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Biomedical subjects

Franco Glieca

Publications and source records attributed to Franco Glieca.

At least 19 recordsLinked to original sources
PubMed2006

Repeat valvular operations: bench optimization of conventional surgery.

BACKGROUND: Repeat heart valve operations have become a quite common procedure. We reviewed our experience with reoperative valvular surgery during a 6-year period to assess the risk factors affecting in-hospital mortality and medium-term survival. METHODS: A series of 316 redo procedures performed on a total of 290 patients in the period between 1997 and 2002 at our institution was retrospectively analyzed. Univariate and multivariable analyses were performed. RESULTS: In-hospital mortality was 3.8%; overall mortality at the end of a 30-month follow-up was 9.3%. We identified advanced New York Heart Association class, advanced age, depressed ejection fraction, emergent or urgent presentation, impairment of renal function, and involvement of tricuspid valve as predictors of mortality. In contrast, duration of cardiopulmonary bypass and multiple valve procedure were not associated with increased short-term risk. CONCLUSIONS: The present study is characterized by particular attention in reducing confounding variables and biases correlated to heterogeneities. The main determinants of mortality are related to the degree of patients' illness rather than to inherent technical factors of reoperations. Although highest-risk individuals (previous coronary artery bypass grafting or coexistence of aortic aneurysm) were excluded from the study, our data suggest that patients undergoing isolated redo valvular procedures now face operative risks that are comparable to primary intervention.

Cardiac Surgical Procedures↗
PubMed2006

Patients with in-stent restenosis have an increased risk of mid-term venous graft failure.

BACKGROUND: This study was designed to evaluate if patients in whom in-stent restenosis developed had an higher risk of early venous graft failure compared with normal patients. METHODS: The study cohort comprised 120 patients (60 with previous in-stent restenosis and 60 controls) who received a total of 165 complementary venous grafts on the circumflex or right coronary artery system (84 in the restenosis group and 81 in the control group). All patients were prospectively followed-up and underwent reangiography at 5-years follow-up. RESULTS: In the restenosis group, 28 venous grafts (33.%) were perfectly patent, 10 showed major irregularities, and 46 were occluded. In the control patients, 50 grafts (61.7%) were perfectly patent (p < 0.001 compared with the restenosis series), 12 showed major irregularities (p = .74), and 19 were occluded (p < 0.0001). In contrast, the 5-year outcome of internal thoracic artery grafts was not affected by history of in-stent restenosis. CONCLUSIONS: Patients who developed in-stent restenosis have an higher risk of early venous graft failure compared with the control patients. Arterial grafts should probably be preferred in these patients.

Aged↗
PubMed2005

Ten-year Echo-Doppler evaluation of forearm circulation following radial artery removal for coronary artery bypass grafting.

OBJECTIVE: To investigate the chronic consequences of radial artery removal for coronary artery bypass surgery on the forearm circulation. METHODS: Thirty-nine patients submitted to radial artery removal for coronary artery bypass were submitted to serial Echo-Doppler evaluation of the flow and morphology of the forearm arteries until 10 years follow-up. RESULTS: The peak systolic velocity of the ulnar artery of the operated side was significantly higher than the control site. The intima-media thickness of the ulnar artery was always significantly higher on the operated side, and this difference reached statistical significance at 10 years follow-up. There was a significantly higher prevalence of atherosclerotic plaques in the ulnar artery (UA) of the operated versus control arm (11/39 vs 0/39; p=0.005). CONCLUSIONS: Radial artery removal for coronary artery bypass surgery leads to a chronic increase in ulnar flow accompanied by increased intima-media thickness and accelerated atherosclerotic disease. These findings may have potentially important implications for surgical indications and patients management.

Blood Flow Velocity↗
PubMed2005

Implantation in coronary circulation induces morphofunctional transformation of radial grafts from muscular to elastomuscular.

BACKGROUND: The purpose of this research was to investigate the in vivo morphofunctional changes induced in the radial artery (RA) by its use as coronary artery bypass conduit by comparing the morphological features and vasoreactivity of the native RA versus the coronary RA graft in the same patient. METHODS AND RESULTS: Ten years after surgery, 10 patients were submitted to intravascular ultrasound examination of the RA graft of the controlateral (in situ) RA and of the internal thoracic artery (ITA) graft and to vasoactive challenges with acetylcholine and serotonin. Quantitative angiographic assessment showed that the mean diameter of the RA coronary grafts was significantly larger than that of the in situ RA and of the ITA (2.89+/-0.40 mm RA grafts, 2.14+/-0.52 mm in situ RA, 2.25+/-0.53 mm ITA grafts; P<0.001). The in situ RA demonstrated a typical muscular architecture, whereas RA coronary grafts showed a clear reduction of the thickness of the medial layer and had a less well-defined muscular component of the media with interposition of elastic tissue. Serotonin endovascular infusion elicited a strong spastic reaction in in situ RAs; the same challenge induced only moderate constriction in RA and ITA coronary grafts. CONCLUSIONS: Implantation in the coronary circulation leads to major anatomic and vasoreactive modifications of the RAs that tend to lose the morphofunctional features of a muscular conduit and assume those of an elastomuscular artery, such as the ITA.

Acetylcholine↗
PubMed2005

Midterm angiographic patency and vasoreactive profile of proximal versus distal radial artery grafts.

BACKGROUND: No data are available on the different angiographic results and the in vivo vasoreactivity of radial artery (RA) grafts obtained from different parts of the conduit, although it is known that the distal segment of the artery has a more pronounced muscular component. This study was conceived to evaluate the angiographic patency and tendency to spasm of proximal versus distal RA grafts. METHODS: In 29 patients, at the time of surgical myocardial revascularization, the radial artery was divided into two separate conduits, so that these patients received a total of 58 radial grafts (29 from the proximal and 29 from the distal portion of the artery). All cases were submitted to midterm angiography and vasoactive challenges to verify angiographic patency and vasoreactive profile. RESULTS: Radial artery patency rate was 28 of 29 for both groups. Nine cases of string sign were reported, all in the distal series (p = 0.001). The perfect patency rate of distal grafts was markedly lower than that of proximal grafts (19 of 29 versus 27 of 29; p = 0.02). Vasoactive challenges testified to a higher vasospastic attitude of distal grafts. CONCLUSIONS: Radial artery grafts obtained from the distal portion of the artery have a higher vasospastic tendency, greater incidence of string sign, and lower midterm perfect patency rate than graft taken from the more proximal part of the artery. The proximal part of the RA should be preferred for use as a conduit for surgical myocardial revascularization.

Angiography↗
PubMed2005

Harmonic scalpel reduces bleeding and postoperative complications in redo cardiac surgery.

BACKGROUND: Intraoperative and postoperative bleeding and injuries to cardiac structures are among the main determinants of complications and hospital and intensive care unit stay after cardiac reinterventions. The harmonic scalpel has been reported to achieve optimal tissue dissection with little blood loss. The present retrospective work was performed to evaluate the safety and usefulness of this device in redo cardiac surgery. METHODS: Ninety-six redo cardiac surgery patients were operated on with the use of harmonic scalpel, and 105 redo patients operated on by traditional electrocautery and scissors were selected from our database and served as controls. Intraoperative and postoperative data of the two groups were collected and compared. Univariate and multiple logistic regression analyses were performed for identification of factors associated with death and with major and minor complications in the overall study population and in both groups, separately. RESULTS: Although mortality and major postoperative morbidity were comparable in the two groups, harmonic scalpel patients presented markedly reduced postoperative bleeding, lower incidence of minor complications, cardiac injuries, major arrhythmias, and need for transfusions. Operative time and mean intensive care unit stay were shorter. Use of ultrascissor was found to be a protective factor against minor morbidity at multivariate analysis. CONCLUSIONS: Our data suggest that harmonic scalpel is safe and is associated with better in-hospital outcome and lower postoperative blood loss in redo cardiac surgery.

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PubMed2004

Survival after aortic valve replacement for aortic stenosis: does left ventricular mass regression have a clinical correlate?

AIM: The effects of post-operative left ventricular mass regression (LVMR) on clinical outcome after aortic valve surgery remains to be established. This study was intended to establish the impact of patient characteristics on post-operative survival in patients referred for aortic valve replacement (AVR), with particular regard to LVMR. METHODS AND RESULTS: Two hundred and sixty consecutive cases submitted to aortic valve replacement for valvular stenosis were prospectively followed for a mean of 28+/-9 months. Baseline, characteristics and extent of LVMR were tested for association with survival by uni- and multivariable analysis. Ten deaths occurred during hospital stay and 52 during out-of-hospital follow-up. Mean left ventricular mass decreased from 190+/-43 to 158+/-70 g/m2 (P<0.001). Older age, advanced functional class, hypertension, reduced left ventricle ejection fraction, and high pre-operative left ventricular mass index were associated with reduced survival. Overall the extent of LVMR did not influence the clinical results, while only early (<6 months) LVMR was weakly associated with mid-term outcome. CONCLUSION: Survival after aortic valve surgery is mainly determined by the pre-operative functional cardiac and systemic status. The extent of LVMR does not correlate with clinical outcome, whereas aggressive treatment of hypertension may improve post-operative survival.

Aged↗
PubMed2004

Skeletonization does not influence internal thoracic artery innervation.

BACKGROUND: This study was designed to compare the effect of surgical harvesting on internal thoracic artery innervation and to assess the eventual presence of denervation supersensitivity in skeletonized grafts. METHODS: Nineteen patients who underwent primary isolated coronary artery bypass grafting were randomly assigned to receive a skeletonized (n = 9) or pedicled (n = 10) internal thoracic artery graft. Immunohistochemical nerve localization using anti-S-100 protein, anti-160-kd neurofilament polypeptide and anti-tyrosine hydroxylase antibodies was performed on distal specimens of arteries to study vascular innervation. Moreover, endovascular vasoactive challenges using serotonin and methylergometrine were performed at early angiographic control to evaluate the eventual presence of denervation supersensitivity. RESULTS: Quantitative analysis of immunohistochemical specimens revealed lack of difference in the number of positive cells between skeletonized and pedicled arteries for all the antibodies used. No difference in the reaction to serotonin and methylergometrine was found between skeletonized and pedicled arteries. CONCLUSIONS: Skeletonization does not influence internal thoracic artery innervation.

Aged↗
PubMed2004

Effect of target artery location and severity of stenosis on mid-term patency of aorta-anastomosed vs. internal thoracic artery-anastomosed radial artery grafts.

OBJECTIVE: To verify the effect of location and severity of stenosis of the target coronary artery (TCA) on mid-term patency of aorta-anastomosed vs. internal thoracic artery (ITA)-anastomosed radial artery (RA) graft. METHODS: During a 3-year period 228 consecutive patients received an RA graft at our institution. In 131 cases the RA was anastomosed to the aorta whereas in 97 the proximal anastomosis was performed on a mammary graft. The two groups were comparable in terms of preoperative variables and TCA characteristics. At a mean follow-up of 6.5 years 128 cases of the aorta-anastomosed and 95 of the mammary-anastomosed group were submitted to control angiography. RESULTS: Mid-term patency and perfect patency rates were 92.1 and 89.8% (118/128 and 115/128) for aorta-anastomosed RA vs. 86.3 and 84.2% for mammary-anastomosed grafts (82/95 and 80/95; P=0.81 and 0.82). The location of TCA did not influence graft patency in the two groups. The severity of the TCA stenosis strongly influenced graft patency in both groups but the threshold for failure was clearly higher in the mammary-anastomosed group. CONCLUSIONS: ITA-anastomosed RA grafts are more vulnerable to the detrimental effect of chronic native competitive flow and should be used only for target vessel with subocclusive stenosis. The location of the distal anastomosis does not influence long-term RA patency.

Aorta↗
PubMed2004

Effect of surgical revascularization of a right coronary artery tributary of an infarcted nonischemic territory on the outcome of patients with three-vessel disease: a prospective randomized trial.

BACKGROUND: We evaluated the in-hospital and long-term effects of surgical grafting of a dominant graftable right coronary artery tributary of an infarcted nonischemic territory in patients with triple-vessel disease who were undergoing coronary artery bypass grafting. METHODS: Of 303 consecutive patients undergoing coronary artery bypass grafting with 3-vessel coronary disease and a dominant right coronary artery tributary of an infarcted nonischemic territory, 154 were randomized to right coronary artery revascularization and 149 to no right coronary artery grafting. In all cases, standard on-pump surgical myocardial revascularization was performed. RESULTS: Overall hospital mortality was 2 of 154 versus 1 of 149 (P =.97); no difference in in-hospital outcome was observed between the 2 groups. At follow-up, cardiac event-free survival was 84 of 152 in the right coronary artery grafting series and 62 of 148 in the non-right coronary artery grafting group (P =.20). However, when the analysis was limited to surviving patients without new scintigraphic evidence of ischemia (to avoid confounding factors derived from ischemia in the left coronary system or right coronary artery graft malfunction), we found that patients who received a right coronary artery graft had fewer cardiac events, a lower incidence of arrhythmia, and less left ventricular dilatation than did the non-right coronary artery revascularized series. CONCLUSIONS: Surgical grafting of a right coronary artery tributary of an infarcted nonischemic territory in patients with 3-vessel coronary artery disease submitted to coronary artery bypass grafting improved late electric stability, ventricular geometry, and event-free survival but did not affect in-hospital or 10-year survival.

Aged↗
PubMed2004

Cardiopulmonary bypass in man: role of the intestine in a self-limiting inflammatory response with demonstrable bacterial translocation.

BACKGROUND: Cardiopulmonary bypass provokes a systemic inflammatory reaction that, in 1% to 2% of all cases, leads to multiorgan disfunction. The aim of this study was to evaluate the possible role of the intestine in the pathogenesis and development of this reaction. METHODS: Eleven selected patients scheduled for elective coronary artery bypass graft surgery were enrolled in a open, prospective clinical study. Gastric tonometry, chromium-labeled test and double sugar intestinal absorption tests, polymerase chain reaction microbial DNA test, and measurement of cytokines and transcriptional factor (nuclear factor kappaB) activation were performed. RESULTS: During the postoperative period, gastric pH remained stable (range,7.2 to 7.3). The partial pressure for carbon dioxide gradient between the gastric mucosa and arterial blood increased significantly (from 1 to 23 mm Hg), peaking in the sixth postoperative hour. Interleukin 6 increased significantly over basal levels, peaking 3 hours after cardiopulmonary bypass (96.3 versus 24 pg/mL). Nuclear factor kappaB never reached levels higher than those observed after lipopolysaccharide stimulation. Escherichia coli translocation was documented in 10 patients: in eight cases from removal of aortic cross-clamps and in two cases from the first postoperative hour. With respect to basal value (6.4%), the urine collection revealed a significant increase in excretion of the radioisotope during the first 24 hours after surgery (39.1%), although there were no significant variations with the double sugar test. CONCLUSIONS: The results obtained showed a correlation between the damage of the gastrointestinal mucosa, subsequent increased permeability, E coli bacteremia, and the activation of a self-limited inflammatory response in the absence of significant macrocirculatory changes and postoperative complications.

Adult↗
PubMed2004

High risk coronary artery bypass patient: incidence, surgical strategies, and results.

BACKGROUND: To describe our experience in the treatment of high risk coronary artery bypass patients and compare patients assigned to on-pump or off-pump surgery. METHODS: During a 42-month period 306 high risk (Euroscore > 5) coronary artery bypass patients were consecutively treated at our institution. On the basis of the coronary anatomy and possibility of achieving a complete revascularization, 197 patients were assigned to off-pump and 109 to on-pump operation. Overall mortality was 6.2% (19 of 306 patients). RESULTS: Although patients treated off-pump had a better cardiac status, no clinical advantages related to the avoidance of cardiopulmonary bypass were found in the overall population. Off-pump patients had more early and late cardiac complications, whereas patients operated on-pump exhibited an higher incidence of postoperative systemic organ dysfunction. Off-pump surgery improved in-hospital outcome only in the subset of patients at highest risk. CONCLUSIONS: Avoidance of cardiopulmonary bypass does not confer significant clinical advantages in all high risk coronary patients; instead, there are particular subsets of patients in whom beating heart surgery can be particularly indicated and others for whom on-pump revascularization appears a better solution. Adaptation of the operation to the single patient is probably the way to improve outcome.

Aged↗
PubMed2003

Long-term results of the radial artery used for myocardial revascularization.

BACKGROUND: No information is available on the long-term results of radial artery (RA) grafts used as coronary artery bypass conduits. METHODS AND RESULTS: In this report, we describe the long-term (105+/-9 months) angiographic results of a series of 90 consecutive patients in whom the RA was used as a coronary artery bypass conduit directly anastomosed to the ascending aorta. The long-term patency and perfect patency rates of the RA were 91.6% and 88%, respectively, versus 97.5% and 96.3% for internal thoracic artery grafts. The severity of stenosis of the target vessel clearly influenced long-term RA patency, whereas location of the target vessel and long-term use of calcium channel blockers did not influence angiographic results. Preserved endothelial function and absence of flow-limiting, fibrous, intimal hyperplasia were also documented. CONCLUSIONS: Ten years after surgery, RA grafts have excellent patency and perfect patency rates. Appropriate surgical technique and correct indication are the key factors for long-term RA patency.

Calcium Channel Blockers↗
PubMed2003

Coronary artery bypass grafting in type II diabetic patients: a comparison between insulin-dependent and non-insulin-dependent patients at short- and mid-term follow-up.

BACKGROUND: Diabetes is a well-established risk factor for coronary artery disease, and it is associated with an increased rate of early and late adverse events after myocardial revascularization by coronary artery bypass grafting. METHODS: A prospective follow-up study was done to evaluate the short-term and mid-term outcomes of type II diabetic patients who had coronary artery bypass grafting at our institution between 1996 and May 1999. A total of 200 patients, 100 insulin-dependent diabetic patients (group I) and 100 non-insulin-dependent diabetic patients (group II), met the inclusion criteria of the study and were included in the clinical follow-up study. RESULTS: The characteristics of the patients of the two groups were similar for baseline clinical angiographic and operative characteristics. In particular, no significant differences in cardiopulmonary bypass and aortic cross-clamping times were noted between the two groups. The number grafts per patient was similar between the two groups. There were no in-hospital deaths, but postoperative complications were different among the two series. In fact, 33% of patients in group I had at least one major complication compared with 20% in group II (p = 0.037). The cumulative number of complications was 148 in group I and 69 in group II, and the mean number of complications per patient was 4.5 and 3.5 in groups I and II, respectively. The major differences in perioperative complication rates were found in the need for prolonged (> 24 hours) ventilation, occurrence of respiratory or renal insufficiency, and mediastinitis. The mean length of stay in the intensive care unit and for total hospitalization were longer in group I than group II (4.3 +/- 2.8 days versus 2.8 +/- 2.7 days [p = 0.010] and 11.1 +/- 2.2 days versus 7.2 +/- 2.4 group II [p < 0.05], respectively). At long-term follow-up, group I patients had a significantly higher mortality rate (29% versus 10%, p < 0.001). Moreover, overall late cardiac and noncardiac complication rates were significantly higher in group I than II (37% versus 22%, p = 0.02). In the multivariate analysis including several preoperative and operative variables, treatment by insulin, advanced age (> 75 years), left ventricular dysfunction (left ventricular ejection fraction < 35%), and complex lesions at coronary angiography (American Heart Association lesion classification type C lesion) were found as independent predictors of increased mortality. CONCLUSIONS: Our data show that patients with insulin-dependent type II diabetes who had coronary artery bypass grafting have a significantly higher rate of major postoperative complications with an extremely unfavorable short- and long-term prognosis. Diabetic patients on insulin treatment should be considered high-risk candidates for coronary artery bypass grafting and require intense perioperative and long-term monitoring. Further studies will be necessary to investigate whether such conclusions may be appropriate for newer surgical strategies such as off-pump operation.

Aged↗
PubMed2003

Genetic control of postoperative systemic inflammatory reaction and pulmonary and renal complications after coronary artery surgery.

BACKGROUND: Although some data suggest that the individual genetic predisposition for developing major or minor degrees of postoperative systemic inflammatory reaction may influence postoperative morbidity, this hypothesis has not been clinically tested to date. Methods and results The -174 G/C polymorphism of the promoter of the interleukin 6 gene was determined preoperatively in 111 consecutive patients submitted to primary isolated coronary artery bypass. The results of the genetic analysis were then correlated with the postoperative interleukin 6 levels and the development of postoperative renal and pulmonary complications. G homozygotes had significantly higher interleukin 6 levels postoperatively (P <.0001 for the difference between areas under the curve). These patients also had worse postoperative pulmonary and renal function. The mean perioperative difference in serum creatinine, potassium, and nitrogen was 0.82 +/- 0.34, 0.99 +/- 0.44, and 10.1 +/- 7.8 mg/dL versus 0.18 +/- 0.14, 0.15 +/- 0.48, and 2.6 +/- 4.1 mg/dL for GG versus non-GG carriers (P <.0001), respectively. The mean respiratory index at 6 and 12 hours was 2.9 +/- 0.8 and 2.8 +/- 0.3 versus 2.1 +/- 0.5 and 1.3 +/- 0.1, respectively (P <.0001). The mean duration of mechanical ventilation was 22.5 +/- 2.1 versus 12.7 +/- 6.7 hours (P <.01). A correlation was found between postoperative interleukin 6 levels and renal and pulmonary complications. CONCLUSION: The interleukin 6 -174 G/C polymorphism modulates postoperative interleukin 6 levels and is associated with the degree of postoperative renal and pulmonary dysfunction and in-hospital stay after coronary surgery.

Alleles↗
PubMed2003

Early vasoreactive profile of skeletonized versus pedicled internal thoracic artery grafts.

BACKGROUND: No data are available on the early vasoreactive profile of skeletonized internal thoracic artery grafts. METHODS: Fifteen patients undergoing primary isolated coronary artery bypass grafting were randomly assigned to receive a skeletonized or pedicled internal thoracic artery graft. On the second postoperative day all patients were subjected to follow-up angiography and endovascular infusion of serotonin, acetylcholine, and isosorbide dinitrate. RESULTS: Internal thoracic artery grafts were widely patent in all cases. Mean diameters of the internal thoracic artery were 1.95 +/- 0.17 mm in the pedicled group and 2.26 +/- 0.40 mm in the skeletonized group. After serotonin challenge, mean internal thoracic artery diameters were reduced to 1.44 +/- 0.34 mm and 1.64 +/- 0.14 mm, respectively; acetylcholine challenge lead to a moderate degree of vasoconstriction (1.55 +/- 0.59 mm in the pedicled group and 1.84 +/- 0.15 mm in the skeletonized group). No statistically significant difference was evident between the two groups at any step. CONCLUSION: Skeletonization does not affect the early vasoreactive profile of internal thoracic artery grafts used for surgical myocardial revascularization.

Acetylcholine↗
PubMed2003

Treatment of mediastinitis using an open irrigation and delayed sternal reconstruction with a pectoralis major muscle flap.

BACKGROUND: Mediastinitis is a very serious complication after cardiac surgery. To date, the optimal treatment of mediastinitis is still controversial: the "closed wound" procedures and the "open wound" treatments are the two conventional modalities reported in the literature. METHODS: Between January 1995 and December 2000, 20 patients, who had previously been submitted to cardiac surgery, were treated by a modification of the "open wound" treatment strategy for postoperative mediastinitis. All patients were scheduled for 2, 6, and 12-month clinical follow-up. The procedure performed consisted of three major steps: 1) early sternum reopening, followed by phase 2) including irrigation of the wound 3 times daily, and the final step 3) of delayed reconstructive surgery using the pectoralis major myocutaneous advancement flap closure technique. We prospectively analyzed the short- and long-term results of these procedures. RESULTS: The overall duration of hospitalization was 25 +/- 10 days; no patient required intensive care unit permanency. Clinical success was achieved in all 20 cases (100%). No recurrences of local (such as fistulas or abscesses) or systemic infections were noted, and no patient required sternal reopening during follow-up. An optimal cosmetic result was obtained in all patients and only 2 cases had persistent sternal pain regressing at the 6-month follow-up control. CONCLUSIONS: Our data suggest that for patients with severe mediastinitis, this treatment strategy is safe. The clinical and esthetic success rates are high, the recovery time rapid, and the rates of short- and long-term complications very low.

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