RESULTS: There were 3 (3%) early deaths due to low output (2 patients) and cerebrovascular accident (1 patient). Follow-up of survivors ranged from 6 to 66 months (mean, 39+/-14 months). Survival was 94%+/-2% and 90%+/-3% at 1 and 5 years. There were 5 late deaths due to cardiac cause (2), cancer (2), and pulmonary embolism (1 patient). No patient had structural valve deterioration, whereas 100% and 95%+/-3% were free from valve-related events at 1 and 5 years. There were two reoperations due to narrowing of the left coronary ostium and endocarditis, with an actuarial freedom from reoperation of 99%+/-1% and 98+/-1% at 1 and 5 years, respectively. Functional results demonstrated a mean peak transprosthetic gradient of 16+/-12 mm Hg, with only 1 patient (1%) with a 55 mm Hg gradient. No cases of valve regurgitation greater than mild were recorded at follow-up. Assessment of New York Heart Association functional class demonstrated a significant improvement (2.9+/-0.6 versus 1.4+/-0.7; p=0.01). All patients were free from anticoagulation. CONCLUSIONS: Aortic valve replacement using the Biocor PSB stentless xenograft offers excellent midterm survival, negligible valve deterioration, and a very low rate of valve-related events, which are comparable to estimates reported with other models of stentless xenografts and currently available stented xenografts. Hemodynamic performance is favorable and quality of life satisfactory.

Aged↗
PubMed1998

Aortic root replacement in adolescents and young adults: composite graft versus homograft or autograft.

BACKGROUND: Aortic root replacement (ARR) is a technically demanding procedure that can be performed using a variety of prosthetic devices. Root replacement in the young, but grown-up, patient poses unique problems in terms of the long-term outcome and active lifestyle that must be guaranteed by this operation. To identify the "ideal" substitute for ARR in the young, clinical results in teenagers and young adults (<35 years) operated on in the past two decades were reviewed. METHODS: Thirty-eight patients younger than 35 years underwent ARR between January 1980 and December 1996. Eighteen patients, aged 30+/-5 years, had ARR with composite graft (group 1), whereas 20 patients, aged 28+/-6 years, had ARR with aortic homografts or pulmonary autografts (group 2). Primary indication for the operation was aortic insufficiency with anuloaortic ectasia (12 of 18) in group 1 and aortic insufficiency with or without anuloaortic ectasia (16 of 20) in group 2. Urgent ARR was required in 3 (17%) group 1 patients and 1 (5%) group 2 patient (p = 0.01). RESULTS: Operative deaths were 2 (11%) in group 1, caused by hemorrhage and low output, and none in group 2. There were 4 (25%) late deaths in group 1, caused by embolism (2), hemorrhage, and myocardial infarction, and 1 (5%) in group 2, caused by arrhythmia. Survival was 81% +/- 9%, and 55%+/-18% at 2 and 10 years in group 1 versus 94%+/-5% at 2 years in group 2 (p = 0.04). Freedom from valve-related events was 93%+/-6% and 62%+/-18% at 2 and 10 years in group 1 versus 100% at 2 years in group 2 (p = 0.02). Freedom from reoperation in group 1 was 75% +/- 22% at 10 years, whereas no reoperations were done in group 2. Seven (58%) group 1 patients versus 1 (5%) group 2 patient were on cardiac medications (p = 0.001), and 11 (92%) group 1 patients versus no group 2 patients were on warfarin therapy at follow-up. All survivors were back to school or prior employment. CONCLUSIONS: Survival early after ARR does not differ depending on the type of prosthesis. Valve-related events are common, and reoperation may be needed late after ARR with composite grafts. Despite limited follow-up with biologic devices, the prevalence of complications with composite grafts makes homograft or autograft ARR preferable in adolescents and young adults.

Adolescent↗
PubMed1998

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

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

Actuarial Analysis↗
PubMed1998

Reoperation on stentless aortic xenografts.

BACKGROUND: Stentless xenografts have been proposed as substitutes for the diseased aortic valve. Cases of valve failure requiring reoperation have thus far been sporadic. To establish the prevalence and outcome of reoperation on stentless aortic xenograft valves, all patients operated on between October 1992 and October 1996 were reviewed. METHODS: One hundred ninety-nine patients, 94 men and 105 women aged 70+/-7 years, had stentless aortic valve replacement for aortic stenosis (in 139), insufficiency (19), or both (38). Three prostheses were used, including the Biocor PSB (Belo Horizonte, Brazil) (106), Toronto SPV (St. Jude Medical, Inc., St. Paul, MN) (52), and O'Brien-Angell (Cryolife, Atlanta, GA) (41). While the Biocor PSB and Toronto SPV prostheses are designed to be implanted freehand with inflow and outflow suture lines, the O'Brien-Angell valve requires a single suture line. RESULTS: There were 7 (3.5%) total and 6 (3%) valve-related reoperative procedures during a follow-up extending up to 4 years (mean 26+/-20 months). All but one valve-related reoperation, due to endocarditis 36 months after implant, were early (less than 12 months after initial operation). Prevalence of valve-related reinterventions was 1%, 0%, and 12%, and freedom from reoperation at 3 years was 98%+/-2%, 100%, and 81%+/-8%, in patients receiving the Biocor PSB, Toronto SPV, and O'Brien-Angell valves, respectively (p = 0.0039). Cause of reoperation was technical in 3 (O'Brien-Angell), pannus in-growth in 1 (O'Brien-Angell), valve tear in 1 (O'Brien-Angell), and endocarditis in 1 (Biocor PSB). All patients survived replacement of the xenograft with a stented bioprosthesis (5) or homograft root (1) and were discharged after a mean hospital stay of 6+/-3 days (range, 4 to 12 days). At follow-up 15+/-8 months after reintervention (range, 6 to 34 months), all patients are symptom-free with no evidence of recurrent valve obstruction, regurgitation, or infection. CONCLUSIONS: Reoperation for stentless xenograft failure is a rare overall event. Implant of the O'Brien-Angell valve may be associated with a higher prevalence of early reintervention because of nonstructural failure. When needed, reoperation on a stentless xenograft is generally a simple procedure and carries a low surgical risk.

Aged↗
PubMed1998

Midterm results after aortic valve replacement with freehand stentless xenografts: a comparison of three prostheses.

OBJECTIVE: The ideal substitute for the diseased aortic valve is yet to be found. For the assessment and comparison of the midterm results after aortic valve replacement with three different types of freehand stentless xenografts, all patients who underwent the operation between October 1992 and April 1997 were reviewed. METHODS: Of 231 patients undergoing aortic valve replacement, 106 patients (group 1) were given the Biocor PSB (Biocor Industria e Pesquisa Ltda, Belo Horizonte, MG, Brazil); 76 patients (group 2) were given the Toronto SPV (St. Jude Medical, Inc., St. Paul, Minn.), and 49 patients (group 3) were given the O'Brien-Angell valve (Bravo Cardiovascular model 300, Cryolife, Inc., Marietta, Ga.). The first two xenografts require inflow and outflow suturelines; the third xenograft needs a single-sutureline implantation. Mean age (70 +/- 6 years; 70 +/- 7 years; 72 +/- 9 years; p = 0.6), prevalence of male sex (56 patients, 53%; 37 patients, 49%; 22 patients, 45%; p = 0.7), of aortic stenosis (72 patients, 68%; 54 patients, 71%; 37 patients, 73%; p = 0.6), and need for associated procedures (51 patients, 48%; 30 patients, 40%; 21 patients, 43%; p = 0.1) were comparable among groups. Mean aortic crossclamp time was shorter in group 3 (96 +/- 24 minutes; 100 +/- 23 minutes; 88 +/- 25 minutes;p = 0.01). RESULTS: Early deaths were 3 of 106 (3%) in group 1, 2 of 76 (3%) in group 2, and 2 of 49 (4%) in group 3. Follow-up of survivors ranged from 1 to 54 months (mean 32 +/- 13 months). Survival at 4 years was 90% +/- 3% in group 1, 95% +/- 3% in group 2, 85% +/- 8% in group 3 (p = 0.3). At 4 years, freedom from valve-related events was 95% +/- 6%, 100%, 70% +/- 8% (p = 0.004), while freedom from valve deterioration was 99% +/- 1%, 100%, 73% +/- 8% (p = 0.001), in group 1, 2, and 3, respectively (p = 0.001). At follow-up, reintervention on the xenograft was necessary in one patient (endocarditis) in group 1, none in group 2, and six in group 3 (technical cause, group 3; valve tear, group 2; pannus, group 1). Regression analysis showed O'Brien-Angell type of xenograft to be predictive of valve-related events (p = 0.02), valve deterioration (p = 0.001), and reoperation (p = 0.001) during follow-up. CONCLUSIONS: Midterm survival after stentless aortic valve replacement is good with all three xenografts. Freedom from valve-related events, valve deterioration, and reoperation are excellent with the Biocor PSB or the Toronto SPV stentless valves but less satisfactory with the O'Brien-Angell valve.

Aged↗
PubMed1998

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

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

Acute Disease↗
PubMed1998

Aortic root replacement: twenty years of experience.

BACKGROUND: Aortic root replacement is a complex surgical procedure which has undergone major technical modifications with time. In order to assess the early and long-term outcome after aortic root replacement with this procedure, our entire experience of a two decade period was reviewed. METHODS: Between January 1979 and March 1997, 156 aortic root replacement operations were performed. One hundred and twenty five patients (80%) were male and 31 female; their mean age was 50 +/- 16 years. Diagnosis was annuloaortic ectasia in 79 patients, aortic dissection in 51 (acute 22, chronic 29), isolated aortic valve pathology in 24 and aneurysm of sinus of Valsalva in 5. Thirty nine patients had aortic root replacement using the standard "Bentall" technique, 73 using the "modified Bentall" technique, 15 using the Cabrol technique. Biologic substitutes of the aortic root were used in 29 patients (19 autografts, 4 homografts, 6 xenografts). Mean follow-up time was 41 +/- 40 months (range 1 month-18 years). RESULTS: There were 12 (7.6%) hospital deaths. Hospital mortality in elective cases was 5% (7/134) and 22% (5/22) in emergent (p = 0.01). A trend toward reduced early mortality was demonstrated in recent years. Mortality was 5% for the "modified Bentall" group, 3% for the "Biologic root" group, 10% for the "Bentall" group and 20% for the "Cabrol" group. Hospital mortality was significant higher in "Cabrol" group than in "modified Bentall" group (p = 0.04). The overall long-term survival rate was 78 +/- 4% at 5 years, 71 +/- 6% at 10 years and 51 +/- 13% at 15 years. No significant difference in survival rate nor freedom from complications was observed among patient groups. Need for reoperation and valve-related adverse events become prevalent after 10 years of follow-up. CONCLUSION: The decrease in early mortality and the satisfying late results demonstrate that aortic root replacement is a low risk surgical procedure and an effective and durable treatment. The availability of biologic substitutes for the aortic root has allowed the extension of this operation to all patient age group, with results comparable to these obtained with composite grafts.

Actuarial Analysis↗
PubMed1998

Functional outcome after myocardial revascularization in ischemic left ventricular failure.

BACKGROUND: Myocardial revascularization in patients with left ventricular failure (ejection fraction < 30%) offers survival comparable to heart transplantation. The functional outcome, however, has yet to be determined. In order to assess the clinical results in patients with LVEF < 30% undergoing coronary artery bypass grafts (CABG), 101 consecutive patients operated between 1/91 and 1/97 were reviewed retrospectively. METHODS: The patients were stratified according to presentation: 65 pts had angina (Group 1) and 36 congestive failure (Group 2). Mean age (62 +/- 7 vs 60 +/- 8 yrs), sex (90 vs 88% male), LVEF (0.28 +/- 0.04 vs 0.29 +/- 0.04), prior myocardial infarction (1.2 +/- 0.4 vs 1.2 +/- 0.5 episodes/pt), presence of vital myocardium at scintiscan or low-dose dobutamine echocardiography (92 vs 93%), need for preoperative IABP (3.1 vs 8.3%), aortic cross-clamp (53 +/- 21 vs 60 +/- 21 min) and cardiopulmonary bypass (104 +/- 31 vs 114 +/- 36 min) times were comparable. RESULTS: There was only 1 (1%) perioperative death due to low-output syndrome. Eleven pts (6 vs 5, Group 1 vs Group 2) had postoperative low-output syndrome, requiring IABP in 7 pts (4 vs 3). There were 14 (10 vs 4, Group 1 vs Group 2) deaths during follow-up (29 +/- 19 months, range 2-67), with an overall actuarial survival of 91 +/- 4 vs 100% at 1 yr and 74 +/- 9 vs 78 +/- 10% at 5 yrs in Group 1 vs Group 2, respectively (p = ns). Actuarial symptom-free survival was 89 +/- 4 vs 84 +/- 6% at 1 yr and 49 +/- 9 vs 28 +/- 11% at 5 yrs, respectively (p = 0.05). Despite the high recurrence of congestive failure (22 vs 66% in Group 1 vs Group 2, p = 0.004), improvement in functional class (3.1 +/- 0.8 vs 1.5 +/- 0.7 in Group 1 and 2.7 +/- 0.7 vs 1.8 +/- 0.5 in Group 2) and LVEF (0.28 +/- 0.04 vs 0.38 +/- 0.04 in Group 1 and 0.29 +/- 0.04 vs 0.40 +/- 0.06 in Group 2) was found in both groups at follow-up. CONCLUSIONS: In spite of improving early and late survival after revascularization for ischemic left ventricular failure, patients presenting with congestive failure have an unsatisfactory symptom-free survival. Further studies are necessary to ascertain the relative indications to revascularization or transplantation in this specific patient subgroup.

Actuarial Analysis↗
PubMed1997

Usefulness of bicuspid homograft reconstruction of the right ventricular outflow tract in infants with complex congenital heart disease.

Homograft supply is limited especially for those sizes required for neonatal and infant cardiac operations. Surgically downsized homografts have been successfully used for right ventricular outflow tract reconstruction in 5 children (mean weight 6.2 kg) with evidence of good hemodynamic performance of the conduits at a mean follow-up time of 3.7 years.

Bioprosthesis↗
PubMed1997

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

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

Adult↗