Biomedical subjects
Publications and source records attributed to F Musumeci.
Photon emission in the visible and near ultraviolet range by samples of human tissue removed during surgery has been measured by means of a low noise photomultiplier coupled to a data acquisition system. The results show that among the 25 analyzed samples the 9 from normal tissues had an emission rate of the order of some tens of photons/cm2 min, while most of the 16 tumor tissue samples had a very much higher rate.
The role of heterotopic heart transplantation in coronary heart disease has not been defined. Between 1983 and 1988, 28 patients with end-stage ischemic heart disease were managed by heterotopic heart transplantation and adjunctive operation on the recipient heart: coronary artery bypass grafts and aneurysmectomy, 20; coronary artery bypass grafts, 5; and aneurysmectomy, 3. Indications were feasibility of operative procedures to the recipient heart and small donor size (61% of the donors were less than 15 years). The 1-year and 5-year actuarial survival was 79% and 63%. Of the 22 patients who survived to 2-year follow-up, all of whom had been severely limited (New York Heart Association grade III/IV) preoperatively, 20 were in grades I or II at 2-year follow-up (p less than 0.001). In 14 of 22 patients (64%), the recipient heart augmented the donor cardiac output substantially, and in 4 the recipient heart supported the patient when the donor heart failed to eject. In conclusion, this series demonstrates the efficacy of heterotopic transplantation combined with operation to the recipient heart in the management of patients with end-stage ischemic heart disease.
The effect of self irradiation on yeast cells has been investigated by counting the young gemmae formation in 104 self irradiated samples, as compared with an equal set of control samples. The results show that the rate of gemmae formation is higher in self irradiated samples; the statistical significance of the results is discussed.
The human gastroepiploic artery has been used as a coronary artery bypass conduit in a limited number of clinical studies. It has been postulated that the capacity of the endothelium to release vasoactive substances may contribute to differing patency rates observed in established bypass grafts. We have now examined endothelial function in the human gastroepiploic artery. Endothelium-dependent relaxations to substance P were observed. A maximum relaxation of 83.25% +/- 8.2% (mean +/- standard error) was attenuated to 48.5% +/- 16.4% in the presence of L-NG-monomethyl-arginine, a specific inhibitor of endogenous nitric oxide synthesis. Removal of the endothelium abolished the relaxations. With a specific radioimmunoassay, concomitant changes in levels of cyclic guanosine 3',5'-monophosphate, the second messenger that elicits smooth muscle relaxation after release of the endothelium-derived relaxing factor, were measured. It was found that the gastroepiploic artery had significantly higher resting and stimulated levels of cyclic guanosine 3',5'-monophosphate than either the internal mammary artery or the saphenous vein. In the presence of the cyclooxygenase inhibitor indomethacin, and indomethacin plus L-NG-monomethylanginine, the maximum relaxation was decreased to 70% +/- 9.5% and 59% +/- 10.8%, respectively. Our data demonstrate that endothelium-derived relaxing factor and prostacyclin may exhibit synergy in the control of vascular tone in this vessel. It is concluded that the endothelium of the gastroepiploic artery has a strong capacity to secrete vasodilators and inhibitors of platelet activity. This could have important influence on long-term patency.
A technique for correction of interrupted aortic arch during heart-lung transplantation is described. This operation was performed in a 14-year-old patient with situs solitus, absent right atrioventricular connection, large atrial septal defect, ventricular septal defect, transposition of the great arteries, type B interrupted aortic arch, and severe pulmonary hypertension. The postoperative course was uneventful. Clinical, radiologic, and nuclear magnetic resonance investigation have shown evidence of good correction of the aortic arch anomaly. We concluded that donor tissue available during heart-lung transplantation is useful in correcting extracardiac anomalies.
Between January 1973 and February 1986, operations were performed on 120 consecutive patients having usual atrial arrangement (atrial situs solitus), concordant atrioventricular connection, and double-outlet right ventricle. The ages at operation ranged from 1 day to 44 years and the weights from 2.6 to 84 kg. Sixty-three patients had one or more palliative procedures. For those, the hospital mortality rate was 9.5%. Palliation was considered a definitive procedure in 13 patients. Ninety-three patients had a reparative operation, with a 26.9% early mortality rate. In the group who had complete correction, taken as a whole, the surgical outcome was significantly affected by the position of the ventricular septal defect and by the year of operation. The year of operation was the main factor that, by multivariate analysis, correlated significantly with the hospital mortality in those patients having a subaortic defect and spiraling great arteries (p less than 0.05). No difference was found among this group for those patients having the morphologic characteristics of tetralogy of Fallot. The change-over point from the Mustard to the arterial switch procedures was the event with the greatest effect on hospital mortality in patients with a subpulmonary ventricular septal defect (p less than 0.025). Two late deaths have occurred among the 21 patients who had palliative intervention only. Sixty of the 68 survivors with intracardiac repair have been followed up for a period of 2 to 184 months (median 44 months). There were five late deaths (8.3%). Eight patients underwent successful reoperation. All except three of the long-term survivors were in functional class I. Good early and long-term results can be anticipated for the intracardiac repair of double-outlet right ventricle when the ventricular septal defect is subaortic or doubly committed. The arterial switch operation has been demonstrated to be the optimal approach for double-outlet right ventricle with subpulmonary ventricular septal defect. Results in patients with noncommitted ventricular septal defect have remained poor.
The absent pulmonary valve syndrome includes agenesis of the pulmonary valve, annular stenosis, and pulmonary insufficiency. The pulmonary arteries are aneurysmal and usually compress the tracheobronchial tree. These features are associated with a ventricular septal defect and right ventricular hypertrophy. Nineteen children aged 5 days to 11 years were treated between 1976 and 1983. Nine were younger than 1 year. Intractable respiratory symptoms and heart failure were the main features in the infant group; five required preoperative assisted ventilation. Older children had decreased exercise tolerance and repeated respiratory infections. Several surgical techniques were used in this series. The best results were achieved when the size of the main, right, and left pulmonary arteries was reduced by extensive anterior resection; the ventricular septal defect was closed; and an aortic homograft was interposed between the right ventricle and the pulmonary artery. Four infants and four children treated in this way survived the operation. Five of the nine operated infants died (56%); all older children survived the operation. At follow-up, six children were asymptomatic and one was in New York Heart Association Class II. All four infants were progressing satisfactorily although all had some residual pulmonary symptoms. Closure of the ventricular septal defect, reduction of the size of the pulmonary arteries, and insertion of an aortic homograft was the optimal treatment in our series.
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Between February, 1969, and March, 1980, 235 consecutive patients underwent repair of tetralogy of Fallot. Of these, 94 patients were less that 4 years of age, including 40 less than 2 years of age. Previous palliative procedures had been performed in 46 patients. Conservative technique to relieve the right ventricular outflow tract (RVOT) obstruction was employed in 194 patients; transannular approach was performed in the remaining 41. There were 18 hospital deaths (7.6%) and 3 late deaths. The early and late results were significantly related to the ratio of the right ventricular to left ventricular systolic peak pressure after repair. Until 1976, the age of patients of operation constituted an operative risk factor. Since 1977, none of the 17 infants who underwent operation died after the repair. In the overall series, the transannular approach to relieve the RVOT obstruction affected the early mortality and the late results. During the last 3 years, only 1 of the 12 patients who received an aortic homograft monocusp transannular gusset died in the hospital, and the 11 survivors were completely symptom free at follow-up.
Forty-four consecutive infants aged from 3 days to 10 months underwent repair of total anomalous pulmonary venous connection using deep hypothermia with circulatory arrest. There were eight (18%) early hospital deaths. Using multivariate analysis no significant association could be shown between early mortality and age or weight at operation, preoperative pulmonary or systemic pressure, and preoperative condition for patients undergoing operation during the most recent five year period. Late pulmonary venous obstruction developed in four (11%) of the survivors and all of these patients died.
Between January 1974 and November 1980, 13 symptomatic infants under 1 year of age with persistent truncus arteriosus type I or II underwent surgery. Pulmonary artery banding was performed in 10 cases, with five deaths. Among the survivors, one developed severe pulmonary vascular disease and only two underwent late intracardiac repair. Primary total correction was performed in three infants and all are well, though one required conduit replacement five and a half years after the initial procedure. Recently, antibiotic sterilised homograft conduits, rather than heterografts, have been preferred as extracardiac conduits in infancy. Early intracardiac repair followed, if necessary, by later conduit replacement appears to have significant advantages over "conventional" pulmonary artery banding and late total correction. Concern remains on the treatment of choice in infants under 3 months of age.
Eighty successive patients underwent the Mustard operation for "simple" transposition of the great arteries (TGA) between January, 1970, and January, 1980. Ages ranged from 42 days to 12.4 years (mean 14.7 months). Balloon atrial septostomy (BAS) with balloon volumes of more than 2.5 ml produced significant increases of arterial oxygen saturation, although the initial benefit of BAS was greater than that found at follow-up catheterization. In these patients the left ventricular (LV) pressure tended to decrease during the first months of life, but this drop was less marked at the end of the first year. Deep hypothermia and cardiocirculatory arrest were employed in all cases. Several modifications were adapted to the original surgical technique in order to reduce last sequelae. There were two early and three late deaths. At follow-up (mean 4.5 years) 74% of patients were symptom free. Sinoatrial and atrioventricular (AV) conduction disturbances were present in five and six patients, respectively. Caval or pulmonary venous obstruction occurred in 13 patients, seven of whom required reoperation. Isolated tricuspid valve incompetence was present in one patient only, but in four it was associated with other defects. Primary right ventricular (RV) failure occurred in one patient. These findings, in relation to mortality, complications, and the excellent clinical results in the majority of survivors, compare favorably with results published for patients with "simple" TGA who have been subjected to other types of physiological or anatomic correction. At the present time, there seems to be no good reason to alter our surgical policy in this group of patients.
The authors present the implementation of the American NNIS System method for active surveillance in the heart surgery and its intensive care unit (ICU) of a large hospital in Rome (almost 1.000 beds). This surveillance was based on full time infection control professionals. Device-associated infection rates were calculated for adult ICU surveillance component. For surgical patient surveillance component we used the surgical site infection (SSI) risk index based on wound class, duration of operation and American Society of Anesthesiology score. The NNIS System method allowed us to understand the most relevant problems in heart surgery patients: in comparison with NNIS data, we found high rates of SSIs both in procedures on valves and in coronary artery bypass grafts. The central line-associated bloodstream infection rate was higher than the American median rate. Therefore, we decided to focus on surgical risk factors linked to SSIs and to revise recommendations for intravascular-device use. In conclusion, in our experience the NNIS System method proved to be a very useful and versatile tool for nosocomial infections active surveillance.
In Italy no nosocomial infection surveillance database has been established despite the fact that a decrease of nosocomial infection rates was one of the priorities of the Italian National Health Plan 1998--2000. Heart surgery operations are the most frequent high risk procedures in western countries. Active surveillance was performed at the heart surgery wards of two Italian hospitals (Rome and Catania, Southern Italy) in accordance with the methods described for the National Nosocomial Infections Surveillance (NNIS) System of the USA. In both hospitals surgical site infections (SSIs) were the most frequently encountered type of nosocomial infections, accounting for 57.2% in Rome and 50% in Catania, and SSI rates in coronary artery bypass grafts with both chest and donor site incisions, calculated by risk index equal to 1, were above the 90th percentile for the NNIS System. The urinary catheter-associated urinary tract infection (UTI) rate (5.8%) in Catania exceeded the 90th percentile for the NNIS System, while the device-associated UTI (1.6%), bloodstream (4.1%) and pneumonia (8.0%) rates, from the hospital in Rome, did not. All device utilization ratios were lower than the 10th percentile for the NNIS System. Our study demonstrated that the NNIS methodology is applicable to Italian hospitals, although with some limitations mainly regarding the minimal surveillance duration required for significant interhospital comparison, and highlighted the need of a national comparison of surveillance data as benchmark.
Between December 1983 and April 1989, 222 combined heart and lung transplant operations were performed for treatment of pulmonary vascular disease and parenchymal lung disease at Harefield Hospital. Seventeen of these patients had emphysema, and 11 of them were followed up for a minimum of 1 year. There were nine male and two female patients. Their mean age was 39 (range, 32 to 54) years. Seven had alpha 1-antitrypsin deficiency. Six patients were receiving continuous oxygen therapy, and two patients were dependent on a ventilator. Postoperatively, the patients' lungs were ventilated for a median of 3 days (range, 24 hours to 2 weeks). Two patients subsequently required further periods of ventilation. Immunosuppression consisted of azathioprine and cyclosporine. Three patients also received low-dose oral steroids. There was one early death, which occurred on the second postoperative day. The remaining patients were followed up for 12 to 53 (mean, 22) months. One patient had cytomegalovirus pneumonitis 6 weeks postoperatively that responded to treatment. There was one late death at 14 months after reoperation for treatment of obliterative bronchiolitis. The overall survival was 91% at 1 year. All survivors achieved an excellent level of rehabilitation. It is concluded that the medium-term results of heart and lung transplantation for treatment of emphysema are good and that patients with alpha 1-antitrypsin deficiency may undergo transplant procedures without substitution therapy.
In this study we investigated the factors influencing the development of hypertension in 488 consecutive heart transplant recipients. The cumulative probability of hypertension (blood pressure persistently above 150/95 mm Hg) developing was 52% at 1 year, 67% at 2 years, 73% at 3 years, and 77% at 4 years after transplantation. The incidence was higher in patients receiving cyclosporine and azathioprine compared with those receiving prednisone and azathioprine immunosuppression. The dose of cyclosporine used did not appear to influence the development of hypertension. Intermittent steroid exposure did not increase the incidence in the cyclosporine group. Male transplant recipients and those older than 20 years appeared more prone to the development of hypertension. A family history of cardiovascular disease also increased the incidence. Preoperative and postoperative kidney dysfunction and transplantation because of ischemic heart disease did not appear to affect the incidence of hypertension. Donor characteristics, including the use of hearts from donors who weighed more than the recipients and from patients dying of spontaneous intracranial hemorrhage, did not appear to increase the incidence of hypertension after heart transplantation.
In order to identify factors affecting early mortality in patients undergoing CABG for unstable angina, several risk factors have been analysed in a group of 120 patients. Systemic hypertension and left ventricular impairment were shown to be significant risk factors (Systemic hypertension, P less than 0.01; EF less than or equal to 0.35, P less than 0.01; LVEDP greater than or equal to 20 mmHg, P less than 0.025). Overall mortality rate was 5% (6/120). No influence could be recognized for age, sex, previous MI, emergency surgery, extension of coronary disease, completeness of revascularization and mode of onset of symptoms.