Biomedical subjects
Publications and source records attributed to A Mazzucco.
We report a patient in whom orthotopic heart transplantation was performed after late failure of ventricular septation for double-inlet left ventricle. This case shows that orthotopic heart transplantation represents a valid therapeutic alternative in children with previous correction of complex congenital heart defects not amenable to further intracardiac repair.
In order to analyze the problems associated with prosthetic valve replacement (PVR) in the pediatric population, we have reviewed 29 children, 3.5 to 15 years of age, who were operated upon from 1970 to 1986. The indications were congenital valve malformations in 16 patients, rheumatic valve disease in 7, degenerative disease in 2 and bacterial endocarditis in 4. Ten children underwent aortic valve replacement (AVR), 14 mitral valve replacement (MVR), 1 tricuspid valve replacement and 4 double valve replacement (mitral-aortic in 3 and mitral-tricuspid in 1). Twenty-one mechanical (11 aortic and 10 mitral) and 12 biological prostheses (8 mitral, 2 aortic, and 2 tricuspid) were implanted. There was 1 hospital death (3.4%). Follow-up data were available for all survivors from 3 to 184 months. There were 8 late deaths (5.9% patient-year), 4 among children with mechanical and 4 among those with biological prostheses. Overall actuarial survival at 14 years is 62.5 +/- 10.2% with no significant difference in survival between AVR (77.8 +/- 14%) and MVR (44.4 +/- 16%) (p = 0.31) at 10 years and between recipients of mechanical (65.7 +/- 13%) or biological prostheses (60.0 +/- 15%) (p = 0.62) at 6 years. No documented embolic or anticoagulant-related complications occurred in the entire series.(ABSTRACT TRUNCATED AT 250 WORDS)
From March 1972 through December 1986, 34 children underwent surgical treatment of mitral valve dysplasia at our institution. There were 14 males and 20 females, with a mean age of 6 years (range, 5 months to 15 years). Eighteen patients had significant mitral valve insufficiency; 16 had significant mitral valve stenosis. Mitral valve reconstruction was possible in 30 patients (88.2%); replacement of the mitral valve with a mechanical prosthesis was necessary in the other 4 patients (11.8%), after at least 1 attempted reconstruction. Five patients died in the hospital (14.7%): 4 after conservative surgery, and 1 after mitral valve replacement. A 6th patient died 26 months after mitral valve replacement and resection of a subaortic membrane. Four patients required reoperation 2 to 66 months after conservative treatment: in 3 of these, the mitral valve was replaced; in the 4th, additional reconstruction was successful. Upon follow-up (range, 3 months to 14 years after surgery), 26 of the 28 surviving patients were asymptomatic; 2-dimensional and Doppler echocardiography performed in 22 patients after mitral valve repair showed normal pulmonary artery pressure in all, and moderate mitral valve dysfunction in 2. Our results indicate that reconstructive surgery for mitral valve dysplasia may prove effective and reliable in children, despite the frequent severity of valve malformation. We believe, therefore, that mitral valve repair should always be attempted in the pediatric population to avoid the disadvantages of prosthetic valve replacement.
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Sixteen out of 293 (5.4%) procedures for percutaneous transluminal coronary angioplasty, performed between 1985 and 1988, were complicated by acute closure and required emergency revascularization surgery. The injured vessel was the left anterior descending artery in 14 cases and the right coronary artery in 2 cases. All patients had persistent chest pain associated with ST-segment elevation in 14 cases and ST-segment depression in 2 cases. Two patients developed cardiogenic shock and were in cardiac arrest at the beginning of operation; one of these died immediately after the operation. Thus the overall mortality rate was 6.2%. Enzyme evidence of myocardial infarction (CPK-MB greater than 40 UI/I) occurred postoperatively in 8 patients (50%), but only the 6 patients (37.5%) with electrocardiographic evidence of myocardial necrosis (new Q-waves or loss of R-wave voltage) showed akinesis of the myocardium perfused by the occluded vessel at the echocardiographic examination performed two weeks after the operation. The occurrence of myocardial infarction was correlated with the degree of preoperative ischemia and hemodynamic deterioration. A collateral flow was present in 3 cases and none of these showed evidence of myocardial necrosis after the operation. Our results show that emergency bypass surgery for failed coronary angioplasty is less satisfactory than elective surgery, and has a higher mortality and myocardial infarction rate. Thus, the risk of emergency operation for complicated dilation must be considered when selecting of candidates for coronary angioplasty.
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Three series of patients undergoing isolated aortic valve replacement with the standard glutaraldehyde-preserved Hancock porcine bioprosthesis, the standard Björk-Shiley spherical disc prosthesis, and the Lillehei-Kaster tilting disc prosthesis were compared during a 15-year follow-up. From March 1970 to December 1985, aortic valve replacement was performed in 506 patients, 379 men and 109 women, whose ages ranged from 17 to 71 years (mean, 47 +/- 12 years); 196 had a Hancock bioprosthesis, 147 a Björk-Shiley prosthesis, and 163 a Lillehei-Kaster prosthesis. There were no significant differences among the three groups in terms of mean age, preoperative New York Heart Association class, valve lesion, associated intracardiac procedures, and operative mortality (11.7% for the Hancock bioprosthesis group, 8.8% for the Björk-Shiley prosthesis group, and 9.2% for the Lillehei-Kaster prosthesis group). Cumulative duration of follow-up is 1140 patient-years (mean, 6.6 +/- 1.5 years, 100% complete) for Hancock bioprosthesis patients, 878 patient-years (mean, 5.9 +/- 0.4 years, 98% complete) for Björk-Shiley prosthesis patients, and 1184 patient-years (mean, 7.3 +/- 0.3 years, 97% complete) for Lillehei-Kaster prosthesis patients. Actuarial survival rates at 15 years are 30% +/- 15% for Hancock bioprosthesis, 49% +/- 6% for Björk-Shiley prosthesis, and 44% +/- 7% for Lillehei-Kaster prosthesis patients. There were eight embolic episodes in Hancock valve recipients (0.7% +/- 0.1%/pt-yr), nine in Björk-Shiley prosthesis recipients (1.0% +/- 0.3%/pt-yr), and nine (0.7% +/- 0.1%/pt-yr) in Lillehei-Kaster prosthesis recipients (p = no significant difference). Actuarial freedom from emboli at 15 years is 89% +/- 4% for Hancock, 92% +/- 3% for Björk-Shiley, and 93% +/- 2% for Lillehei-Kaster prosthesis recipients (p = no significant difference). A significant difference was found in the incidence of the following complications. (1) Anticoagulant-related hemorrhage: 0.1% +/- 0.1%/pt-yr for Hancock bioprosthesis, 1.3% +/- 0.3%/pt-yr for Björk-Shiley prosthesis, and 1.9% +/- 0.4%/pt-yr for Lillehei-Kaster prosthesis patients (p less than 0.001), with an actuarial freedom at 15 years of 97.6% +/- 1% for Hancock, 85% +/- 5% for Björk-Shiley, and 68.8% +/- 10% for Lillehei-Kaster recipients (p less than 0.001). (2) Structural deterioration: 3.7% +/- 0.6%/pt-yr for Hancock and none for Björk-Shiley and Lillehei-Kaster patients (p less than 0.001), with an actuarial freedom of 100% for Björk-Shiley prosthesis and Lillehei-Kaster prosthesis patients and 38.4% +/- 12% for Hancock bioprosthesis patients at 15 years.
From May 1983 to July 1987 a total of 153 Hancock II porcine bioprostheses have been implanted in 130 patients with a mean age of 59 +/- 8 years (range 29 to 76 years). Mitral valve replacement was performed in 72 patients, aortic valve replacement in 35, and mitral-aortic valve replacement in 23. Cumulative follow-up of 121 survivors is 223 patient-years and 100% complete (range 0.4 to 4.5 years). The actuarial survival rate at 4 years is 88% +/- 8% for mitral, 86% +/- 7.8% for aortic, and 84% +/- 8% for mitral-aortic valve replacement. Minor thomboembolism occurred in two patients (0.9% +/- 0.6%/pt-yr) with an actuarial freedom from emboli at 4 years of 100% for mitral, 96% +/- 3.7% for aortic, and 91% +/- 8.6% for mitral-aortic valve replacement. Anticoagulant-related hemorrhage occurred in 10 patients (4.4% +/- 1.4%/pt-yr) with an actuarial freedom at 4 years of 90% +/- 4.8% for mitral, 89% +/- 5.8% for aortic, and 84% +/- 10.6% for mitral-aortic valve replacement. Failure of the porcine bioprosthesis was observed in three patients with an actuarial freedom at 4 years of 96% +/- 3.6% for aortic, 91% +/- 8% for mitral, and 91% +/- 8.6% for mitral-aortic valve replacement. Actuarial freedom from all porcine bioprosthesis-related complications at 4 years is 85.7% +/- 6.6% for aortic, 79% +/- 9% for mitral, and 70% +/- 13% for mitral-aortic valve replacement. No instances of primary tissue failure occurred.(ABSTRACT TRUNCATED AT 250 WORDS)
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Lung perfusion was evaluated in 19 patients in whom a Fontan operation had been performed at a mean age of 3.7 years. First pass and equilibrium data were acquired during the lung particle perfusion scan 0.5 to 7.9 years (mean 3.7 years) following the Fontan procedure. Abnormalities of lung perfusion were documented in 8 patients. Minimal underperfusion of small areas of either right or left lung were noted in 4 patients, while the remaining 4 had evidence of major perfusion defects, involving both lungs. The perfusion defects were localized, in the majority of cases, on the side where a palliative procedure had been performed before the Fontan operation: it is of note that all our patients without palliative procedures did not show abnormalities in lung perfusion. Major abnormalities of lung perfusion seemed related to possible intimal thrombosis or emboli due to prolonged polycythemia or to pulmonary vessel distortion due to long-standing shunts.
The Hancock pericardial xenograft has been used in our Institution since August 1981 as an alternative to porcine bioprostheses. Up to July 1984, 97 Hancock pericardial xenografts have been implanted in 84 patients; of 76 operative survivors with a mean age of 55.2 +/- 13 years (range 13-75 years), 50 had undergone aortic valve replacement, 16 mitral valve replacement and 10 mitral-aortic valve replacement. Follow-up ranged from 0.5 to 5.2 years with a cumulative duration of 239 patient/years and is 99% complete. Actuarial survival is 92% +/- 4% for patients with aortic valve replacement and 84% +/- 10% for patients with mitral valve replacement at 5 years, and 77% +/- 14% for those with mitral-aortic valve replacement at 4 years. Thromboembolic episodes occurred in 2 patients (1 after aortic and 1 after mitral valve replacement). The actuarial freedom from emboli is 100% for patients with mitral-aortic valve replacement at 4 years, and 96% +/- 3% for patients with aortic and 93% +/- 6% for patients with mitral valve replacement at 5 years. Reoperation was performed in 13 patients (9 aortic, 2 mitral and 2 mitral-aortic valve replacements), because of endocarditis in 3 (2 aortic and 1 mitral valve replacement), paravalvular leak in 1 (aortic valve replacement), and primary tissue failure in 9 (6 aortic, 1 mitral and 2 mitral-aortic valve replacements). Actuarial freedom from primary tissue failure is 72% +/- 9% for aortic and 83% +/- 8% for mitral Hancock pericardial xenografts at 5 years. Eleven xenografts explanted because of primary tissue failure were studied pathologically.(ABSTRACT TRUNCATED AT 250 WORDS)
The fate of 103 patients consecutively operated upon for chronic left ventricular aneurysm between 1978 and 1986 was examined with a multivariate statistical approach to verify the operative indications and results. In the early risk phase, up to 39 days after operation, 15 patients (15%) died. Mortality was mostly due to a low output syndrome and was significantly related to older age and to functional (NYHA) and anginal (CCS) class. In the late risk phase, starting 1.9 years after surgery, 9 patients died (10%) and the significant risk factors were anterior aneurysm and older age at operation. Actuarial survival curves showed 82% survival at 5 years and 61% at 9.5 years. In 25 patients older than 50 years and with an anterior aneurysm, these rates were 51% and 34%, respectively. Improved functional class was observed in 87% of the patients interviewed, but 30% complained of angina or new infarctions. Survival free of ischemia was 64% at 5 years and 13% at 9.5 years. This development of ischemic recurrences was significantly related to older age and to incomplete revascularization despite multiple grafts. These results suggest modification of the grafting policy and of the techniques of repair in identified high-risk subsets.
In the surgery of aortic dissection, only a small section of aorta compared to the extent of the aortic damage, is usually replaced. The disease is not cured by surgery and needs continuous postoperative surveillance and medical therapy. We report the follow-up of 105 patients who were operated upon between January 1970 and April 1986 and discharged from hospital. Overall actuarial survival was 90% at 5 years, 52% at 10 years and 39% at 15 years. There were 20 deaths, mostly (85%) related to cardiovascular causes. Survival times were correlated, using multivariate methods, with several pre-, peri- and postoperative variables to identify significant risk factors and to calculate actuarial survivals. We found that postoperative low output syndrome (p = 0.007) and stroke (p = 0.04) adversely affected survival and that previous aortic disease or operation (p = 0.004) was associated with an increased rate of dissection-related complications. On the contrary, preoperative hypertension was related to a significantly better survival (p = 0.01) and survival free of dissection-related complications (p = 0.001). When dissection was related to hypertension, adequate postoperative medical treatment neutralized the progression of the aortic damage and its consequences. When dissection was not due to hypertension, the observed survival was unsatisfactory, probably because of a more fragile aorta and inadequate medical follow-up therapy.
All patients undergoing isolated aortic valve replacement with a standard Hancock porcine bioprosthesis (PB), from 1970 to 1983, were reviewed. There were 196 patients, 162 male and 34 female patients, with a mean age of 48 +/- 12 years. Operative survivors were followed up from 3 to 15.6 years (mean follow-up, 6.6 +/- 1.5 years), with a cumulative follow-up of 1,140 patient-years, being 100% complete. Actuarial survival was 51 +/- 15% at 14 years. Eight patients sustained systemic embolic episodes (0.7 +/- 0.2%/patient-year); actuarial freedom from emboli is 89.4 +/- 4.3% at 14 years. Reoperation was performed in 53 patients: in 6 because of endocarditis (0.5 +/- 0.2%/patient-year), in 7 because of perivalvular leak (0.6 +/- 0.2%/patient-year), and in 40 because of PB primary tissue failure (3.5 +/- 0.5%/patient-year). Actuarial freedom from PB-related deaths, PB failure, and overall PB-related complications at 14 years was 66.3 +/- 19, 34.3 +/- 11, and 30 +/- 10%, respectively. This long-term experience shows that the performance of the Hancock PB appears satisfactory up to 8 years, while it progressively deteriorates beyond 10 years because of the impact of primary tissue failure on valve durability, justifying the restriction of its use in the aortic position in selected patients.
Reoperation in porcine valve recipients is becoming increasingly frequent, owing to the limited durability of the valves. In reviewing our experience with first reoperation for porcine valve failure in 191 patients over a 17-year period, we found that following certain routine surgical steps can minimize complications and improve the surgical outcome. Extended dissection of the heart is useful during mitral bioprosthetic replacement to enhance visualization of the failing device while retracting the left atrium without undue tension on fragile structures such as the left innominate vein-superior vena cava junction. This maneuver can be avoided, however, when replacement of an aortic bioprosthesis is required. Excision of a porcine valve is performed by peeling off the fibrous tissue overgrown on the sewing ring, which exposes the underlying sutures, cutting each knot, and finding a plane between the stent and the native valve annulus by careful blunt dissection. Care is taken not to cut the Dacron cloth of the sewing ring to avoid the potential for embolization of the silicone sponge contained within it. The use of this technique helps to minimize postoperative complications such as paravalvular leak or atrioventricular block and to preserve the native annulus, which facilitates insertion of a new prosthesis. Our experience indicates that first reoperation in porcine valve recipients can be performed with low risk, particularly in elective cases, and with a low incidence of complications related to repeat median sternotomy.