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Biomedical subjects

G B Luciani

Publications and source records attributed to G B Luciani.

At least 19 recordsLinked to original sources
PubMed2001

Modified ultrafiltration reduces morbidity after adult cardiac operations: a prospective, randomized clinical trial.

BACKGROUND: Extracorporeal circulation contributes to morbidity after open-heart surgery by causing a systemic inflammatory reaction. Modified ultrafiltration is a technique able to remove the fluid overload and inflammatory mediators associated with use of cardiopulmonary bypass. It has been shown to reduce morbidity after cardiac operations in children, but the impact on adult cardiac procedures is unknown. METHODS AND RESULTS: Five hundred seventy-three consecutive adult patients were prospectively randomized to either ultrafiltration after cardiopulmonary bypass (treatment) or to no ultrafiltration (control). Parsonnet score was used to assess the severity of the patients' clinical conditions. Analysis was done with Student's t test or Mann-Whitney U test for continuous variables and Fisher's exact test or Pearson's chi(2) for discrete variables. Hospital mortality was 2.5% (7 of 284) in the treatment group versus 3.8% (11 of 289) in the control group (P=0.357). Hospital morbidity was lower in treated patients (66 of 284 [23.2%] versus 117 of 289 [40.5%], P=0.0001). Cardiac morbidity was similar (26 of 284 [9.1%] versus 35 of 289 [12.1%], P=0.251), whereas significantly lower rates of respiratory (20 of 284 [7.0%] versus 36 of 289 [12.5%], P=0.029), neurological (5 of 284 [1.8%] versus 14 of 289 [4.8%], P=0.039), and gastrointestinal (0 of 284 versus 4 of 289 [1.4%], P=0.044) complications were found in treated patients. Transfusion requirements were also lower in treated patients (1.66+/-2.6 versus 2.25+/-3.8 U/patient, P=0.039). Duration of intensive care (39.9+/-49.2 versus 46.3+/-72.8 hours, P=0.218) and hospital stay (7.6+/-3.5 versus 7.9+/-4.4 days, P=0.372) were comparable. CONCLUSIONS: Modified ultrafiltration after cardiopulmonary bypass is associated with a lower prevalence of early morbidity and lower blood transfusion requirements. The impact on length of hospital stay needs further analysis. Routine application of modified ultrafiltration after adult cardiac operations is warranted.

Adolescent↗
PubMed2001

Over twenty-year follow-up of the standard Hancock porcine bioprosthesis implanted in the mitral position.

BACKGROUND: To define the long-term results of 331 standard Hancock porcine bioprostheses implanted in the mitral position between 1973 and 1980. METHODS: Of 331 patients (225 male patients, 68%), mean age 49+/-10 years (range 14 to 69 years), 88% were in New York Heart Association functional class III or IV and 77% were in atrial fibrillation. Follow-up time extended more than 20 years (mean 13.9 years, range 0.3 to 24.7 years) for a total of 4,601 patient-years. RESULTS: Overall operative mortality was 6.3%. At 5, 10, 15, and 20 years, the actuarial survival rate of patients were 71%+/-2%, 46%+/-3%, 30%+/-3%, and 22%+/-2%, respectively. Actuarial estimates of freedom from structural valve deterioration were 95%+/-1%, 67%+/-3%, 32%+/-3%, and 14%+/-3%; from reoperation were 96%+/-1%, 72%+/-3%, 36%+/-4%, and 18%+/-4%; from thromboembolism were 89%+/-2%, 82%+/-3%, 74%+/-4%, and 51%+/-2%; and from anticoagulant-related hemorrhage were 98%+/-1%, 96%+/-1%, 91%+/-1%, and 86%+/-4%. Estimates of freedom from all valve-related mortality at 5, 10, 15, and 20 years were 89%+/-2%, 76%+/-3%, 64%+/-4%, and 48%+/-4%. Multivariate analysis showed younger age to be a significant risk factor for reoperation. Age at operation did not correlate with structural valve deterioration. CONCLUSIONS: The long-term results with the standard Hancock bioprosthesis implanted in the mitral position appear satisfactory, particularly up to 15 years from implantation. Protection from stroke, anticoagulant hemorrhage, and endocarditis was good.

Adolescent↗
PubMed2001

Long-term results after aortic valve replacement with the Biocor PSB stentless xenograft in the elderly.

BACKGROUND: This study seeks to define the long-term results after Biocor PSB stentless aortic valve replacement (AVR) in elderly patients, including the effects of No-React treatment. METHODS: We reviewed the outcomes of 106 consecutive patients, aged 70+/-6 years, having Biocor PSB (93 standard, 13 No-React) AVR between October 1992 and October 1996. RESULTS: There were three early deaths (3%) and 15 late deaths (15%), during a mean follow-up of 5.8+/-1.6 years. At 8 years, survival was 82%+/-4% and freedom from cardiac death was 94%+/-3%. Freedom from valve failure was 92%+/-4% at 8 years (No-React: 92%+/-8% at 4 years). Replacement of the xenograft was required in 5 patients. Freedom from reoperation was 91%+/-4% at 8 years (No-React: 92%+/-8% at 4 years). Four bleeding and two embolic events were recorded: overall valve-related event-free survival was 81%+/-7% at 8 years (No-React: 76%+/-12% at 4 years). Age of long-term survivors averaged 77+/-5 years and their New York Heart Association status was 1.3+/-0.6 (versus 2.9+/-0.6 preoperatively, p = 0.01). CONCLUSIONS: Satisfactory freedom from cardiac events and from valve deterioration added to uniform improvement in functional status despite advanced age and high prevalence of comorbid conditions make AVR with the Biocor PSB xenograft a valid long-term therapy for the elderly. No-React treatment does not influence xenograft durability.

Adult↗
PubMed2001

Bicuspid aortic valve disease and pulmonary autograft root dilatation after the Ross procedure: a clinicopathologic study.

OBJECTIVE: Bicuspid aortic valve disease has been associated with histologic abnormalities of the aortic root. Recent reports have suggested similar alterations may exist in the pulmonary artery of patients with bicuspid aortic valve. The present study was undertaken to define the histologic condition of the aortic and pulmonary artery root in bicuspid aortic valve disease and the relationship with pulmonary autograft root dilatation after the Ross procedure. METHODS: In 17 patients undergoing aortic root replacement with the pulmonary autograft, biopsy specimens of the aortic root and pulmonary artery trunk were collected. Clinical and histologic findings of patients with bicuspid aortic valves were compared with those with tricuspid aortic valves. RESULTS: There were 9 patients (8 male, 1 female) with bicuspid aortic valve (group 1) and 8 (all male) with tricuspid aortic valve (group 2). Mean age was comparable (24.4 +/- 9.8 vs 23.6 +/- 10.8 years, P =.9). Aortic insufficiency as an indication for operation was more common in group 1 (9/9 vs 5/8, P =.007), whereas preoperative aortic root dilatation was equally prevalent (4/9 vs 1/8, P =.1). Prior aortic valve repair had been performed in 2 patients (1/9 vs 1/8, P =.9). Prevalence of cystic medionecrosis of the aortic wall was similar in the 2 groups (4/9 vs 3/8, P =.6). Cystic medionecrosis of the pulmonary artery trunk was found only in 1 patient with tricuspid aortic valve (0/9 vs 1/8, P =.3). During a mean follow-up of 26.5 +/- 12.2 months (32.1 +/- 12.7 vs 20.1 +/- 7.4 months, P =.04), prevalence of pulmonary autograft root dilatation (greater than 4.0 cm) was equally represented in patients with native bicuspid or tricuspid aortic valve (3/9 vs 2/8, P =.6). CONCLUSIONS: Histologic abnormalities of the pulmonary artery root are rare and equally prevalent in young patients with bicuspid and tricuspid aortic valves. On the contrary, root dilatation is relatively common late after autograft root replacement but appears unrelated to bicuspid aortic valve disease or to pre-existing degenerative changes of the pulmonary artery root.

Adult↗
PubMed2001

Aortic insufficiency after surgical repair of acute type a aortic dissection: incidence, indications for reoperation and medical management.

Recurrent aortic insufficiency presents in as many as 20% of patients late after repair of acute type A aortic dissection. This underscores the need for life-long follow up and appropriate management of patients after such surgery. The prevalence of, and risk factors for, recurrent aortic regurgitation, and the indications for and results of medical and surgical treatment are discussed.

Acute Disease↗
PubMed2001

Comparison of late outcome after stentless versus stented xenograft aortic valve replacement.

The long-term outcomes of 292 patients having stented xenograft aortic valve replacement (AVR) (group 1) and 376 having stentless AVR (group 2) were compared. Patients in group 1 were older (75 +/- 9 years v 70 +/- 6 years, P =.01), had more advanced cardiac disease (New York Heart Association [NYHA] classification III-IV: 85% v 75%, P =.03), and more associated procedures (53% v 41%, P =.01). Early mortality was higher in Group 1 (6.2% v 2.6%, P =.02), primarily due to cardiac cause (5.4% v 1.5%, P =.009). During follow-up (37 +/- 30 months v 43 +/- 35 months, P = not significant [ns]), 66 late deaths were recorded (12% v 9%, P = ns). At 8 years, survival (70% +/- 5% v 81% +/- 3%, P =.01) freedom from cardiac death (85% +/- 1% v 92% +/- 3%, P =.02) and prosthesis-related death (79% +/- 5% v 95% +/- 2%, P =.004) was higher in Group 2, but freedom from structural deterioration was similar (92% +/- 5% v 93% +/- 3%, P = ns). Late functional status was equally satisfactory (NYHA classification I-II: 89% v 90%, P = ns). Stentless AVR may confer selective survival advantages. Because freedom from valve failure is similar to stented xenografts, extension of stentless AVR to patients without anatomic contraindications appears justified.

Actuarial Analysis↗
PubMed2000

Predictors of left ventricular outflow obstruction following single-stage repair of interrupted aortic arch and ventricular septal defect.

This study looked at echocardiographic predictors of left ventricular outflow obstruction after primary neonatal repair of interrupted aortic arch and ventricular septal defect. Results of this study indicate that the only significant independent predictor of left ventricular outflow obstruction is aortic valve diameter; all patients with an aortic valve diameter <4.5 mm (Z score <-5) subsequently developed obstruction, whereas patients with annuli >4.5 mm (Z score >-5) remained free from obstruction.

Abnormalities, Multiple↗
PubMed2000

Predicting outcome after reoperative procedures on the aortic root and ascending aorta.

OBJECTIVE: Reoperations on the ascending aorta after prior aortic procedures are formidable challenges. In order to identify factors predictive of clinical outcome using a uniform surgical approach, results of a 15-year experience were reviewed. METHODS: Between 1983 and 1998, 78 reoperations on the ascending aorta were performed in 71 consecutive patients. There were 56 males and 15 females, aged 54+/-13 years (10-73 years), with a mean interval to first reoperation of 60+/-76 months (5-223 months). The original operation was replacement of ascending aorta (23), aortic valve (25), aortic root (7), ascending aorta with valve preservation (9), ascending aorta and aortic valve (7). Surgical approach included femoral vessels dissection and repeat sternotomy, with femoro-femoral bypass limited to cases of traumatic reentry. Reoperation consisted in replacement of the aortic root (48), ascending aorta (15), ascending aorta and aortic valve (6), aortic root with ascending aorta and arch (6), ascending aorta and aortic arch (3). Average aortic crossclamp and cardiopulmonary bypass times were 122+/-86 and 188+/-60 min, respectively. RESULTS: Early deaths were five (7%), due to low output syndrome (3), hemorrhage (1) and sepsis (1). Mortality for emergent reoperation was significantly higher (38 vs. 3%, P=0.001). A total of 39 early complications were observed in 78 reinterventions (50%), including: traumatic reentry requiring emergent femoro-femoral bypass (4), reexploration for bleeding (4), respiratory failure (12), sepsis (5), transient neurologic dysfunction (4), renal failure (3), myocardial infarction (3), circulatory insufficiency requiring mechanical life support (2), and wound infection (2). Average intensive care unit stay was 4.5+/-9.7 days (0.5-40 days). Survival was 92+/-4%, 78+/-10% and 78+/-10% at 1, 5, and 10 years, respectively. At follow-up (mean 34+/-36 months, 1-170), survivors were in satisfactory clinical conditions (1.6+/-0. 8 mean NYHA class, 1-3) with no evidence of renal, respiratory or neurologic dysfunction. Multivariable analysis showed emergent reoperation (P=0.001), prior aortic valve replacement (P=0.005) and need for arch replacement (P=0.03) to be predictive of higher operative mortality. Longer duration of bypass (P=0.01) and aortic arch replacement (P=0.04) were predictive of higher prevalence of postoperative complications. CONCLUSIONS: Reoperations on the ascending aorta via repeat sternotomy without preventive femoral bypass are associated with low operative risk and high prevalence early complications. Emergent reintervention due to aortic dissection, particularly in patients with prior aortic valve replacement, and need for arch repair are predictive of poorer perioperative outcome. Long-term outlook of hospital survivors is satisfactory.

Adolescent↗
PubMed2000

Predicting long-term functional results after myocardial revascularization in ischemic cardiomyopathy.

OBJECTIVE: The goal of the present study was to define the early and late functional results after revascularization in ischemic cardiomyopathy and to identify variables predictive of a favorable outcome. METHODS: A retrospective review of all consecutive patients with ischemic cardiomyopathy undergoing myocardial revascularization between January 1991 and June 1998 was undertaken. One hundred sixty-seven patients (140 men) aged 60 +/- 8 years (range, 39-77 years) with angina (n = 107), congestive heart failure (n = 54), or silent ischemia (n = 6) were identified. One hundred six (63%) patients with angina were in Canadian Cardiovascular Society class III or IV, and 40 (24%) patients with congestive failure were in New York Heart Association class III or IV. The preoperative left ventricular ejection fraction averaged 0.28 +/- 0.05 (range, 0.16-0. 30). Thirteen (8%) patients required preoperative mechanical life support. A mean of 2.9 +/- 0.9 grafts per patient were performed, with an average myocardial ischemia time of 53 +/- 23 minutes and bypass time of 104 +/- 31 minutes. RESULTS: There were 3 (1.7%) early deaths and 21 (13%) deaths during follow-up (2.7 +/- 2.1 years; range, 0.3-7.8 years), producing a survival of 94% +/- 2% and 75% +/- 10% at 1 and 5 years, respectively. Despite a significant increase in left ventricular ejection fraction (0.28 +/- 0.05 vs 0. 38 +/- 0.09, P =.0001), only 89 (54%) patients were symptom-free at follow-up. Freedom from recurrent angina was 98% +/- 1% and 81% +/- 8%, whereas freedom from congestive failure was 78% +/- 11% and 47% +/- 20% at 1 and 5 years, respectively. Follow-up New York Heart Association class in patients with congestive failure was improved (40/54 class III-IV vs 11/54 class III-IV, P =.0001). Multivariate analysis showed a lower ejection fraction (P =.01), preoperative congestive failure (P =.03), and a need for preoperative intra-aortic balloon pumping (P =.03) to be associated with a greater prevalence of recurrent congestive failure, whereas male sex (P =.01), preoperative angina (P =.04), use of the internal thoracic artery (P =.03), and higher number of grafts (P =.01) were associated with lower prevalence. Male sex (P =.06), higher number of grafts (P =.04), and shorter duration of myocardial ischemia (P =. 04) were also predictive of improvement in New York Heart Association class at follow-up. CONCLUSIONS: Despite satisfactory early and late survival, late functional outcome after myocardial revascularization in ischemic cardiomyopathy remains suboptimal because of recurrence or persistence of congestive failure. Selection of appropriate surgical candidates and extensive use of complete revascularization with the internal thoracic artery may substantially improve functional results.

Adult↗
PubMed2000

Aortic valve replacement via minimal-access complete sternotomy.

Minimally invasive approaches to the chest for aortic valve replacement have been proposed recently in an attempt to reduce postoperative pain, length of hospital stay, and scarring. An alternative approach entailing a minimal skin incision and a complete median sternotomy is presented herein. This technique combines the advantage of limited cosmetic impact with the pattern of postoperative pain and the ventilatory mechanics typical of the sternotomy, which enables extubation upon skin closure and early discharge from the hospital.

Aortic Valve↗
PubMed2000

Experience with stentless aortic xenografts.

BACKGROUND AND AIM OF THE STUDY: The study aim was to define the long-term results after aortic valve replacement (AVR) with freehand stentless xenografts. METHODS: A retrospective analysis was performed of 376 consecutive patients (195 males, 181 females; mean age 70 +/- 7 years; range: 26-87 years) who underwent stentless AVR between October 1992 and April 2000. In total, 164 patients received Toronto SPV, 106 Biocor PSB, 101 Cryolife-O'Brien, and five other valves. Indication for surgery was valve stenosis (n = 246), regurgitation (n = 50), mixed lesion (n = 75) and prosthetic valve failure (n = 5). Mean preoperative NYHA functional class was 2.9 +/- 0.6 (range: 2-4). Associated procedures were required in 153 patients (41%), including coronary artery bypass grafting (n = 97), mitral operation (n = 26), ascending aortic replacement (n = 17) and 'other' (n = 13). Mean valve size was 25 +/- 3 mm (range: 21-29 mm), mean aortic cross-clamp time was 96 +/- 23 min (range: 42-186 min), and mean cardiopulmonary bypass time 128 +/- 34 min (range: 65-363 min). RESULTS: Ten patients (2.7%) died in hospital, due to cardiac causes (n = 6), cerebrovascular accident (n = 3) and multiorgan failure (n = 1). During a mean follow up of 40 +/- 20 months (range: 1-90 months) there were 33 late deaths. Survival was 96 +/- 1%, 83 +/- 3% and 80 +/- 4% and valve-related event-free survival 97 +/- 1%, 87 +/- 2% and 82 +/- 6% at one, five and seven years, respectively. Valve failure occurred in 21 (6%) patients (10 structural, nine non-structural, two endocarditis): freedom from structural valve deterioration was 99 +/- 1%, 95 +/- 2% and 92 +/- 4% at one, five and seven years. Reoperation on the xenograft was required in 17 (5%) patients, giving a freedom from reoperation of 99 +/- 1%, 94 +/- 2% and 90 +/- 4% at one, five and seven years. Freedom from valve failure and reoperation were significantly lower with Cryolife-O'Brien valves, but freedom from structural valve failure was similar. The average NYHA class was improved at follow up (1.4 +/- 0.7 versus 2.9 +/- 0.6 preoperatively, p = 0.01). CONCLUSION: Long-term survival and freedom from valve-related adverse events after stentless AVR in an elderly population were satisfactory. Freedom from structural deterioration was excellent and comparable for all xenograft models, while non-structural deterioration may have been more common with one valve model. Despite the advanced patient age, functional improvement late after operation may be expected.

Adult↗
PubMed2000

[Neurologic outcome in infants surgically treated for congenital cardiopathy: preliminary data].

INTRODUCTION: Both surgical techniques for correction of congenital heart diseases (CHD) and intraoperatory neurologic protection improved during the last 20 years. Nevertheless cardiac surgery is still a risk for neurologic morbidity. METHODS AND PATIENTS: Analysis of the postoperative neurologic status of infants younger than 6 months who underwent cardiac surgery from January 1998 to December 1999. We reviewed the EEG tracings, cranial ultrasound reports (CUS) and CT scans of 48 patients. Diagnoses were: ventricular septal defect = 15, Fallot (TOF) = 9, patent ductus arteriosus (PDA) = 5, coarctation of aorta = 4, atrio-ventricular septal defect = 4, transposition of great arteries (TGA) = 3, hypoplastic left heart syndrome = 2, pulmonary atresia = 2, total anomalous pulmonary veins drainage = 2, double outlet right ventricle = 1, cor triatriatum = 1. Mean age (range) at intervention was 54 days (2-150), 44 infants (91.7%) survived at follow-up: 23 EEG, 22 CUS and 2 CT were performed in the recent postoperative. Among survivors 5/44 had neurologic complications. EEG was altered in 4: two of them (1 TOF, 1 TGA) had pathologic CUS and CT as well (ischemic pattern in the former, atrophy in the latter). Finally a preterm newborn with PDA had mild abnormalities at CUS. After a mean follow-up of 16 +/- 6 months 3/5 patients had mild-to-moderate psychomotor delay and 2 recovered. CONCLUSIONS: According to our preliminary data the prevalence of neurologic complications in infants who undergo cardiac surgery seems to be low. The pathological findings of the recent postoperative seem to recover up to normalization in some cases at mid-term follow-up. As expected, permanent complications effect more often complex CHD. Further follow-up studies to school age will be mandatory to check the very final results of cardiac surgery performed during early infancy.

Electroencephalography↗
PubMed1999

Preservation of the aortic valve in acute type A dissection complicated by aortic regurgitation.

BACKGROUND: The aim of the present study was to verify the efficacy of preserving the aortic valve in patients with acute type A aortic dissection complicated by significant aortic regurgitation. METHODS: From January 1979 to December 1996, 178 patients (125 males; mean age 57 +/- 9 years) underwent emergency surgery for acute type A aortic dissection, with an overall operative mortality rate of 21%. Based on a retrospective analysis of the preoperative angio- or echocardiographic findings, the 141 survivors were divided into 2 groups: Group 1 (G1) included 80 patients (57%) with no or mild aortic regurgitation, and Group 2 (G2) the remaining 61 patients with moderate-to-severe aortic regurgitation. The native aortic valve was preserved by means of a uniform technique consisting of reconstruction of the aortic root and sinotubular junction in 99 patients (70%) [68 in G1 (85%) and 31 in G2 (51%)]. Forty-two patients required aortic valve (8 patients; 6%) or total root replacement (34 patients; 24%). RESULTS: At a mean follow-up of 4 +/- 3.6 years (range, 6 months to 19 years), 19 of the 99 patients with a preserved aortic valve developed moderate-to-severe aortic insufficiency [19%; 7/68 in G1 (10%) and 12/31 in G2 (39%)]. Multivariate analysis revealed that moderate-to-severe preoperative aortic valve insufficiency was a significant risk factor for development of postoperative aortic valve regurgitation (p = 0.008). Reoperation was necessary in 7 G1 patients (10%) and in 8 G2 patients (26%), with an actuarial freedom from reoperation at 5 and 10 years of 93% +/- 7% and 80% +/- 9% in G1 patients, and 81% +/- 8% and 40% +/- 15% in G2 patients (p = 0.045). CONCLUSIONS: Preservation of the aortic valve and aortic root is recommended in patients with acute type A aortic dissection and absent or mild aortic insufficiency. Patients presenting with moderate-to-severe aortic regurgitation and treated conservatively present an increased risk of recurrent valvular insufficiency.

Adolescent↗
PubMed1999

Recurrence of aortic insufficiency after aortic root remodeling with valve preservation.

BACKGROUND: Aortic root remodeling (ARR) has recently been proposed for patients with aortic aneurysms and valve insufficiency (AI). To define factors associated with a favorable functional outcome, a review of the mid-term results with ARR was undertaken. METHODS: Between March 1994 and October 1997, 17 consecutive patients (11 men, 6 women), aged 57 +/- 11 years (range 35-71), had elective ARR for aortic aneurysm with or without annuloaortic ectasia (13), sinus of Valsalva aneurysm (3), or chronic aortic dissection (1). Moderate or severe AI was present in 11 patients (65%). Preoperative aortic root diameter was 58 +/- 5 mm (range 51-70). ARR involved replacement of all three aortic sinuses and coronary button reimplantation, using grafts with a mean diameter of 28 +/- 2 mm (range 24-30). RESULTS: There was one early death (6%) due to multiple organ failure. Survivors were followed for 16 +/- 12 months (range 1-44). Actuarial 3-year survival was 94% +/- 6%. Discharge echocardiogram showed a decrease in AI in all patients: AI was absent in 11 (69%) and mild in 5 (31%). Recurrence of moderate or severe AI after a mean of 16 +/- 9 months (range 9-28) was noted in 6 patients (37%), 3 of whom had no AI at discharge. Five of 6 patients required aortic valve replacement. Comparison of demographic and operative variables showed that severe preoperative AI (67% vs 20%, p = 0.06), annuloaortic ectasia (100% vs 20%, p = 0.002), and cystic medial necrosis (100% vs 20%, p = 0.002) were significantly more prevalent in patients developing severe AI at follow-up. The 10 patients (63%) with absent AI showed durable competence of the valve and relief from symptoms at follow-up. CONCLUSIONS: Despite early restoration of valve competence, AI may recur and progress after ARR at medium-term follow-up in a proportion of patients. The severity of preoperative AI and the nature of aortic root disease may negatively influence the durability of repair. Continued observation of results with ARR appears mandatory to identify the appropriate surgical candidates.

Adult↗