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Biomedical subjects

G B Luciani

Publications and source records attributed to G B Luciani.

At least 55 records · Page 3Linked to original sources
PubMed1997

Continuous versus intermittent furosemide infusion in critically ill infants after open heart operations.

BACKGROUND: Use of intravenous furosemide is generally avoided in critically ill neonates and infants soon after open heart operations to prevent fluctuations in intravascular volume and resulting circulatory instability. METHODS: To assess and compare the safety and efficacy of continuous versus intermittent intravenous furosemide, we undertook a prospective, randomized trial in 26 consecutive patients less than 6 months of age. Inclusion criteria were presence of low-output syndrome requiring inotropic support (24/26 patients) or pulmonary hypertension requiring vasodilator therapy (10/26 patients) within 6 hours of discontinuation of cardiopulmonary bypass. Eleven patients received 0.1 mg x kg(-1) x h(-1) continuous intravenous furosemide (group 1) and 15 received 1 mg/kg bolus every 4 hours (group 2) for 24 hours. Mean age (3.7 +/- 3.4 versus 1.8 +/- 2.5 months) and weight (4.6 +/- 2.1 versus 4.3 +/- 1.7 kg) were comparable. RESULTS: Group 2 infants showed slightly greater absolute urinary output (2.5 +/- 1.1 mL/kg per hour versus 3.3 +/- 1.1 mL/kg per hour, p = 0.05). However, urinary output per dose of drug was significantly larger in group 1 infants (1.0 +/- 0.4 versus 0.5 +/- 0.2 mL x kg(-1) x h(-1); p = 0.002) with lesser fluctuations (variance, 1.9 +/- 1.6 versus 3.8 +/- 2.1; p = 0.02) and fluid replacement needs (20.6 +/- 3.8 versus 51.8 +/- 14.4; p = 0.001). Electrolyte replacement requirements were similar. A trend toward greater hemodynamic instability in group 2 patients (heart rate variance 88.4 +/- 79.8 versus 128.3 +/- 82.7; p = 0.09; central venous pressure variance 2.8 +/- 1.90 versus 4.1 +/- 3.7; p = 0.07; mixed venous oxygen saturation variance, 32.3 +/- 27.6 versus 45.7 +/- 20.4; p = 0.06) was noted. All patients who completed the study protocol survived operation and were discharged home. CONCLUSIONS: We conclude that (1) commonly used doses of both intermittent and continuous intravenous furosemide infusion can be safely administered to critically ill neonates and infants as early as 6 hours after operation, (2) continuous infusion yields an almost comparable urinary output with a much lower dose of furosemide, and (3) intermittent administration is associated with greater fluctuations in urinary output and greater needs for fluid replacement therapy.

Cardiac Output, Low↗
PubMed1997

The clamshell incision for bilateral pulmonary artery reconstruction in tetralogy of Fallot with pulmonary atresia.

BACKGROUND: Patients with tetralogy of Fallot/pulmonary atresia often have bilateral pulmonary artery lesions, including diminutive central and peripheral vessels, major aortopulmonary collaterals, and distortion from previous operations. Staged procedures through lateral thoracotomies and median sternotomies have traditionally been used for repair. METHODS: Between October 1993 and December 1995, 10 patients 3 months to 15 years old with complex tetralogy of Fallot/pulmonary atresia underwent repair via a clamshell approach. Nine had undergone a mean of 2.8 +/- 0.8 previous operations (range 1 to 4). Indications for operation were repair of pulmonary artery arborization anomalies in 10 (4 unilateral, 6 bilateral), with unifocalization in 6 (2 unilateral, 4 bilateral). RESULTS: Eight of 10 patients had concomitant complete repair. There were no deaths at a mean follow-up of 17.1 +/- 4.0 months (range 12 to 26). Mean ventilation time was 3.7 +/- 2.1 days (range 1 to 14) and hospital stay 8.7 +/- 4.6 days (range 4 to 19). At follow-up, the peak right ventricular/left ventricular pressure ratio in patients who received complete repair was 0.44 +/- 0.13 (0.30 to 0.67). One patient (10%) required reoperation because of pseudoaneurysm of the main pulmonary artery 14 months after repair, and one had successful stent placement because of recurrent left and right pulmonary artery stenosis 8 months after repair. Two infants who underwent complete unifocalization and central pulmonary artery reconstruction are awaiting completion of repair. CONCLUSIONS: The clamshell approach to complex tetralogy of Fallot/ pulmonary atresia provides simultaneous exposure of bilateral central and peripheral pulmonary artery lesions and intracardiac pathologic conditions. This procedure appears safe and may decrease the number of operations required to complete repair of tetralogy of Fallot/pulmonary atresia in selected patients.

Adolescent↗
PubMed1997

The clamshell approach for the surgical treatment of complex cardiopulmonary pathology in infants and children.

BACKGROUND: The surgical approach to children with complex cardiovascular and pulmonary anomalies is still controversial. Staged operations through multiple incisions are often performed in this setting. OBJECTIVE: The different applications and clinical advantages of a bilateral thoracosternotomy approach to complex cardiothoracic disease requiring surgical repair were reviewed retrospectively. METHODS: Between January 1993 and June 1995, 33 patients, aged between 2 months and 17 years (mean 7.8 +/- 5.3) underwent surgical treatment of complex cardiovascular or pulmonary disease using a clamshell approach. Twenty-one patients (64%) had undergone 1-5 previous surgical procedures (mean 2.5 +/- 1.0/patient). The technique involved supine position placement, submammary incision, access to the pleural space bilaterally through the fourth intercostal space and transverse division of the sternal body. RESULTS: Four groups of patients were operated on via this approach: (1) patients undergoing lobar, lung or heart-lung transplantation (40%); (2) patients undergoing repair of tetralogy of Fallot/pulmonary atresia (36%); (3) patients with previously corrected miscellaneous procedures (12%), including completion of Fontan, one-stage repair of left main bronchial stenosis and atrial septal defect, one-stage repair of partial anomalous pulmonary venous connection and aortic coarctation, and repair of congenital pulmonary venous stenosis. There were two early (< 30 days) deaths, giving a perioperative mortality of 6% for the entire series. Complications included postoperative hemorrhage in 4 patients (12%), prolonged ventilation time due to mechanical failure in 4 (12%). There were no wound infections. Analysis of complications by group showed the lung transplant group to be more affected (18% of patients experienced complications). Except for 2 infants undergoing complete unifocalization and presently awaiting completion of repair of tetralogy of Fallot/pulmonary atresia, in the remaining 31 (94%) a definitive surgical treatment could be performed in one-stage. CONCLUSIONS: The bilateral thoracosternotomy allows optimal exposure of all intrathoracic anatomic structures making one-stage surgical repair possible in a variety of complex cardiovascular and pulmonary anomalies. Early mortality and technique-related morbidity do not differ from those reported with the conventional approaches to the different disease conditions. A wider application of the clamshell approach for the management of complex intrathoracic pathology in infants and children is advocated.

Adolescent↗
PubMed1997

[Replacement of the aortic valve with a pulmonary autograft: experience at the University of Verona].

BACKGROUND: Early and long term results after surgical replacement of the aortic valve depend to a large degree on the type of valve substitute used. Pulmonary autograft offers many theoretical advantages, particularly in young patients. METHODS: Between July 1994 and August 1996, 15 patients (12 male) with a mean age of 28 +/- 6 years (range 14 to 36 years) were selected for aortic valve replacement with a pulmonary autograft. The aortic valve disease was isolated insufficiency in 7 cases (47%), stenosis in 3 (20%) and mixed lesion in 5 (33%). One patient in the last group had bacterial endocarditis (Streptococcus mitis). Seven patients (47%) had a bicuspid aortic valve. In 3 cases (20%) the autograft was inserted as a scalloped subcoronary implant. Twelve patients (80%) had total aortic root replacement with re-implantation of the coronary ostia. The right ventricular outflow tract was reconstructed with a cryopreserved homograft (13 pulmonary; 2 aortic). The aortic cross-clamp time was 156 +/- 18 minutes with a total bypass time of 221 +/- 26 minutes. RESULTS: All patients survived the operation. Three postoperative bleeding (20%) necessitated re-exploration. Mean post-operative hospital stay was 10 +/- 2 days. All patients were discharged on aspirin for the period of three months. One patient (7%) with moderate neo-aortic valve insufficiency died suddenly 11 months post-operatively. All survivors are asymptomatic, in NYHA FC 1 at a mean follow-up time of 15.7 months. Freedom from reoperation, valve related complication and endocarditis is 100%. Two-dimensional (2-D) echocardiography six months postoperatively showed a mean left ventricular outflow gradient of 13 +/- 4 mmHg with no evidence of aortic regurgitation in 11 cases (78.5%) and trivial in 3 (21.5%). CONCLUSIONS: Although the Ross operation is technically more challenging and requires a longer operating time than standard procedures, this does not seem to affect early mortality and morbidity. Clinical and haemodynamic results appear to be gratifying. Continued patients evaluation particularly with regard to evidence of valve degeneration and arrhythmias in the long term is warranted.

Adolescent↗
PubMed1997

Current techniques to reduce blood loss after the Ross procedure.

BACKGROUND AND AIMS OF THE STUDY: Although pulmonary autograft (PA) offers many theoretical advantages, the operation is more complex and the need for extensive reconstruction carries an increased risk for postoperative bleeding. The study aim was to evaluate the impact of different pharmacological and surgical strategies on total blood loss and blood product requirements after PA use. METHODS: Between July 1994 and March 1997, 26 patients (22 males) with a mean age of 26 +/- 8 years (range: 11 to 36 years) underwent aortic valve replacement with PA (22 root; four subcoronary implant). A relatively high incidence of re-exploration for bleeding (n = 3) and significant total blood loss during our early experience (Group I, n = 8), prompted the subsequent introduction of different strategies (Group II, n = 18). These included perioperative use of aprotinin, reinforcement of suture lines of the neo-aortic root with autologous pericardium and accurate hemostasis of the raw surface on the back of the right ventricular outflow tract (RVOT) during a brief period of circulatory arrest, also with application of fibrin glue, RESULTS: There were no hospital deaths. No patients in group II required re-exploration or transfusion, and mean total postoperative blood loss was reduced (group I, 720 +/- 465 ml/m2 body surface area (BSA), versus group II, 323 +/- 84 ml/m2 BSA). By-pass and aortic cross-clamp times were not significantly longer in group II patients. At a mean follow up of 15 months, all 25 survivors are asymptomatic, in NYHA functional class I, and with normal social interactions. CONCLUSIONS: Early survival after aortic valve replacement with the PA appears comparable with the use of more conventional valve substitutes. Blood loss containment by routine application of medical and surgical strategies appears feasible. In view of the common concern about blood transfusion, particularly in young patients, these findings may help to widen the range of indications for the Ross procedure.

Adolescent↗
PubMed1997

Coronary translocation during aortic root replacement with the pulmonary autograft: complications and their management.

BACKGROUND AND AIMS OF THE STUDY: Aortic root replacement with the pulmonary autograft has become an alternative to replacement of the diseased aortic valve with mechanical or biological prostheses. Due to greater technical complexity of the operation, complications with autograft root replacement (ARR) may be more common. In particular, a higher prevalence of coronary complications has been suggested. METHODS: In order to assess the prevalence, cause and management of coronary complications after ARR, results with 26 consecutive operations were reviewed and compared with previously published series. Between July 1994 and Apri 1997, 22 males and four females (mean age 26 +/- 8 years; range: 11 to 36 years) underwent aortic root (n = 22) or valve replacement (n = 4) with a pulmonary autograft for regurgitation (n = 14), stenosis (n = 4) or both (n = 8). Associated lesions were present in 10 (38%) patients, including three cases of major coronary artery anomalies such as origin of the circumflex from the right coronary sinus, high origin of the right coronary, aneurysmal and calcified right and left main coronaries, both in one patient. RESULTS: There were no early deaths. Major complications occurred in six patients; re-exploration for bleeding was required in three (11%) and partial take down of repair for coronary complications in three (11%), all with preoperative coronary anomalies. Two of the latter patients presented with intraoperative right ventricular ischemia due to kinking of the right coronary (corrected by re-implantation at a higher level), and one had intraoperative hemorrhage due to rupture of a calcified left main coronary, which required transection of the pulmonary homograft above the valve to expose the tear. Recovery was prompt in all patients (mean ICU stay 35 +/- 28 h) with no metabolic or electrocardiographic evidence of ischemia. Echocardiography at discharge showed satisfactory biventricular kinetics in all; mild regurgitation of the autograft was found in two (8%) who had undergone subcoronary implant, and absent or trivial in 22 (92%). One patient died suddenly 13 months after ARR; hence actuarial survival rate was 100% and 96% at 12 and 24 months, respectively. At mean follow up of 15 +/- 11 months (range 1 to 32 months), all patients are in NYHA class I and have returned to school or prior employment. CONCLUSIONS: Complications with coronary artery translocation during ARR may be a definite risk, particularly in the presence of coronary anomalies. Prompt recognition and an aggressive intraoperative approach, including partial take down of the repair, may limit the morbidity of this complex surgical procedure.

Adolescent↗
PubMed1996

Surgical repair of transposition of the great arteries in neonates with persistent pulmonary hypertension.

BACKGROUND: Pulmonary hypertension due to persistent fetal circulation is rarely associated with transposition of the great arteries and intact ventricular septum. Previous attempts at management of affected neonates using prostaglandin E1 and balloon atrial septotomy followed by surgical repair have been largely unsuccessful. METHODS: Between September 1992 and April 1995, 45 neonates underwent repair of transposition of the great arteries with the arterial switch operation. Two patients (4%) with transposition of the great arteries and intact ventricular septum presented with profound reversed differential desaturation and right-to-left shunting at the level of the ductus arteriosus after balloon atrial septotomy. A diagnosis of persistent pulmonary hypertension was established and both neonates entered an experimental management protocol using inhaled nitric oxide and rapid arterial switch operation. RESULTS: Preoperative hemodynamic stabilization was achieved in 1 patient using 40 parts per million of inhaled nitric oxide, whereas the other required in addition extracorporeal membrane oxygenation for severe biventricular dysfunction. Both underwent successful surgical repair 4 to 5 days after admission, but received postoperatively 1 week of inhaled nitric oxide therapy for persistent pulmonary hypertension. Follow-up echocardiography at 3 months showed good biventricular function and normal geometry of the ventricular septum, suggesting low pulmonary artery pressure, in both. CONCLUSIONS: A management protocol using inhaled nitric oxide and extracorporeal membrane oxygenation followed by the arterial switch operation was successfully used in neonates with transposition of the great arteries, intact ventricular septum, and persistent pulmonary hypertension. Wider use of preoperative and postoperative inhaled nitric oxide may improve the surgical outcome of this difficult subset of patients.

Extracorporeal Membrane Oxygenation↗
PubMed1996

One-stage repair of interrupted aortic arch, ventricular septal defect, and subaortic obstruction in the neonate: a novel approach.

BACKGROUND: One-stage repair of interrupted aortic arch, ventricular septal defect, and severe subaortic stenosis represents a surgical challenge. Techniques that use extracardiac conduits to bypass the subaortic area or involve transaortic or transatrial resection of the conal septum have shown limitations and have failed to reduce the high mortality rate associated with subaortic obstruction. METHODS AND RESULTS: A new operative approach was used in nine neonates (2.1 to 3.9 kg) who underwent one-stage repair of interrupted aortic arch (type B, eight patients; type C, one patient), ventricular septal defect, and severe subaortic stenosis. All patients had severe subaortic stenosis according to preoperative echocardiography (mean ratio of subaortic to descending aortic diameter, 0.63 +/- 0.08). With a transpulmonary (seven patients) or transatrial (two patients) approach and without resection of the conal septum, the ventricular septal patch was placed on the left side of the septum to deflect the conal septum anteriorly and away from the subaortic area. There were no early or late deaths. Median intensive care unit and hospital stays were 17 days (6 to 47 days) and 21 days (10 to 55 days), respectively. On follow-up echocardiography (1 to 29 months, median 12 months), no patients had significant residual subaortic obstruction and one patient had mild residual arch obstruction (20 mm Hg). Growth of the subaortic region was demonstrated in all patients (mean ratio of subaortic to descending aortic diameter, 1.20 +/- 0.10; < 0.001). CONCLUSIONS: Relief of severe subaortic stenosis during one-stage neonatal repair of aortic arch interruption and ventricular septal defect can be accomplished successfully without resection of the conal septum.

Aorta↗
PubMed1996

Aortic root replacement with the pulmonary autograft in children with complex left heart obstruction.

BACKGROUND: The optimal surgical treatment of complex (multiple level or recurrent) left ventricular outflow tract obstruction (LVOTO) in infancy is controversial. Staged procedures expose the children to the need for reoperation, and currently available techniques of aortoventriculoplasty are associated with the morbidities of biological and mechanical prostheses. METHODS: Between July 1992 and January 1996, we have performed 24 aortic root replacements with the pulmonary autograft in pediatric patients (< 18 years). Of this group, 8 were infants and children with complex LVOTO aged 9 days to 22 months (mean, 8.6 +/- 8 months) and weighing 3.3 to 10.2 kg (mean, 6.3 +/- 2.6 kg). The diagnoses were interrupted aortic arch/ventricular septal defect/subaortic stenosis in 3, recurrent aortic stenosis in 2, aortic stenosis and subaortic stenosis in 1, and aortic stenosis/subaortic stenosis/mitral stenosis/regurgitation in 2. All patients had undergone one to three previous operative procedures (mean, 1.5 +/- 0.8 procedures/patient). Preoperative echocardiographic peak LVOT gradient was 71.7 +/- 25 mm Hg (range, 40 to 110 mm Hg) and aortic annulus size was 7.2 +/- 2.3 mm (range, 4 to 10.6 mm). The surgical technique included replacement of the aortic root with the pulmonary autograft combined with incision of the conal septum to relieve subaortic stenosis or accommodate for size discrepancy between the aortic and pulmonary autograft root and a pulmonary homograft placed in the right ventricular outflow tract. RESULTS: There were no perioperative or late deaths at follow-up (range, 2 to 25 months; mean, 13.5 +/- 8 months). Mean hospital stay was 15 +/- 17 days (range, 4 to 53 days). Three children had the following complications: diaphragmatic paresis (1), delayed pericardial effusion (1), and atrioventricular block requiring a pacemaker (1). In follow-up, echocardiographic findings showed absent aortic regurgitation in 3 and trivial aortic regurgitation in 5, and no significant LVOTO (mean peak gradient, 6.2 +/- 7.6 mm Hg; range, 0 to 16 mm Hg). Pulmonary homograft regurgitation was absent in 5, trivial in 2, and moderate in 1. Peak right ventricular outflow tract gradient by echocardiogram was trivial in 7, and a significant gradient of 55 mm Hg has developed in 1 infant. There were no infective or embolic complications during follow-up. CONCLUSIONS: Our experience shows that aortic root replacement with the pulmonary autograft can be performed in children with excellent clinical results. The technique of root replacement combined with ventriculoplasty allows definitive and simultaneous relief of complex and multiple-level obstructive lesions. Considering the growth potential of the pulmonary autograft, this should be regarded as the optimal treatment modality in infants with complex LVOTO:

Aorta, Thoracic↗
PubMed1995

Myocardial revascularization using branches of the left internal mammary artery.

To increase the number of arterial grafts in patients with multivessel coronary disease, we have used branches of the left internal mammary artery (LIMA) as bypass grafts. From March 1990 to June 1993, 15 patients (13 males and 2 females) aged 38 to 65 years (mean 57 +/- 8), received a total of 30 LIMA branch anastomoses. The two terminal branches were used to perform a "Y" graft to the left anterior descending coronary artery territory in 13 patients. A pericardiophrenic branch was used in four cases. Five patients (33.3%) had complete myocardial revascularization using IMA only. There were neither early nor late deaths and all patients are free from angina at a mean follow-up of 20 months (6 to 45 months). However, early postoperative cardiac catheterization, performed in 12 patients (80%), revealed a 20% occlusion rate for each terminal branch and a 50% occlusion rate for the pericardiophrenic branch. Technically challenging due to the small diameter of the grafts, the terminal LIMA branches should be limited to selected patients when more conventional arterial or vein conduits are not available. More proximal branches have a higher occlusion rate and their use is not recommended.

Adult↗