Transmyocardial laser revascularization. Personal experience

Background. Indirect revascularization is a therapeutic approach in case of severe angina not suitable for percutaneous or surgical revascularization. Transmyocardial revascularization (TMR) is one of the techniques used for indirect revascularization and it allows to create transmyocardial channels by a laser energy bundle delivered on left ventricular epicardial surface. Benefits of the procedure are related mainly to the angiogenesis caused by inflammation and secondly to the destruction of the nervous fibers of the heart. Patients and method. From September 1996 up to July 1997, 14 patients (9 males – 66.7%, mean age 64.8±7.9 years) underwent TMR. All patients referred angina at rest; Canadian Angina Class was IV in 7 patients (58.3%), III in 5 (41.7%). Before the enrollment, coronarography was routinely performed to find out the feasibility of Coronary Artery Bypass Graft (CABG): 13 patients (91,6%) had coronary arteries lesions not suitable for direct revascularization; this condition was limited only to postero-lateral area in one patient submitted to combined TMR + CABG procedures. Results. Mean discharge time was 3,2±1,3 days after surgery. All patients were discharged in good clinical conditions. Perfusion thallium scintigraphy was performed in 7 patients at a mean follow-up of 4±2 months, showing in all but one an improvement of perfusion defects. Moreover an exercise treadmill improvement was observed in the same patients and all of them are in good clinical conditions, with significantly reduced use of active drugs. Conclusion. Our experience confirms that TMR is a safe and feasible procedure and it offers a therapeutic solution in case of untreatable angina. Moreover, it could be a hybrid approach for patients undergoing CABGs in case of absence of vessels suitable for surgical approach in limited areas of the heart

Giant Aneursym of the Ascending Aorta 37 Years after Aortic Valve Replacement

Giant ascending aorta aneurysms (AAA), which are larger than 10 cm, are rare. We hereby present the case of a giant AAA of about 13 cm, incidentally detected several years after aortic valve replacement and treated according to the Cabrol technique without postoperative complications. [Arch Clin Exp Surg 2013; 2(2.000): 129-131

The role of psychological support in cardiac surgery: initial experience

The scientific literature has pointed out several predictors of negative outcome after surgery such as pain and depression, negatively affecting the postoperative outcome in cardiac surgery. From January 2009 until June 2010, 15 patients scheduled for cardiac surgery were enrolled. The patients were assessed by psychological evaluation either in the hospital stay either in the rehabilitation period with the aim of identifying their emotional condition (sentiments about the onset of the disease, support received from family and friends) even by means of preformed tests for anxiety and depression (tests of Stay and Back). Thus, in our preliminary experience, the psychological evaluation failed to detect the occurrence of postoperative complications. Conversely, the psychological evaluation is very effective in detecting a poor emotional state and the psychological support decreases the degree of anxiety and depression with positive effects on postoperative outcome. In conclusion, a standardize test for anxiety and depression should be used for patients at hospital admission to detect who may benefits by psychological support

A Retrospective Study of Combined Cardiac and Carotid Surgery

Introduction: A combined carotid endarterectomy (CEA) and cardiac procedure has higher early risk of stroke than isolated CEA because of the widespread atherosclerosis in patients selected for simultaneous procedures. In this retrospective study, we review the results of combined coronary artery bypass grafting (CABG) and carotid endarterectomy (CEA) procedures. Materials and methods: Between January 2000 and December 2007, 91 patients with a mean age of 69.2+6.6 (24/67 female/male) underwent combined operations (CEA-CABG) on cardiopulmonary bypass (CPB) as elective surgery. The study population was divided, as follows: Group A: 83 patients (91.2%) had both venous and arterial revascularization; Group B: 8 patients (8.8%) had total arterial revascularization. CEA was performed in case of stenosis more than 80% and always before cardiac operation. These techniques were used: standard procedure (54.8%), eversion (39.2%), patch enlargement (6%). Immediately after the vascular procedure, CABGs were performed through median sternotomy. The mean EUROscore was 6.9+2.5%. Results: All neurological complications were in the group who underwent both venous and arterial revascularization (Group A), where a proximal anastomosis was made. All complications and deaths were in group A. Six patients had stroke (6.6%) and 2 had acute myocardial infarction (AMI) (2.2%). There were 8 in-hospital deaths (8.8%) and 1 late death (for stroke after five months). Conclusions: In our center, the incidence of stroke in simultaneous cardiovascular procedures was 5.5 times greater than in isolated cardiac or vascular procedures, which was probably related to the widespread vessels disease. An aortic cross clamp and surgical procedure on the ascending aorta are relevant risk factors for developing neurological events; much attention should be paid to aortic manipulation. In the sub-group who underwent total arterial revascularization with associated CEA procedures, we had no neurological events. A partial cross clamp and proximal anastomosis are relevant risk factors for developing neurological events. Therefore, in combined operations (CEA associated with CABG), it is probably more favourable performing a total arterial revascularization, avoiding partial ascending aortic clamping. [Arch Clin Exp Surg 2012; 1(4.000): 201-205

Hypothermic Cardiac Arrest in the Homeless: What Can We Do?

Accidental deep hypothermia with body temperature <28°C induces high mortality rates for neurological and cardiac complications. Although several reports described successful treatment of hypothermic arrest by extracorporeal membrane oxygenation (ECMO), the field of warming in the homeless is almost completely unquestioned although the malnutrition and the co-morbidities are usually believed as relevant risk factors for poor outcome. This article describes the experience of successful warming by ECMO in two homeless victims of unwitnessed cardiac arrest, who survived without neurological or cardiac complications. In conclusion, this is an initial experience and further research is required, although our results are appreciable in this high risk subset of population