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Biomedical subjects

A Milano

Publications and source records attributed to A Milano.

At least 37 records · Page 2Linked to original sources
PubMed1999

The Edwards Prima stentless valve: hemodynamic performance at one year.

BACKGROUND: The Edwards Prima stentless valve (EPSV) is a porcine aortic root cylinder with resected coronary ostia, fixed in glutaraldehyde at low pressure. The purpose of this study was to evaluate the hemodynamic performance of the EPSV 1 year after aortic valve replacement. METHODS: From December 1994 to February 1996, 29 patients underwent aortic valve replacement with EPSV used in the subcoronary position (group 1, n = 23) or as a root replacement (group 2, n = 6). Hemodynamic performance of EPSV was assessed by two-dimensional Doppler echocardiography at 1 week, 6 months, and 1 year by calculating peak transprosthetic velocity, peak and mean gradients, effective orifice area, degree of aortic regurgitation, and regression of left ventricular hypertrophy. RESULTS: There were no operative deaths. One patient in group 2 died after 3 months at reoperation for endocarditis. In group 1 early mean gradient (25+/-5 mm Hg for 23 mm and 19+/-5 mm Hg for 25 mm) decreased at 6 months and 1 year in the 23-mm size (17+/-7 mm Hg and 15+/-4 mm Hg, p < 0.01) and at 1 year in the 25-mm size (14+/-4 mm Hg, p = 0.03) without modifications of the effective orifice area in both sizes. A significant reduction in left ventricular hypertrophy occurred at 6 months and 1 year in both sizes. In group 2 lower early gradients were recorded with subsequent improvement at follow-up; reduction in left ventricular hypertrophy occurred as well. CONCLUSIONS: The EPSV used in the subcoronary position has shown high early gradients, which partially regressed at 6 months, with further improvement at 1 year. Gradients are attributed to inward folding of the Dacron cloth at the right coronary ostium, being more evident in patients with aortic stenosis without dilatation of the aortic root and coronary ostia close to the annulus. In such patients a better early hemodynamic result can be obtained by using the EPSV as a root replacement.

Aged↗
PubMed1999

Simultaneous coronary artery bypass grafting and transmyocardial laser revascularization through a small left thoracotomy.

We report a patient in whom coronary artery bypass grafting with the left internal mammary artery to the left anterior descending coronary artery and laser transmyocardial revascularization were simultaneously performed through a left small thoracotomy. The patient recovered uneventfully and 9 months following surgery he is free of angina and has increased effort tolerance. This case underlines the feasibility of combining these two minimally invasive procedures through the same approach in selected patients.

Coronary Artery Bypass↗
PubMed1999

[Myocardial revascularization with arterial conduits: comparison of bilateral internal mammary artery and single internal mammary artery].

The use of bilateral internal mammary artery (BIMA) grafting for myocardial revascularization has been demonstrated to provide long-term benefits compared to revascularization using single left internal mammary artery (SIMA) and venous conduits. However, it is still controversial whether the use of BIMA is associated with a higher hospital mortality and morbidity. The present study retrospectively evaluated the possible advantages related to the use of BIMA at 3-year follow-up and whether the presence of operative risk factors in patients with BIMA could limit the application of the procedure in myocardial revascularization. We compared two groups of 100 patients matched for preoperative clinical characteristics, who underwent myocardial revascularization on the left coronary system with BIMA (93 males and 7 females, mean age 59 +/- 4 years) or with SIMA and venous conduits (86 males and 14 females, mean age 63 +/- 6 years). Hospital mortality rate was 2% in both groups, the use of BIMA being not a significant risk factor for hospital mortality and morbidity. The mean follow-up was 36 +/- 6 months for the BIMA group and 40 +/- 10 months for the SIMA group. At 3 years, there was no significant differences in the actuarial freedom from cardiac death (96 +/- 2% for BIMA vs 94 +/- 2% for SIMA patients), myocardial infarction (98 +/- 2 vs 97 +/- 2%), angina (93 +/- 2 vs 91 +/- 2%), symptomatic heart failure (92 +/- 3 vs 92 +/- 2%), coronary angioplasty/reoperation (96 +/- 2 vs 97 +/- 2% ), and total cardiac events (80 +/- 4 vs 76 +/- 4%). BIMA grafting was not an independent predictor of late cardiac events. In 66 patients who underwent a late angiographic or echo-Doppler study, the patency rate was 100% for the left mammary artery, 94% for the right mammary artery and 69% for venous conduits. In conclusion, myocardial revascularization with BIMA in situ is associated with low hospital mortality and morbidity, good clinical outcome and excellent patency rate at 3 years, with apparently no significant differences when compared to the use of SIMA and venous conduits. The low hospital mortality and morbidity and the satisfactory medium-term results in our opinion justify a more extensive use of BIMA in myocardial revascularization.

Aged↗
PubMed1999

Recurrent myxoma of the left ventricle. Case report and review of the literature.

A 29-year-old female was found to have a left ventricular mass while in the 14th week of gestation. Seven years earlier she had undergone removal of a left ventricular myxoma. At re-operation, after elective interruption of pregnancy, a recurrent left ventricular myxoma was successfully excised. According to a review of the literature recurrence of an isolated, localized left ventricular myxoma has not been previously reported.

Adult↗
PubMed1999

Combined mitral and tricuspid valve repair in acute infective endocarditis.

Combined repair of the mitral and tricuspid valves involved with acute infective endocarditis was carried out in a 38-year-old drug addict. Mitral valve repair included vegetectomy, closure of posterior leaflet perforation, and posterior annuloplasty with a patch and a strip of glutaraldehyde-tanned autologous pericardium, respectively, while the tricuspid valve was reconstructed with the use of artificial chordae and valve bicuspidalization. At five months follow up the patient is asymptomatic, with echocardiographic evidence of only trivial mitral and tricuspid incompetence, and no signs of recurrent infection. This case report supports the use of valve reconstruction as a valuable option in patients in whom there is simultaneous involvement of the mitral and tricuspid valves with infective endocarditis.

Adult↗
PubMed1999

Prospective evaluation of frequency and nature of transcranial high-intensity Doppler signals in prosthetic valve recipients.

BACKGROUND AND AIM OF THE STUDY: In asymptomatic prosthetic valve recipients, high-intensity transient signals (HITS) observed with transcranial Doppler (TCD) are a phenomenon of obscure clinical relevance which nature has not yet been elucidated convincingly. METHODS: Eighty-three patients without carotid disease, history of cerebrovascular accidents, and with negative preoperative TCD undergoing either valve replacement (mitral, n = 11; aortic, n = 56; mitral + aortic, n = 6; 40 mechanical prostheses, 29 biological prostheses, 10 homografts) or mitral repair (n = 10) were evaluated prospectively by means of TCD at discharge, three months and one year after surgery, to analyze the presence, incidence and characteristics of HITS. Furthermore, in 12 patients positive for HITS, TCD was repeated during a 30-min period of 100% O2 inhalation. RESULTS: Twenty-five patients (30%) were positive for HITS at all postoperative controls, although no neurological symptoms were observed. Mechanical prostheses showed a significantly higher incidence of HITS (85%) than biological prostheses (10%, p <0.001), repaired mitral valves (0%, p <0.001) and homografts (0%, p <0.001). At multivariate analysis the presence of a mechanical prosthesis was the only significant predictor of detection of HITS after valve replacement. During O2 inhalation, a significant decrease in the number of HITS per hour (55 +/- 79 versus 22 +/- 31, p = 0.002) occurred, which returned to initial values when room-air breathing was resumed. CONCLUSIONS: Prosthetic valve replacement, particularly when mechanical devices are used, is associated with the generation of HITS which persist throughout the follow up period, but remain clinically silent. The decrease of HITS during O2 inhalation strongly supports the hypothesis of the gaseous nature of such signals and confirms the validity of this method in helping to differentiate gaseous microemboli from solid microemboli in prosthetic valve recipients.

Adult↗
PubMed1999

Cardiopulmonary exercise testing in patients with 21mm St. Jude Medical aortic prosthesis.

BACKGROUND AND AIM OF THE STUDY: Small-sized prostheses may be associated with high transprosthetic gradients, particularly in patients with a body surface area (BSA) >1.70m2, affecting left ventricular mass regression, symptom improvement and long-term survival. However, the influence of such gradients on exercise tolerance has not been clearly defined. The study aim was to verify the utility of cardiopulmonary exercise testing (CPX) in detecting patient-prosthesis mismatch, and to identify the clinical and echocardiographic data that predict exercise tolerance at CPX in patients with a 21mm St. Jude Medical (SJM) aortic prosthesis. METHODS: Twenty patients (one male, 19 females; mean age 66 +/- 9 years) with a 21 mm SJM prosthesis were evaluated by means of 2D echocardiography and CPX at 36 +/- 10 months after operation. Patients were divided into groups on the basis of a BSA of <1.70 m2 (group 1, n = 12) or > or =1.70 m2 (group 2, n = 8). RESULTS: At echocardiography, left ventricular mass reduction was 16 +/- 10% versus 9 +/- 6% in groups 1 and 2, respectively, mean gradient (MG) was 15 +/- 6 versus 17 +/- 4 mmHg (p = NS), effective orifice area index (EOAi) 0.86 +/- 0.10 versus 0.79 +/- 0.09 cm2/m2 (p = 0.05). At CPX, group 2 patients showed a significantly lower exercise duration (p = 0.02), maximum workload (p = 0.02), peak O2 uptake (p = 0.01), anaerobic threshold (AT) (p = 0.03), ventilatory equivalent for CO2 at AT (p = 0.007), and O2 cost of work (p = 0.03). Group 1 patients showed a ventilatory origin for their effort dyspnea, while group 2 patients showed a significant circulatory component. At multivariate analysis, BSA, age, EOAi and MG were independent predictors of CPX results. CONCLUSIONS: In patients with a 21 mm aortic SJM prosthesis and a BSA > or =1.70m2, CPX allows detection of patient-prosthesis mismatch, in terms of impaired exercise tolerance due to circulatory causes. CPX results can be anticipated on the basis of the patient's BSA, age, EOAi and MG. In these patients, technical solutions allowing implantation of a larger prosthesis should be considered whenever an active lifestyle is anticipated after aortic valve replacement.

Aged↗
PubMed1999

Late patency of recycled internal mammary artery: verification by Doppler echocardiography and coronary angiography.

We report the case of a 57-year-old man who had presented with exertional angina early in 1997 and had subsequently undergone myocardial revascularization with the use of both internal mammary arteries. Two months after surgery, the patient was readmitted to the hospital with unstable angina. Coronary angiography revealed a 90% occlusion of the left internal mammary artery anastomosis, which was attached to the left anterior descending coronary artery. At reoperation, the left internal mammary artery was detached from the left anterior descending coronary artery, probed and injected with papaverine, checked for patency, and regrafted to the same coronary artery. Recycling of the left internal mammary artery was facilitated by the harvesting and routing technique that had been used during the previous operation. At the patient's 1-year follow-up visit, both Doppler echocardiography and coronary angiography showed patency of the recycled graft. We conclude that recycling of the left internal mammary artery is a safe and effective option in selected patients who require reoperation after myocardial revascularization.

Angina Pectoris↗
PubMed1998

Operative technique for thoracoscopic transmyocardial laser revascularization.

We describe herein the operative steps used to perform a transmyocardial laser revascularization by thoracoscopy. A special technique and specific equipment are required for the efficacy and safety of the procedure. Our preliminary results with this novel approach suggest that it could be a valid alternative to the thoracotomic procedure.

Coronary Disease↗
PubMed1998

Early results of transmyocardial revascularization with a holmium laser.

BACKGROUND: Transmyocardial laser revascularization (TMLR), a surgical technique designed to improve perfusion in the ischemic myocardium by creating transmural channels, has been performed thus far using a carbon dioxide laser, with apparently gratifying early results. We have investigated clinically TMLR using a holmium laser as sole therapy for patients with coronary artery disease that is not amenable to traditional treatment such as coronary artery bypass grafting or percutaneous transluminal coronary angioplasty. METHODS: From November 1995 to December 1996, 16 patients underwent TMLR using a holmium laser. Their mean age was 68 +/- 6 years and 75% were men. Previous coronary artery bypass grafting or percutaneous transluminal coronary angioplasty had been performed in 81% and 31% of the patients, respectively. Before operation, their mean anginal class was 3.4 +/- 0.5 and their mean left ventricular ejection fraction was 0.49 +/- 0.06. Six patients had unstable angina. RESULTS: There were no operative deaths. The mean duration of TMLR was 27 +/- 13 minutes and the mean duration of the entire operation was 120 +/- 40 minutes. There were no major postoperative complications and the mean hospital stay was 8 +/- 4 days. There were 2 late deaths, 1 that occurred 40 days after TMLR as a result of stroke and 1 that occurred 4 months after TMLR as a result of myocardial infarction. Current survivors have been followed up for a mean of 10 +/- 4 months (range, 3 to 15 months), with 7 patients followed up for 1 year. At last follow-up, the mean anginal class had decreased to 1.8 +/- 0.7 (p = 0.001) and the patients had increased exercise tolerance and a reduced number of hospitalizations. However, no statistically significant changes in the percentage of segments with fixed or reversible ischemia and no statistically significant differences in the viability scores of lased and nonlased segments were observed. CONCLUSIONS: Transmyocardial laser revascularization using a holmium laser is a simple technique with low operative risk and low morbidity. Early results confirm that clinical improvement is obtained in most patients, although significant changes in myocardial perfusion are not evident in the short term.

Aged↗
PubMed1998

Valve-related complications in elderly patients with biological and mechanical aortic valves.

BACKGROUND: Controversy still exists about the choice of aortic prosthesis in elderly patients. This study investigates valve- and anticoagulant-related morbidity and mortality in elderly patients after aortic valve replacement (AVR) with a biologic (BP) or mechanical prosthesis (MP). METHODS: Between 1981 and 1995, 355 consecutive patients aged 70 years or older (mean, 74+/-4 years; range, 70 to 87 years) underwent isolated AVR. There were 222 (63%) replacements with an MP and 133 (37%) with a BP. Mean follow-up was 3.7+/-2.8 years (range, 3 months to 15 years), with a total follow-up of 1,214 patient-years. RESULTS: Hospital mortality was 7.6% (27 of 355), decreasing to 4.6% in the last 3 years. There were 55 late deaths, 33 in patients with MP and 22 in those with BP. At 10 years there was no significant difference between MP and BP recipients in the actuarial estimates of survival (51%+/-8% versus 33%+/-13%), freedom from valve-related death (82%+/-7% versus 72%+/-12%), and freedom from thromboembolism (84%+/-7% versus 94%+/-3%). In contrast, 10-year freedom from anticoagulant-related hemorrhages was 74%+/-8% for MP and 99%+/-1% for BP (p = 0.02). Only 1 structural deterioration occurred, in a patient with BP. CONCLUSIONS: Satisfactory early results can be obtained in elderly patients after AVR with both MP and BP. The comparable low late survival in the two groups was predominantly influenced by non-valve-related deaths. A higher incidence of anticoagulant-related hemorrhages limits the use of MP in elderly patients. Thus, in this population, BP should be preferred not just on the basis of their expected longer durability, but mainly to avoid the risk of anticoagulant-related hemorrhages.

Actuarial Analysis↗
PubMed1998

Predicting outcome after myocardial revascularization in patients with left ventricular dysfunction.

In order to identify the risk factors which could predict outcome after coronary artery bypass grafting in patients with left ventricular dysfunction, 80 consecutive patients with an ejection fraction < or = 30%, who underwent isolated coronary artery bypass grafting at the authors' centre between January 1994 and May 1996 were evaluated. Preoperatively, mean(s.d.) ejection fraction was 27.1(3.8)%, 56 patients (70%) had angina, and 56(70%) were in New York Heart Association (NYHA) functional class III or IV. There were five operative deaths, with a hospital mortality rate of 6.3%. Significant risk factors for hospital death were NYHA class IV, preoperative ventricular arrhythmias and left ventricular end-diastolic volume index > 110 ml/m2. At mean follow-up of 15(7) (range 6-30) months, there were six late deaths, five of which were from cardiac causes. Actuarial survival rate at 2 years was 82(5)% and freedom from cardiac death 84(5)%. Risk factors for overall mortality from cardiac causes were preoperative grade 2 mitral regurgitation, associated with left ventricular dilatation, and renal dysfunction (creatininaemia > or = 180 micromol/l). At follow-up, mean ejection fraction was 37.5(8.4)%, and the overall functional status had improved: 12 patients (18%) had angina and eight (12%) were in NYHA class III and IV. Myocardial revascularization in patients with left ventricular dysfunction can be performed with acceptably low operative risk, good survival rate at 2 years, and functional status improvement. Patients with extensive ventricular dilatation, associated with significant mitral regurgitation, have a lower life expectancy and less functional benefits from coronary artery bypass grafting. These patients are better treated by cardiac transplantation.

Aged↗
PubMed1998

Transmyocardial holmium laser revascularization: feasibility of a thoracoscopic approach.

OBJECTIVE: Creation of transmyocardial channels from the epicardium to the left ventricular cavity with the use of a laser is a modern approach in the treatment of patients with chronic ischemic heart disease unsuitable for coronary angioplasty or bypass grafting. We present the results of transmyocardial laser revascularization (TMLR) with a holmium laser as sole therapy in 22 patients operated on between November 1995 and February 1997. METHODS: There were five females (23%) and 17 males (77%), with a mean age of 67+/-7 years (range 53-74 years). Previous myocardial revascularization had been performed in 77% of the patients. Pre-operatively, 12 patients (55%) were in angina class III and ten (45%) in class IV (mean 3.5+/-0.5); unstable angina was present in seven patients (32%). In 20 patients, TMLR was performed through a limited thoracotomy, while in two a thoracoscopic approach was used. Each patient received a mean of 33+/-8 channels in 27+/-13 min, while total operation lasted 130+/-28 min. RESULTS: There were no hospital deaths and no major post-operative complications. Mean hospital stay was 7+/-3 days; the two patients undergoing thoracoscopic TMLR were discharged after 4 and 5 days, respectively. Two deaths were observed after 40 days and 4 months after TMLR, due to stroke and myocardial infarction. Mean follow-up of current survivors is 10+/-6 months (range 3-15 months), with seven patients followed for over 12 months. At last follow-up, mean angina class is 1.9+/-0.6 (P < 0.001). A significant increase in exercise tolerance and a reduction of the number of hospitalizations for angina were also observed. However, no significant changes in myocardial perfusion were observed. CONCLUSIONS: The present study demonstrates that: (1) TMLR with a holmium laser yields clinical improvement in the majority of patients with severe angina unsuitable for conventional surgical treatment, (2) gratifying results in terms of improved anginal status and exercise tolerance are achieved, despite the lack of significant changes in myocardial perfusion at early follow-up and (3) TMLR through a thoracoscopic approach is a feasible procedure.

Aged↗
PubMed1998

Quadricuspid aortic valve.

A quadricuspid aortic valve was observed in a patient requiring aortic valve replacement because of severe aortic regurgitation, while in another it was accidentally detected by means of transesophageal echocardiography performed during coronary artery bypass grafting. This report discusses the apparent rarity of this malformation and stresses the need for periodical controls in patients known to have a quadricuspid aortic valve.

Adult↗