The religious beliefs of Jehovah's Witnesses who refuse homologous and autologous blood transfusion poses serious problems for surgeons when operating on patients requiring a mean transfusion requirement of =/>2 units of blood.After a number of encouraging studies in a randomised sample of patients 2-3 and after the treatment of some Jehovah's Witnesses 1, a group of 45 patients (23 females and 22 males) underwent elective heart surgery between June 1998 and December 2000. The patients, who were all Jehovah's Witnesses, received pre-treatment with epoetin alpha and ferrous sulphate. In the light of recent studies, it was also decided to repeat medullary preconditioning using the same intervals but with a higher dose. The patients underwent surgery involving myocardial revascularisation, mitral and/or aortic valve replacement, associated interventions, valvuloplasty and ascending aortic aneurysms. After obtaining informed and signed consent, the treatment protocol comprised the administration of 140 IU/kg epoetin alpha three times a week for 3 weeks associated with oral ferrous sulphate 3 times a day. Hematochemical levels (hemoglobin, free hemoglobin, hematocrit, ferritin, transferrin, haptoglobin, reticulocytes, iron levels) were monitored from admission to Day Hospital to discharge.No patient in the study required blood transfusion.The short, medium and long-term follow-up reconfirmed the substantial reliability of this drug linked to the absence of collateral effects.

BACKGROUND:This study aimed to evaluate the advantages offered by a myocardial revascularisation technique proposed by Kolessov in 1967: minimally invasive thoracotomy for myocardial revascularisation. The aim was to assess its short and medium-term benefits. During the course of the 1980s, the problems linked to extracorporeal circulation (ECC) and the contraindications for traditional myocardial revascularisation led to a renewed popularity of "beating heart" revascularisation techniques.METHODS:The largest and most extensive series of patients in the literature undergoing myocardial revascularisation during left mini-thoracotomy was reported by Calafiore et al. In this study we report the series treated by our centre which, albeit involving only 32 cases, obtained good results in the short and medium term. This surgical procedure can only be applied to patients presenting monovasal obstructive coronary disease affecting the anterior interventricular artery (IVA) which must not present small calibre, calcified walls or a lateralised or intramyocardial anatomic position.RESULTS:Invasive and non-invasive instrumental tests carried out to control the distal anastomoses of the left internal mammary artery (IMA) did not reveal angulations and/or stenosing tractions before the anastomosis of IMA to a significant extent also for treatment, when isolating IMA, able to obtain the longest possible length and the best mobility. No infection of surgical wounds was reported postoperatively, as sometimes occurs in median longitudinal sternotomy.CONCLUSIONS:The 2-year follow-up showed the resolution of angina in 100% of the patients studied, as well as a satisfactory and rapid renewal of social relations.

Coronary artery aneurysms involve the right coronary artery, the left anterior descending and the left circumflex coronary arteries in descending order of frequency; aneurysms involving the main left coronary artery are extremely rare. Atherosclerosis is the most common cause. Only eleven patients surgically treated with atherosclerotic left main coronary artery aneurysms are reported. We observed the twelfth case of atherosclerotic aneurysm of the left main coronary artery, successfully treated. In a 65-year-old man we found a large aneurysm originating at the distal segment of the left main coronary artery. A thromboendarterectomy was per-formed and was extended back into the left main and down the left anterior descending artery. An aneurysmorrhaphy and a three-vessel coronary artery bypass grafting were also performed. Three years later the patient was asymptomatic. Management of these cases is still controversial and based on anedoctal experience rather than controlled trials. Although surgery has been recommended to prevent complications, there are no available data comparing medical and surgical management. We feel that coronary bypasses should be performed in coronary artery aneurysm patients only when indicated by the severity of stenosis or progressive angina despite medical therapy. It is our opinion that anurysmorraphy should preserve native flow as much as possible.

Fourteen years after surgery for replacement of the aortic valve, an interesting case previously unreported was brought to our attention. The female patient came to our OP Dept for a routine follow-up: she had been found at surgery to have a quadricuspid aortic valve. Operation dated October 1985. At a careful appraisal of the world-wide literature, we noticed that such an association of pathologies had never been reported before: quadricuspid aortic valve, paroxystical supraventricular tachycardia and right double kidney with double renal pelvis and double proximal ureter. Other anomalies associated with the quadricuspid valve, available in the literature are: patent duct, subvalvular fixed aortic stenosis, ventricular septal defect, hypoplastic anterior mitral leaflet and pulmonary stenosis. The pathologic findings at autopsy of this congenital malformation vary between 0.008% and 0.033%; attention must be turned to the fact that the incidence can be underestimated if not expressly searched for. The first quadricuspid aortic valve was described in 1862 by Balington in an autoptic report and sixty other cases have been reported since. In rare cases this pathology has been diagnosed at angiography. At follow up our patient remains in SR with rare transitory episodes of supraventricular tachycardia.

The case of a patient with Osteogenesis imperfecta is reported who underwent surgery for mitral valve replacement. Osteogenesis imperfecta is a hereditary disease of the connective tissue, associated with bone fragility, bluish colouring of the sclerae, loss of hearing and dental anomalies. Osteogenesis imperfecta is included in a group of hereditary pathologies with Ehlers-Danlos syndrome, Hurler syndrome, pseudoxanthoma elasticum and Marfan syndrome. In the literature there are few cases of patients with osteogenesis imperfecta operated for mitral valve disease secondary to such disease. The patient also has a positive family history and a severe anaemia: this was treated with epoetin-alpha and ferrous sulphate during the three weeks before surgery. The response to epoietin treatment was good while clinical outcome was poor due to rupture of the posterior ventricular wall in the 12th postoperative hour. The use of epoietin-alpha is discussed.

We report the cases of two patients, previously operated for mitral mechanical valve replacement who developed thrombosis of the prosthesis. The two patients were successfully treated with pharmacological thrombolysis with no recurrence. One patient developed late peripheral embolization most probably due to late mobilisation of a thrombotic fragment. Our experience with surgical management is reported (39 mitral and 5 aortic prosthetic thrombosis from 1982 to 1999 among 89 patients with prosthetic malfunction). Average time interval between surgery and thrombus formation is 26 months (max 204, min 1 month). Rate of mitral thrombosis is 3.9% and aortic 0.25%. Clinical presentation spreads from almost asymptomatic patients to critically ill patients with pulmonary oedema or frank cardiogenic shock. Temporary suspension of anticoagulant therapy (83% in our study group) to rule out minor surgery, appears to be the most frequent cause of thrombosis. Transthoracic or better transoesophageal echo-cardiography and Doppler are by far the most accurate diagnostic tools that can entirely replace angiographic assessment. Operative mortality was 64% in the prosthetic mitral thrombosis and 20% in the aortic one. Thrombolytic treatment may be affected by minor to relevant complications such as peripheral or central embolization but in our experience and according to the literature it seems much less hazardous than re-do surgery. Thrombolytic treatment is advocated for critical patients unless emergency institution of cardio pulmonary bypass is required and/or indicated. Re-do surgery remains indicated for all other cases of prosthetic malfunction.

BACKGROUND This study evaluates the real effectiveness of epoetin-alpha associated with ferrous sulphate, in reducing blood transfusion in patients undergoing elective open heart surgery not treated with autologous donation. METHODS Sixty patients had been divided into 2 groups: group A (30 patients) treated with 525 mg ferrous sulphate three time a day per os for 3 weeks; group B (30 patients) treated with epoetin-alpha 10,000 UI twice a week and 525 mg ferrous sulphate 3 times a day. Grouping of patients has been randomized. In both groups hemoglobin, hematocrit, reticulocytes, iron values, ferritine, transferrine, and serological values, have been evaluated sequentially before treatment, before surgery, day of operation, 1st, 2nd, 3rd, 7th postoperative days and at discharge. RESULTS In group A 86% patients needed blood transfusion (26 out of 30); in group B only 3% of patients needed blood transfusion (1 patient). One year follow up didn't show side effects related to epoetin-alpha. CONCLUSIONS This study confirms the real effectiveness of epoetin-alpha in reducing the postoperative need for homologous blood transfusion. No side effects due to epoetin-alpha treatment have been proved. The conclusion is drawn that epoetin-alpha can be used as an alternative to blood transfusion or in association with predeposit and in the treatment of basal anemia.

We describe a new surgical technique adopted for the repair of Stanford type A aortic dissection. In order to minimize the risk of malperfusion caused by retrograde flow during cardiopulmonary bypass, we avoid femoral artery cannulation. On the hypothesis that it is best not to interfere with the hemodynamics of the dissection, we cannulate the dissected ascending aorta, in either the true or false lumen. We here report 2 cases of successful surgical treatment of Stanford type A aortic dissection. In both cases, the false lumen was cannulated under deep hypothermic circulatory arrest, without clamping the aorta. While the patient was cooling, a 10-mm GORE-TEX side arm was sutured to a Dacron graft prosthesis. Repair of the aortic arch was carried out 1st. The aortic cannula was inserted into the GORE-TEX side arm, the tubular prosthesis was cross-clamped, and cardiopulmonary bypass was reinstituted. After this, the aortic bulb was repaired as usual and the tubular prosthesis was sutured to the bulb. No postoperative cerebral complication occurred. Our experience must be confirmed by more cases and a longer follow up.

Objective. Aortic valve incompetence associated with severe aortic ectasia is usually treated by aortic valve and ascending aorta replacement. In cases of isolated aortic ectasia or in Type A aortic dissection the valve is often normal and the incompetence is just due to annular dilatation. Such conditions lead to the application of various valve-sparing surgical techniques, as described by Senning et al., showing the advantages of preservation of the native valve, but the disadvantage of a high technical complexity and a high incidence of recidivation. Methods: We describe a valve-sparing surgical procedure, which has the advantage of a direct and simple approach together with satisfying mid-term results. After the aortic bulb has been fully transected, the excessive wall tissue is resected by two or three triangular excisions just above the valve commissures. Wall excision was indicated in those patients with an aortic diameter exceeding 65 mm at the sine-tubular junction. Tissue excision should not exert tension on to the coronary ostia or excessively reduce aortic diameter. Three external Teflon strips, overriding each other, are placed around the aortic bulb and are included in the direct suture of the edges of the triangular excisions. They are fixed by a running suture over the free border of the bulb. Aortic valve commissures are resuspended when needed. In this way, the aortic bulb, with a competent valve, is wrapped in a prosthetic and inextensible graft. The aortic continuity is then re-established with the interposition of a tubular dacron graft. Results: From April 1990 to December 1995, 21 patients (mean age 48 years, range 32-70) scheduled for surgery for aortic valve incompetence associated with annuloaortic ectasia were treated with this technique. In one patient the procedure failed to achieve a satisfying valve competence and the valve was replaced. In another case a prolapse of the noncoronary cusp required reoperation with aortic valve replacement, without further complications. At follow-up time (mean 42 months, range 18-78), all patients were well and healthy, with control echoes showing no residual valve incompetence and with invariate bulb diameters at every successive examination. Conclusions: Our experience shows that this new valve-sparing approach allows safe and persistent correction of aortic valve incompetence and annuloaortic ectasia although longer term follow up is needed. (C) 1998 Elsevier Science B.V. All rights reserved.

The high mortality index related to surgical therapy with direct suture of rupture of left ventricular free wall following acute myocardial infarction, suggested we analyze and use alternative techniques. So we applied sutureless technique described by Padro to two patients. We used a Teflon patch fixed to the ventricular wall with a biocompatible synthetic glue, an ethyl-2-cyanoacrylate monomer, without any direct suturing of the infarcted myocardium. The two patients survived the operation and were discharged from the hospital 12 and 14 days after surgery. The sutureless technique allows, in our opinion, a more confident and safe aggressive attitude to subacute left ventricular free wall rupture.

OBJECTIVE The authors describe 9 cases of rhabdomyolytic acute renal failure (ARF) as a complication of cardiopulmonary bypass. EXPERIMENTAL DESIGN Retrospective research between June 1992 and March 1994. SETTING Department of Cardiac Surgery. PATIENTS 931 consecutive patients undergoing major cardiac surgery. INTERVENTIONS Patients affected by rhabdomyolytic ARF were treated with pharmacological therapy and/or plasmapheresis/continuous arteriovenous hemofiltration. In seven patients indirect cannulation of the femoral artery was used. MEASURES Incidence, risk factors of syndrome results obtained with pharmacological treatment, CAVH and plasmapheresis were evaluated. Statistical analysis was performed with ANOVA, Tukey Kramer test and chi2 test (p<0.05 as significant). RESULTS The syndrome occurred in 0.96% (9/931 patients) of the total cases; 11.3% (6/53 -p<0.0000) in patients undergoing a direct femoral artery cannulation for cardiopulmonary bypass and 9.5% (2/21, p<0.01) in patients in which the aortic balloon pump was used. Six patients develop acute anuric renal failure and underwent plasma exchange and hemodialysis (1 case) or CAVH (5 cases); 3 patients underwent early medical treatment and developed developed acute renal failure (ARF) with preserved diuresis. Early medical therapy appeared to prevent the evolution towards anuric ARF. The indirect cannulation of the femoral artery does not seem to produce a rhabdomyolytic ARF syndrome. In patients with direct femoral artery cannulation risk factors appear to be: arteriopathy (p<0.001), prolonged extra corporeal circulation (p<0.001), low cardiac output syndrome (p<0.001), continuous i.v. infusion of epinephrine (p<0.0001). CONCLUSIONS Rhabdomyolytic acute renal failure is a severe complication, early identification of patients ¿at risk¿ is most important. The preventive measures and the therapy adopted proved efficient.

The case of a 37-year-old female patient is reported with systemic lupus erythematosus and severe renal function impairment, and associated aortic insufficiency, obstructive coronary disease and aneurysm of the left ventricular inferior free wall. Renal failure, hematologic disorder and the need for high-dose steroid therapy to control the autoimmune disease were considered the main surgical risks. Surgery included aortic valve replacement and plication of the ventricular aneurysm. The postoperative course was free of any major complications related to surgery or SLE disease.

OBJECTIVE:Authors describe 1 case of rhabdomyolytic acute renal failure as a complication of Cardiopulmonary bypass.EXPERIMENTAL DESIGN:Case report.SETTING:Department of Cardiac Surgery.INTERVENTIONS:Patient affected by rhabdomyolytic acute renal failure was treated with pharmacological therapy, plasmapheresis and continuous arteriovenous hemofiltration (CAVH).RESULTS:Anuric acute renal failure was diagnosed in 2nd post surgical day; serum myoglobin values was 16000 micrograms/l (normal values in non surgical patients < 88 micrograms/l), creatine phosphokinase serum values was 8790 UI/L (with Mb fraction < 8%). Patient underwent CAVH and two a day sessions of plasmapheresis; hematochemical and hemodynamic parameters improved progressively with resolution of acute renal failure and resumption of the diuresis on the 10th day. The CAVH was suspended on the 11th day and plasmapheresis on the 5th. Rhabdomyolytic syndrome should be correlated to the direct cannulation of the femoral artery for cardiopulmonary bypass and to prolonged time of extracorporeal circulation, with consequent leg ischemia/reperfusion induced injury which occurs during the extracorporeal circulation and continued during postoperative period; contributory causes should be the low cardiac output syndrome and alpha vasoconstrictor effect of high dose continuous intravenous administration of epinephrine.CONCLUSIONS:Rhabdomyolytic acute renal failure is a severe complication of cardiopulmonary bypass; plasmapheresis and continuous arteriovenous hemofiltration seems to be suitable treatments.

Extreme technical accuracy is crucial in coronary artery surgery. Although late graft patency depends mostly upon the patient's own biochemical status in chronic ischemic patients who have undergone elective surgery, graft disease is certainly promoted by an inaccurate technique or by careless arterial harvesting, which may cause both intimal lesions and anastomotic strictures. We describe a technique of internal thoracic-coronary artery anastomosis that fully prevents contact between vessels and surgical instruments. In order to enable the suturing of a fully dilated vessel, intracoronary papaverine is injected into the clamped aortic root while the heart is still beating and before systemic cooling begins. The suturing technique applies some microvascular principles, the chief being a high number of stitches incorporating the least amount of tissue, to avoid bulk.

We compared a series of 7 consecutive patients who underwent mitral valve replacement with preservation of both leaflets to a control group of 97 patients who underwent standard mitral valve replacement at our institution during the same period. Use of inotropic drugs and duration of postoperative intensive care were compared and shown to be markedly reduced in the study group; however, statistical analysis was not applied due to the small number of patients. Comparison of the available pre- and postoperative echocardiographic values showed a decrease in left ventricular end-diastolic and end-systolic diameters in patients with preserved leaflets, particularly in those with mitral regurgitation of degenerative origin.

The present report describes an unusual case (apparently the 10th in the world literature) of a type-A aortic dissection with full circumferential detachment of the ascending aortic intima and intussusception thereof into the aortic arch and descending aorta, partly occluding the arch vessels. Computed tomographic scanning and 2-dimensional echocardiography failed to detect an intimal flap and a false lumen in the ascending aorta. Aortic dissection was visualized by aortography. The ascending aorta was surgically repaired and the aortic valve resuspended. The pertinent literature is reviewed.

High dose aprotinin has been used in cardiac surgery (Royston 1987) to reduce post operative bleeding. A low dose aprotinin ie 2000000 KIU in the oxygenator prime, has been also proposed. OBJECTIVE. To evaluate postoperative losses and holomogous blood transfusions, in patients undergoing cardiac surgery treated with low and high dose aprotinin. METHODS AND MATERIALS. Ninety-nine patients, between January and May 1993, have randomized in 3 groups: A, high dose aprotinin; B, low dose aprotinin; C, control. All patients were treated with additional blood saving techniques routinely used in our center. Statistical analysis was performed by means of ANOVA and Tukey Kramer test. MAIN RESULTS. Five patients (3 in group A, 1 each in groups B and C) have been excluded during the trial. The groups resulted omogeneus and comparable. Total blood losses were 372 +/- 159 ml in group A, 401 +/- 178 ml in group B (difference are not significative); the 621 +/- 255 m1 in group C are highly significative. Patients transfused were 18.7% in group C, 10.34% in group A and 6.20% in group B. CONCLUSIONS. Effects of low dose aprotinin are comparable to high dose. Further advantages with low dose are reduction of collateral effects and intolerance phenomena and a better cost benefits ratio.