Challenges in rheumatic valvular disease: Surgical strategies for mitral valve preservation

In developing countries, rheumatic fever and carditis still constitutes a major public health problem. Patients have special characteristics that differ from those with rheumatic mitral valve disease we still see in developed countries. They are usually young, poor, uneducated, and have low compliance to prophylaxis / therapy. In addition, they usually have great difficulty in accessing medical care. In these situations, the rate of complications associated to valve replacement is significantly increased. Alternatively, mitral valve repair is now known to achieve better long-term results in this pathology, but this was not widely recognized three or four decades ago, when first reports showed worse results after repair of rheumatic regurgitation than with degenerative valves. This has been reported by several groups in developing countries in different continents, with high incidence of repairs and excellent long term results. It is, therefore, becoming increasingly clear that, although, the results may not compare to those obtained with degenerative pathology, repair of rheumatic valves, when feasible, is the procedure of choice, especially in these underprivileged populations.info:eu-repo/semantics/publishedVersio

Open anastomosis: an alternative for proximal vein graft anastomoses in significantly diseased aortas

We describe a simple technique of constructing proximal vein graft anastomoses, in an open fashion, under brief periods of very low pump flows. We have used this technique without complications in more than 100 patients with significantly diseased ascending aorta wall. In our opinion, this technique is a good alternative to other, more complex, approaches often described

Risk-prediction for postoperative major morbidity in coronary surgery

OBJECTIVE: Analysis of major perioperative morbidity has become an important factor in assessment of quality of patient care. We have conducted a prospective study of a large population of patients undergoing coronary artery bypass surgery (CABG), to identify preoperative risk factors and to develop and validate risk-prediction models for peri- and postoperative morbidity. METHODS: Data on 4567 patients who underwent isolated CABG surgery over a 10-year period were extracted from our clinical database. Five postoperative major morbidity complications (cerebrovascular accident, mediastinitis, acute renal failure, cardiovascular failure and respiratory failure) were analysed. A composite morbidity outcome (presence of two or more major morbidities) was also analysed. For each one of these endpoints a risk model was developed and validated by logistic regression and bootstrap analysis. Discrimination and calibration were assessed using the under the receiver operating characteristic (ROC) curve area and the Hosmer-Lemeshow (H-L) test, respectively. RESULTS: Hospital mortality and major composite morbidity were 1.0% and 9.0%, respectively. Specific major morbidity rates were: cerebrovascular accident (2.5%), mediastinitis (1.2%), acute renal failure (5.6%), cardiovascular failure (5.6%) and respiratory failure (0.9%). The risk models developed have acceptable discriminatory power (under the ROC curve area for cerebrovascular accident [0.715], mediastinitis [0.696], acute renal failure [0.778], cardiovascular failure [0.710], respiratory failure [0.787] and composite morbidity [0.701]). The results of the H-L test showed that these models predict accurately, both on average and across the ranges of patient deciles of risk. CONCLUSIONS: We developed a set of risk-prediction models that can be used as an instrument to provide information to clinicians and patients about the risk of postoperative major morbidity in our patient population undergoing isolated CABG

Non-cardioplegic coronary surgery in patients with severe left ventricular dysfunction

OBJECTIVES: Although most surgeons use cardioplegia for myocardial protection during coronary artery bypass grafting (CABG), some still use non-cardioplegic methods with very good early and long-term outcome. However, the results in patients with severe left ventricular dysfunction remain unproved. This study evaluates the perioperative mortality and morbidity in patients with severe left ventricular dysfunction submitted to CABG using non-cardioplegic methods. METHODS: From April 1990 through December 1997, 3,180 patients were consecutively subjected to isolated CABG using non-cardioplegic methods, for construction of the distal anastomoses. This prospective study is based on the 107 (3.4%) patients with severe impairment of the left ventricular function (ejection fraction 20 mmHg. Cardiopulmonary bypass time was 73.1 +/- 21.7 min. The mean number of grafts per patient was 3.2. At least one internal mammary artery was used in all cases and 16 patients (14.9%) had bilateral internal mammary artery grafts (1.2 arterial grafts/patient). Endarterectomies were performed in 23 (21.5%) patients. RESULTS: Perioperative mortality was 2.8% (respiratory-1; cardiac-2). Forty one (38.3%) patients required inotropes, but for longer than 24 h in only 12 (11.2%), and two (1.9%) needed intra-aortic counterpulsation. The incidence of myocardial infarction was 2.8%. Two (1.9%) patients had reintervention for haemorrhage and another five (4.6%) for sternal complications. The incidences of supraventricular arrhythmias, renal failure and cerebrovascular accident were 16.8%, 3.6% and 2.8%, respectively. The mean time of hospital stay was 9.3 +/- 6.4 days. CONCLUSION: These results appear to demonstrate that non-cardioplegic methods afford good myocardial protection and operating conditions with excellent applicability, even in patients with severe left ventricular dysfunction

Coronary artery bypass surgery in young adults: excellent perioperative results and long-term survival

OBJECTIVES: To analyse perioperative results, long-term survival and freedom from complications after coronary artery bypass grafting (CABG) in young adults. METHODS: A total of 163 patients, 40 years old or younger, had isolated CABG from January 1989 to December 2010. Pre- and perioperative demographic and clinical data were retrieved from a prospectively organised database. Follow-up data were obtained by letter or telephone interviews. The mean age of the patients was 37.6 ± 2.9 years and 146 were men (90%). Fifty-three patients (32.5%) had angina class III/IV; 106 (65.0%), previous myocardial infarction; and 23 (14.1%), impaired left ventricular function (ejection fraction <40%). Indication for surgery was 3-vessel disease in 101 cases (62.0%), 2-vessel disease in 30 (18.4%) and single-vessel disease in 32 (19.6%). The left main stem was affected in 16 patients (9.8%). The mean EuroSCORE II was 0.92 ± 0.71. A total of 417 grafts were constructed (mean 2.6 grafts/patient), 247 of which (59.2%) were arterial. RESULTS: There were no in-hospital deaths. The mean hospital stay was 7.1 ± 4.0 days. Four patients (2.5%) were lost to follow-up, which extended from 3 to 25 years (mean 15.1 ± 5.5 years). There were 22 late deaths, 72.7% of cardiac or unknown origin. The 5-, 10- and 20-year survival rates were 98.7 ± 10.9, 95.2 ± 1.8 and 79.4 ± 4.4%, respectively. Twenty-six patients (18.1%) had non-fatal cardiac adverse complications (myocardial infarct, percutaneous re-revascularization or class III/IV angina), for 5-, 10- and 20-year freedom from complications of 97.9 ± 1.2, 91.9 ± 2.5 and 65.7 ± 7.1%, respectively. Twenty-two patients (17.5%) needed re-revascularization, for 5-, 10- and 20-year freedom from re-revascularization of 97.6 ± 1.4, 91.9 ± 2.6 and 69.5 ± 6.7%, respectively. CONCLUSIONS: Despite the aggressive nature of coronary artery disease in young patients, perioperative death and morbidity rates are low, with good long-term survival and low rates of re-revascularization.info:eu-repo/semantics/publishedVersio

Right atrial aneurysm: case report

We report the case of a 49-year-old patient, with recent onset of fatigue, who was diagnosed with atrial fibrillation, which was cardioverted electrically. A diagnosis of right atrial aneurysm, with no other cardiac pathology, was made. An aneurysmectomy was performed. Both surgery and postoperative recovery were uneventful

Left ventricular aneurysms: early and long-term results of two types of repair

OBJECTIVE: Controversy still exists regarding the optimal surgical technique for postinfarction left ventricular (LV) aneurysm repair. We analyze the efficacy of two established techniques, linear vs. patch remodeling, for repair of dyskinetic LV aneurysms. METHODS: Between May 1988 and December 2001, 110 consecutive patients underwent repair of LV aneurysms. These represent 2.0% of a total group of 5429 patients who underwent isolated CABG during the period. Seventy-six (69.1%) patients were submitted to linear repair and 34 (30.9%) to patch remodelling. There were 94 (84.5%) men and 17 women, with a mean age of 59.2+/-9.2 years. Coronary surgery was performed in all patients (mean no. of grafts/patient, 2.7+/-0.8) and 14 (12.7%) had associated coronary endarterectomy. Forty-four (40.0%) patients had angina CCS class III/IV (linear 43.4%, patch 32.4%, NS) and the majority was in NYHA class I/II (88.2% in both groups). Left ventricular dysfunction (EF>40%) was present in 72 (65.5%) patients (linear 61.8%, patch 73.5%, NS). RESULTS: There was no perioperative mortality, and major morbidity was not significantly different between linear repair and patch repair groups. During a mean follow-up of 7.3+/-3.4 years (range 4-182 months) 14 patients (14.3%) had died, 12 (85.7%) of possible cardiac-related cause. Actual global survival rate was 85.7%. Actuarial survival rates at 5, 10 and 15 years were 91.3, 81.4 and 74%, respectively. There was no significant difference in late survival between the patch and the linear groups. At late follow-up the mean angina and NYHA class were, 1.3 (preoperative 2.4, P<0.001) and 1.5 (preoperative 1.7, NS), respectively, with no difference between the groups. There was no significant difference in hospital readmissions for cardiac causes (linear 22.8% and patch 37.0%). CONCLUSIONS: The technique of repair of postinfarction dyskinetic LV aneurysms should be adapted in each patient to the cavity size and shape, and the dimension of the scar. Both techniques achieved good results with respect to perioperative mortality, late functional status and surviva

Primary cardiac angiosarcoma. Extended resection of the right atrial wall. Case report.

We report the case of a 51-year-old patient who presented with tiredness and leg swelling, with recurrent pericardial effusion; a right atrial tumor, suggestive of sarcoma, was diagnosed, which responded poorly to chemotherapy. In the absence of metastases, surgery for excision of the tumor was undertaken. Two months after surgery she had a new recurrence of pericardial effusion and chemotherapy was reinitiated. She is currently well and asymptomatic, with no signs of recurrence ten months after surgery and nearly 24 months after the initial diagnosis