Retrocaval right internal mammary artery for left ventricular marginal arteries grafting.
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Humans↗
Biomedical subjects
Edvin Prifti
Publications and source records attributed to Edvin Prifti.
A modified technique for repair of the anomalous origin of the right pulmonary artery from the ascending aorta.
We report a modified technique of right pulmonary artery implantation to the main pulmonary artery with interposition of a tube created from the great arterial wall for an anomalous origin of the right pulmonary artery from the right lateral aspect of the ascending aorta. This technique offers extra autologous tissue length and reduced tension at the anastomotic site. It also offers the possibility to place the anomalous right pulmonary artery anterior to the ascending aorta, avoiding the aortic compression. This technique was employed successfully in a 15-week-old female.
Anastomosis, Surgical↗
A modified 'single patch' technique for complete atrioventricular septal defect correction.
We propose a modified single-patch technique consisting in plication of the patch on the left side, which then is sutured with the free edge of the left atrioventricular valve. The proposed technique offers all the advantages of the single-patch technique and at the same time provides additional tissue for reconstructing appropriately the left atrioventricular valve in cases with leaflet tissue deficiency such as severely dysplastic valve, double orifice left atrioventricular valve. This modification augments the left atrioventricular valve tissue appropriately to the orifice size, promotes leftward displacement and improved coaptation with the mural leaflet.
Cardiac Surgical Procedures↗
Early and long term outcome of the arterial switch operation for transposition of the great arteries: predictors and functional evaluation.
OBJECTIVES: The aims of this report were to study the early and late outcome in terms of mortality, freedom from reoperation, predictors for late pulmonary stenosis (PAS) and insufficiency of the neo-aortic valve (AVI) in patients with transposition of the great arteries (TGA) undergoing arterial switch operation (ASO). MATERIALS AND METHODS: Between January 1990 and December 2001, 134 patients with TGA underwent ASO. The patients were divided in Group I (n=88)-TGA with intact ventricular septum and Group II (n=46)-TGA with ventricular septal defect (VSD). The pulmonary artery was reconstructed employing the direct anastomosis technique (PT-I) in 21 (15.7%) patients, the double-patch technique (PT-II) in 41 (30.6%), single pantaloon patch (partial circumference) (PT-III) in 46 (34%) and single pantaloon patch (total circumference) (PT-IV) in 35 (26%) patients. The mean follow-up was 3.4+/-1.3 years. RESULTS: The hospital mortality was 17 (12.7%) patients. The mortality in Group I was significantly lower than Group II (P=0.002). The overall actuarial survival at 1, 3 and 5 years follow-up resulted to be 98, 93, and 91.5%, resulting to be significantly higher in Group I (P=0.032). The multivariate analysis revealed the complex TGA (P=0.007), VSD (P=0.032), coronary anomalies (P=0.004), aortic coarctation or hypoplastic aortic arch (P=0.021), left ventricular outflow tract obstruction (LVOTO) or moderate PAS (P=0.041) as strong predictors for poor free-reoperation cumulative survival. A strong inverse correlation was found between the mean trans-pulmonary gradient at follow-up and the age at the operation (r=-0.41, P<0.0001). The univariate analysis revealed the PT-I technique (P=0.002), prior moderate PAS (P=0.0001), and age <1 month (P=0.018) as strong predictors for moderate-to-severe PAS. The neo-AVI incidence was significantly higher in Group II (P=0.011). Predictors for neo-AVI were male sex (P=0.003), preoperative neo-AV Z-score >1 (P<0.001), prior or concomitant operation for aortic coarctation or hypoplastic aortic arch (P=0.001), LV retraining (P=0.003). CONCLUSION: ASO remains the procedure of choice for the treatment of various forms of TGA with acceptable early and later outcome in terms of overall survival and free reoperation. Strong predictors for poor overall free-reoperation survival are complex TGA, VSD, coronary anomalies, aortic coarctation and LVOTO or moderate PAS. The pulmonary artery reconstruction using a single 'pantaloon patch' seems to offer less residual stenosis. Patients with a VSD and a significant mismatch between the neo-aortic root and distal aorta are at a higher risk for developing postoperative neo-AVI.
Abnormalities, Multiple↗
Reconstructive surgery for congenitally malformed mitral valve.
BACKGROUND AND AIMS OF THE STUDY: The study aims were to evaluate early and mid-term survival and freedom from reoperation in patients with isolated mitral valve (MV) congenital malformation (MVCM) or in association with other cardiac defects, and to identify predictors for poor early and late outcome. METHODS: Between January 1990 and February 2001, 58 children with MVCM underwent MV-conserving surgery; patients were allocated to group I (n = 21) with isolated MVCM, and group II (n = 37) with MVCM and associated congenital heart defects (ACHD). MV stenosis was identified in 10 (48%) group I patients, and 11 (30%) group II patients (p = NS); MV insufficiency was present in 11 (52%) patients in group I, and in 26 (70%) of group II (p = NS). The most frequently found MVCM were annular dilatation (n = 13) cases and elongated chordae (n = 14). Hammock MV was found in nine patients (15%). RESULTS: Six (10%) hospital deaths occurred. Mortality was 5% (n = 1) in group I, and 13% (n = 5) in group II (p = 0.4). Mean repair techniques per patient was 2.05+/-0.4 and 2.3+/-0.3 in groups I and II respectively (p = 0.009). Mechanical ventilation time was 2.1+/-1 and 2.8+/-0.7 days in groups I and II (p = 0.003). The incidence of postoperative mitral regurgitation grade > or =1 was significantly higher in group II (p = 0.008). At five-year follow up, actuarial survival was 91.5% in group I and 86% in group II (p = 0.037). Actuarial reoperation-free survival was 85% in group I and 73% in group II (p = 0.01). Multivariate analysis showed age >12 months (p = 0.033), hammock MV (p = 0.0088) and ACHD (p = 0.0048) were strong predictors for poor event-free survival. CONCLUSION: MV repair for MVCM provides acceptable early and mid-term outcome in terms of mortality and freedom from reoperation. ACHD significantly reduce early and late postoperative survival and freedom from reoperation.
Adolescent↗
Early postoperative outcome and hemodynamic performance of the sorin pericarbon stentless aortic valve.
BACKGROUND AND AIMS OF THE STUDY: Stentless aortic bioprostheses offer potential advantages in terms of durability and hemodynamic performance. The study aim was to evaluate the early postoperative performance of the Sorin Pericarbon stentless bioprosthesis. METHODS: Between November 1999 and December 2000, 34 patients (12 males, 22 females; mean age 71.2 +/- 4.8 years; range: 48-85 years) underwent aortic valve (AV) replacement with the Sorin Pericarbon stentless bioprosthesis. Twenty-two patients were in NYHA classes III-IV, and 12 were in classes I-II. Twenty-one patients had AV stenosis, nine AV regurgitation, and four mixed pathology. Doppler-echocardiography was performed before surgery, at hospital discharge and at six-month follow up. At this time, 20 patients also underwent echo-Doppler stress testing, with peak transvalvular gradient measured at rest and during exercise. RESULTS: There were two hospital deaths (not valve-related). No significant perioperative complications were recorded. At hospital discharge, the aortic peak gradient was 15.7 +/- 10.6 mmHg; nil or trivial aortic regurgitation was found in three patients. During six months follow up no endocarditis or thromboembolic events were registered. At six months postoperatively, the transvalvular peak gradient showed a small but significant decrease (11.3 +/- 3.5 mmHg at six months, p = 0.036). Mean left ventricular mass index was also decreased significantly (118.4 +/- 28.5 versus 98.4 +/- 17.8 g/m2, p = 0.024). Left ventricular ejection fraction and effective orifice area were not changed significantly during follow up. In patients undergoing exercise testing (mean maximal workload 96 +/- 48 W), the peak aortic gradient was increased (not significantly) at exercise peak (from 14.7 +/- 6.5 to 17.2 +/- 6.7 mmHg, p = 0.086). CONCLUSION: The excellent early postoperative outcome of this experience with the Sorin Pericarbon stentless valve encourages the use of this prosthesis. Long-term follow up and further evaluations are required with regard to hemodynamic performance and durability.
Aged↗
[Ministernotomy improves the postoperative course in aortic valve replacement].
BACKGROUND: The advantages and the safety aspects of ministernotomy, in aortic valve replacement, are presently under investigation. The aim of this study was to compare the postoperative results between ministernotomy access and standard total sternotomy access. METHODS: Between January 1997 and July 2002, 98 patients underwent elective aortic valve replacement. They were divided into two groups: group Gm (49 patients) undergoing a ministernotomy approach ("reversed C" or "reversed L") and group Gs (49 patients) undergoing conventional total sternotomy. RESULTS: The length of the skin incision was significantly shorter in group Gm (p < 0.001). The total operative time was significantly longer in group Gm (p = 0.02), but no significant differences were found in the cardiopulmonary bypass and aortic cross-clamping times. Mean mediastinal drainage, incidence of bleeding > 800 ml, mechanical ventilation time, intensive care unit stay and hospital stay were significantly greater in group Gs. Five days after the surgical procedure, spirometric analysis demonstrated a significant reduction in total lung capacity, and in maximum expiratory and inspiratory pressures in group Gs compared with group Gm (p = 0.003, p = 0.001, p = 0.01, respectively). CONCLUSIONS: Our results showed that in addition to cosmetic advantages, ministernotomy is also associated with a better outcome in terms of sternal stability, blood loss and transfusions, and postoperative pain. Ministernotomy also improved the recovery of respiratory function, with a shorter mechanical ventilation time and allowed an earlier hospital discharge.
Aortic Valve↗
Off-pump total arterial myocardial revascularization according to the right Y-graft configuration.
OBJECTIVES: The aims of this study were as follows: 1) to evaluate the early outcome of the off-pump total arterial myocardial revascularization according to the right y-graft (lambda-graft) configuration and 2) to compare baseline flow and maximum flow between patients undergoing on-pump and off-pump right y-graft (RYG) construction. METHODS: Between December 1998 and January 2001, 47 patients (Group I) and 20 patients (Group II) with three vessel disease underwent on-pump and off-pump coronary artery bypass graft (CABG) respectively according to the RYG configuration. The mean age was 55.5 +/- 4.7 years and 55 +/- 6.4 years in Groups I and II, respectively. The RYG was constructed employing both internal mammary arteries (IMAs) only, in 21 and 8 patients in Groups I and II, respectively, presenting proximal-middle third stenosis of the left anterior descending artery (LAD) and right coronary artery (RCA). The modified RYG configuration employing both IMAs and radial artery (RA) was performed in 26 and 12 patients in Groups I and II, respectively, presenting middle-distal third stenosis of the LAD and distal stenosis of the RCA or posterior descending artery stenosis. Postoperatively all patients underwent transthoracic echo color-Doppler (TTECD) contrast enhanced (by Levovist) before and after adenosine provocative testat one week and three months after operation. RESULTS: There were no hospital deaths. The mean mechanical ventilation was significantly different in Group I versus Group II patients, 18 +/- 4.4 hours versus 13 +/- 5.7 hours, respectively (p = 0.041). The mean intensive care unit stay was 1.5 +/- 0.6 days in Group I and 1 +/- 0.4 days in Group II (p = 0.033). There were no differences between Groups I and II regarding the IMA diameter, mean velocity, and mean flow. At follow-up time, 6 +/- 2.4 months after the surgical procedure, all patients were alive and free of angina. The coronary flow reserve (CFR) at LIMA main stem was significantly higher at three months when compared to the values at one week after the surgical procedure within the same group, (LIMA)CFR (three months) = 2.37 +/- 0.6 versus (LIMA)CFR (one week) = 2.07 +/- 0.4 (p = 0.005) in Group I and (LIMA)CFR (three months) = 2.4 +/- 0.4 versus (LIMA)CFR (one week) = 2.06 +/- 0.3 (p = 0.004) in Group II. Similarly, the CFR at RIMA main stem were significantly higher at three months when compared to the values at one week after the surgical procedure: (RIMA)CFR (three months) = 2.47 +/- 0.7 versus (RIMA)CFR (one week) = 2.1 +/- 0.5 (p = 0.004) in Group I and (RIMA)CFR (three months) = 2.48 +/- 0.5 versus (RIMA)CFR (one week) = 2.08 +/- 0.4 (p = 0.008) in Group II. CONCLUSION: The flow dynamic data, almost identical between patients undergoing off-pump and on-pump total arterial myocardial revascularization (TAMR) according to the RYG configuration, demonstrate that this technique can be applied with excellent results without the employment of cardiopulmonary bypass in selected coronary artery disease patients.
Cardiopulmonary Bypass↗
Beating heart ischemic mitral valve repair and coronary revascularization in patients with impaired left ventricular function.
OBJECTIVE: The aim of this study is to evaluate in a cohort of patients with impaired left ventricular (LV) function and ischemic mitral valve regurgitation (MVR), the effects of on-pump/beating heart versus conventional surgery in terms of postoperative mortality and morbidity and LV function improvement. MATERIALS AND METHODS: Between January 1993 and February 2001, 91 patients with LVEF between 17% and 35% and chronic ischemic MVR (grade III-IV), underwent MV repair in concomitance with coronary artery bypass grafting (CABG) Sixty-one patients (Group I) underwent cardiac surgery with cardioplegic arrest, and 30 patients (Group II) underwent beating heart combined surgery. Aortic valve insufficiency was considered a contraindication for the on-pump/beating heart procedure. Mean age in Group I was 64.4 +/- 7 years and in Group II, 65 +/- 6 years (p = 0.69). RESULTS: The in-hospital mortality in Group I was 8 (13%) patients versus 2 (7%) patients in Group II (p > 0.1). The cardiopulmonary bypass (CPB) time was significantly higher in Group I (p < 0.001). In Groups I and II, respectively (p > 0.1), 2.5 +/- 1 and 2.7 +/- 0.8 grafts per patient were employed. Perioperative complications were identified in 37 (60.7%) patients in Group I versus 10 (33%) patients in Group II (p = 0.025). Prolonged inotropic support of greater than 24 hours was needed in 48 (78.7%) patients (Group I) versus 15 (50%) patients (Group II) (p = 0.008). Postoperative IABP and low cardiac output incidence were significantly higher in Group I, p = 0.03 and p = 0.027, respectively. Postoperative bleeding greater than 1000 mL was identified in 24 patients (39.4%) in Group I versus 5 (16.7%) in Group II (p = 0.033). Renal dysfunction incidence was 65.6% (40 patients) in Group I versus 36.7% (11 patients) in Group II (p = 0.013). The echocardiographic examination within six postoperative months revealed a significant improvement of MV regurgitation fraction, LV function, and reduced dimensions in both groups. The postoperative RF was significantly lower in Group II patients 12 +/- 6 (%) versus 16 +/- 5.6 (%) in Group I (p = 0.001). The 1, 2, and 3 years actuarial survival including all deaths was 91.3%, 84.2%, and 70% in Group I and 93.3%, 87.1%, and 75% in Group II (p = ns). NYHA FC improved significantly in all patients from both groups. CONCLUSION: We conclude that patients with impaired LV function and ischemic MVR may undergo combined surgery with acceptable mortality and morbidity. The on/pump beating heart MV repair simultaneous to CABG offers an acceptable postoperative outcome in selected patients.
Aged↗
Anomalous origin of the right pulmonary artery from the ascending aorta.
OBJECTIVES: The aim was to review our experience with the surgical repair of the anomalous origin of the right pulmonary artery (AORPA) from the aorta. MATERIALS AND METHOD: Between January 1991 and March 2001, five patients with AORPA underwent surgical correction. One patient presented isolated AOPA from the aorta. Implantation of the anomalous PA to the main PA trunk was performed by (1). direct anatomosis employing an autologous pericardial patch in two patients; (2). using an aortic flap in two patients with AORPA; and (3). using an aortic and pulmonary flaps in another patient. The mean follow-up time was 27 months. RESULTS: One patient died due to progressive heart failure unresponsive to inotropic support. Early postoperative pulmonary hypertension crisis was identified in patient 4, that was managed by intravenous prostacyclin. The same patient necessitated mechanical ventilation for 11 days. The mean residual gradient for all survivors was 9.5 +/- 4 mmHg. The postoperative Tc-99 m scintigraphy demonstrated 72 +/- 4.5(%) lung perfusion. At follow-up the survival was 100%. None of the followed patients required reoperation. CONCLUSION: The AORPA from the aorta is a rare but important entity, necessitating a scrupulous preoperative and intraoperative evaluation. The techniques employing autologous tissues for enlarging and lengthening the AORPA seem to be associated with better results in terms of postoperative restenosis.
Anastomosis, Surgical↗
Repair of complete atrioventricular septal defect with tetralogy of fallot: our experience and literature review.
OBJECTIVES: The aim of this report is to describe the rationale of our surgical approach, to explore the best management for complete atrioventricular septal defect associated with the tetralogy of Fallot (CAVSD-TOF), and to present our outcome in relation to the previously reported series. MATERIALS AND METHODS: Between January 1990 and January 2002, 17 consecutive children with CAVSD-TOF underwent complete correction. Nine patients (53%) underwent previous palliation. Mean age at repair was 2.9 +/- 1.9 years. Mean gradient across the right ventricular outflow tract was 63 +/- 16 mmHg. All children underwent closure of septal defect with a one-patch technique, employing autologous pericardial patch. Maximal tissue was preserved for LAVV reconstruction by making these incisions along the RV aspect of the ventricular septal crest. LAVV annuloplasty was performed in 10 (59%) patients. Six patients (35%) required a transannular patch. RESULTS: Three (17.6%) hospital deaths occurred in this series. Causes of death included progressive heart failure in two patients and multiple organ failure in the other patient. Two patients required mediastinal exploration due to significant bleeding. Dysrhythmias were identified in 4 of 11 patients undergoing a right ventriculotomy versus none of the patients undergoing a transatrial transpulmonary approach (p = ns). The mean intensive care unit stay was 3.2 +/- 2.4 days. Two patients required late reoperation due to severe LAVV regurgitation at 8.5 and 21 months, respectively, after the intracardiac complete repair. The mean follow-up time was 36 +/- 34 months. All patients survived and are in NYHA functional class I or II. The LAVV regurgitation grade at follow-up was significantly lower than soon after operation, 1.1 +/- 0.4 versus 1.7 +/- 0.5 (p = 0.002). At follow-up, the mean gradient across the right ventricular outflow tract was 17 +/- 6 mmHg, significantly lower than preoperatively (p < 0.001). CONCLUSIONS: Complete repair in patients with CAVSD-TOF seems to offer acceptable early and mid-term outcome in terms of mortality, morbidity, and reoperation rate. Palliation prior to complete repair may be reserved in specific cases presenting small pulmonary arteries or severely cyanotic neonates. The RVOT should be managed in the same fashion as for isolated TOF; however, a transatrial transpulmonary approach is our approach of choice.
Cardiac Surgical Procedures↗
Surgical revascularization of coronary bifurcations employing a single arterial graft according to the "omega-anastomosis" technique: initial experience.
OBJECTIVES: The aim of this study was to evaluate the early postoperative outcome in patients undergoing "omega-anastomosis" construction, a technique that permits revascularization of coronary bifurcations employing a single arterial graft. MATERIALS AND METHODS: Between January 2000 and March 2002, omega-anastomosis was employed in 12 patients. The main indication for omega-anastomosis construction was the presence of a significant stenotic lesion involving one of the coronary tree's bifurcations, presenting a relevant secondary branch. There were ten men and two women, with a mean age of 55.4 +/- 4.3 years (range 48 to 66). The omega-anastomosis was constructed employing a single arterial graft (internal mammary artery or radial artery) effectively tailored to obtain a bi-petal shape and anastomosed to the coronary bifurcation according to a three-foliate anastomosis. All patients underwent postoperative coronary angiography. RESULTS: There were no hospital deaths, neither ECG nor enzymatic alterations. One patient was reoperated for excessive bleeding. The mean aortic cross-clamp time and duration of CPB (cardiopulmonary bypass) were 64 +/- 18 minutes (range 45 to 108) and 89 +/- 26 minutes (range 67 to 135), respectively. Thirty-four arterial conduits were used: 12 LIMA, 12 RIMA, and 10 RA. Twelve omega-anastomoses were constructed, in six patients employing the RA, and in six other patients employing one of the internal mammary arteries (IMAs). Five left Y-grafts between the in situ LIMA and free LIMA graft and one right Y-graft between the RIMA and RA were constructed. The mean ICU stay was 14.4 +/- 5.7 hours. The postoperative coronary angiography revealed a good patency of the "omega-anastomosis." Transthoracic color Doppler echocardiography (TTECD) demonstrated a normal IMAs flow pattern in all cases. CONCLUSIONS: We define the reported configuration as a possible surgical alternative to achieve total arterial myocardial revascularization in multi-vessels patients, associated with excellent postoperative outcome that should be part of the coronary surgical armamentarium.
Aged↗