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Biomedical subjects

O Alfieri

Publications and source records attributed to O Alfieri.

At least 55 records · Page 3Linked to original sources
PubMed1999

Primary cardiac sarcoma in pregnancy: a case report and review of the literature.

Primary cardiac sarcoma (PCS) is a rare disease with a poor prognosis, because of diagnostic delay, therapeutic difficulties, and high metastatic potential. Surgery is the standard treatment. A case of PCS in pregnancy is reported, with a review of published surgical series of PCSs, focusing on the role of surgery and adjuvant therapy. Prompt surgery improved cardiac function and patients' outcome in comparison with untreated cases. The role of adjuvant treatment was analyzed only in a few series, mainly without distinction between postoperative chemotherapy and radiotherapy; adjuvant therapy improved survival in the larger series of resected PCSs. Only three other cases of PCS in pregnancy were reported. In the present case, resection was performed with no major complication for the mother and the infant. Even if the patient's survival was short, cardiac surgery allowed prolonging of pregnancy until an acceptable possibility of fetal survival was reached. Although resection is not curative in most cases, surgery remains the treatment of choice for PCS and has a definite palliative significance. The role of postoperative chemotherapy and radiotherapy is difficult to ascertain; however, adjuvant chemotherapy seems advisable in high-grade tumors.

Adult↗
PubMed1999

Management of pacing system related complications in patients undergoing dynamic cardiomyoplasty.

Integrity of the electrical circuit is a necessary requirement for appropriate heart/wrapped skeletal muscle interaction to be achieved in cardiomyoplasty. This article describes the management of two different complications after a cardiomyoplasty procedure involving the electrical system (infection of the abdominal cardiomyostimulator pocket and intramuscular lead fracture). Minimal approaches were carried out, which ensured the successful treatment of the infective and of the mechanical insult, and represent useful strategy for solving such uncommon problems.

Cardiomyoplasty↗
PubMed1999

Cardiac papillary fibroelastoma: report of two cases.

We report 2 cases of cardiac papillary fibroelastoma in aortic position that were successfully treated by complete surgical excision, without damage to the aortic valve. This rare cardiac tumor can be associated with serious embolic or hemodynamic complications and therefore, prompt surgical intervention is required.

Adult↗
PubMed1999

Refractory angina despite patent coronary artery bypass grafts: treatment with transmyocardial laser revascularization and scintigraphic evidence of improved myocardial perfusion.

Progression of coronary artery disease that causes recurrent angina in patients who have already undergone coronary artery bypass grafting (CABG) is a challenge to cardiac surgeons. The presence of myocardial ischemia that is not due to bypass grafts occlusion, but to the quality of the coronary vessels characterized by diffuse atherosclerotic peripheral disease, makes the situation even more difficult, since it is not possible to perform myocardial revascularization either by percutaneous transluminal angioplasty (PTCA) or by means of new grafts. We report the case of a patient who, 4 years after triple CABG, developed refractory angina despite patency of bypass grafts (to left anterior descending artery, obtuse marginal branch and posterior descending) and maximally tolerated conventional medical treatment. Native coronary arteries were occluded. Because of the exiguous caliber of the distal portion of epicardial vessels and poor run-off, a redo CABG was judged to be unfeasible. Transmyocardial laser revascularization (TMLR) was performed through left anterior thoracotomy, minimizing the risk of damage to the grafts. Clinical improvement (from CCS class IV to 0) and scintiscan showing improved myocardial perfusion to the laser-treated regions confirm the effectiveness of TMLR in otherwise inoperable coronary artery disease.

Angina Pectoris↗
PubMed1998

Preserved skeletal muscle structure with modified electrical stimulation protocol in a cardiomyoplasty patient: a clinico-pathological report.

Experimental and clinical studies have recently shown variable degrees of structural abnormalities in the transposed and chronically stimulated muscle graft after cardiomyoplasty procedure. The postoperative stimulation protocol of wrapped skeletal muscle has been claimed to be a major determinant of late structural derangement. Therefore, a modified stimulation protocol had been used after a cardiomyoplasty procedure in a 63-year-old patient. Improved postoperative hemodynamic data could be detected by pressure/volume analysis. After unexpected sudden death occurred at 15 months, autoptic examination showed preserved muscle structure, suggesting that a prudent stimulation protocol may maintain muscle viability and contribute to effective cardiac support.

Cardiomyoplasty↗
PubMed1998

The edge-to-edge technique: a simplified method to correct mitral insufficiency.

OBJECTIVE: Repair of mitral regurgitation (MR) is more demanding in case of prolapse of the anterior leaflet, posterior leaflet with calcified annulus, or prolapse of both leaflets. We evaluated a repair which consists of anchoring the free edge of the prolapsing leaflet to the corresponding free edge of the facing leaflet: the 'edge-to-edge' (E-to-E) technique. The correction results in a double orifice valve when the prolapse is in the middle portion of the leaflet and in a smaller valve orifice when the prolapse is close to a commissure. METHODS: Out of 432 patients with MR submitted to valve repair between January 1991 and September 1997, 121 (mean age 56 +/- 15.8 years) underwent E-to-E correction. The most prevalent etiology was degenerative disease (82 patients, 68%). The mechanism of MR was anterior leaflet prolapse (61 patients), posterior leaflet prolapse (24 patients), prolapse of both leaflets (28 patients) and other complex mechanisms (8 patients). In 72 patients, a double orifice was created, the paracommissural repair was done in 49 patients. RESULTS: Hospital mortality was 1.6%. Overall survival was 92 +/- 3.1% at 6 years with 95 +/- 4.8% freedom from reoperation. Mortality was unrelated to the type of repair. Mitral stenosis was never observed after the correction. At the follow-up (mean 2.2 +/- 1.5 years), all patients but 15 are class I or II. Symptoms at the follow-up are not related to residual MR. CONCLUSIONS: Midterm results of this alternative repair technique are promising, considering the high prevalence of complex anatomical lesions. The technique is simple, easily reproducible and rapidly feasible also when mitral exposure is suboptimal.

Adolescent↗
PubMed1998

[Models of preoperative risk stratification in cardiac surgery: the prediction of mortality or of survival?].

BACKGROUND: The need to assess the quality of heart surgery outcomes stimulated the development of pre-surgical risk stratification models in order to predict outcome on the basis of patient characteristics. The aim of the study was to compare the predictive accuracy of hospital mortality according to the following three models: Parsonnet (NBI Score), Higgins (CCF Score) and Roques (French Score), in a setting totally independent from the one in which the models were derived. METHODS: For each of the 516 patients undergoing heart surgery at our institution between January 1992 and December 1993, we calculated the pre-surgical risk according to the three models. Then we compared the predicted mortality against the observed mortality by means of the Shannon accuracy index, the ROC curve analysis and the overestimation histogram. RESULTS: Overall observed mortality (1.5%) was similar to the predicted mortality by the NBI Score (1.5 +/- 2.1%, p = ns), the CCF Score (1.7 +/- 2.0%, p = ns) and the French Score (1.9 +/- 2.5%, p = ns). The predictive accuracy of global mortality is very high and equal with the three models, and it is very low in the 8 patients who died (NBI Score = 0.06 +/- 0.06; CCF Score = 0.125 +/- 0.067; French Score = 0.102 +/- 0.07, p = ns). The area under the ROC curve is identical in the 3 models. CONCLUSIONS: The predicted mortality obtained by the three models is not significantly different from the observed mortality and therefore, the global accuracy is similar and very high, while it is very low for patients who will die. The models for pre-surgical risk stratification are useful for comparing the results among different institutions or different surgeons, or for monitoring the results over time in the same institution, but they cannot be used to accurately predict the individual risk of hospital mortality.

Aged↗
PubMed1997

Left ventricular pressure-volume relationships before and after cardiomyoplasty in patients with heart failure.

BACKGROUND: The aim of this study was to elucidate whether beneficial effects of cardiomyoplasty (CMP) in patients with dilated cardiomyopathy are the result of a decrease in existing ventricular dilatation or a prevention of further dilatation. METHODS AND RESULTS: Combined micromanometer-conductance catheters were used to evaluate left ventricular pressure-volume relationships in six patients with dilated cardiomyopathy before and at 6 and 12 months after CMP. Acute changes in preload and afterload were induced by a standardized leg-tilting intervention and a bolus infusion of nitroglycerin. After CMP, end-diastolic volume (EDV) decreased from 138+/-10 to 103+/-18 mL/m2 (P<.01) at 6 months and to 83+/-17 mL/m2 (P<.01) at 12 months. End-diastolic pressure (EDP) decreased from 20.2+/-6.4 to 13.9+/-7.7 mm Hg (P<.01) at 6 months after CMP. Peak ejection rate and ejection fraction increased at 6 months after CMP from 594+/-214 to 799+/-214 mL/s (P<.05) and from 26.6+/-4.7% to 40.1+/-8.3% (P<.05), respectively. Peak dP/dt decreased at 12 months after CMP from -842+/-142 to -712+/-168 mm Hg/s (P<.05). Leg-tilting before CMP increased EDP from 20.2+/-6.4 to 25.6+/-5.2 mm Hg (P<.01), end-systolic pressure (ESP) from 118+/-17 to 122+/-17 mm Hg (P<.05), and tau from 50.8+/-2.8 to 53.8+/-2.3 ms (P<.05). Six months after CMP, leg-tilting also increased EDV from 103+/-18 to 110+/-22 mL/m2 (P<.05) and ESV from 62+/-14 to 66+/-14 mL/m2 (P<.05). Before CMP, nitroglycerin decreased EDP from 20.2+/-6.4 to 10.4+/-3.8 mm Hg (P<.01), ESP from 118+/-17 to 96+/-11 mm Hg (P<.05), ESV from 100+/-11 to 89+/-7 mL/m2 (P<.05), and tau from 50.8+/-2.8 to 44.5+/-3.7 ms (P<.05). Six months after CMP, nitroglycerin decreased EDP, ESP, and tau to similar values. CONCLUSIONS: Our findings show that up to 1 year after CMP, marked decreases in left ventricular volume are present. Our measurements suggest that CMP actively reduced the dilated ventricle but did not prevent a higher EDV on an increased venous return. The latissimus dorsi muscle wrap contraction results in better synchronization of contraction and more rapid emptying of the left ventricle.

Cardiomyopathy, Dilated↗
PubMed1997

Risk stratification for open heart operations: comparison of centers regardless of the influence of the surgical team.

BACKGROUND: Risk-adjusted mortality was previously used to compare institutions as a whole or surgeons. Because the same surgical team is working in two different hospitals, the aim of our study was to assess whether the institution can make a difference in surgical mortality. METHODS: Preoperative data of 554 patients in institution A and 500 in institution B were prospectively collected during the same period of time. All patients were operated on by the same surgeon with the same first assistant and anesthesiology staff in both institutions. Patient population was stratified according to Parsonnet's predictive model, in five risk groups, and mortality was adjusted by the direct standardization method. RESULTS: At institution A it was observed that in-hospital mortality was 2.3% (95% confidence interval, 1.3% to 4.0%), and in institution B 4.0% (95% confidence interval, 2.5% to 6.1%). The difference between the two mortality rates (1.7%; 95% confidence interval, -0.5% to 3.8%) is not statistically significant (p = 0.16), nor is the difference within each class. The standardized mortality ratio was 3.6% (95% confidence interval, 2.7% to 4.8%) and 5.8% (95% confidence interval, 4.6% to 7.2%), respectively. The difference of 2.2% (95% confidence interval, 0.5% to 3.8%) is statistically significant (p = 0.01). CONCLUSIONS: The institution can affect mortality of patients undergoing open heart operations, regardless of the influence of the surgical team.

Cardiac Surgical Procedures↗
PubMed1997

Cardiomyoplasty as an isolated procedure to treat refractory heart failure.

OBJECTIVE: Cardiomyoplasty represents a controversial therapy for chronic heart failure. The aim of this study is to review our experience of such a surgical procedure as an isolate approach to treat refractory left ventricular dysfunction. METHODS: Twenty-two patients were considered candidates for cardiomyoplasty because of chronic heart failure. Mean age was 58.7 +/- 5.3 (range 48-71 years), 19 patients were male and 3 were female. Ischemic or idiopathic etiology was present in 11 cases, respectively. Traditional as well as innovative techniques were used to assess hemodynamic function. Pre-operative hemodynamic profile included mean left ventricular ejection fraction of 20 +/- 5.8% (9-28%), absence of severe right ventricular failure, and mean left ventricular end-diastolic diameter of 75.5 +/- 7.4 mm (range 61-92 m). All patients were in New York Heart Association Class III or Intermittent IV despite conventional medical therapy. RESULTS: There was no intra-operative death. No additional surgery was performed. Left latissimus dorsi (LD) muscle was used in 20 cases, and right LD in two patients. Early mortality occurred in one patient (low cardiac output syndrome), whereas late mortality in five patients (three sudden deaths, one lung cancer, one heart failure). Mean follow-up is 20.7 +/- 16.7 months (3-51 months). Actuarial survival at 4 years is 70%. Cardiac index increased at 6 months (3.08 +/- 0.5 l/min per m2, P = 0.04), but no other significant changes were observed in the long term (3.03 +/- 0.7 l/min per m2, 3 +/- 0.7 l/min per m2, and 2.85 +/- 0.7 l/min per m2, at 12, 24 and 36 months, respectively). Ejection fraction improved at 6 and 12 months (29.1 +/- 1.03%, P = 0.0017; and 27.3 +/- 5.6%, P = 0.0091, respectively), while no substantial augmentation was documented at 2 and 3 years (25.6 +/- 2.5% and 25.1 +/- 4.0%, respectively). Left ventricular end-diastolic diameter was markedly reduced at 6 (73.2 +/- 8.0 mm, P = 0.0176), 12 (69.4 +/- 8.5 mm, P = 0.002) and 24 months (71.1 +/- 7.0 mm, P = 0.011), and was then stable (74.0 +/- 9.1 mm, P = 0.47) at 36 months. Postoperative pressure/volume loop evaluation showed some improvement of hemodynamic function from skeletal muscle assistance. Acute pulmonary edema episodes, as well as number of hospitalizations, were considerably reduced following cardiomyoplasty. CONCLUSIONS: In our experience, cardiomyoplasty was shown to exert moderate beneficial influence on left ventricular performance, to significantly reduce cardiac dilatation and to promote the stabilization of the disease course.

Actuarial Analysis↗
PubMed1997

[Repair in rheumatic mitral valve insufficiency].

OBJECTIVES: Emerging evidence indicates that etiology plays an essential role in the results of mitral valve repair. In this study, we examined the long-term performance of this procedure in 61 consecutive patients with pure rheumatic mitral insufficiency. PATIENTS: Patient ages ranged from 4 to 74 years (mean: 51.7 +/- 16). Preoperatively, 94% of the patients were in NYHA class II or III. RESULTS: There was no hospital mortality. According to actuarial methods 94.1% of the patients were alive 7 years postoperatively and 83.3% were reoperation free. Freedom from reoperation was significantly higher in patients who received a prosthetic ring than in those who had other types of annuloplasty (96.7% vs 59.3%; p = 0.001). As opposed to the literature, in our series there was no relationship between valve failure and age at the time of reoperation. There were only two cases of thromboembolism and one of infective endocarditis. CONCLUSIONS: This study confirms that mitral valve reconstruction in rheumatic valve insufficiency can yield satisfactory long-term clinical results, although they are less than optimum compared with those obtained in patients with degenerative disease. Favourable results depend on routine use of a prosthetic ring as well as adequate patient selection. Attention should be focused on improved detection and suppression of rheumatic activity at the time of operation.

Actuarial Analysis↗
PubMed1996

Continuous versus intermittent warm blood cardioplegia: functional and energetics changes.

BACKGROUND: The aim of this study was to compare the protective effects of continuous warm blood cardioplegia (CWBC) and intermittent warm blood cardioplegia (IWBC) in an experimental model of blood-perfused, isolated rabbit heart. METHODS: In the CWBC group, cardiac arrest was induced by continuous infusion of blood cardioplegia (10 mEq/L KCl) followed by 30 minutes of reperfusion with blood. In the IWBC group, after 5 minutes of perfusion with blood cardioplegia (10 mEq/L KCl), coronary flow was abolished for 10 minutes, followed by reperfusion with blood cardioplegia for 5 minutes. This sequence was repeated three times for a total period of 45 minutes. Finally the hearts were reperfused for 30 minutes with blood. RESULTS: Infusion of potassium induced a marked increase in coronary perfusion pressure (from 50 +/- 3 to 98 +/- 1 mm Hg; p < 0.01), which remained elevated throughout in the CWBC group, whereas in the IWBC group, it dropped to 0 during each no-flow period. In both groups, cardioplegia resulted in a significant reduction in oxygen consumption (from 5.5 +/- 0.2 to 0.6 +/- 0.03 mL O2.min-1.100 g-1 wet wt; p < 0.01). During CWBC, glucose extraction was significantly reduced (from 152 +/- 10 to 64 +/- 18 micrograms.min-1.g-1 wet wt; p < 0.01). Free fatty acid uptake and creatine kinase and lactate release were not affected. During IWBC, in contrast, a transient but significant release of creatine kinase (from 643 +/- 254 to 2,234 +/- 296 mU.min-1.g-1 wet wt; p < 0.01) and lactate (from 63 +/- 22 to 374 +/- 32 micrograms.min-1.g-1 wet wt; p < 0.01) occurred after each period of ischemia. Despite these metabolic differences, both cardioplegic procedures allowed a prompt and complete recovery of mechanical function and tissue content of high-energy phosphates. CONCLUSIONS: Both CWBC and IWBC exert optimal protection in the isolated blood perfused rabbit heart. Thus, IWBC can be safely used to improve visualization of the surgical field.

Adenine Nucleotides↗
PubMed1996

Valve repair for traumatic tricuspid regurgitation.

OBJECTIVE: The review of six cases of valve repair for traumatic tricuspid regurgitation in our institution and 74 in the literature in order to assess effective methods of treating this lesion. METHODS: Tricuspid valve regurgitation is a rare complication of blunt chest trauma. Optimal treatment for this condition is still controversial ranging from long-term medical therapy to early surgical correction. We followed the cases of six consecutive patients with post-traumatic tricuspid incompetence who were successfully treated with reparative techniques. All patients were male and their ages ranged from 18 years to 42 years. Valve regurgitation was always secondary to blunt chest trauma due to motor vehicle accident. The mechanism of valve insufficiency was invariably anterior leaflet prolapse due to chordal or papillary muscle rupture associated with annular dilatation. Surgical procedures included Carpentier ring implant (5 patients), Bex posterior annuloplasty (1 patient), implant of artificial chordae (4 patients), papillary muscle reinsertion (2 patients), commissuroplasty (1 patient) and "artificial double orifice" technique (1 patient). RESULTS: Tricuspid insufficiency improved in all patients after the correction. No complications were recorded and all patients were asymptomatic at the follow-up. CONCLUSIONS: Since post-traumatic tricuspid regurgitation is effectively correctable with reparative techniques, early operation is recommended to relieve symptoms and to prevent right ventricular dysfunction.

Adolescent↗