Minimally invasive thoracic retractors.
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Cardiac Surgical Procedures↗
Biomedical subjects
Massimo Massetti
Publications and source records attributed to Massimo Massetti.
Limited role of aortic size in the genesis of acute type A aortic dissection.
OBJECTIVE: Increased dimension of the aortic root and proximal aorta is considered a significant risk factor for catastrophic events that involve the ascending aorta. The objective of this study was to determine the possible correlation between pre-dissection aortic diameter and the occurrence of Stanford type A aortic dissection. METHODS: Samples of dissected ascending aortas were obtained from 220 patients at the time of their operation. Two groups were identified: patients with connective tissue disorders (Group 1, n=94) and those without (Group 2, n=126). Measurements of the true (intimal) lumen were conducted and extrapolated as reliable approximation of pre-dissection aortic diameter. The possible association of intimal diameter with anthropometric and demographic data was analyzed. RESULTS: Median aortic diameter was, respectively, 41.8 and 41.3mm for patients with and without connective tissue disorders (41.4mm for the entire cohort). Data analysis indicated that 57% of patients had aortic diameter above 40 mm, while patients with frank aneurysm accounted only for 10%; this proportion was higher in Group 1 compared to Group 2 (17.2% vs 4.7%). Poor or no correlation was demonstrated between aortic size and any of the anthropometric or demographic variables assayed. Significant subgroup differences were found among patients with a history of cigarette smoking, hypertension, diabetes, chronic renal insufficiency, and bicuspid aortic valve. CONCLUSION: Although aortic diameter remains a strong indication for preventive surgery in patients with inherited connective tissue disorders, acute aortic dissection occurs rarely in the setting of true ascending aortic aneurysms, and despite normal or near-normal aortic size in more than one-third of subjects. Dissection superimposing on small aortic diameters can be regarded as an expression of substantial functional tissue susceptibility to aortic catastrophic events.
Adult↗
Can an early peri-anastomotic LITA stenosis be reversible?
Peri-anastomotic graft stenosis is a possible complication of coronary artery bypass graft operations. Early failure of myocardial revascularization may result from graft stenosis with inherent difficulties in perioperative diagnosis and subsequent management. We report the case of a 58-year-old man who experienced early preanastomotic left internal thoracic artery bypass stenosis that progressively resolved during a 2-year period without reoperation or interventional angioplasty. Although the mechanisms underlying graft stenosis remain unclear, this case emphasizes the role of repeated coronary angiography in the choice of treatment.
Adrenergic beta-Antagonists↗
Repair of aortic leaflet prolapse: the "sliding leaflet technique".
Valve-preserving aortic replacement has become an accepted therapeutic option for aortic dilatation with normal valve leaflets. The presence of a leaflet prolapse often induces the choice of a composite graft repair. In these cases, however, the repair of a leaflet prolapse is possible and represents a valuable alternative to a prosthetic valve. The conventional techniques of repair of a cusp prolapse are designed to restore coaptation through a reduction of free margin length. The sliding leaflet technique is an alternative procedure conceived to repair the prolapsed valve cusp by remodeling both the free margin and the annular insertion.
Aorta↗
Back from irreversibility: extracorporeal life support for prolonged cardiac arrest.
BACKGROUND: The survival of patients after prolonged cardiac arrest is still inadequate. Extracorporeal life support (ECLS) represents an alternative therapeutic method for patients who do not respond to conventional cardiopulmonary cerebral resuscitation. This technology is used to support the circulation of a patient with severe cardiac failure. METHODS: Between June 1997 and January 2003, 40 ECLS procedures were performed in patients who presented with refractory cardiac arrest. During external cardiac massage, the patient was connected to an extracorporeal circuit by the insertion of an arterial and venous cannula through the femoral vessels. The extracorporeal circuit included a centrifugal pump and an oxygenator. Mean age was 42 +/- 15 years; the average time of external cardiac massage was 105 +/- 44 minutes. RESULTS: Once the circulation was restored, 22 patients were disconnected from the extracorporeal circulation because of brain death or multiorgan failure; after 24 hours, among the 18 survivors, 6 were weaned off the pump, 9 were bridged to a ventricular assist device, and 2 patients were directly bridged to cardiac transplantation. Eight patients are alive and without any sequelae at 18 month's follow-up. CONCLUSIONS: In prolonged cardiac arrest with failing conventional measures, rescue by extracorporeal support provides an ultimate therapeutic option with a good outcome in survivors. Our results encourage the wider application of ECLS for refractory cardiocirculatory arrest in selected patients. The high rate of neurologic death needs further improvements in the early phase of resuscitation maneuvers.
Adult↗
Acute type A dissection and advanced age.
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Age Factors↗
Ketamine preconditions isolated human right atrial myocardium: roles of adenosine triphosphate-sensitive potassium channels and adrenoceptors.
BACKGROUND: The authors examined the effect of ketamine and its S(+) isomer on isolated human myocardium submitted to hypoxia-reoxygenation in vitro. METHODS: The authors studied isometric contraction of human right atrial trabeculae suspended in an oxygenated Tyrode's modified solution at 34 degrees C. Ten minutes before a 30-min hypoxic period followed by a 60-min reoxygenation, muscles were exposed for 15 min to racemic ketamine and its S(+) isomer at 10, 10, and 10 m alone or in the presence of 8.10 m 5-hydroxydecanoate, 10 m HMR 1098 (sarcolemmal adenosine triphosphate-sensitive potassium channel antagonist), 10 m phentolamine (alpha-adrenoceptor antagonist), and 10 m propranolol (beta-adrenoceptor antagonist). Force of contraction at the end of the 60-min reoxygenation period was compared between groups (mean +/- SD). RESULTS: Ketamine (10 m: 85 +/- 4%; 10 m: 95 +/- 10%; 10 m: 94 +/- 14% of baseline) and S(+)-ketamine (10-6 m: 85 +/- 4%; 10 m: 91 +/- 16%; 10 m: 93 +/- 14% of baseline) enhanced recovery of force of contraction at the end of the reoxygenation period as compared with the control group (47 +/- 10% of baseline; P < 0.001). Ketamine-induced preconditioning at 10 m was inhibited by 5-hydroxydecanoate (60 +/- 16%; P < 0.001), HMR 1098 (60 +/- 14%; P < 0.001), phentolamine (56 +/- 12%; P < 0.001), and propranolol (60 +/- 7%; P < 0.001). CONCLUSIONS: In vitro, ketamine preconditions isolated human myocardium, at least in part, via activation of adenosine triphosphate-sensitive potassium channels and stimulation of alpha- and beta-adrenergic receptors.
Adenosine Triphosphate↗
Less invasive radial artery harvesting: two years' experience.
BACKGROUND: For coronary surgery we often use the radial artery (RA) instead of the saphenous vein, trying to exploit the advantages offered by this conduit. To eliminate the problems regarding alteration of upper-extremity function after RA procurement related to the standard conventional harvesting technique, we started using the less invasive harvesting technique with surprisingly good preliminary results. To compare the outcomes of open versus less invasive harvesting procedures, a prospective, nonrandomized study was developed by 2 centers. METHODS: From January 2001 to March 2003, there were 87 consecutive patients in the less invasive radial artery harvesting (LIRAH) group and 90 patients in the conventional radial artery harvesting (CRAH) group. Patient characteristics and demographics were similar in the groups. Data collection was made to evaluate possible benefits of the LIRAH technique in terms of fewer forearm and hand complications, better aesthetics, and improved patient satisfaction. RESULTS: Between January 11, 2001, and March 30, 2003, 177 patients underwent either primary or redo coronary artery revascularizations with procurement of the RA for use as a conduit with the less invasive harvesting technique. The mean follow-up was 2 months. Four patients died, and overall mortality was 2.26%. One hundred seventy-three patients were successfully examined during the first postoperative control, 85 in the LIRAH group and 88 patients in the CRAH group. Objective and subjective data were collected from the consultant. The overall average age was 60.5 years (range, 40-77 years). In the LIRAH group, the mean overall incision length (when 2 incisions were necessary, both incision lengths were measured) was 5.6 cm (range, 4-10 cm), and the mean vessel length was 16 cm (range, 10-19 cm). Eighteen patients (20.6%) necessitated double incision. Mean harvesting time (from incision to skin closure) was 43.3 min (range, 25-70 min). Fourteen patients (16.4%) presented some kind of complication during the study. There were no cases with acute ischemia, bleeding, or re-exploration. Seventy-five patients (88.2%) found the cosmetic result excellent. Ten patients (11.8%) found it good, and none considered it mediocre. In the CRAH group, the mean incision length was 20 cm (range, 18-22 cm), and the mean vessel length was 18 cm (range, 17-20 cm ). Mean harvesting time (from incision to skin closure) was 30.8 min (range, 14-45 min). Thirty-four patients (38.6%) presented some kind of complication during the study. Three patients (3.5%) found the cosmetic result excellent. Forty-three (48.8%) found it good, and 42 (47.7%) considered it mediocre. CONCLUSIONS: A potential of fewer neurological forearm postoperative complications, better aesthetics, and improved patient satisfaction can be achieved by the LIRAH technique.
Adult↗
Cannulation of the extrathoracic left common carotid artery for thoracic aorta operations through left posterolateral thoracotomy.
The femoral artery is the usual site of arterial cannulation in thoracic aorta operations through left posterolateral thoracotomy that require cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest (DHCA). The advantage of this perfusion route is in limiting the duration of circulatory arrest. It is associated, however, with the risk of retrograde embolization or, in cases involving aortic dissection, malperfusion of vital organs. To prevent these risks, we have used the extrathoracic left common carotid artery as the perfusion route. From December 1999 to January 2003, we used cannulation of the left extrathoracic common carotid artery in 42 thoracic aorta operations through posterolateral thoracotomy with an open proximal anastomosis technique during DHCA. The indication for thoracic aortic repair was atherosclerotic ulcer in 7 cases, chronic aortic aneurysm in 18, acute type B dissection in 5, and chronic type B dissection in 12. Cannulation of the extrathoracic left common carotid artery was successful in all patients. Postoperative recovery was uneventful, with no cerebrovascular events in all cases. No cannulation-related complications were observed. One patient died from cardiac insufficiency on postoperative day 5. No peripheral neurological deficits (paraplegia or paraparesis) were observed. Postoperative complications included atrial fibrillation in five patients, reoperation to control hemorrhage in six, respiratory insufficiency in nine, and renal insufficiency in six. These results indicate that cannulation of the left extrathoracic common carotid artery is a useful, reliable method for proximal perfusion during CPB in patients undergoing repair of the descending thoracic aorta through left posterolateral thoracotomy. By providing effective perfusion of the brain, this technique can prolong safe DHCA time. Another advantage is the prevention of cerebral emboli, ensuring retrograde flow to the aortic arch.
Adult↗
The "elephant trunk" technique made easier.
In patients with diffuse aneurysmal disease, the "elephant trunk" technique, which uses surplus intravascular graft length to facilitate subsequent operations on the downstream aorta, is an accepted method of treatment. Nevertheless, in the presence of large aneurysms without a definite neck beyond the left subclavian artery, there is an increased risk of rupture at the level of the distal anastomosis. My colleagues and I herein describe a modified elephant trunk technique performed with a new prosthesis, which was conceived to overcome the difficulties and the risks inherent in a large aneurysmal neck.
Aged↗
Long-term durability of resection and end-to-end anastomosis for ascending aortic aneurysms.
BACKGROUND: Ascending aortic aneurysms with normal sized sinotubular junction are generally treated by resection of the dilated aorta and replacement with tubular graft. Aortic resection and direct end-to-end anastomosis has been applied to repair aortic coarctation, interrupted aortic arch, and traumatic aortic rupture. No data exist regarding the long-term durability of this approach in ascending aortic aneurysms. The aim of this case-control study was to illustrate the durability of this operation by presenting our entire experience and the long-term follow up of a cohort of 34 patients who underwent ascending aortic aneurysm resection and primary end-to-end anastomosis between January 1990 and March 2003 in Caen University Hospital (Caen, France). METHODS: The mean age of patients was 61.5 +/- 12.5 years, and there were 18 male and 16 female patients. The operative technique included extensive mobilization of the arch, supra-aortic trunks, and inferior vena cava to enable approximation of the aortic ends, thus avoiding tension on the suture lines. Associated aortic valve replacement was performed in 27 patients; mechanical valves were used in 19. A bicuspid aortic valve was present in 9 patients; in 3 cases the valve was regurgitant. Aortic valve regurgitation was present in a total of 7 patients. Patients were followed up at regular intervals; total follow-up was 2187 patient-months, with a median follow-up time of 72 months per patient (25th-75th percentile 10.5-102.7 months). RESULTS: One patient died 10 days after the operation of aortic rupture related to suture infection caused by mediastinitis. Late deaths occurred in 3 patients, who died 12, 62, and 71 months after the operation, but none of these deaths were attributable to late aortic repair failure. No patient in this series required reoperation, including patients with aortic regurgitation or bicuspid aortic valve. Follow-up was 91.1% complete at the closing date of April 1, 2003. The Kaplan-Meier estimate of survival for all patients was 120.4 months (95% confidence interval 105.1-135.7 months). The median of preoperative maximal aortic diameter was 55.1 mm (range 50.3 to 67.5 mm, 25th-75th percentile 50.5-56.8 mm). The median immediate postoperative diameter was 40.3 mm (range 33.4-46.4 mm, 25th-75th percentile 37.2-42.0 mm, P <.0001 relative to preoperative diameter), and the median length of the resected aortic segment was 52 mm (range 48-76 mm, 25th-75th percentile 50.1-66.4 mm). The median decrease of aortic diameter was 24.9 mm (range 8.9-32.6 mm, 25th-75th percentile 18.2-26.6 mm). The median aortic diameter at the end of the follow-up was 41.0 mm (range 34.6-46.1 mm, 25th-75th percentile 37.0-43.2 mm, P =.6 relative to immediate postoperative diameter). CONCLUSIONS: Ascending aorta aneurysm resection and primary end-to-end anastomosis provides effective long-term outcome and in selected cases represents a good alternative to aortic interposition grafting. Aortic regurgitation and bicuspid aortic valve do not represent a contraindication for this treatment.
Adult↗
Engineering cardiac and aortic procedures.
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Aorta↗
Residual dissection of the brachiocephalic arteries: significance, management, and long-term outcome.
OBJECTIVES: Residual dissection of the brachiocephalic arteries after operations for acute type A dissection is considered a benign condition that does not expose patients to late neurologic events. This retrospective study, conducted on an outpatient clinic basis between June 1995 and May 2003, had the objectives of evaluating the consequences of residual dissection of the brachiocephalic arteries, investigating the long-term outcomes of patients with this condition, and illustrating our approach to the condition. METHODS: Forty-two of 137 patients with spontaneous aortic dissection were identified as having residual dissection of the brachiocephalic arteries. There were 30 men and 12 women, with median age of 64.8 years. Patients were followed for a median time of 3.17 years (25th-75th percentile, 1.43-4.40 years; maximum, 7.5 years). The main outcome was the occurrence of cerebral ischemic events (transient ischemic attack or stroke) or death. The functional consequences of brachiocephalic artery dissection were studied by using duplex scanning and transcranial Doppler ultrasonography. RESULTS: Twenty-four focal neurologic complications occurred in 13 of 42 patients (incidence, 30.9%); major strokes occurred in 6 patients, and none were fatal. Minor strokes occurred in 12 patients. In all patients the damaged territory was dependent on a dissected artery. Kaplan-Meier (90-months) freedom from focal neurologic events was 55.7% (95% confidence interval, 33.7%-72.9%). Mean time of freedom from focal neurologic events was 64.5 months (95% confidence interval, 53.1-75.9 months). Positive transcranial Doppler monitoring for microembolic signals was 24.1%, and patients with clinical symptoms had higher microembolic signal counts than did those without symptoms (8.4/h vs 1.9/h, P <.001). Reduced cerebrovascular reactivity to hypercapnia, calculated by using the breath-holding index values, was associated with severely impaired brachiocephalic artery perfusion. The multivariable model for predictors of late stroke (minor and major) included the following variables: microembolic signal count (1 signal/h increase; relative risk, 1.27 [95% CI, 1.12-1.77]), breath-holding index (0.10 increase; relative risk, 0.91 [95% CI, 0.87-0.94]), and the presence of at least one carotid axis with a thrombosed false channel (relative risk, 0.82 [95% CI, 0.64-0.93]). Sixteen operations were performed in 12 patients to relieve residual dissection. CONCLUSIONS: These results suggest an increased risk of ischemic events ipsilateral to the dissected arteries. Strict follow-up and identification of subjects at risk implies the exact knowledge of vessel anatomy and perfusion status. Ultrasonographic transcranial Doppler examination plays an important role in the clinical work-up of these patients.
Aged↗
Cerebral autoregulation after hypothermic circulatory arrest in operations on the aortic arch.
BACKGROUND: The purpose of this study was to determine whether patients who undergo thoracic aorta repairs with the aid of hypothermic circulatory arrest experience impairments in cerebral autoregulation, and to ascertain the influence of three different techniques of cerebral protection on autoregulatory function. METHODS: Sixty-seven patients undergoing elective aortic arch procedures with hypothermic circulatory arrest were tested for cerebral dynamic autoregulation using continuous transcranial Doppler velocity and blood pressure recordings. Twenty-three patients were treated using hypothermic circulatory arrest without adjuncts (group 1), 25 using antegrade cerebral perfusion (group 2), and 19 using retrograde cerebral perfusion (group 3). RESULTS: There were no hospital deaths. Two major strokes occurred in this series; 9 patients experienced temporary neurologic dysfunction: in all these patients severe impairment of cerebral autoregulation was observed. Cerebral autoregulation in the immediate postoperative period was preserved only in patients treated with antegrade cerebral perfusion. Severe impairments were observed in the other two groups in which the degree of autoregulatory response was inversely correlated to the duration of the cerebral protection time during hypothermic circulatory arrest. Postoperative improvement of autoregulatory function was observed in the majority of patients. Our data suggest the exposure to brain damage in the presence of autoregulation impairment, thus indicating that postoperative hypotensive phases may further contribute to neurologic impairment. CONCLUSIONS: The status of cerebral autoregulation in the postoperative period after hypothermic circulatory arrest procedures is profoundly altered. The degree of impairment is influenced by the cerebral protection technique. This study indicates the beneficial role of antegrade perfusion during hypothermic circulatory arrest for the preservation of this function and suggests that postoperative cerebral autoregulation impairment can be regarded as an expression of central nervous system injury.
Aged↗
The inotropic and lusitropic effects of ketamine in isolated human atrial myocardium: the effect of adrenoceptor blockade.
We studied the direct myocardial effects of racemic ketamine, in the presence of alpha- and beta-adrenoceptor blockade, on isolated human right atrial myocardium. Isometric force of contraction (FoC), its first derivative with time (+dF/dt), the contraction relaxation coupling parameter R2 = (+dF/dt) / (-dF/dt), and time to half relaxation (T(1/2)) were recorded before and after addition of 10(-6), 10(-5) and 10(-4) M racemic ketamine alone and in the presence of alpha-adrenoceptor blockade (phentolamine 10(-6) M) and beta-adrenoceptor blockade (propranolol at 10(-6) M). Ketamine had a moderate positive inotropic effect at 10(-5) M (FoC, 104% +/- 5% of baseline value; P = 0.03) and 10(-4) M (FoC, 107% +/- 11% of baseline value; P = 0.09). Racemic ketamine had a negative inotropic effect in the presence of propranolol (FoC, ketamine 10(-6) M, 77% +/- 11%; ketamine 10(-5) M, 63% +/- 16%; ketamine 10(-4) M, 62% +/- 17% of baseline; P < 0.001) but not phentolamine (FoC, ketamine at 10(-6) M, 94% +/- 6%; ketamine 10(-5) M, 96% +/- 5%; and ketamine 10(-4) M, 98% +/- 15% of baseline). Ketamine decreased T(1/2) (ketamine 10(-5) M, 94% +/- 3% of baseline value; P < 0.001 and ketamine 10(-4) M, 90% +/- 9% of baseline value; P = 0.007) but did not modify R2. In human right atrial myocardium, racemic ketamine induced a moderate positive inotropic effect and hastened isometric relaxation. In the presence of beta-adrenoceptor blockade it induced a direct negative inotropic effect.
Adrenergic Antagonists↗
Flap suffocation: an uncommon mechanism of coronary malperfusion in acute type A dissection.
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Aortic Dissection↗
Resection of anterior mediastinal tumor through a ministernotomy: preliminary experience with ten cases.
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Adult↗
Abdominal aneurysm rupture and left main stenosis: emergency one-stage repair with off-pump coronary surgery.
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Aortic Aneurysm, Abdominal↗