Biomedical subjects
Publications and source records attributed to A Carcagnì.
We report the case of a 52-year-old woman with partial left anomalous pulmonary venous return who was successfully treated surgically without the use of extracorporeal circulation by diverting the anomalous left vertical vein into the left atrium through a postero-lateral thoracotomy.
BACKGROUND: Even though success rates of percutaneous transluminal coronary angioplasty (PTCA) are influenced by gender, women are at higher risk for adverse procedural events. Plaque dissection has been demonstrated to cause more adverse cardiac events during PTCA in the female gender than the male, but it is not clear how much it could influence stent implantation and procedural complications in the stent era. This study sought to evaluate whether the prevalence of dissection is equal in men and women with similar vessel size, which factors are associated with the risk of this complication and whether stenting has modified the immediate outcome. METHODS: Three hundred thirty-nine lesions were studied in 100 consecutive women and 128 men with a vessel diameter < or = 3.5 mm, who underwent PTCA in our catheterization laboratory between March 1998 and March 1999. RESULTS: Procedural success rates were similar in the two groups (93.9% women vs 97.6% men). Complications were one coronary artery bypass graft and five acute myocardial infarctions. In the group of women, however, there was a significant increase in the incidence of plaque dissection during the procedure (37.9 vs 21.7%, p = 0.001), with consequent increased need for stenting (70.4 vs 52.2%, p < 0.05) to achieve adequate final results. Moreover, dissection was strongly associated (p = 0.03) with procedural complications. Multivariate analysis of the whole patient cohort showed the risk of dissection to be associated only with the female gender (p = 0.009), diabetes (p = 0.029), and type C lesion morphology (p = 0.019). CONCLUSIONS: Women are at higher risk of plaque dissection, which is associated with adverse procedural events and an increased need for stenting.
Percutaneous transluminal coronary angioplasty is a validated method for coronary revascularization over coronary surgery in elderly patients. We describe two cases in patients in their nineties. Case n. 1: a 95-year-old patient with post-infarction angina that was not controlled well by medical therapy. On admission to our department, the patient was in good hemodynamic condition and a transthoracic echocardiographic examination confirmed normal left ventricular systolic function. Coronary angiography showed a severe calcified stenosis of the left anterior descending coronary artery, which was successfully treated with coronary angioplasty and stenting. After three months, the patient was readmitted because of angina. A new coronary angiogram showed diffuse in-stent restenosis, which was successfully treated with rotational atherectomy and angioplasty. The patient was asymptomatic at follow-up after 6 months. Case n. 2: a 91-year-old patient was admitted for an unstable angina. On admission to our department the patient was in good hemodynamic condition. Coronary angiography showed a severe stenosis of the left anterior descending coronary artery that was successfully treated with angioplasty and stenting. The patient was asymptomatic at 6-month follow-up. These cases show that coronary revascularization can successfully be performed even in patients in their nineties when medical therapy is unsuccessful and the patients are considered at high risk for surgery.
BACKGROUND: Improvements in anesthetic and surgical management of patients with left ventricular dysfunction have resulted in a decline in perioperative mortality and morbidity. Nevertheless, coronary artery bypass grafting (CABG) in patients with left ventricular ejection fraction < or = 0.30 remains a surgical challenge. METHODS: Fifty-one patients with end-stage coronary artery disease and left ventricular ejection fraction between 16 and 30% underwent CABG. Mean age at operation was 66.1 +/- 7.85 years. Selection criteria included the clinical diagnosis of ischemic heart disease with angiographic demonstration of critical coronary artery obstructive lesions. Mean number of grafts per patient was 2.94 (range 1-5). Average duration of cardiopulmonary bypass was 74.5 +/- 22.4 min and mean aortic cross clamp time was 47.6 +/- 17 min. RESULTS: No operative and in-hospital deaths occurred. Eight patients (15.7%) had postoperative low cardiac output syndrome, requiring intraaortic balloon counterpulsation. There were two major neurological complications (3.9%). There were four late deaths (7.8%), due to recurrence of untreatable congestive heart failure. Left ventricular ejection fraction increased from a mean of 25.51 +/- 4.75% preoperatively to 31.35 +/- 9.9% postoperatively (p < 0.001). Improvement in NYHA functional class (preoperatively 2.98 +/- 0.79 vs 2.35 +/- 0.6 postoperatively, p < 0.001) was found in this group at follow-up. CONCLUSIONS: CABG leads to an excellent prognosis in high risk patients with ischemic heart disease and low left ventricular ejection fraction, improving their functional and clinical outcome and consequently their life expectancy.
The prognosis of Tricuspid Atresia, a rare congenital heart disease, has been changed by surgery. The criteria for Fontan operation have been well established in the literature and adult patients rarely fulfil these criteria; however, in very selected cases Fontan operation can be performed also in adults. A 33 year old woman with tricuspid atresia and previous palliation with classical right Glenn and with left modified Blalock-Taussing, underwent modified Fontan operation because increasing cyanosis and moderate exercise intolerance. Three weeks after operation the patient was readmitted with severe heart failure because of a tight obstruction at the anastomosis between right atrium and main-left pulmonary artery. The stenosis was treated with balloon and stenting achieving large pathway. Our experience confirms that after a modified Fontan, if cardiac failure occurs, an immediate full investigation have to be done.
The term "hybrid revascularization" describes the combined use of minimally-invasive surgery without cardiopulmonary bypass and percutaneous coronary revascularization in selected cases. The theoretical advantage of a less invasive surgical intervention must be weighted against the need for additional percutaneous procedures, with their own risks and limitations. We describe our initial experience with hybrid revascularization at the Istituto Clinico Humanitas in Milan. From 7/97 to 10/98, twelve patients underwent hybrid revascularization or a combined percutaneous and surgical intervention. A "classic" hybrid approach, consisting of minimally-invasive direct coronary artery bypass to the left anterior descending coronary artery and angioplasty or stenting of arteries in the right coronary artery or circumflex territories, was used in nine patients. In three patients, myocardial revascularization could be completed with percutaneous procedures after bypass surgery without cardiopulmonary bypass (in two patients because of severe aortic calcification) or valve surgery in a patient with two previous bypass operations. In-hospital complications were observed in three patients. Two required urgent median sternotomy (one for impending cardiac tamponade, one for conversion to bypass on extra-corporeal circulation). One patient developed atheroembolism after percutaneous intervention: after hospital discharge, there was a recurrence of symptoms, clinical deterioration with renal failure and eventually death. At a mean follow-up of 152 +/- 91 days (range 17 to 283) after minimally-invasive surgery and 166 +/- 122 days (range 13 to 397) after angioplasty, all surviving patients are well and free of anginal symptoms. Closer collaboration between surgical and interventional operators may offer a novel approach to effective treatment of difficult patient subsets. However, our initial experience suggests that a cautious evaluation of possible risks and benefits must carefully be entertained in each patient who may be considered a candidate for hybrid revascularization or combined percutaneous and surgical intervention.
We assessed the influence and clinical consequences of different AV delay on ventricular filling in 30 patients (mean age 60 +/- 5 years) who had DDD pacemakers for AV block. All 30 patients presented a normal ejection fraction, but in 18 cases (Group I), an echo-Doppler examination revealed ventricular hypertrophy (mean end-diastolic wall thickness of 1.4 +/- 0.16 cm, LV mass index 155 +/- 17 g/m2), and an abnormal relaxation pattern (isovolumetric relaxation time = 124.72 +/- 11.82; early to late peak velocity = 0.6 +/- 0.03; deceleration time = 296.83 +/- 34.02 ms). Group II included the remaining 12 patients who had a normal filling pattern. In all 30 patients, the pattern was reassessed following modification of the AV delay (200, 150, 100, and 75 ms). Patients at baseline (AV delay of 200 ms) also underwent an exercise test with determination of respiratory gas exchange. In Group I, 13 (72.5%) patients were classified as Weber class B (VO2 Max 16.8 +/- 1.7 mL/min per kg); and 5 (27.5%) were Class A (VO2 Max 22.5 +/- 1.4 mL/min per kg). In Group II, all 12 patients were classified as Weber Class A. In Group II, changes in AV delay caused no consistent variations in filling pattern, and therefore AV delay was not modified. In Group I patients, since reduction to 100 ms resulted in normalization of the filling pattern, the AV delay was programmed to 100 ms. A graded exercise test repeated after 6 months' follow-up showed an improved Weber class in 13 patients (from B to A) and greater VO2 Max in the remaining five already in Class A. We concluded that, in sequential paced patients with normal ejection fraction but abnormal relaxation pattern, modification in AV delay can induce normalization of filling and improvement in cardiac functional capacity.
The influence and clinical consequences of different atrioventricular delays on ventricular filling have been studied in 30 patients (mean age 60 +/- 5 years) who implanted DDD pacemaker for complete A-V block. All patients presented a normal ejection fraction: 63.9 +/- 6.5%. In 18 subjects (Group I) an echo-Doppler examination revealed ventricular hypertrophy (mean end-diastolic wall thickness of 1.4 +/- 0.16 cm; left ventricular mass index 155 +/- 17 g/m2) and an abnormal relaxation pattern (isovolumic relaxation time 124 +/- 11: early to late peak velocity 0.6 +/- 0.03; deceleration time of the early diastolic peak 296 +/- 34 ms). Group II included the remaining 12 patients without left ventricular hypertrophy and normal filling pattern. In all 30 patients the filling pattern was reassessed following modification of the A-V delay (200, 150, 100 and 75 ms). Patients at baseline (200 ms of A-V delay) underwent an exercise test with determination of respiratory gas exchange. In Group I, 13 (72.5%) patients were classified as Weber class B (VO2 max 16.8 +/- 1.7 ml/min/kg) and 5 (27.5%) as class A (VO2 max 22.5 +/- 1.4 ml/min/kg). In Group II, all 12 patients were classified as Weber class A (VO2 max 23.1 +/- 1.1 ml/ min/kg). In Group II, changes in A-V delay caused no homogeneous variation in filling pattern. A-V delay was not modified in this group. In Group I, the reduction of A-V delay to 100 ms resulted in filling normalization. In this group A-V delay was programmed definitely to 100 ms. Graded exercise test repeated at 6 months follow-up showed an improved Weber class in 13 patients (from B to A) and greater VO2 max in the remaining 5 already in class A. We conclude that, in sequential paced patients with normal ejection fraction but abnormal relaxation pattern, a modification of A-V delay can induce filling normalization and improve cardiac functional capacity.