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Letter by Pocar regarding article, “Impact of left ventricular to mitral valve ring mismatch on recurrent ischemic mitral regurgitation after ring annuloplasty”
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Perfusione spinale retrograda selettiva durante ischemia da clampaggio aortico: modello sperimentale nel suino
No full textBACKGROUND. Spinal cord damage represents a devastating complication of thoracic and thoracoabdominal aortic surgery. Retrograde perfusion as an alternative route to protect the spinal cord has recently been investigated with controversial results. MEHODS. Ten juvenile pigs were divided into control and study groups (A and B, respectively). Through a lateral thoracotomy the distal aortic arch was cannulated and connected to a cardiotomy reservoir. All animals underwent 40-minute single cross-clamping of the proximal descending aorta while keeping proximal systolic arterial pressure above 100 mmHg. In group B, normothermic arterial blood was delivered retrogradely through the azygos vein, maintaining perfusion pressure within 25-30 mmHg. Animals were allowed to recover to perform a primary neurologic evaluation. RESULTS. Flaccid paraplegia was uniformly observed in group A. In group B, all animals showed mild-to-moderate voluntary hind limb movements on awakening. Controls also showed urine incontinence short after cross-clamping, and this was not observed in group B. A different veno-arterial oxygen step-down was observed in blood collected from the excluded aorta in the two groups. CONCLUSIONS. Preliminary results indicate that controlled retrograde normothermic perfusion alone through the azygos system provides some degree of protection from spinal cord ischemia. Bladder dysfunction may represent a simple test to detect massive cord damage intraoperatively. Retrograde spinal cord perfusion warrants further investigation
Simplified thoracic aortic aneurysm repair
No full textDescending thoracic and thoracoabdominal aortic operations still represent a challenge for the cardiovascular surgeon. In recent years, endovascular stent grafting has become a popular alternative to a conventional operation in selected patients, but is not always readily available or is technically contraindicated; also, long-term results are unknown. We describe a simplified surgical technique to secure a standard vascular prosthesis by performing a modified "elephant trunk" operation and discuss potential indications for its application
Ventricular restoration with associated mitral annuloplasty: determinants of late outcome
No full textBackground. Mitral annuloplasty may be associated to surgical ventricular restoration (SVR), but risk-to-benefit ratio remains poorly defined. We sought to outline outcome determinants in this high-risk population.
Methods. Twenty-six patients with ischaemic cardiomyopathy, prior anteroseptal AMI, NYHA class III-IV, and EF ≤35% who underwent SVR and prosthetic ring mitral annuloplasty were analyzed. Associated cardiac surgical procedures except CABG were excluded. Risk factors for adverse events were identified with logistic and Cox regression. Probabilities of late events were estimated with the Kaplan-Meier method. Primary endpoints were death and hospitalisation for recurrent HF.
Results. Preoperative characteristics: age 66 ± 8 years; NYHA class 3.2 ± 0.4; EF 27 ± 5%; WMSI 2.4 ± 0.2; end-systolic volume index (ESVI) 80 ± 25 ml/m2; MR degree 3.3 ± 0.5; EuroSCORE II 15 ± 11. CPB and aortic crossclamp times were 203 ± 68 and 131 ± 28 min. Operative mortality was 11%. No independent predictors of early death emerged. High-dose inotropic support, IABP, and ECMO were necessary in 13, 12, and 1 case. At a mean follow-up of 49 ± 3 months (longest, 112 months), the probability of survival
at 1, 3, 5, and 7 years after the operation were 84%, 76%, 72% and 54%, whereas the corresponding probabilities of rehospitalisation for HF were 81%, 52%, 48% and 12%. Baseline ESVI (p=0.03; HR=1.02) and cross-clamp time (p=0.02; HR=1.04) were outlined as independent predictors of late death, but no predictor of recurrent heart failure emerged.
Conclusions. Surgical mitral-ventricular restoration can be performed with a near-10% operative risk, and results in over 50% survival at 7 years in advanced ischemic cardiomyopathy. Myocardial viability testing likely represents a crucial additional tool to stratify and optimize patients’ selection with respect to late outcome
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