Search

From 1980 to 1996, 111 patients (83 females, 28 males, mean age 51.47 +/- 15.73 years, range 1-76) underwent mitral valve replacement. Seventy-five patients underwent replacement of a biological valve and 36 of a mechanical valve. Three patients underwent a third operation. Seventy prostheses were replaced because of a structural dysfunction. Other causes of valve failure were: 24 thrombosis (23 mechanical and 1 biological), 10 endocarditis (7 mechanical, 3 biological) and 4 leakages (3 mechanical and 1 biological). One patient who had recurrent anticoagulant-related haemorrhage underwent reoperation to replace his mechanical valve with a biological prosthesis. Two patients had their valve replaced because of mismatch between size of the valve and body surface area. Thirteen operations were performed on emergency and 29 on urgency. There were 22 in-hospital deaths with a hospital mortality of 19.82%. Fourteen deaths (63.63%) occurred in patients operated on emergency or urgency. All deceased patients were in NYHA functional class III or IV. Our data suggest that risk of reoperation on mitral prosthesis is highly influenced by the preoperative functional class. In spite of the fact that replacement of biological valves should be more elective than that of mechanical valves, we did not find any difference between the two groups of patients.

The study was designed to assess the diagnostic accuracy and usefulness of intraoperative transesophageal echocardiography (TEE) during repair of aortic dissection. To this end, 32 patients with ascending aortic dissection, undergoing replacement of the ascending aorta, were examined. The diagnosis was validated in each case by intraoperative and/or autopsy findings. The accuracy of TEE was studied in three different periods of surgical operation: before cardiopulmonary bypass (TEE pre-CPB), during CPB (TEE-CPB) and after CPB (TEE post-CPB). In comparison with TEE performed in the intensive care unit 70 +/- 40 min before surgery, TEE pre-CPB showed a higher diagnostic accuracy (100 vs 96%) in classification of the dissection type, a higher sensibility in the identification of intimal tears (83 vs 75%), involvement of the coronary arteries (71 vs 62%) and of aortic arch branches (81 vs 71%); there was no statistically significant difference in the detection of the aortic valve involvement (100 vs 100%). TEE-CPB showed normal perfusion of the true lumen in all but one patient, in whom TEE-CPB showed retrograde perfusion of the false lumen, promptly resolved by fenestration of the false lumen. TEE post-CPB showed persistence of the intimal flap in non repaired segments in all the patients with type I aortic dissection: in 60% of them there was no communication between the true and false lumen; in 40% of them there was a communication between the two lumina, which was proximal in 25% and distal in 15%; all patients did not show thrombosis of the false lumen. TEE post-CPB allowed also the evaluation of flow in left aortic arch branch vessels in 77% of the patients and in the coronary arteries in 70%, and showed well functioning prosthesis in all patients. In each case aortic regurgitation was mild; however, one case had severe insufficiency which was corrected at the time of surgery with annuloplasty. Ejection fraction was normal in 45% of the patients, whereas it was decreased in the remaining patients. Intraoperative TEE during repair of aortic dissection is accurate and useful: it allows improvement in preoperative diagnosis just before CPB, optimizing surgical technique; it gives also important information for the management of patients immediately after CPB and for the follow-up.

This study was designed to assess the sensibility, specificity and diagnostic accuracy of transesophageal echocardiography (TEE) and X-ray contrast enhanced computed tomography (CT) in the diagnosis of aortic dissection and its complications. Fifty patients with clinically suspected aortic dissection were examined. Imaging results were validated in each case by intraoperative and/or autopsy findings and/or the results of cineangiography. The Stanford and DeBakey classifications were used to differentiate the dissection type; the patients were also subdivided by TEE according to a modified DeBakey classification. The sensibility of TEE to detect aortic dissection was 100%, significantly higher (p0.05) than that of CT for type A dissections (77.2%). The two imaging procedures did not statistically differ (NS) in the detection of type B dissection (CT sensibility 87.5%). The specificity of TEE for the detection of type A aortic dissection was 94%; it was not significantly higher (NS) than that of CT (CT specificity 86.6%). Both TEE and CT had no false negative findings in the diagnosis of type B aortic dissection (100%; TEE vs CT, NS). TEE was reliable in the correct identification of the primary entry site in the ascending aorta (80%), the arch (62.5%) and descending aorta (71.4%), and also in the involvement of coronary arteries (62.5%), and aortic arch branch vessels (71.4%); CT scanning was not effective in detecting any of these complications. Aortic regurgitation was accurately identified by TEE in each case. Both TEE and CT scanning correctly identified thrombosis of the false lumen and pericardial effusion. Intraoperative TEE documented in all patients postrepair persistence of the intimal flap in aortic segments that were not operated; flow in the false lumen was detected in 46.6% of the patients; in 26.6% of them secondary tears, not seen before surgical treatment, were detected. In conclusion, TEE allows a bedside, safe and accurate diagnosis and classification of aortic dissection. It also provides the diagnostic information necessary for the therapeutical decision making. Intraoperative TEE allows improvement in preoperatory diagnosis and gives important information for the management of the patient immediately after cardiopulmonary bypass and in the follow-up.

The aim of our study was to assess the sensibility and specificity of Doppler echocardiographic evaluation of left ventricular diastolic function during acute cardiac rejection. We studied 34 patients who had undergone a recent heart transplant and compared the echocardiographic results with the histologic findings. We considered the following parameters of left ventricular filling: early peak of mitral flow velocity; pressure half-time (PHT); isovolumic relaxation time (IVRT). We divided the patients into two groups according to the histologic findings: Group I (25 patients who had at least 1 episode of mild-moderate rejection), Group II (6 patients without documented rejection after at least three consecutive biopsies). Three patients with clinically evident rejection were excluded from the analysis. In Group I cardiac rejection was associated with a statistically significant decrease in IVRT (p0.0005), without significant changes in heart rate and in the early peak of mitral flow velocity. In Group II Doppler parameters remained unchanged. These variations were not associated with changes in echocardiographic morphologic parameters and in parameters of ventricular systolic function. IVRT and PHT returned to normal values after adequate immunosuppressive treatment. Considering variations of IVRT and PHT of at least 20%, we obtained a sensibility of 88% for isolated variations of PHT and a specificity of 93% for consensual variations of PHT and IVRT. Therefore, the assessment of the left ventricular diastolic function by Doppler echocardiography represents a safe and non-invasive method for an early detection of acute cardiac rejection.

Active infective endocarditis (AIE) involving native and especially prosthetic aortic valve is often complicated by conduction abnormalities. These conduction disturbances are considered to represent extension of infection from the valve to the annulus and surrounding myocardium. The authors report their experience of conduction disorders in 6/8 patients in whom the aortic prosthetic valve infection was complicated by periprosthetic abscess. They underline the importance of conduction abnormalities as early markers of severe complication in patients with AIE. In fact, their detection is a useful tool in revealing severe complications since clinical, laboratory and other noninvasive examinations do not always allow early diagnosis of the extension of infection to the surrounding myocardium.