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Left ventricular remodeling, through long-term left ventricular chamber dilation and increased wall stress can result in alteration of ventricular architecture and impairment of systolic and diastolic performance. Most of the studies regard post acute myocardial infarction remodeling, knowledge is still lacking about preoperative and postoperative factors which predict the long-term prognosis of patients who underwent venous coronary artery bypass graft surgery. We evaluated 243 patients (225 males, 18 females, mean age 65 +/- 7.3 years) submitted to venous coronary artery bypass graft surgery and 10-year follow-up (123 +/- 20 months). Global mortality was 17.6% (n = 43), significantly higher in patients with ejection fraction (EF) < 50% (log-rank test p < 0.001). The survivors (n = 200) were subdivided into two groups according to postoperative EF: patients with EF > or = 50% (n = 160) and patients with EF < 50% (n = 40). Multivariate analysis revealed that cardiovascular risk factors (hypertension, diabetes, hypercholesterolemia, smoking), number of grafts and infarct location were not associated with EF reduction. Only multivessel disease was significantly associated with EF reduction (p = 0.008). Preoperative echocardiographic parameter analysis evidenced that regional ventricular wall motion score was significantly higher in patients with reduced EF (EF < 50% 11 +/- 7.5; EF > or = 50% 6 +/- 4.1, p < 0.001) and left ventricular dilation (p < 0.001). Multivariate analysis revealed that the strongest correlates of EF < 50% were left ventricular wall motion score index > 10 (odds ratio 5.8, 95% confidence interval 2.8-11.7) and multivessel disease (odds ratio 9.0, 95% confidence interval 2.6-31.08). This study revealed that echocardiographic detection of preoperative ventricular wall motion score may be useful to assess patients at high risk of ventricular remodeling after venous coronary artery bypass graft surgery.

Degenerative aortic stenosis represents the most common form of aortic stenosis. The aim of this study was to evaluate the relationship between symptoms, valvular disease severity and prognosis. We studied the evolution of valvular aortic stenosis in 65 patients (39 males and 26 females, mean age 77.78 +/- 6.2 years) for a period of 7 years. All patients were submitted to accurate anamnestic examination, ECG, color Doppler echocardiography. Sixteen patients (26%) underwent cardiac catheterization. Associated diseases were: hypertension (45%), diabetes (40%), dyslipidemia (29%), chronic obstructive lung disease (6%). In 64% patients, the diagnosis of aortic stenosis was made after symptoms onset, and in 36% was occasional. Mean age at symptoms onset was 70 +/- 17 years: dispnoea was present in 81%, chest pain in 32%, and syncope in 8%. At the beginning of the follow-up, echocardiography showed, aortic stenosis to be mild in 21.73%, moderate in 60.8% and severe in 17.4%. At the end of the follow-up, mild stenosis was present in 9.5%, moderate in 38.7%, and severe in 51.8%. At entry, 56.6% had pure aortic stenosis, 34.78% had steno-insufficiency and 8.7 had an associated mitral valve insufficiency. At the end of the follow-up pure aortic stenosis was present in 17%, steno-insufficiency in 40%, and associated mitral valve insufficiency in 4.3%. Surgery was performed in 21% of the patients (77% valve replacement and 23% valve replacement and aortocoronary bypass). The mortality, at the end of the follow-up, was 31%. Causes of death were: heart failure (61%), arrhythmias (23%), and surgical complications (16%).(ABSTRACT TRUNCATED AT 250 WORDS)

In the progression from myocardial hypertrophy to heart failure, abnormalities in the interstitial space of the heart seem to play a critical role. The formation of an extracellular oedema and the alterations in coronary subendocardial perfusion are associated with the development of interstitial fibrosis. Cardiac experimental studies documented the presence of augmented interstitial fluid volume and pressure and a subsequent remodelling of the fibrillar network of the extracellular space of the myocardium during the phases of the cardiovascular response to a sudden overload. Variations of the Starling's forces balance caused by enhanced endothelial permeability or due to an impairment of cardiac lymphatic drainage may contribute to the development of an acute heart failure. During stable hyperfunction, the organization of a chronic oedema should account for interstitial changes in the hypertrophic myocardium. Reactive fibrosis seems to be under hormonal control. The activation of the renin-angiotensin-aldosterone system is responsible for interfascicular and intercellular accumulation of fibrillar collagen within the cardiac interstitium. Perivascular fibrosis in the subendocardium may impair intramyocardial distribution of coronary flow. When an inadequate hypertrophy occurs, because of an elevation in ventricular wall stress, myocardial oxygen consumption rises and this may lead to the exhaustion of coronary blood flow reserve in the subendocardial layers. This underperfusion may be responsible for the development of myocardial ischemia. Coronary hemodynamic changes in the microcirculation as those prompted by interstitial alterations may contribute to the onset of myocyte necrosis and to the formation of restorative fibrosis. The progressive mechanical overload of the spared hypertrophied myocytes could explain the initiation of a positive feedback mechanism which perpetuates endomyocardial perfusion impairment, interstitial oedema and remodelling, finally, causing myocyte deaths and fibrous tissue proliferation. These structural alterations and their pathophysiological counterparts appear to be closely related to the evolution from compensatory hypertrophy to chronic myocardial failure in hypertrophic heart disease.

The authors report a case of non traumatic dissection of the left extracranial internal carotid artery. Their main topics deal with the clinical-diagnostic aspects and the therapeutic approaches adopted, compared with the specific literature's most recent data. In addition they have discussed--some--investigations aimed at the best follow-up of those diseases.

This report reviews 218 patients who underwent internal mammary artery (IMA) grafting alone or with vein graft between 1986-1989. Our experience with IMA started with a single attached graft for proximal left anterior descending lesions in young patients affected from stable angina. After that our indications became more extensive. One IMA was utilized in 209 cases, both two IMAs in the remaining 9. Sequential IMA graft was performed in 16 patients and free IMA graft in 8. There were 242 IMA anastomosis and 295 associated vein by-passes. The overall operative mortality was 2.3%. Perioperative complications include myocardial infarction in 3 (1.4%), reoperation for bleeding in 4 (1.8%) and sternal wound complication in 4 (1.8%). These results are comparable to those of patients having only saphenous vein by-pass during the same period. At the follow-up actuarial survival rate at 42 months was 94 1.8% and 90% of these patients were completely asymptomatic. We include that IMA grafting shows low operative risk and provide excellent short term results. Our findings and the high long term patency rate of this conduit encourage us to extend the indication to IMA and to perform those surgical techniques that make possible multiple mammary coronary anastomosis.

We report a case of a 49 year-old woman suffering from severe aortic regurgitation due to Takayasu's disease involving the ascending and abdominal aorta and the brachial arteries. The patient was managed successfully with aortic valve replacement. Considering the Literature data, the pathogenesis of the aortic insufficiency and the main surgical and anaesthesiologic problems related to the Takayasu's disease are discussed.

The aim of this work was to identify the best treatment available for massive pulmonary thromboembolism which still remains a frequent and sometimes lethal complication for surgical and non-surgical patients. The Authors underline the difficulties of diagnosis and the need for therapy at the earliest possible stage. At present, clinical management involves the use of: anticoagulants, thrombolytic agents and surgical embolectomy. In conclusion, the authors state that pulmonary thromboembolism, even when massive, has been transformed into a medically interesting pathology which can be cured using heparin and thrombolytic agents. However, surgical treatment is mandatory when patients reveal adverse effects to drug therapy, when medical therapy is insuccessful, or when patients are seriously ill with recurrent cardiac arrest.

After examining the modalities of sternal perfusion and the techniques of median sternotomy, with special regard to closure techniques, personal experience of 1000 sternotomies is reviewed. Complications may be major or minor, incidence was 1,8% and total mortality two cases. After reviewing the various causes of sternal dehiscence, reported and personal experience of the various techniques for preventing and treating the complication is discussed.

The AA. examine their experience concerning 23 patients operated on for a discrete subaortic stenosis since 1969. Immediate results are satisfactory, even if there have been postoperative complications in 26% of the patients. Late results are less satisfactory, above all because of the progression of aortic insufficiency far from the operation. Date of literature are nor allowing valuable indications about the natural history of the patient after surgical treatment, because of the scarcity of postoperative hemodynamic controls and, especially, of serial examinations. The AA. believe, on the ground of considered data and personal experience, that it is prudent, awaiting for further critical evaluation of late results, to limit surgical indications, in asymptomatic patients, to cases with left ventricular-aortic gradient superior to 70 mmHg.

Two cases of patients with discrete subaortic stenosis complicated by aortic regurgitation resulting from the sequelae of bacterial endocarditis and treated by valvular replacement are described. A correct preoperative evaluation was due to echocardiographic data and pressure curves; left ventriculography did not show any evidence of subaortic obstruction in any of the cases. In one patient, bacterial endocarditis involved mitral valve too, which was replaced by an artificial prostheses. Bacterial endocarditis is very rare in patients with discrete subaortic stenosis, but it must be regarded as a factor complicating the natural history of cardiopathy.

Personal experience acquired in the course of 177 mitral valve replacements with a Lillehei-Kaster prosthesis up to June 1977 is discussed. Intraoperative mortality was 8.5%. Postoperative mortality (as at 31-12-1976) was 5.3%. The clinical, radiological, and ergometric findings were fully satisfactory. Haemodynamic examination at rest and during effort revealed improved pressure and heart capacity values. The mean transprosthetic gradient at rest was 5.61 and rose to 13.53 (after uncalibrated effort). Thromboembolism was noted in 5 patients (3.1%), as in the literature. The haemodynamic features and low thrombogenicity of the Lillehei-Kaster prosthesis would thus appear to make it a sound replacement for the mitral valve.

20 patients with partial form of persistent common atrioventricular canal underwent surgery at the Centro di Cardiochirurgia "A. Blalock", University of Turin, between 1969 and 1974. In each case the treatment of lesions took place in the following order: the repair or replacement (one case) of the mitral valve; the closing with a patch of the atrial septal defect; the repair, in one case, of the tricuspid. The most frequent post-operative complications were arrhythmias, which in two cases consisted of a total atrioventricular block. Only one patient died postoperatively for an acute pulmonary oedema following an imperfect mitral valve correction. Six months after surgery, another patient died from bacterial endocarditis. Thirteen of the eighteen surviving patients showed excellent results at the clinical and/or hemodynamic check; two had fair results and three had poor results. In two cases, mitral insufficiency was hemodynamically aggravated, whilst in another five it disappeared. In eight, a slight apex systolic murmor 1-2/6 persisted, which was not correlated with any radiological or electrocardiographical sign of mitral insufficiency (and for three of these, not even a hemodynamic one). The authors consider that the most difficult problem in surgical therapy for these malformations is still the treatment of mitral lesions.

The authors study retrospectively some preoperative echocardiographic findings and their importance as predictors of reversible myocardial dysfunction. The functional status of 57 survivors after isolated aortic valve replacement was evaluated with exercise testing and on this ground the patients, were divided into three groups: A (28 pts) greater than 60%; C (10 pts) less than 40%; B (19 pts) from 40% to 60%. The authors conclude that the postoperative improvement in functional status is strictly correlated with some preoperative echocardiographic indexes (end-diastolic dimension, end-systolic dimension, shortening fraction, mean end-systolic radius/thickness ratio, end-systolic wall stress, myocardial mass, ejection fraction) with are also predictive of operative mortality. The authors consider the principal values of beginning left ventricular impairment: a) end-systolic dimension greater than or equal to 5.5 cm; b) shortening fraction less than 27%; c) mean end-systolic radius/thickness ratio greater than 2.5; d) end-systolic wall stress greater than 240 mmHg.

Recent epidemiological data relating congenital stenosis of the aorta are cited. An anatomical criterion is used in the formation of three classification groups, each containing a number of different types. There are no clear-cut clinical pictures corresponding to these anatomical varieties, however, so that differential diagnosis is dependent on the haemodynamic and contrastographic data. There are, on the other hand, clinical signs that serve as pointers to the site of the stenosis.

The changes in thrombocythemia in patients subjected to extracorporeal circulation (ECC) and pretreated with dipyridamole per os have been examined and compared with a control group in whom the drug was not used; in all patients a circuit with bubble oxygenator was employed. Measurements were carried out before sternotomy, 10' and 60' after ECG, 1 h after the start of intensive therapy and on the 1st surgical day. The variations in thrombocythemia were assessed in consideration of the thrombocythemia/Ht ratio, so as to eliminate the dilution variable. On the basis of the results obtained, it is considered that preoperative treatment with dipyridamole is effective in limiting the fall in thrombocythemia during ECC. The effect of the drug is prevalent in the initial stage of ECC, probably reducing platelet aggregation to non-biological surfaces of the circuit.

The echocardiography of 25 patients with Björk-Shiley disc prosthesis (16 aortic, 7 mitralic, 1 both mitralic and aortic and 1 both mitralic and tricuspidal) was studied. Mitralic prosthesis were placed with the shortest disc segment looking forward; aortic prosthesis faced the shortest disk segment looking towards the coronaric sinus. The echo's morphology is related to the multiple relationships among position and direction of the prosthesis and the probe. In the aortic echocardiogram, it is possible to recognize echoes from the ring dissociated by anterior and posterior aortic walls. Between them echoes corresponding to the open disc appear, making a quadrangular figure. The values of the internal diameter of the ring obtained were very similar to the real value (difference 0-1 mm). Mitralic echocardiogram is characterized by the valvular disc movement tracing the typical quadrangular pattern, which is due to its opening and closure. Echoes of the supporting apparatus can be recorded directing the probe toward the heart base. In aortic and mitralic prosthesis, disc movements can be estimated. Opening and closure speed rate and their correlation vary on a large scale, both within different patients and in the same patient. Maximum disc excursion appears to be a more homogeneous and constant data in long-term controls and can be used to estimate valvular functionality: in aortic prosthesis valve the obtained value (mean = 17.46 +/- 0.53 "ES") is similar to the real diameter of the disc, in mitral prosthesis valve the value obtained (mean = 17.50 +/- 0.74 "ES") is shorter than the real value.