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Biomedical subjects

U Bortolotti

Publications and source records attributed to U Bortolotti.

At least 73 records · Page 4Linked to original sources
PubMed1994

[Role of transesophageal echocardiography in mitral valve repair].

This study was designed to prove the utility of intraoperative echocardiography in the mitral valve repair, that offers many advantages over valve replacement. We have assessed 21 consecutive patients, 12 with mitral incompetence and 9 with mitral stenosis, undergoing mitral valve surgery over a period of 6 months. Preoperative transthoracic and intraoperative transesophageal or epicardial echocardiography were performed in all patients. We have assessed, before and after repair, the valve morphology, the presence and the severity of mitral regurgitation, the pulmonary venous flow, the presence of left ventricular outflow tract obstruction. The intraoperative echocardiographic examination revealed a successful mitral repair in all patients except one in whom, for the persistence of severe mitral regurgitation after repair, valve replacement was performed. In none patient systolic anterior motion of mitral apparatus was observed. Intraoperative echocardiography seems to be a useful technique to assess the adequacy of mitral valve repair before chest closure and, in the case of failure, the need for further surgery (valve reconstruction or replacement).

Adult↗
PubMed1994

Results of heart transplantation by extending recipient selection criteria.

From November 1985 to July 1993, 29 out of 241 patients (12%) who underwent heart transplantation (HTx) at our institution had one or more "classical" contraindications to HTx: age > or = 60 years (20 patients); insulin-dependent diabetes mellitus (5 patients); irreversible renal failure requiring combined heart-kidney transplantation (2 patients); previous surgery for malignancy (1 patient); familial hypercholesterolemia (1 patient) and active systemic infection (1 patient). The main indication for HTx was ischemic cardiomyopathy (21 patients, 61%). Immunosuppression regimen consisted of Cyclosporine and Azathioprine, oral prednisone being subsequently added in 6 patients because of persistent rejection. There were 2 perioperative deaths and one late death. Follow-up ranged from 1 to 88 months (mean, 28 +/- 20) with an actuarial survival at 5 years of 85 +/- 8%. Annual cardiac catheterization demonstrated normal graft function and coronary arteries in all. No significant differences in survival, incidence of rejection and infection, renal function and duration of hospitalization were found when these patients were compared with those with no contraindications to HTx. In conclusion, HTx can be performed with good early clinical results in selected patients with "classical" contraindications to HTx; longer follow-up, however, is needed to confirm whether extension of the recipient selection criteria justified.

Adult↗
PubMed1994

Early and late outcome after reoperation for prosthetic valve dysfunction: analysis of 549 patients during a 26-year period.

Factors influencing operative mortality and late survival of 549 patients undergoing a first reoperation for prosthetic valve failure during the interval from 1966 to 1992 were analyzed; 347 patients had reoperation on a mitral prosthesis, 173 on an aortic prosthesis and 29 on both aortic and mitral prostheses. Univariate analysis showed that hospital mortality was higher in patients in functional class IV compared with those in class II-III (35% vs. 8%, p < 0.001), in those who required emergency reoperation (57% vs. 11%, p < 0.001), in those reoperated for endocarditis (59%) or valve thrombosis (43%) compared with those reoperated for structural valve deterioration (9%, p < 0.001), and in those with a failing mechanical prosthesis compared to patients with a bioprosthesis (21% vs. 10%, p < 0.05). Furthermore, operative mortality decreased from 41% in the period from 1966 to 1977, to 12% from 1977 to 1983 and to 8% from 1984 to 1992 (p < 0.001). Hospital survivors were followed from 0.1 to 22 years (mean follow-up 11 +/- 5 years) with an overall actuarial survival at 15 years of 24 +/- 5%. At 15 years actuarial survival is 24 +/- 5% for patients in preoperative functional class II-III and 20 +/- 6% for those in functional class IV (p < 0.05). It is concluded that in prosthetic valve recipients both early and late outcome is greatly influenced by preoperative clinical status. Increasing surgical experience, better myocardial protection and patient management have contributed to reducing the operative risk. More accurate patient follow up and possibly earlier reoperation might also improve the long term outcome.

Adolescent↗
PubMed1994

The Cabrol technique for replacement of the aortic valve and totally calcified ascending aorta: a case report.

Simultaneous replacement of the ascending aorta and aortic valve with a valved conduit was performed in a patient with aortic valve disease and totally calcified ascending aorta. Coronary circulation could be re-established by using the Cabrol technique, but only after extensive decalcification of the aortic wall surrounding the coronary ostia. This technique appears particularly suitable in patients who require combined replacement of the ascending aorta and aortic valve in the presence of diffuse calcification of the aortic root.

Aged↗
PubMed1994

Donor shortage in heart transplantation. Is extension of donor age limits justified?

Chronic shortage of donor organs for heart transplantation led us to extend donor age limits. To verify the effectiveness of such a policy we have compared the results of heart transplantation in 45 patients with donors more than 40 years of age (group 1) with those of 72 patients older than 50 years of age who had heart transplantation with younger donors (group 2) between November 1985 and December 1992. The two groups were comparable in terms of mean recipient age, recipient and donor sex, and indication for heart transplantation. Mean donor age was 46 +/- 4 years (range 41 to 59 years) in group 1 and 23 +/- 7 years (range 8 to 39 years) in group 2 (p < 0.001). In group 1 cerebrovascular accidents were more common as the cause of donor death (60% versus 16%, p = 0.001), and no difference was found in ischemic time (144 +/- 47 minutes versus 140 +/- 48 minutes, p = not significant). There were 6 early (< 30 days) deaths in group 1 (13%) and 10 in group 2 (14%; p = not significant). Fatal acute graft failure was more prevalent, but not significantly so, in group 1 (10% versus 5.5%, p = not significant). Mean follow-up was 29 +/- 20 months (range 3 to 78 months) in group 1 and 30 +/- 20 months (range 3 to 80 months) in group 2 (p = not significant). At 5 years actuarial survival was 80% +/- 6% in both groups with comparable graft performance at echocardiographic and hemodynamic control studies. A significant difference was found in freedom from any type of coronary artery abnormality between group 1 (49% +/- 13%) and group 2 (77% +/- 8%) at 5 years (p < 0.05); however, freedom from coronary stenotic lesions only was similar. Major conduction disturbances have occurred more frequently in patients of group 1 (37% versus 12%; p = 0.003) without any difference in the need for permanent pacing. Donors older than 40 years of age can be accepted for heart transplantation with early and long-term results comparable with those obtained with younger donors. The impact of a higher incidence of coronary abnormalities on late performance of older grafts must be assessed at longer follow-up. Our results indicate that, because of the current organ shortage, extension of donor age limits is justified, even up to the sixth decade of life in selected cases.

Actuarial Analysis↗
PubMed1993

Clinical results of steroid-free induction immunosuppression after heart transplantation.

Between January 1987 and September 1991, 112 operative survivors of heart transplantation were initially immunosuppressed with cyclosporin A and azathioprine without prednisone. Eighty-eight patients (79%) remained on a regimen of double therapy for a mean follow-up of 25 +/- 15 months (range, 1 to 54 months), whereas 24 patients (21%) had oral prednisone, 5 mg/day, added to maintenance therapy for persistent or repeated rejection. There were 5 early deaths (4%) because of acute rejection (4 patients) or infection (1 patient). Only 1 patient died late after heart transplantation of chronic rejection. Actuarial survival was 95% +/- 2% and 94% +/- 3% at 12 and 48 months, respectively. Mean rate of acute rejection was 1.7 +/- 1.0 episodes per patient, with a 5% +/- 2% freedom from rejection at 48 months. Ten patients (9%) required in-hospital treatment for infection; the actuarial freedom from infectious episodes was 85% +/- 4% at 48 months. Actuarial freedom from hypertension was 43% +/- 7% at 48 months. At annual catheterization, mean left ventricular ejection fraction was 0.64 +/- 0.08 and 0.62 +/- 0.05 at 1 year and 4 years, respectively, with evidence of coronary lesions in 9 patients (8%). In conclusion, steroid-free immunosuppression after heart transplantation is associated with a high incidence of acute rejection. However, the excellent medium-term survival and the low incidence of both infection and chronic rejection seem to justify a wider use of such treatment.

Adolescent↗
PubMed1993

Severe ischemic left ventricular failure: coronary operation or heart transplantation?

Severe left ventricular failure in ischemic heart disease may contraindicate conservative surgical procedures. To redefine therapeutic indications, the clinical and angiographic data of 143 patients (137 men and 6 women) with ischemic heart disease and a left ventricular ejection fraction less than 0.30 who were seen by us between June 1985 and December 1990 were retrospectively analyzed. Patients were divided into three groups according to therapy: medical only, 72 (group 1); myocardial revascularization, 20 (group 2); and heart transplantation, 51 (group 3). Clinical status was poorer in group 3, with congestive heart failure as predominant symptom; angina was more frequent in group 2. No difference was noted in hemodynamic variables. Four early deaths (20.0%) occurred in group 2 and 7 (13.7%) in group 3. Follow-up ranged from 1 to 64 months (mean, 22 +/- 19 months), with an actuarial survival of 28% +/- 9%, 80% +/- 8% and 82% +/- 5% at 5 years in groups 1, 2, and 3, respectively. Even though postoperative New York Heart Association class was better in group 3 (1.0 versus 2.3 in group 2; p < 0.01), the difference in survival was not significant. Although in patients with ischemic heart disease and low left ventricular ejection fraction heart transplantation offers the best clinical results, considering the donor shortage, we conclude that myocardial revascularization may still be performed with good midterm results.

Actuarial Analysis↗
PubMed1993

Fatal obstruction of the left ventricular outflow tract caused by low-profile bioprostheses in the mitral valve position.

Two cases of fatal left ventricular outflow tract obstruction following mitral valve replacement with low-profile bioprostheses are described. This unfortunate experience shows that correct orientation of the prosthesis is mandatory also when using low-profile bioprosthetic valves to avoid this complication, particularly in patients with a small left ventricular cavity.

Aged↗
PubMed1993

Reoperation in patients with a bioprosthesis in the mitral position: indications and early results.

Our experience with 221 patients undergoing a first reoperation for bioprosthesis failure in the mitral position is reviewed. Most, (196, 89%) were reoperated because of structural valve deterioration, 16 (7%) had periprosthetic leak and nine (4%) had prosthetic endocarditis. Operative mortality (23 patients overall, 10.4%) was significantly higher in those patients who were in NYHA functional class IV or had impaired left ventricular function, in those reoperated because of prosthetic endocarditis and those undergoing emergency reoperation. Those patients who had structural valve deterioration, good left ventricular function and who were reoperated electively had the lowest operative risk. With increasing experience and the use of standardized surgical techniques, the results of reoperation for bioprosthetic failure have improved considerably in recent years. A further reduction in operative risk can be expected with better patient selection, obtained through more careful non-invasive assessment of valve performance to detect the initial signs of bioprosthetic failure.

Adolescent↗
PubMed1993

Long term survival without anticoagulation after aortic valve replacement with a Lillehei-Kaster prosthesis. A case report.

A patient who underwent aortic valve replacement with a Lillehei-Kaster prosthesis developed an early duodenal ulcer requiring suspension of warfarin treatment. Subsequently he was managed without oral anticoagulants, receiving only antiplatelet agents, starting from the third postoperative year. Neither thromboembolic nor hemorrhagic complications occurred but at reoperation, performed almost 20 years later for prosthetic stenosis caused by a fibrous ring, and aneurysm of the ascending aorta, mild fresh thrombus was found on the prosthetic ring. Although the long term outcome of patients with a mechanical aortic prosthesis can occasionally be successful even without long term anticoagulation, such management appears to be justified only in highly selected cases.

Anticoagulants↗
PubMed1993

Tricuspid valve endocarditis: repair with the use of artificial chordae.

We report on a patient who developed tricuspid valve endocarditis on a permanent endocardial pacemaker lead. At operation the endocardial lead was removed and accurate debridement of the tricuspid tissue was performed. Tricuspid valve reconstruction included commissural plication and the construction of artificial polytetrafluoroethylene chordae from the anterior leaflet to the anterior papillary muscle to obtain valve competence.

Aged↗
PubMed1993

Pulmonary atresia, intact ventricular septum, and Ebstein anomaly of the tricuspid valve. Anatomic and surgical considerations.

Pulmonary atresia with intact ventricular septum is a disorder that involves the whole right ventricle. An associated Ebstein deformity of the tricuspid valve is found in 10% of the cases, further complicating the anatomy and the function of the right ventricle. From January 1966 to December 1990, pulmonary atresia, intact ventricular septum, and Ebstein deformity of the tricuspid valve were observed in 11 cases in our institution; four of them were necropsy findings and the remaining seven were patients treated surgically. Of the latter, two were boys and five were girls (age range 1 day to 18 days). Two patients were managed by pulmonary valvotomy, three by systemic-pulmonary artery shunt, and two had a combination of the two. Operative mortality was 57%. Eight hearts were available for morphologic study. All had viscero-atrial situs solitus, D-loop ventricular structure, and normally related great arteries. A correlation between the degree of tricuspid valve dysplasia and right ventricular cavity size was observed in all. Furthermore, in five cases the anterior leaflet of the tricuspid valve obstructed the right ventricle at the ostium infundibuli level. In two of our surgical patients, a protruding anterior tricuspid valve leaflet was identified and excised and both patients survived. Ebstein anomaly of the tricuspid valve further complicates surgical management and outcome of pulmonary atresia and intact ventricular septum. Potential obstruction at the ostium infundibuli level should always be considered during repair. Various degrees of right ventricular inlet dysplasia, always present in this complex, may contraindicate an anatomic correction. In these cases a modified Fontan-type procedure should be considered as a valid surgical option.

Abnormalities, Multiple↗
PubMed1992

Long-term echocardiographic Doppler monitoring of Hancock bioprostheses in the mitral valve position.

Echocardiographic and Doppler studies were performed in 134 patients with a Hancock bioprosthesis in the mitral valve position during a follow-up period of 1 to 216 months. Among the xenografts, 57% were clinically normal and 43% had severe dysfunction. Among the normal bioprostheses, 35% had echocardiographically thickened mitral cusps (> or = 3 mm) with normal hemodynamic function; by setting the lower 95% confidence limit of valve area at 1.7 cm2 these patients had a significantly (p < 0.01) smaller valve area than that of normal control subjects. Evaluation of all thickened normal mitral valves showed the highest incidence of thickening at 9 years after implantation. Valve replacement surgery was subsequently performed in 33 patients with dysfunctioning bioprosthetic and echocardiographic diagnosis was confirmed in 91% of explanted valves (bioprosthetic stenosis 21%, incompetence 46%, and combined stenosis and regurgitation 33%). In 2 valves that were found to be stenotic on echocardiographic examination, a calcium-related commissural tear was also observed at reoperation, and in another, a paravalvular leak was found. Dystrophic calcification, isolated (64%) or occasionally associated with fibrous tissue overgrowth (21%), was the main cause of failure. Pannus was present in prostheses with longer satisfactory function (168 +/- 31 vs 124 +/- 21 months; p < 0.001). Long-term performance was evaluated by the Kaplan-Meier method for up to 18 years of follow-up. Freedom from structural valvular disfunction after mitral replacement was 89% at 6 years, 77% at 8 years, 56% at 10 years, 31% at 12 years, 16% at 15 years, and 15% at 18 years.

Actuarial Analysis↗
PubMed1992

Giant intrapericardial solitary fibrous tumor.

A 60-year-old man with a large pericardial effusion was found to have a giant intrapericardial solitary fibrous mesothelioma firmly attached to the ascending aorta and pulmonary trunk. Nine months after excision of the mass the patient is free from symptoms and signs of tumor recurrence. Solitary fibrous mesothelioma is a rare benign tumor and its excision is curative; however, because of the lack of information on its long-term behavior, close noninvasive follow-up of this patient is necessary.

Echocardiography↗