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Massimo Bonacchi

Publications and source records attributed to Massimo Bonacchi.

At least 19 recordsLinked to original sources
PubMed2006

Does off-pump coronary revascularization reduce the release of the cerebral markers, S-100beta and NSE?

OBJECTIVES: The aims of this study were to (1) compare the release of S-100 beta and NSE in off-pump coronary artery bypass grafting (CABG) versus on-pump surgery; (2) investigate whether the S-100 beta and NSE serum concentrations correlate with cardiopulmonary bypass (CPB) duration. MATERIALS AND METHODS: Between October 2002 and May 2004, 42 patients undergoing first time CABG surgery were enrolled in the study. The exclusion criteria were: LVEF<35%, age>70 years, previous myocardial infarction, REDO surgery, the presence of valvular heart disease and/or cerebrovascular disease, abnormal preoperative carotid vessels angiography, coronary artery disease involving the distal circumflex artery, renal dysfunction, coagulopathy. The patients were randomly assigned either to undergo on-pump CABG surgery [group I, n=24 patients] or off-pump CABG [group II, n=18 patients]. Blood was not re-transfused from the cardiotomy suction. All patients presenting haemolysis were excluded from the study. RESULTS: The preoperative S-100beta was 0.13+/-0.08 (microg/l) and NSE 7+/-1.5 (microg/l) in group I and 0.12+/-0.1 (microg/l) and 6.9+/-2.7 (microg/l), respectively in group II. Six hours after the surgery, S-100beta in patients of group I reached a maximum level of 1.38+/-0.4 (microg/l) and NSE of 17.7+/-6.5 (microg/l) compared to 0.5+/-0.11 (microg/l) [S-100B] and NSE 8.6+/-4.2 (microg/l) in group II (p=0.001). Three (12%) patients in group I and none (0%) in group II suffered postoperative delirium, p=0.247. No strokes occurred linear regression analysis revealed a strong correlation between cardiopulmonary bypass duration and S-100beta and NSE peak levels, p<0.0021 (r(2)=0.36) and p<0.0001 (r=0.81), respectively. CONCLUSION: Coronary artery bypass surgery with CPB causes a significantly greater increase in NSE and S-100beta serum levels than off-pump surgery and correlates with CPB duration.

Aged↗
PubMed2006

Mitral valve surgery simultaneous to coronary revascularization in patients with end-stage ischemic cardiomyopathy.

Mitral valve regurgitation (MVR), occurring as a result of myocardial ischemia and global left ventricular (LV) dysfunction, predicts a poor outcome in terms of survival and morbidity. Between 1995 and 2003, 180 consecutive patients with impaired LV function and chronic ischemic MVR underwent cardiac surgery. Fifty-four patients (group I), MVR (grade III-IV) underwent simultaneous MV surgery and coronary artery bypass grafting (CABG); 40 patients (group II), MVR (grade II-III), and 86 patients (group III), MVR (grade I-II), underwent CABG alone. In group I, MV repair was performed in 36 patients (group IA) and MV replacement in 18 (group IB). The incidence of hospital death was similar between groups. The actuarial event-free survival was significantly lower in group than in groups II and III (P = 0.0045) and I (P = 0.038). The overall actuarial survival was significantly higher in group IA than in group IB (P = 0.027). Postoperatively, the LV ejection fraction (P < 0.001), LV end-diastolic diameter (P < 0.001), LV end-systolic diameter (P < 0.01), and cardiac index (P < 0.001) improved significantly in group I. The regurgitation fraction decreased significantly in Groups I and III after surgery (P < 0.001 and P = 0.003, respectively). Both MV repair and replacement that preserves subvalvular apparatus in patients with end-stage ischemic myocardiopathy offer an acceptable outcome. Mitral valve repair simultaneous to CABG improves significantly the LV function and its geometry. In patients with mild to moderate mitral regurgitation, CABG alone may be performed with good overall survival, but with lower event-free survival than those undergoing concomitant mitral valve repair.

Aged↗
PubMed2006

Perioperative and clinical-angiographic late outcome of total arterial myocardial revascularization according to different composite original graft techniques.

Total arterial myocardial revascularization (TAMR) is advisable because of the excellent long-term patency of arterial conduits. We present early and midterm outcomes of five different surgical configurations for TAMR. Between January 1998 and May 2004, 112 patients (aged 56.5 +/- 4.5 years, 20% female) with three-vessel disease underwent TAMR. The internal mammary arteries (IMAs) were harvested in a sketelonized fashion. The surgical techniques for TAMR consisted in Y or T composite grafts (n = 88, 78%) constructed between the in situ right IMA (RIMA) and the free left IMA (LIMA) graft (n = 58) or the radial artery (n = 30) (RA) in three different configurations. The other techniques consisted in T- and inverted T-graft (n = 24, 22%) constructed between the RA conduit and the free LIMA graft in two different configurations. The mean follow-up time was 40 +/- 23 months. Postoperative angiographic control was performed in 76/111 (70%) patients. Overall, 472 arterial anastomoses (average 4.2 per patient) were performed. One (0.9%) patient, undergoing the inverted T-graft technique, died on postoperative day 2. Another patient (0.9%), undergoing the lambda-graft technique using both IMAs and RA, suffered a new myocardial infarction probably due to RA conduit vasospasm. One week after surgery, after the transthoracic echocardiographic Doppler with adenosine provocative test, the coronary flow reserve (CFR) at the LIMA and RIMA main stems were 2 +/- 0.4 and 2.4 +/- 0.3, respectively. At 12-month follow-up, after adenosine provocative test, the CFRs at the LIMA and RIMA stems were significantly higher than the values at 1 week after surgery within the same group; (LIMA)CFR (1 week) 2.4 +/- 0.3 (12 months) vs 2 +/- 04 (1 week), P = 0.002; (RIMA)CFR 2.58 +/- 0.4 vs 2.4 +/- 0.3, P = 0.001. The CFR at the RIMA main stem was higher in all measurements within the same group than in the LIMA main stem, but not significantly. In one patient undergoing the lambda-graft technique using both IMAs, the RIMA was found to have a string sign. Postoperative angiography in 50 patients showed that the patency rate for the LIMA was 100%, for the RIMA 97.3%, and for the RA 96.7%. Angiography at 3-year follow-up in 76 patients documented excellent patency rates of the LIMA (97.4%), RIMA (95%), and RA (87%). Survival at 7 years was 92.5%, event-free survival 89.3%, and freedom from angina 94%. Total arterial myocardial revascularization using different surgical configurations is safe and effective. The use of composite arterial grafts provides excellent clinical and angiographic results, with a low rate of angina recurrence and late cardiac events. These configurations allow for complete arterial revascularization.

Adult↗
PubMed2005

Skeletonized bilateral internal mammary arteries for non-elective surgical revascularization in unstable angina.

OBJECTIVE: The aim of this study was to evaluate the feasibility, safety and outcome of skeletonized bilateral internal mammary arteries (BIMA) in patients with unstable angina (UA) undergoing non-elective myocardial revascularization. METHODS: Between January 1997 and December 2003, 758 patients, mean age 62+/-12 years, underwent non-elective coronary artery bypass grafting (CABG) for unstable angina. Two hundred and five (27%) were operated emergently and 503 (73%) urgently. BIMA were employed in 320 (42%) patients (Group B) and isolated left IMA and/or saphenous vein grafts in the remaining 438 (58%) patients (Group M). RESULTS: In-hospital mortality (B = 5.9% and M = 5.3%), and perioperative myocardial infarction (B = 2.2%; M = 1.96%) were similar between the two groups (P = ns). Actuarial survival at 1, 3 and 7 years was 98.7, 97.5 and 96.2% in B and 99, 94.3 and 88.4% in M (P < 0.05 at 7 years follow-up). At 7 years follow-up, the event-free cardiac survival (92 vs. 87%, P = 0.021), angina-free survival (98.6 vs. 94%, P = 0.039), reoperation-free cardiac survival (98 vs. 95%, P = 0.04) and infarct-free cardiac survival (98.7 vs. 96%, P = 0.05) were better in Group B. Multivariate analysis identified age > 65 years (P = 0.02), LVEF < 35% (P = 0.01), > 1 ischemic irreversible area (P = 0.03) as independent predictors for late deaths, while the use of the LIMA (P=0.006) and both mammary arteries (P=0.001) decreased the risk of late deaths. CONCLUSIONS: The use of BIMA in non-elective CABG for UA is safe and effective. Mid-term outcome, however, are superior with improved freedom from cardiac death, from coronary reintervention and from myocardial infarction.

Aged↗
PubMed2005

Pharmacological modulation of the hyperpolarization-activated current (I f) in human atrial myocytes: focus on G protein-coupled receptors.

AIMS: In human atrial myocytes (HuAM) two beta-adrenergic receptors (beta-AR) and four splicing-variants of the serotonin 5-HT(4) receptor are present. Multiple coupling with G stimulatory (G(s)) and G inhibitory (G(i)) proteins has been proposed for both beta(2)-AR and 5-HT((4b)) subtypes, but no functional data exist in HuAM. Serotonin (5-HT) and catecholamines are able to trigger arrhythmias in human atrium, but the underlying cellular mechanisms are not completely understood. The pacemaker current (I(f)) is an inward Na(+)/K(+) current, constitutively present in HuAM and directly modulated by cAMP; I(f) could play a role in triggering human atrial arrhythmias. This study evaluated the different G protein coupling of beta(1)-AR, beta(2)-AR and 5-HT(4) receptors by assessing the modulation of I(f) by selective stimuli. METHODS: HuAM were isolated from right atrial appendages and utilized for patch-clamp recording. The coupling of receptor subtypes with G(i) proteins was tested by incubating HuAM in pertussis toxin (PTX). RESULTS: Beta(1)-AR stimulation (Isoprenaline [ISO] + ICI 118,551), and 5-HT caused a concentration-dependent significant shift of the half activation potential of I(f) activation curve (DeltaV(h)), P < 0.01. beta(2)-AR stimulation (ISO 1 microM + CGP 20712A) also significantly shifted V(h) (P < 0.0001), but with DeltaV(h)[beta(2)-AR] significantly smaller than the effect caused by 1 microM beta(1)-AR stimulation (P < 0.05). Pre-treatment of HuAM with PTX did not alter the effect of beta(1)-AR stimulation (both 0.1 and 1 microM) and 1 microM 5-HT on I(f), but significantly increased the effect in response to beta(2)-AR stimulation and 0.1 microM 5-HT (P < 0.05 for both), thus suggesting a G(i) protein coupling of these receptors. CONCLUSIONS: Our results provide the first functional evidence of the different G protein coupling of beta(1)-AR, beta(2)-AR and 5-HT(4) receptors in HuAM. Further they support the view that I(f) current might play an important role in triggering catecholamines and serotonin-induced atrial arrhythmias.

Aged↗
PubMed2004

Atrial natriuretic peptide modulates the hyperpolarization-activated current (If) in human atrial myocytes.

OBJECTIVES: The relationship between atrial stretching and changes in cell excitability is well documented. Once stretched, human atrial myocytes (HuAM) release atrial natriuretic peptide (hANP). Receptors for hANP (NPR) are coupled to a guanylyl cyclase (GC) activity, and are present on HuAM, but the electrophysiological effects of hANP are largely unknown. We investigated the effect of hANP on If, the hyperpolarization-activated current present in HuAM, and the underlying intracellular pathway. METHODS: HuAM were isolated from atrial appendages and utilized for patch-clamp recording. RESULTS: hANP caused a significant and concentration dependent shift of the midpoint activation potential (DeltaVh) toward less negative potentials of 6.9 +/- 1.0 mV at 0.1 nM; 13.0 +/- 2.6 mV at 1 nM and 15.3 +/- 2.2 mV at 10 nM (p < 0.001 for all); a parallel increase of If rate of activation occurred. The effect of hANP was completely blocked by isatin, a potent antagonist of NPR (p < 0.01 vs. hANP). In the presence of the inhibitors of guanylyl cyclase (ODQ and LY83583), hANP caused a significantly smaller DeltaVh (p < 0.01 vs. hANP for both). 8Br-cGMP mimicked the effect of hANP, both in the presence and absence of KT5823, a selective inhibitor of Protein kinase G. Pretreatment with pertussis toxin (PTX) did not change the effect of hANP, thus excluding a major role for the coupling of NPR with the Gi-Proteins system. Pretreating cells with cyclopentyladenosine (CPA), an A1-adenosine receptor agonist, completely blocked hANP effect. Adding hANP to maximal serotonin concentration produced an additive response. CONCLUSIONS: Our data demonstrate for the first time that ANP is able to increase If, likely through a modulation of intracellular cGMP and cAMP levels. This effect could have implications in the relationship between stretch and arrhythmogenesis in the human atrium.

Adenosine↗
PubMed2004

Repair of complete atrioventricular septal defects in patients weighing less than 5 kg.

BACKGROUND: The aim of this study was to evaluate the impact of weight less than 5 kg at operation on mortality and morbidity in patients with atrioventricular septal defect (AVSDc) undergoing total correction. METHODS: Between January 1990 and December 2002, 190 consecutive patients with AVSDc underwent total biventricular correction. They were divided into two groups: group I (n = 64 patients weighing < 5 kg) and group II (n = 126 patients weighing > 5 kg). Associated major cardiac malformations were found in 49 (25.8%) patients. Associated left atrioventricular valve (LAVV) malformations were found in 35 (18.4%) patients. The mean follow-up time was 4.1 +/- 2.9 years (range 2 months-10.7 years). RESULTS: The in-hospital mortality in group I was 7.8% (5 patients) versus 8.7% (11 patients) in group II (p = 0.95). Major associated cardiac malformations (p < 0.001) and pulmonary hypertension (p = 0.006) were found to be strong predictors for poor postoperative survival. At discharge the mean LAVVR grade in group I was 1.45 +/- 1.2 versus 1.2 +/- 1 in group II (p = 0.13). The actuarial overall survival rates at 1, 3, 5, and 7 years were 96.5%, 92.5%, 91.5%, and 89% respectively and the actuarial overall reoperation free survival rates at 1, 3, 5, and 7 years were 95%, 87%, 84%, and 73%. Twenty-three patients underwent reoperation due to severe left atrioventricular valve regurgitation (LAVVR). Strong predictors for overall reoperation free survival were the operation year before 1995 (p < 0.001), postoperative LAVVR greater than or equal to 2 (p = 0.006), major associated cardiac malformations (p = 0.00034), associated LAVV malformations (p = 0.0044), and non or partial LAVV cleft closure (p = 0.012). The actuarial survival rates between patients weighing less than 5 kg versus patients weighing more than 5 kg were similar (p = 0.51); instead the overall reoperation free survival was significantly lower in patients weighing less than 5 kg (p = 0.022) according to the log-rank test. Weight less than 5 kg (p = 0.023, beta = -0.6) was one of the predictors for reoperation due to severe LAVVR in this series. CONCLUSIONS: We may conclude that in the current era repair of AVSDc can be carried out successfully in patients less than 5 kg, however, weight less than 5 kg at initial complete repair seems to be a predictor for late reoperation due to LAVVR. Suture separation at the cleft site or between the leaflets of the newly created mitral valve and the patch remain the main causes of postoperative LAVVR in patients weighing less than 5 kg.

Cardiac Surgical Procedures↗
PubMed2004

[Use of skeletonized double mammary arteries for emergency/urgency myocardial revascularization in unstable angina: technical aspects and long-term outcome].

BACKGROUND: Surgical revascularization employing bilateral internal mammary arteries (IMAs) is an excellent procedure in elective surgery, but its role in urgent/emergent procedures is still debating. This retrospective study evaluates the feasibility, safety and surgical early outcomes of employing double skeletonized IMAs in patients with unstable angina (UA) undergoing urgent/emergent revascularization. METHODS: From January 1997 to May 2004, 824 patients (491 males, 333 females, mean age 64 +/- 12 years) underwent urgent revascularization for UA. Bilateral IMAs were employed in 346 (42%) patients (group B) and isolated and/or saphenous vein grafts in the remaining 478 (58%) patients (group M). There were no significant differences in preoperative risk factors between the two groups (mean EuroSCORE value). RESULTS: Postoperative stay was free from complications in 87% of patients of group B and 91% of group M. In-hospital mortality (group B 5.9%, group M 5.3%, p = NS) and perioperative myocardial infarction (group B 2.2%, group M 1.96%, p = NS), mean coronary care unit stay and total hospital stay were similar in both groups. Actuarial survival at 1, 3, 5 and 7 years was respectively 98.7, 97.5, 96.9 and 96.1% in group B and 99, 93.4, 92.1 and 88.4% in group M (p < 0.05). At a mean follow-up of 6.6 years the event-free survival (p = 0.021) and reoperation-free cardiac survival (p = 0.003) were better in group B. Multivariate analysis identified that age > 65 years (p = 0.01), congestive heart failure (p = 0.001), left ventricular ejection fraction < 35% (p = 0.03), and > 1 ischemic irreversible area (p = 0.02) are negative predictors for reoperation-free cardiac survival. The employment of the left IMA (p = 0.006) and of both IMAs (p = 0.001) were positive predictors for the overall survival and reoperation-free cardiac survival. CONCLUSIONS: Our results show that the use of skeletonized bilateral IMAs is associated with an acceptable risk and a lower incidence of postoperative complications in patients with UA, improving late outcomes in this group of patients.

Actuarial Analysis↗
PubMed2003

Anomalous origin of the left pulmonary artery from the aorta. Our experience and literature review.

Three patients with anomalous origin of the left pulmonary artery (AOLPA) from the aorta underwent surgical correction. Two patients presented with an isolated malformation and one with an associated ventricular septal defect. One of the patients with an isolated malformation presented with an AOLPA from the descending thoracic aorta. Implantation of the AOLPA to the main PA trunk was performed by direct anastomosis in two patients and by interposition of a synthetic graft in the other patient with AOLPA from the descending aorta. All patients survived the operation. Low cardiac output was identified in one patient. The mean residual gradient through the anastomotic site was 21 mmHg at follow-up. We found almost 72 cases with AOLPA reported in the literature with a high mortality rate in patients not undergoing surgery. The most frequently found associated malformation is tetralogy of Fallot and ventricular septal defect. AOLPA from the aorta is a rare but important entity, necessitating a scrupulous preoperative and intraoperative evaluation. Patients with AOLPA can undergo surgical repair with excellent results.

Adult↗
PubMed2003

The "omega-anastomosis": a new revascularization technique for coronary bifurcations.

We report the "omega-anastomosis," a new technique permitting the revascularization of both coronary branches beyond a bifurcation by using a single arterial graft. This technique consists of a longitudinal incision in the main coronary artery, which extends to both coronary branches beyond the bifurcation. The arterial conduit's distal extremity is cut vertically and tailored to produce a "bipetal" shape, which is used to enlarge and create an acceptable roof for both coronary branches beyond the bifurcation.

Anastomosis, Surgical↗
PubMed2003

In situ retrocaval skeletonized right internal thoracic artery anastomosed to the circumflex system via transverse sinus: technical aspects and postoperative outcome.

BACKGROUND: The aim of this study was to investigate whether, by using the in situ right internal thoracic artery via the transverse sinus (eventually retrocaval), both the proximal and distal major branches of the circumflex system could be grafted and to evaluate the early and late outcome in these patients. METHODS: Between January 1997 and March 2002, 452 consecutive patients underwent grafting of the circumflex system with the in situ skeletonized right internal thoracic artery routed via the transverse sinus. The mean age was 62.4 +/- 10.3 years. A mean of 2.2 +/- 0.3 arterial grafts per patient were used, and 271 (60%) patients underwent total arterial myocardial revascularization. At 3 months after surgery, 86 patients (right Y or T graft) underwent echo color Doppler imaging before and after an adenosine provocative test. The mean follow-up was 27 +/- 8 months. RESULTS: The success rate of skeletonized right internal thoracic artery grafting to the circumflex system branch was 100%. There were 15 (3.4%) hospital deaths. In 116 patients who underwent postoperative angiography, the total patency rates of the right and left internal thoracic arteries were 94% and 96.6%, respectively. Strong predictors for nonfunctional internal thoracic artery grafts were a small internal thoracic artery caliber (P <.001), recipient coronary artery diameter less than 1.5 mm (P =.012), stenotic lesions of less than 60% (P =.016), and diffuse stenotic lesions (P =.015) of the recipient coronary artery. In 86 patients who underwent postoperative echo color Doppler imaging, the flow reserves at the main stem of the left and right internal thoracic arteries were 2.24 +/- 0.5 and 2.48 +/- 0.6, respectively. Cumulative actuarial survival at 3 years was 96.3%, and event-free cumulative survival was 93%. The Cox model revealed a left ventricular ejection fraction of less than 35% (P =.016), age greater than 70 years (P =.025), New York Heart Association grade greater than III (P =.0019), nontotal arterial myocardial revascularization (P =.002), and the preoperative presence of more than 1 ischemic area (P <.001) as strong predictors for poor overall cumulative event-free survival. CONCLUSIONS: The skeletonized right internal thoracic artery, placed via the transverse sinus and eventually retrocaval, can reach most branches of the circumflex system and is associated with an excellent patency rate. The predictors for poor overall event-free survival seem to be similar to those of the general population undergoing conventional coronary artery bypass grafting. Use of bilateral internal thoracic arteries and in situ right internal thoracic artery grafting via the transverse sinus offers the possibility of various configuration constructions, making possible total arterial myocardial revascularization with a minimum number of arterial conduits.

Adult↗
PubMed2003

Postoperative outcome in patients with anomalous origin of one pulmonary artery branch from the aorta.

OBJECTIVES: The aim was to review our experience with the surgical repair of the anomalous origin of one pulmonary branch from the aorta (AOPA). MATERIALS AND METHOD: Between January 1991 and March 2002, eight patients with AOPA underwent surgical correction. Three patients presented isolated AOPA. Five patients presented right AOPA and three, left AOPA. Implantation of the AOPA to the main pulmonary artery was performed by: (I) direct anastomosis in two patients with left AOPA; (II) interposition of a synthetic graft in one patient with left AOPA; (III) employing an autologous pericardial patch in two patients with right AOPA; (IV) using an aortic flap in three other patients with right AOPA. The mean follow-up time was 37.7 months. RESULTS: One patient died postoperatively due to progressive heart failure unresponsive to inotropic support. Early postoperative pulmonary hypertension crisis was identified in another patient. Within 1 year after surgery, the mean residual gradient across the anastomotic site at follow-up was 14+/-8 mmHg. The patient undergoing interposition of a synthetic graft presented a residual gradient of 29 mmHg and underwent reoperation at almost 2.5 years after the first correction. The residual gradient in patients undergoing correction according to technique I was 17+/-3 mmHg, and in patients undergoing implantation of the AOPA according to techniques III or IV was 9.5+/-4.6 mmHg (P=0.11). Similarly, the Tc-99m scintigraphy demonstrated that a lower lung perfusion (the lung perfused from the respective AOPA compared with the contralateral lung) in patients undergoing AOPA implantation according to technique I was 59+/-6(%) and in patients undergoing techniques III or IV was 72+/-4.5(%) (P=0.038). At follow-up, all patients were alive. CONCLUSION: The AOPA from the aorta is a rare but important entity, necessitating a scrupulous preoperative and intraoperative evaluation. Patients presenting this anomaly may undergo correction using various surgical techniques with acceptable results. The techniques employing autologous tissues for enlarging and lengthening the AOPA seems to be associated with less restenosis at the anastomotic site, however, larger series of patients are required to confirm such outcome.

Anastomosis, Surgical↗
PubMed2003

Postoperative outcome in patients with accessory mitral valve tissue.

Accessory mitral valve tissue (AcMVT) is a rare congenital malformation causing left ventricular outflow tract obstruction (LVOTO). The analysis of various published reports reveals 90 patients presenting with AcMVT, ranging in age from newborns to 77 years old. Severe LVOTO is present in most cases, though mild LVOTO was found in 15 patients (16.7%), and 3 other patients (3.3%) presented with no LVOTO. In our practice, we found this anomaly in 5 patients; one presenting with severe LVOTO, two with mild LVOTO, and another who developed moderate LVOTO after a myocardial infarction episode. 68 patients (75.5%) underwent cardiac surgery, with a postoperative mortality of 6 (8.9%). Postoperatively, a residual mild gradient across the left ventricular outflow tract was identified in 9 patients (13.2%). Nine other patients (13.2%) required reoperation due to severe LVOTO. Mild-to-moderate postoperative mitral or aortic valve regurgitation was found in 7 (10.3%) and 5 (7.3%) patients, respectively. Based on reported intraoperative findings, we have classified this anomaly as Type I-FIXED TYPE (A - nodular, B - Membranous), Type II-Mobile type (A - Pedunculated, B - leaflet-like). Type IIB is divided into 1) rudimentary chordae and 2) developed chordae. Based in our own experience and after the analysis of various reports, we conclude that patients with AcMVT causing LVOTO may undergo safe mass excision with acceptable postoperative mortality and morbidity. The removal of the AcMVT should in no way compromise mitral valve function, and its excision should be made subject to careful evaluation of the surrounding structures.

Adolescent↗
PubMed2003

Total correction of complete atrioventricular septal defect with tetralogy of Fallot.

BACKGROUND AND AIM OF THE STUDY: The authors' experience in surgical management of tetralogy of Fallot in association with complete atrioventricular septal defect (CAVSD-TOF) is reported. METHODS: Between January 1990 and September 2001, 146 children with CAVSD underwent complete correction. ASD closure was performed using a one-patch technique, with autologous pericardial patch. Seventeen patients presented with CAVSD-TOF, of whom nine (53%) had undergone previous palliation. Mean age at repair was 2.9 +/- 1.9 years. The mean gradient across the right ventricular outflow tract (RVOT) was 63 +/- 16 mmHg. Six patients (35%) required a transannular patch. RESULTS: Overall in-hospital mortality was 10%. Among patients with CAVSD-TOF, three died in hospital (18%); causes of death were progressive heart failure (n = 2) and multiple organ failure (n = 1). Two patients required mediastinal exploration due to significant bleeding, and two late reoperation for severe left atrioventricular valve regurgitation after intracardiac repair. Mean follow up was 36 +/- 34 months. All patients survived and are currently in NYHA class I or II. At follow up, mean gradient across the RVOT was 17 +/- 6 mmHg, significantly less than the preoperative value (p < 0.001). CONCLUSION: Complete repair in patients with CAVSD-TOF offers acceptable early and mid-term outcome in terms of mortality, morbidity and reoperation rate. Palliation prior to repair may be preferred in cases with small pulmonary arteries, or in severely cyanotic neonates. The RVOT should be managed as for isolated TOF, but a transatrial-transpulmonary approach is the surgery of choice.

Cardiac Surgical Procedures↗
PubMed2002

Does ministernotomy improve postoperative outcome in aortic valve operation? A prospective randomized study.

BACKGROUND: The aim of this study was to compare the postoperative outcome obtained in patients undergoing elective aortic valve operation, either through ministernotomy or conventional sternotomy. METHODS: Between January 1999 and July 2001, 80 consecutive patients undergoing elective aortic valve replacement were randomly divided into two groups: group I (n = 40 patients) undergoing a ministernotomy approach (reversed-C or reversed-L), and group II (n = 40 patients) undergoing conventional sternotomy. RESULTS: The length of skin incision was significantly shorter in group I than in group II (8.2+/-1.3 cm versus 23.7+/-2.6 cm, p < 0.001). No significant differences were found in cardiopulmonary bypass duration, associated procedures, or aortic cross-clamping times. Total operating time was 3.7+/-0.46 hours in group I compared with 3.4+/-0.6 hours in group II (p = 0.014). A similar incidence of cardiac, neurologic, infective, and renal complications between groups was found. Mean mediastinal drainage and mean blood transfusions (amount of blood transfused) per patient were greater in group II (p < 0.004 and p < 0.001, respectively). Twenty-five (62.5%) patients in group II and 15 (37.5%) patients in group I required postoperative blood transfusion (p = 0.04). Mechanical ventilation time was significantly longer in group II (6.2+/-1.8 hours versus 4.4+/-0.9 hours, p = 0.006). Five days after the surgical procedure, spirometric data analysis demonstrated a significantly lower total lung capacity and maximum inspiratory and expiratory pressures in group II compared with group I (p = 0.003, p = 0.007, and p < 0.001, respectively). CONCLUSIONS: Our results showed that ministernotomy had not only important cosmetic advantages but also beneficial effects in blood loss and transfusion, postoperative pain, and probably in sternal stability. Ministernotomy also improved recovery of respiratory function and allowed earlier extubation and hospital discharge.

Aged↗
PubMed2002

Repair of congenital malformations of the mitral valve: early and midterm results.

BACKGROUND: The aims of this study were to determine early and midterm survival and freedom from reoperation, and to identify the predictors for poor postoperative outcome in children undergoing mitral valve (MV) repair owing to congenital malformations of the mitral valve. METHODS: Between January 1990 and February 2001, 94 consecutive children with congenital MV disease underwent valve repair. The mean age was 5.2+/-3.3 years (range 20 days to 15 years). Twenty-five (26.6%) children were less than 1 year old. Isolated MV disease was found in 21 (22.4%) patients. MV stenosis was the predominant lesion in 21 (22.4%) patients with a mean left atrial to left ventricle diastolic peak gradient of 24.5+/-9.2 mm Hg. MV regurgitation was the predominant pathophysiology in 73 (77.6%) patients with a mean regurgitation grade of 3.3+/-0.7. RESULTS: The hospital mortality was 8.5% (8 of 94). Three patients required permanent pacemaker implantation owing to complete atrioventricular block. Two patients underwent mediastinal exploration for significant bleeding. Postoperatively the echocardiography color Doppler study demonstrated a significantly lower mean end diastolic left atrium to left ventricle gradient 8.7+/-2.2 mm Hg (p < 0.001) in patients with MV stenosis and a mean regurgitation grade of 0.9+/-0.6 (p < 0.001) in patients with MV regurgitation. Actuarial survival and actuarial reoperation-free survival were 89.2% and 76.3%, respectively. Multivariate analysis demonstrated that age less than 1 year (p = 0.035), hammock MV (p = 0.0093), cardiothoracic ratio greater than 0.6 (p < 0.0001), and associated cardiac anomalies (p = 0.003) were strong predictors for poor overall freedom from reoperation and midterm survival. CONCLUSIONS: Mitral valve repair for congenital mitral valve disease yields acceptable early and midterm mortality and reoperation rates. Strong predictors for poor overall freedom from reoperation and midterm survival were age less than 1 year, hammock MV, cardiothoracic ratio greater than 0.6, and associated cardiac anomalies.

Actuarial Analysis↗
PubMed2002

Early and long-term outcome in patients undergoing aortic root replacement with composite graft according to the Bentall's technique.

OBJECTIVE: The aims of this study were: (i) to evaluate the early and long-term outcome in patients undergoing aortic root replacement (ARR) with a composite graft; (ii) to identify the predictors for poor overall survival in this pool of patients. MATERIAL AND METHODS: Between January 1989 and December 2000, 212 patients underwent ARR with a CG. Mean age was 56+/-14 years, ranging from 16 to 77. Annuloaortic ectasia was the most frequent cause of aortic disease in this series, 81 (38%) patients, followed by atherosclerotic aneurysm 57 (27%) and type A acute aortic dissection 52 (24.5%). Marfan's syndrome was present in 37 (17.5%) patients. Duration of follow-up ranged from 1 to 120 months, mean 59+/-35 months. RESULTS: The overall hospital mortality was 16 (7.5%) patients. Eight of them had aortic dissection and four Marfan syndrome. The most frequently found complication resulted to be renal failure in 22 (10%) patients and low cardiac output in 15 (7%) patients. The incidence of perioperative myocardial infarction, neurological complications, respiratory complications, renal failure and coagulopathy incidence were significantly higher in patients with cardiopulmonary bypass (CPB) time >170 min, CA >40 min, and total aortic arch replacement. The actuarial survival at 1, 3 and 5 years resulted to be 91.8, 86 and 81.5%, instead the actuarial survival without re-operation resulted to be 89, 82 and 78%. The actuarial survival in patients with aortic dissection was significantly lower versus non-dissection (P=0.022). The multivariate analysis revealed the aortic dissection (P=0.03), age >65 years (P=0.014), associated coronary artery disease (P=0.002), NYHA functional class>/=3 (P=0.027), LVEF <35% (P=0.002) and total arch reconstruction (P=0.003) as strong predictors for poor overall survival in patients undergoing ARR. CONCLUSIONS: The ARR with a CG offers acceptable early and long-term outcome. The predictors for poor overall survival in patients undergoing ARR seems to be preoperative aortic dissection extended into the aortic arch, older age, depressed left ventricular function and associated coronary artery disease.

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