Settepani Dott. Fabrizio
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Long-term effects of primary graft dysfunction after heart transplantation.
J Card Surg2022 May;37(5):1290-1298. doi: 10.1111/jocs.16364.
Settepani Fabrizio, Pedrazzini Giovanna L, Olivieri Guido M, Merlanti Bruno, Cannata Aldo, Lanfranconi Marco, Frigerio Maria, Russo Claudio F
Abstract
BACKGROUND:
We studied the incidence of primary graft dysfunction (PGD), its impact on in-hospital and follow-up outcomes and searched for independent risk factors.
METHODS:
During an 18-year period, 508 individuals underwent heart transplantation at our institution. Patients were diagnosed with none, mild, moderate or severe PGD according to ISHLT criteria.
RESULTS:
Thirty-eight patients (7.5%) met the ISHLT criteria for mild PGD, 92 (18.1%) for moderate PGD and 23 (4.5%) for severe PGD. Patients were classified into none/mild PGD (77.4%) and moderate/severe PGD (22.6%) groups. In-hospital mortality was 12.4% (7.8% for none/mild PGD and 28.7% for moderate/severe PGD; p?.001). Survival at 1, 5, and 15 years was 85.5?±?1.9% versus 67.2?±?4.5%, 80?±?2.2% versus 63.5?±?4.7%, and 60.4?±?3.6% versus 45.9?±?8.4%, respectively (p?.001). Excluding the events occurring during the first month of follow-up, survival was comparable between the two groups (93.1?±?1.4% vs. 94.7?±?2.6 at 1 year and 65.6?±?3.8% vs. 70.4?±?10.4% at 15 years, respectively; p?=?.88). Upon multivariate logistic regression analysis preoperative mechanical circulatory support (odds ratio [OR]?=?5.86) and preoperative intra-aortic balloon pump (IABP) (OR?=?9.58) were independently associated with moderate/severe PGD.
CONCLUSIONS:
Our results confirm that PGD is associated with poor in-hospital outcome. The poor outcome does not extend beyond the first month of follow-up, with comparable survival between patients with none/mild PGD and moderate/severe PGD in the short and long-term. Mechanical circulatory support and preoperative IABP were found to be independent risk factors for moderate/severe PGD.
© 2022 Wiley Periodicals LLC.
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[Imaging in acute aortic syndrome: not just dissection].
G Ital Cardiol (Rome)2020 Sep;21(9):656-668. doi: 10.1714/3413.33961.
Mele Donato, Rizzo Massimiliano, Campana Marco, D'Andrea Antonello, Di Giannuario Giovanna, Gimelli Alessia, Khoury Georgette, Pino Paolo G, Berretta Paolo, Settepani Fabrizio, Chiodi Elisabetta, Di Eusanio Marco, Moreo Antonella,
Abstract
Acute aortic syndrome includes three main pathological conditions: aortic dissection (AD), intramural hematoma (IMH) and penetrating aortic ulcer (PAU). These are life-threatening conditions, therefore early diagnosis and interventional/surgical treatment are fundamental for the survival of affected individuals. While anatomical findings of classical AD provided by imaging techniques are known to all cardiologists, imaging findings of IMH and PAU are less known, as are their prognostic implications and consequences on management and treatment strategies. This review aims to describe and discuss findings and role of imaging techniques in patients with IMH and PAU.
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[Functional tricuspid regurgitation: imaging, surgical indications, reparative techniques and results].
G Ital Cardiol (Rome)2020 Nov;21(11):865-877. doi: 10.1714/3455.34441.
Settepani Fabrizio, Berretta Paolo, Fratto Pasquale, Di Giannuario Giovanna, D'Andrea Antonello, Campana Marco, Murzi Michele, Iafrancesco Mauro, Mangino Domenico, Moreo Antonella, Di Eusanio Marco
Abstract
Although the indications for surgical management of severe functional tricuspid regurgitation (TR) are now generally accepted, controversy persists concerning the role of intervention for moderate TR. However, there is a trend for intervention in this setting, particularly in patients with annular dilation. Echocardiographic imaging is the gold standard to identify functional TR and distinguish it from a primitive or degenerative form. Currently, surgery remains the best approach for the interventional treatment of TR. Ring annuloplasty seems to provide better results than suture annuloplasty (De Vega technique) and rigid rings appear to be more reliable in the long term, in comparison with flexible bands. Tricuspid valve repair is more beneficial compared with replacement, except in highly selected cases of long-standing TR with multifactorial mechanism.
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[Follow-up after surgical treatment of type A acute aortic dissection: current evidence and controversies].
G Ital Cardiol (Rome)2020 Nov;21(11):858-864. doi: 10.1714/3455.34440.
Berretta Paolo, Iafrancesco Mauro, Settepani Fabrizio, Mele Donato, Di Giannuario Giovanna, Murzi Michele, Fratto Pasquale, Pino Paolo Giuseppe, Mangino Domenico, Moreo Antonella, Di Eusanio Marco
Abstract
Type A acute aortic dissection (TA-AAD) is a catastrophic condition for which emergency surgery is the mainstay of therapy. Surgical treatment of TA-AAD is centered on excision of the proximal intimal tear, replacement of the ascending aorta and re-establishment of a dominant flow in the distal true lumen. In patients who survive surgery, a dissected distal and/or proximal aorta remains, posing a risk of subsequent aneurysmal degeneration, rupture and malperfusion, and secondary extensive interventions are often required. However, knowledge regarding the risk factors of progression of residual aortic dissection is limited, and no well-defined recommendations for clinical and imaging follow-up have been generated thus far. The aim of this paper is to review and discuss on the current evidence and controversies on the long-term management of patients operated on for TA-AAD.
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Switch from minimally invasive biventricular mechanical support to cardiopulmonary bypass during heart transplant.
Eur J Cardiothorac Surg2021 Jan;59(1):271-273. doi: 10.1093/ejcts/ezaa343.
Settepani Fabrizio, Marianeschi Stefano Maria, Costetti Alessandro, Russo Claudio Francesco
Abstract
An easily reproducible surgical technique to switch from percutaneous minimally invasive biventricular mechanical support to cardiopulmonary bypass during heart transplantation is illustrated. After cannulation of the distal ascending aorta with a standard arterial cannula, the ProtekDuo® cannula and the ProtekSolo® Transseptal cannula were partially retracted to reach the superior and inferior vena cava, respectively, and connected to the pump circuit for the venous drainage. With this cardiopulmonary bypass configuration, orthotopic heart transplantation was routinely performed and, at the end of the procedure, the 2 cannulas were uneventfully removed.
© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
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IgG4-Related Aortitis: Multimodality Imaging Approach.
Ann Thorac Surg2017 Mar;103(3):e289. doi: 10.1016/j.athoracsur.2016.09.040.
Settepani Fabrizio, Monti Lorenzo, Antunovic Lidija, Torracca Lucia
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Impact of Cusp Repair on Reoperation Risk After the David Procedure.
Ann Thorac Surg2016 Nov;102(5):1503-1511. doi: 10.1016/j.athoracsur.2016.04.061.
Settepani Fabrizio, Cappai Antioco, Basciu Alessio, Barbone Alessandro, Moz Monica, Citterio Enrico, Ornaghi Diego, Tarelli Giuseppe
Abstract
BACKGROUND:
We assessed whether additional cusp repair during valve-sparing aortic root replacement affects the echocardiographic mid-term results; a subgroup analysis among patients with bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) was performed.
METHODS:
Between June 2002 and May 2015, 157 consecutive patients underwent valve-sparing aortic root replacement with the David technique. Thirty patients (19%) had BAV. In 19 patients (12%), cusp motion or anatomic abnormalities contributed in determining aortic regurgitation requiring an additional cusp repair. Mean follow-up was 7 ± 3.4 years.
RESULTS:
The cumulative 1-, 5-, and 12-year survival rates were 98%, 94%, and 90%, respectively. Fourteen patients (9%) required aortic valve replacement during follow-up. In 2 patients the underlying cause was bacterial endocarditis. Freedom from aortic valve reoperation was 96% at 1 year, 92% at 5 years, and 89% at 12 years. Reoperation rate was significantly higher (p
CONCLUSIONS:
Adjunctive cusp repair seems to affect the mid-term reoperation risk in patients with BAV and not in patients with tricuspid aortic valve. We recommend caution in using this technique in case of asymmetric BAV requiring cusp repair.
Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
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Outcome of open total arch replacement in the modern era.
J Vasc Surg2016 Feb;63(2):537-45. doi: 10.1016/j.jvs.2015.10.061.
Settepani Fabrizio, Cappai Antioco, Basciu Alessio, Barbone Alessandro, Tarelli Giuseppe
Abstract
OBJECTIVE:
To shed light on contemporary results of open total aortic arch surgery, we undertook a systematic review to identify all reports on this procedure published in the last 10 years.
METHODS:
Extensive electronic literature search was undertaken to identify all published articles from 2004 to 2014 that provided results on total aortic arch replacement. According to inclusion and exclusion criteria, 21 relevant studies were selected and meta-analyzed to assess outcomes.
RESULTS:
The pooled estimate for operative mortality was 5.3%. Permanent and transient neurologic deficit occurred postoperatively at a pooled rate of 3.4% and 5.2%, respectively. Pooled rate of irreversible spinal cord injury was 0.6%, whereas renal failure occurred at a pooled rate of 4.1%. Prolonged intubation occurred at pooled rate of 15.4%. Among elective patients, pooled rate of mortality and permanent neurologic deficit was 2.9% and 2.2%, respectively, with a significant difference compared with urgent/emergency surgery cases.
CONCLUSIONS:
The main findings from this meta-analysis indicate that total aortic arch replacement can be performed with satisfactory mortality and morbidity. The pooled rates of mortality and permanent neurologic deficit among elective cases were surprisingly low, and these data have an even greater prominence when they are compared with outcomes of hybrid arch series. Under urgent/emergency surgery, early mortality and neurologic complications showed an about threefold higher rate. Moderate hypothermic circulatory arrest and early rewarming seem to provide proper renal protection, with an intermediate risk of prolonged intubation.
Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
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Iatrogenic left ventricular false aneurysm.
J Cardiovasc Med (Hagerstown)2016 Dec;17 Suppl 2():e158. doi: 10.2459/JCM.0000000000000310.
Cappai Antioco, Settepani Fabrizio, Barbone Alessandro, Ornaghi Diego, Malvindi Pietro Giorgio
Abstract
: We present a false aneurysm of ventricular left apex after mitral valve in valve prosthesis transapical implantation.
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Hybrid Versus Conventional Treatment of Acute Type A Aortic Dissection.
J Card Surg2015 Sep;30(9):707-13. doi: 10.1111/jocs.12598.
Settepani Fabrizio, Cappai Antioco, Basciu Alessio, Barbone Alessandro, Citterio Enrico, Ornaghi Diego, Tarelli Giuseppe
Abstract
BACKGROUND:
To determine whether the hybrid approach to acute type A aortic dissection results in improved outcomes in terms of mortality, neurologic complications, need for distal aortic reintervention, and false lumen thrombosis compared with the conventional approach.
METHODS:
Data from comparative studies of hybrid versus conventional treatment of acute type A aortic dissection were combined through meta-analysis. Pooled odd ratios were calculated using random effects models.
RESULTS:
Seven comparative studies including 967 patients were identified; of these, 503 underwent conventional proximal aortic repair and 429 extensive distal aortic repair including a stented elephant trunk technique. Between the two groups there was no significant difference in operative mortality (p?=?0.96), permanent neurologic deficit (p?=?0.95), and late mortality (p?=?0.59). Distal aortic repair showed a higher rate of false lumen thrombosis of the thoracic aorta (odd ratio 11.16; p?0.001) and a reduced risk of distal reintervention (odd ratio 0.37; p?=?0.01). In sub-group analysis, frozen elephant trunk procedure showed a lower rate of distal aortic reintervention and a higher rate of false lumen thrombosis than antegrade/retrograde stent deployment techniques (p?=?0.008 and
CONCLUSIONS:
Distal aortic repair may reduce the risk of distal reintervention and increase the rate of false lumen thrombosis without significant increase in operative mortality and permanent neurologic deficit; however, no benefit with respect to late mortality was found. The frozen elephant trunk may reduce the risk of distal aortic reintervention and may increase the false lumen thrombosis of the thoracic aorta in comparison with antegrade/retrograde stent deployment procedures.
© 2015 Wiley Periodicals, Inc.
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Balanced Double Aortic Arch in an Older Patient.
Ann Thorac Surg2015 Jun;99(6):2221. doi: 10.1016/j.athoracsur.2014.12.100.
Settepani Fabrizio, Cappai Antioco, Basciu Alessio, Barbone Alessandro, Tarelli Giuseppe
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Vertebral erosion due to spontaneous thoracic aortic false aneurysm.
Tex Heart Inst J2015 Apr;42(2):188-9. doi: 10.14503/THIJ-13-3949.
Cappai Antioco, Settepani Fabrizio, Tarelli Giuseppe, Malvindi Pietro Giorgio
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Cusp repair during aortic valve-sparing operation: technical aspects and impact on results.
J Cardiovasc Med (Hagerstown)2015 Apr;16(4):310-7. doi: 10.2459/JCM.0000000000000031.
Settepani Fabrizio, Cappai Antioco, Raffa Giuseppe M, Basciu Alessio, Barbone Alessandro, Berwick Daniele, Citterio Enrico, Ornaghi Diego, Tarelli Giuseppe, Malvindi Pietro G
Abstract
AIMS:
Aortic valve-sparing operations are nowadays considered safe and reliable procedures in terms of mid-term and long-term results. Although surgical techniques regarding the modality of grafts' implantation have been properly addressed, the modality of cusp repair, when needed, is still open to debate. We sought to review the literature to try to shed light on when the cusp repair is required and how it should be performed.
METHODS:
We searched the PubMed database using the keywords aortic valve-sparing operation, aortic valve-sparing reimplantation, valve-sparing aortic root replacement, aortic valve repair, and aortic cusp repair. Only studies that included and described in detail the technique of cusp repairs in adjunct to aortic valve-sparing operation were considered.
RESULTS:
Bicuspid aortic valve more often requires correction when compared with tricuspid valve. The range of the techniques varies from the 'simple' free margin plication to the more complex triangular resection with patch repair. Results in the literature seem to be encouraging, showing that, in most of the cases, cusp repair does not affect valve competence in the mid-term and long-term.
CONCLUSION:
Correction of the cusp is a delicate balance between undercorrection that could lead to residual prolapse and overcorrection that could lead to cusp restriction. Although complex repair of the aortic valve in addition to root replacement provided satisfactory results, it should be reserved for experienced centers with a large volume of patients.
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Preserving the left subclavian artery patency in challenging proximal neck during thoracic endovascular aortic repair.
J Cardiovasc Med (Hagerstown)2017 May;18(5):374-377. doi: 10.2459/JCM.0000000000000104.
Settepani Fabrizio, Raffa Giuseppe Maria, Malvindi Pietro Giorgio, Tarelli Giuseppe, Brambilla Giorgio, Pedicini Vittorio
Abstract
Coverage of the left subclavian artery in thoracic endovascular aortic repair is still a controversial procedure. We report a case of 30-year-old patient with a chronic rupture of the aortic isthmus and short proximal lending zone (10 mm) treated by thoracic endovascular aortic repair using a balloon catheter inflated at the origin of the left subclavian artery (and protruding in the aortic arch) to both preserve the arterial branch patency and fully exploit the proximal neck.
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Unusable radial artery for severe atherosclerosis in a young patient.
J Card Surg2015 Mar;30(3):263-4. doi: 10.1111/jocs.12356.
Settepani Fabrizio, Cappai Antioco, Citterio Enrico, Melis Licia C M, Tarelli Giuseppe
Abstract
We report a young diabetic patient who was found to have an unusable radial artery (RA) for coronary bypass grafting because of severe and diffuse atherosclerosis. Techniques to diagnose RA conduits, which are not usable for coronary surgery, are reviewed.
© 2014 Wiley Periodicals, Inc.
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[CircuLite Synergy ventricular assist device: a new approach to end-stage congestive heart failure].
G Ital Cardiol (Rome)2014 Feb;15(2):116-22. doi: 10.1714/1424.15781.
Barbone Alessandro, Pini Daniela, Ornaghi Diego, Visigalli Maria Maddalena, Ardino Laura, Bragato Renato, Curzi Mirko, Cioccarelli Sara Anna, Di Diodoro Lara, Basciu Alessio, Cappai Antioco, Settepani Fabrizio, Citterio Enrico, Cappelleri Alessio, Calcagnino Margherita, Mangiavacchi Maurizio, Tarelli Giuseppe, Lettino Maddalena, Vitali Ettore
Abstract
BACKGROUND:
The Synergy system, a miniature partial circulatory support device, is implanted by an off-pump, minimally invasive surgical approach. The system has been optimized to improve performance in an EU clinical trial for chronic ambulatory heart failure. This therefore offers the possibility of treating elderly chronic heart failure patients who might not usually be considered for long-term circulatory support.
METHODS:
From June 2007 to December 2012, 63 patients were implanted with the Synergy system (12 patients ?70 years) using four different releases of the device. Briefly, the system draws blood through the inflow cannula from the left atrium into the micro-pump (placed in a right subclavicular pocket) and pumps it through an outflow graft to the right subclavian artery. In this paper, we present an intermediate analysis of the clinical trial as performed on April 30, 2013, leading to the placing of the CE mark.
RESULTS:
Mean duration of support is ongoing at 230 days (range 23-1387). Follow-up showed improved hemodynamic response, with additional improvements in 6-min walk distance (299 ± 144 to 420 ± 119 m) and Minnesota Living with Heart Failure Questionnaire (69.5 ± 20.4 to 49.2 ± 24.3). Older patients had longer mean durations of support (337 vs 188 days). On average, elderly and younger patients showed similar improvements in hemodynamics and 6-min walk distance (107 ± 120 vs 130 ± 121 m). Major adverse cardiac events included bleeding (n=4) with one bleeding related to renal failure resulting in death.
CONCLUSIONS:
Clinical use of the Synergy device was associated with a significant functional improvement. Very low adverse event rates were reported with the latest device release. Older patients had smaller body sizes and worse renal function than younger patients. Both groups experienced similar hemodynamic benefits and functional improvements. The risk of bleeding and renal dysfunction appears to be increased in the elderly, though still within acceptable ranges compared to other full support devices. Minimally invasive long-term circulatory support devices, like Synergy, offer a new treatment option that might be available even for the elderly chronic heart failure population.
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Analysis of postsurgical aortic false aneurysm in 27 patients.
Tex Heart Inst J2013 ;40(3):274-80.
Malvindi Pietro Giorgio, Cappai Antioco, Raffa Giuseppe Maria, Barbone Alessandro, Basciu Alessio, Citterio Enrico, Ornaghi Diego, Tarelli Giuseppe, Settepani Fabrizio
Abstract
Aortic false aneurysm is a rare complication after cardiac surgery. In recent years, improved results have been reported in regard to the surgical management of these high-risk lesions. We retrospectively examined 28 consecutive cases (in 27 patients) of postsurgical aortic false aneurysm diagnosed at our institution from May 1999 through December 2011. Twenty-four patients underwent reoperation. Cardiopulmonary bypass was instituted before sternotomy in 15 patients (63%). Isolated repair of the aortic false aneurysm was performed in 15 patients. Four patients (including one who had already undergone repeat false-aneurysm repair) declined surgery in favor of clinical monitoring. Eleven patients were asymptomatic at the time of diagnosis. In the other 16, the main cause was infection in 7, and previous operation for acute aortic dissection in 9. The in-hospital mortality rate was 16.6% (4 patients, 3 of whom had infective false aneurysms). Relevant postoperative sequelae were noted in 7 patients (29%). The cumulative 1-year and 5-year survival rates were 83% and 62%, respectively. The 4 patients who did not undergo reoperation were alive at a median interval of 23 months (range, 9-37 mo). Two underwent imaging evaluations; in one, computed tomography revealed an 8-mm increase of the false aneurysm's maximal diameter at 34 months. Aortic false aneurysm can develop silently. Surgical procedures should be proposed even to asymptomatic patients because of the unpredictable evolution of the condition. Radical aortic-graft replacement should be chosen rather than simple repair, because recurrent false aneurysm is possible.
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Minimally invasive direct coronary artery bypass in the era of percutaneous coronary intervention.
J Cardiovasc Med (Hagerstown)2015 Feb;16(2):118-24. doi: 10.2459/JCM.0b013e3283630c60.
Raffa Giuseppe M, Malvindi Pietro G, Ornaghi Diego, Citterio Enrico, Cappai Antioco, Basciu Alessio, Barbone Alessandro, Fossati Francesca, Tarelli Giuseppe, Settepani Fabrizio
Abstract
AIM:
Minimally invasive coronary artery bypass (MIDCAB) allows revascularization of the left anterior descending coronary (LAD) artery through a less traumatic surgical approach. However, the procedure is technically challenging and concern still exists, mainly based on graft patency. The purpose of this study is to critically evaluate short and long-term benefits of this surgical treatment.
METHODS:
Between June 1997 and July 2012, 306 patients underwent MIDCAB on LAD. The mean age was 62?±?10 years (range, 32-87 years) and 264 patients (86.3%) were men. Mean ejection fraction was 54%. Eighty-nine procedures (29.1%) were performed using a hybrid approach by means of MIDCAB and postoperative (60 patients, 67.4%) or preoperative (29 patients, 32.6%) percutaneous interventions on non-LAD vessels. A EuroScore more than 6 was found in 43 (14%) patients. The average follow-up time was 9.5?±?3.2 years and was 89% complete.
RESULTS:
Six patients (1.9%) required intraoperative conversion to sternotomy, whereas cardiopulmonary bypass institution after the sternotomy was necessary in one. Postoperative acute myocardial infarction occurring nine patients (2.9%), low output syndrome in four (1.3%). Postoperative mortality was 1.6% (n?=?5), and perioperative stroke rate 0.6% (n?=?2). Five and 10-year survival were 94.1 and 86.9%, respectively. Freedom from death due to cardiac events and major cardiac and cerebral events at 10 years was, respectively, 97.1 and 92.1%.
CONCLUSIONS:
The results confirm the favorable short and long-term results of the MIDCAB procedure. MIDCAB, in experienced centers, can represent an alternative treatment option for LAD disease.
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Conversion to sternotomy during sternal-sparing coronary artery surgery.
J Card Surg2013 Jul;28(4):386-7. doi: 10.1111/jocs.12110.
Raffa Giuseppe M, Settepani Fabrizio
Abstract
Conversion to a full sternotomy may complicate up to 1.8% of the sternal-sparing coronary artery surgery. Left internal mammary artery injury and anastomotic problems are the common causes. The purpose of this article is to retrospectively review the outcomes of six patients that required conversion to sternotomy during minimally invasive direct coronary artery bypass and also to point out technical aspects in order to avoid such a complication.
© 2013 Wiley Periodicals, Inc.
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Mitral and aortic valve prosthetic endocarditis after percutaneous closure of mitral paravalvular leak.
Ann Thorac Surg2013 Feb;95(2):e45-6. doi: 10.1016/j.athoracsur.2012.08.020.
Malvindi Pietro Giorgio, Raffa Giuseppe Maria, Cappai Antioco, Barbone Alessandro, Basciu Alessio, Settepani Fabrizio, Citterio Enrico, Ornaghi Diego, Tarelli Giuseppe, Vitali Ettore
Abstract
A 67-year-old man presented to our hospital with massive mitral and aortic valve prosthetic endocarditis 2 months after transcatheter percutaneous closure of a mitral paravalvular leak with an Amplatzer duct occluder device (AGA Medical Corp, Plymouth MN). He underwent successful reoperation for valve prosthesis replacement and reconstruction of the anterior fibrous trigone. Although transcatheter treatment of periprosthetic valve defects has been shown to be feasible, follow-up data are still limited. This procedure should be reserved only for patients who are not eligible for open surgical procedures and those with small periprosthetic defects.
Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
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Hamartoma of mature cardiac myocytes in adults and young: case report and literature review.
Int J Cardiol2013 Feb;163(2):e28-30. doi: 10.1016/j.ijcard.2012.08.052.
Raffa Giuseppe Maria, Malvindi Pietro Giorgio, Settepani Fabrizio, Melotti Flavia, Monti Lorenzo, Spaggiari Paola, Basciu Alessio, Cappai Antioco, Citterio Enrico, Tarelli Giuseppe
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Sutureless repair for postinfarction cardiac rupture: a simple approach with a tissue-adhering patch.
J Thorac Cardiovasc Surg2013 Feb;145(2):598-9. doi: 10.1016/j.jtcvs.2012.08.049.
Raffa Giuseppe M, Tarelli Giuseppe, Patrini Davide, Settepani Fabrizio
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Postsurgical aortic false aneurysm: pathogenesis, clinical presentation and surgical strategy.
J Cardiovasc Med (Hagerstown)2013 Aug;14(8):593-6. doi: 10.2459/JCM.0b013e32835369f2.
Raffa Giuseppe M, Malvindi Pietro G, Ornaghi Diego, Basciu Alessio, Barbone Alessandro, Tarelli Giuseppe, Settepani Fabrizio
Abstract
Postsurgical aortic false aneurysm occurs in less than 0.5% of all cardiac surgical cases and its management is a challenge in terms of preoperative evaluation and surgical approach. Although infections are well recognized as risk factors, technical aspects of a previous operation may have a role in pseudoaneurysm formation. The risk factors and clinical presentation of pseudoaneurysms and the surgical strategy are revisited in this article.
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6 months of "temporary" support by Levitronix left ventricular assist device.
Artif Organs2012 Jul;36(7):639-42. doi: 10.1111/j.1525-1594.2011.01428.x.
Barbone Alessandro, Malvindi Pietro Giorgio, Sorabella Robert A, Cortis Graziano, Tosi Paolo F, Basciu Alessio, Ferrara Pietro, Raffa Giuseppe, Citterio Enrico, Settepani Fabrizio, Ornaghi Diego, Tarelli Giuseppe, Vitali Ettore
Abstract
An otherwise healthy 47-year-old man presented to the emergency department in cardiogenic shock after suffering a massive myocardial infarction due to left main occlusion. He was initially supported by extracorporeal membrane oxygenation and subsequently was converted to paracorporeal support with a Levitronix left ventricular assist device. He experienced multiple postoperative complications including renal failure, respiratory failure, retroperitoneal hematoma requiring suspension of anticoagulation, and fungal bloodstream infection precluding transition to an implantable device. He was reconditioned and successfully underwent orthotopic heart transplant 183 days after presentation. A discussion of the relevant issues is included.
© 2012, Copyright the Authors. Artificial Organs © 2012, International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.
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Bicuspidy does not affect reoperation risk following aortic valve reimplantation.
Interact Cardiovasc Thorac Surg2012 Jun;14(6):717-20. doi: 10.1093/icvts/ivs059.
Malvindi Pietro Giorgio, Raffa Giuseppe Maria, Basciu Alessio, Citterio Enrico, Cappai Antioco, Ornaghi Diego, Tarelli Giuseppe, Settepani Fabrizio
Abstract
Aortic valve reimplantation has been shown to be a safe procedure. However, evidences of durability in bicuspid aortic valves (BAVs) are limited in the literature. Between 2002 and 2011, 132 patients (mean age 61 ± 12 years) underwent aortic valve reimplantation. In 24 patients (18%), aortic valve was bicuspid. Mean follow-up was 50 ± 26 months (range 1-102 months) and was 99% complete. In-hospital mortality was 0.8% (1 patient). Survival at 1 and 5 years was 99 and 94%, respectively. Overall freedom from aortic valve reoperation at 1 and 5 years was 96 and 90%, respectively, without significant difference between patients with bicuspid and tricuspid aortic valve. Freedom from aortic valve regurgitation >2+/4+, excluding patients reoperated, was at 1 and 5 years of 100 and 99%, respectively. Patients with valve cusp repair showed a higher rate of aortic valve reoperation; however, only postoperative aortic regurgitation >2+/4+ was significant risk factor for redo procedure at multivariate analysis. Aortic valve reimplantation in BAV without cusp repair provides excellent mid-term results. Further observations and longer follow-up are necessary to determine if BAV sparing, even in the presence of cusps alterations, could allow satisfying durability.
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Aortic valve replacement for paraprosthetic leak after transcatheter implantation.
J Card Surg2012 Jan;27(1):47-51. doi: 10.1111/j.1540-8191.2011.01351.x.
Raffa Giuseppe M, Malvindi Pietro Giorgio, Settepani Fabrizio, Ornaghi Diego, Basciu Alessio, Cappai Antioco, Tarelli Giuseppe
Abstract
Conversion to surgical aortic valve replacement (AVR) has been described as a complication following transcatheter aortic valve implantation. This complication occurs in up to 8% of cases and, to the best of our knowledge, preoperative data and surgical outcomes of such patients have not been properly evaluated. Mild paraprosthetic regurgitation is commonly observed after transcatheter aortic valve implantation and usually leads to a benign clinical course. Unequal distribution of valve calcifications is described as a potential mechanism. We report a case of a perioperative paraprosthetic regurgitation that underwent successful urgent surgical AVR and review the incidence and results of paraprosthetic leaks following transcatheter implantation.
© 2011 Wiley Periodicals, Inc.
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Compliance of the Valsalva graft's pseudosinuses at midterm follow-up with cardiovascular magnetic resonance.
Ann Thorac Surg2011 Jan;91(1):92-6. doi: 10.1016/j.athoracsur.2010.09.023.
Monti Lorenzo, Mauri Giovanni, Balzarini Luca, Tarelli Giuseppe, Brambilla Giorgio, Vitali Ettore, Ornaghi Diego, Citterio Enrico, Settepani Fabrizio
Abstract
BACKGROUND:
In previous studies, the Valsalva graft's compliance at the level of the Dacron pseudosinuses was found similar to that of normal sinuses shortly (2±1 months) after the operation. We sought to investigate with cardiac magnetic resonance the compliance of the Valsalva graft pseudosinuses at midterm follow-up.
METHODS:
Seven patients (group A) and 7 age-matched controls (group B) were studied with steady-state free precession and phase-contrast cardiac magnetic resonance for aortic root and ascending aorta evaluation. Blood pressure was measured during phase-contrast acquisition to derive the following mechanical properties of the vascular prosthesis: pulsatility, compliance, distensibility, and elastic modulus.
RESULTS:
Mean postoperative follow-up was 55±9.84 months. Mean age was 69.2±4.98 years in group A, and 65.7±7.16 years in group B. All the studied variables were coherent in showing a significant difference between the two groups, and between aortic root (skirt portion of the graft) and ascending aorta (tubular part of the graft) in group A. The presence of periaortic fibrosis did not show any correlation with the ascending aorta's mechanical properties.
CONCLUSIONS:
At midterm follow-up, the pseudosinuses compliance of the Valsalva graft is still appreciable and significantly greater than the tubular portion.
Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
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Use of the Valsalva graft and long-term follow-up.
J Thorac Cardiovasc Surg2010 Dec;140(6 Suppl):S23-7; discussion S45-51. doi: 10.1016/j.jtcvs.2010.07.060.
De Paulis Ruggero, Scaffa Raffaele, Nardella Saverio, Maselli Daniele, Weltert Luca, Bertoldo Fabio, Pacini Davide, Settepani Fabrizio, Tarelli Giuseppe, Gallotti Roberto, Di Bartolomeo Roberto, Chiariello Luigi
Abstract
OBJECTIVE:
The Valsalva graft is a specifically designed Dacron graft that, on implantation and pressurization, generates pseudosinuses of Valsalva. We reviewed a multicenter experience of the reimplantation procedure with the Valsalva graft in patients with aneurysms involving the aortic root.
METHODS:
A total of 278 patients underwent valve-sparing aortic root replacement using the Valsalva graft at 4 different Italian cardiac surgery centers and were studied by clinical assessment and echocardiography. Of the 278 patients, 220 were men (79%), with a mean age of 56 ± 15 years. Of the patients, 42 (15%) had Marfan syndrome, 31 (11%) had a bicuspid aortic valve, 13 (5%) had acute aortic dissection, and 136 (49%) had grade 3 or 4+ aortic insufficiency. Concomitant cardiac procedures were performed in 78 patients (28%). Additional aortic leaflet repair was necessary in 25 patients (9%). The mean crossclamp time was 120 ± 27 minutes.
RESULTS:
There were 5 (1.8%) operative and 5 (1.8%) late deaths. The mean follow-up was 52 ± 28 months (range, 2-112 months) and was 100% complete. The cumulative actuarial survival was 95.2% (268 patients). A total of 32 patients (11%) had grade 3 to 4+ aortic insufficiency, and 17 of these required late aortic valve replacement (range, 3-78 months). At 10 years of follow-up, the freedom from aortic valve reoperation rate was 91%, and the rate of freedom from residual aortic insufficiency not needing reoperation was 88%.
CONCLUSIONS:
The reimplantation type of valve-sparing procedure can be facilitated by the use of the Valsalva graft and can be performed with satisfactory perioperative and midterm results. How an optimal root reconstruction will affect the second decade of follow-up has yet to be determined.
Copyright © 2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.
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Reimplantation valve-sparing aortic root replacement with the Valsalva graft: what have we learnt after 100 cases?
Interact Cardiovasc Thorac Surg2009 Jul;9(1):113-6. doi: 10.1510/icvts.2009.202622.
Settepani Fabrizio, Bergonzini Marcello, Barbone Alessandro, Citterio Enrico, Basciu Alessio, Ornaghi Diego, Gallotti Roberto, Tarelli Giuseppe
Abstract
OBJECTIVES:
Reimplantation valve-sparing aortic root replacement has been increasingly performed with improving perioperative and mid-term results. The success of this operation primarily depends on preserving the highly sophisticated dynamic function of the aortic valve by recreating an anatomical three-dimensional configuration similar to the normal aortic root, thus minimizing the mechanical stress and strain on the cusps. Over the years several techniques have been proposed to reproduce the sinuses of Valsalva. We reviewed our experience with aortic valve reimplantation by means of a modified Dacron graft that incorporates sinuses of Valsalva, in a series of 100 consecutive patients.
METHODS:
During a 60-month period, 100 patients with aortic root aneurysm underwent aortic valve reimplantation using the Gelweave Valsalva prosthesis. There were 74 males and the mean age was 60+/-12 years (range 28-83 years). Five patients had the Marfan's syndrome, 15 had a bicuspid aortic valve. Cusp repair was performed in five patients. The mean follow-up time was 28.6 months (range 1-60). Transesophageal echocardiogram was performed at the end of each procedure to assess the aortic valve in terms of competence, dynamic motion and level of coaptation within the graft.
RESULTS:
There was one hospital death and two late deaths. Overall survival at 60 months was 91.7+/-5.1%. Five patients developed severe aortic incompetence (AI) during follow-up requiring aortic valve replacement (AVR). The 60 months freedom from re-operation due to AI was 90.9+/-4.4%. One patient had moderate AI at latest echocardiographic study. The 60 months freedom from AI>2+ was 91.6+/-7.9%. Cox regression identified cusp's repair as independent risk factor (P=0.001) for late reimplantation failure (AVR or AI>2+). There were no episodes of endocarditis and the majority of the patients (88%) were in New York Heart Association functional class I.
CONCLUSIONS:
The aortic valve reimplantation with the Gelweave Valsalva prosthesis provided satisfactory mid-term results. An accurate assessment of the level of coaptation of the aortic cusps in respect to the lower rim of the Dacron graft by means of intraoperative transesophageal echocardiogram at the end of each procedure is mandatory in order to avoid early reimplantation failure. Cusp's repair may play an important role in the development of late AI. However, long-term results are needed in order to define the durability of this technique.
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Reimplantation valve-sparing aortic root replacement for aortic root aneurysm in the elderly: are we pushing the limits?
J Card Surg2010 ;25(1):56-61. doi: 10.1111/j.1540-8191.2008.00782.x.
Settepani Fabrizio, Szeto Wilson Y, Bergonzini Marcello, Barbone Alessandro, Citterio Enrico, Berwick Daniele, Gallotti Roberto, Bavaria Joseph E
Abstract
OBJECTIVES:
Reimplantation valve-sparing aortic root replacement has been increasingly performed with improving perioperative and midterm results. However, extending the age criterion in patient selection remains a debate. This study reviews the results of reimplantation valve-sparing aortic replacement in patients greater than 60 years of age.
METHODS:
During a 51-month period, 63 patients with aortic root aneurysms underwent reimplantation valve-sparing aortic root replacement. The Gelweave Valsalva prosthesis (TERUMO CardioVascular Systems Corp., Ann Arbor, MI, USA) was used in all but one case. The patients were predominantly male, and the mean age was 67 years (range, 61-83 years). Four patients had congenital bicuspid aortic valves, and cusp repair was required in one patient. The mean follow-up was 25 months (range, 1-51 months).
RESULTS:
There were one hospital and two late deaths. Overall survival at 51 months was 84 +/- 9.9%. During follow-up, one patient developed severe aortic incompetence (AI) requiring an aortic valve replacement (AVR). Freedom from reoperation at 51 months was 92.8 +/- 6.8%. Moderate AI was present at latest echocardiogram in one patient. Freedom from moderate or severe AI at 51 months was 90 +/- 9.4%. There was no episode of endocarditis on follow-up. Univariate analysis demonstrated that no preoperative or intraoperative factor was a predictor for late reimplantation failure.
CONCLUSIONS:
Reimplantation valve-sparing aortic root replacement in patients greater than 60 years old can be performed with satisfactory perioperative and midterm results. Long-term results are needed to define the durability of this technique and its role in this subset of patients.
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Reoperation for aortic false aneurysms: our experience and strategy for safe resternotomy.
J Card Surg2008 ;23(3):216-20. doi: 10.1111/j.1540-8191.2008.00597.x.
Settepani Fabrizio, Muretti Mirko, Barbone Alessandro, Citterio Enrico, Eusebio Alessandro, Ornaghi Diego, Silvaggio Giuseppe, Gallotti Roberto
Abstract
BACKGROUND AND AIM OF THE STUDY:
To review our experience with reoperation for aortic false aneurysms (FA) and to present an analysis of the relevant surgical approaches and risks.
METHODS:
From May 1999 to June 2006, 11 patients underwent a total of 13 reoperations due to aortic false aneurysms, with an incidence of 3% of all thoracic aortic cases. Cardiopulmonary bypass (CPB) and cooling were started before sternotomy in all cases. Three different strategies were adopted for patients depending on the position of the FA in the mediastinum as indicated by a preoperative CT scan. These included: deep hypothermic circulatory arrest (18 degrees C), moderate hypothermia (28 degrees C), and mild hypothermia (32 degrees C). In two patients, the sternotomy ruptured the FA causing profuse hemorrhaging. In all the other cases sternotomy was performed without complication. The repair consisted in simple repair by direct suture (10 cases) or extensive repair by refashioning the anastomosis (three cases).
RESULTS:
Two hospital deaths occurred with a hospital mortality rate of 16.7%. Permanent neurological deficit developed in one patient. Transient neurological deficit in the form of left lower limb weakness was observed in one patient. False aneurysm recurrence developed in two cases. Among patients present at follow-up (nine survivors), four are in NYHA class I and five in class II.
CONCLUSIONS:
Aortic false aneurysms carry a high mortality and morbidity rate. Nevertheless, we believe that selecting the right strategy according to the position of the FA in the chest can reduce surgical risk, thus permitting relatively safe resternotomy.
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Aortic root replacement with the Carboseal composite valve graft: analysis of risk factors.
Interact Cardiovasc Thorac Surg2005 Aug;4(4):360-4.
Settepani Fabrizio, Eusebio Alessandro, Ornaghi Diego, Barbone Alessandro, Citterio Enrico, Manasse Eric, Silvaggio Giuseppe, Gallotti Roberto
Abstract
This retrospective analysis of a selected series of Bentall-De Bono procedures was carried out in order to evaluate the performance of the Carboseal composite valve graft (Sulzer Carbomedics Inc, Austin, TX, USA). Between October 1997 and April 2004, 120 patients underwent aortic root replacement with the Carboseal Composite Valve Graft. The mean age of patients was 59.7+/-13.4 years (range, 21-83 years); 96 patients (80%) were male. Eighty-nine patients (74.2%) had annulaortic ectasia, 10 patients (8.3%) post-stenotic dilatation, 3 (2.5%) post dissection aneurysm, 2 (1.7%) acute type A dissection and 1 (0.8%) endocarditis. The average follow-up duration was 29.2 months (range 2-82 months). Hospital mortality was 1.7% (2 of 120 patients). The actuarial survival rate (including hospital mortality) was 97.2+/-1.5% at 1 year, 91.6+/-3.5% at 3 years and 84.0+/-8.0% at 5 years. Chronic renal failure was an independent risk factor for late mortality (P=0.02). The actuarial freedom from pseudoaneurysms at 3 years was higher among patients without Marfan syndrome (94.7+/-3.2% vs. 75.0+/-21.6% at 3 years, P
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Aortic valve-sparing operations in patients with aneurysms of the aortic root or ascending aorta: preliminary results.
Interact Cardiovasc Thorac Surg2005 Apr;4(2):137-9.
Settepani Fabrizio, Ornaghi Diego, Barbone Alessandro, Citterio Enrico, Eusebio Alessandro, Manasse Eric, Silvaggio Giuseppe, Gallotti Roberto
Abstract
OBJECTIVE:
Aortic valve-sparing operations were developed to preserve the native aortic valve in patients with aneurysms of the aortic root or ascending aorta and normal aortic valve leaflets. This paper describes our initial experience with valve-sparing operations and early clinical and echocardiographic results obtained.
METHODS:
From October 2002 to March 2004, 32 consecutive patients underwent aortic valve-sparing operations at the Istituto Clinico Humanitas, Rozzano, Italy. Preoperative transesophageal echocardiography showed moderate or severe aortic incompetence (AI) in 15 patients (47%). Twenty-nine patients underwent reimplantation of the aortic valve and 3 patients remodeling of one sinus. In 2 cases prolapsing cusp repair was carried out.
RESULTS:
There were no intraoperative deaths. At discharge, two-dimensional echocardiogram showed no or trivial aortic incompetence (AI) in 17 (52%) patients and mild AI in 13 (42%); 2 (6%) patients had severe AI requiring reoperation, respectively 4 and 6 weeks later.
CONCLUSIONS:
The valve-sparing procedures showed good preliminary results, thus encouraging further use of this type of repair. However, further larger studies and long-term results are needed in order to define the durability of these techniques.
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Reimplantation valve-sparing aortic root replacement in Marfan syndrome using the Valsalva conduit: an intercontinental multicenter study.
Ann Thorac Surg2007 Feb;83(2):S769-73; discussion S785-90.
Settepani Fabrizio, Szeto Wilson Y, Pacini Davide, De Paulis Ruggero, Chiariello Luigi, Di Bartolomeo Roberto, Gallotti Roberto, Bavaria Joseph E
Abstract
BACKGROUND:
Introduced by DePaulis in 2000, the Gelweave Valsalva graft (Sulzer Vascutek, Refrewshire, Scotland) is a modified Dacron conduit (DuPont, Wilmington, DE), with prefashioned sinuses of Valsalva. The aim of this study was to evaluate the mid-term results of the reimplantation valve-sparing aortic root replacement using the Gelweave Valsalva prosthesis in Marfan syndrome patients.
METHODS:
A retrospective review was performed of 35 patients with Marfan syndrome in four centers who underwent the reimplantation valve-sparing aortic root replacement using the Gelweave Valsalva prosthesis.
RESULTS:
The patients were predominantly men, with a mean age of 36.5 +/- 12.6 years (range, 14 to 62 years). Two patients presented with acute type A dissections and underwent emergent operations. Elective hemiarch reconstruction using hypothermic circulatory arrest was required in 11 patients. Aortic valve cusp repair was performed in 2 patients. There were no operative or hospital deaths, and no patients died during follow-up. The mean follow-up was 19 months (range, 1 to 60 months). Significant (>2+) aortic insufficiency (AI), requiring aortic valve replacement, developed in 3 patients during follow-up that requiring aortic valve replacement. The 5-year freedom from reoperation owing to structural valve deterioration was 88.9% +/- 8.1%. There were no episodes of clinically significant thromboembolism.
CONCLUSIONS:
Reimplantation valve-sparing aortic root replacement with the Gelweave Valsalva prosthesis in Marfan patients provides satisfactory mid-term results, thus encouraging further use of this type of repair. However, long-term results are needed in order to define the durability of this technique.
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Early results of valve-sparing reimplantation procedure using the Valsalva conduit: a multicenter study.
Ann Thorac Surg2006 Sep;82(3):865-71; discussion 871-2.
Pacini Davide, Settepani Fabrizio, De Paulis Ruggero, Loforte Antonino, Nardella Saverio, Ornaghi Diego, Gallotti Roberto, Chiariello Luigi, Di Bartolomeo Roberto
Abstract
BACKGROUND:
This study evaluates the midterm clinical results of valve-preserving aortic root reconstruction by means of a modified conduit incorporating sinuses of Valsalva.
METHODS:
During a 5-year period, 151 patients with aneurysm of the aortic root underwent a reimplantation type of valve-sparing procedure using the Gelweave Valsalva prosthesis that incorporates sinuses of Valsalva. There were 121 males (80.1%), and the mean age was 56.4 +/- 14.4 years (range, 14 to 83). Fourteen percent of the patients had Marfan syndrome and 8.6% had bicuspid aortic valve. Seven patients (4.6%) suffered from acute aortic dissection. Aortic replacement was extended to the arch in 14 patients (9.3%). Sixteen patients (10.6%) had associated cusp repair.
RESULTS:
In-hospital mortality was 3.3%, and it was significantly higher among patients operated on for acute dissection (p = 0.001) and in symptomatic patients (III-IV New York Heart Association class; p = 0.021). Follow-up (mean, 18 months; range, 1 to 60) was 100% complete. There were 2 late deaths. Ten patients (6.8%) had 3 to 4+ aortic regurgitation, and 8 of these required late aortic valve replacement. Cusp repair was associated with a high incidence of late aortic valve replacement (p = 0.005). At 5 years, freedom from aortic valve replacement and freedom from grade 3 to 4 aortic insufficiency was 90.8% +/- 3.3% and 88.7% +/- 3.6%, respectively.
CONCLUSIONS:
The reimplantation valve-sparing procedure with the Gelweave Valsalva prosthesis provides satisfactory results for patients with aortic root aneurysm. Aortic cusp repair may lead to late aortic insufficiency. Proper leaflet evaluation is of paramount importance in preventing residual valve regurgitation.
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The Ross operation: an evaluation of a single institution's experience.
Ann Thorac Surg2005 Feb;79(2):499-504.
Settepani Fabrizio, Kaya Abdullah, Morshuis Wim J, Schepens Marc A, Heijmen Robin H, Dossche Karl M
Abstract
BACKGROUND:
Pulmonary autograft aortic root replacement was used in adults. Risk factors for aortic valve incompetence (AI) and pulmonary homograft valve stenosis are identified.
METHODS:
From February 1991 through May 2003, 103 patients, with a mean age of 35.2 +/- 9.5 years, underwent aortic root replacement with the pulmonary autograft. Annulus reinforcement (reduction annuloplasty or use of root ring) was carried out in 45 patients. In all but 1 patient, the right ventricular outflow tract was reconstructed with a cryopreserved pulmonary homograft. Mean follow-up duration was 6.0 +/- 2.8 years (range 0.3 to 11 years).
RESULTS:
There were no hospital deaths. Overall patient survival was 98.9 +/- 1.0% at 1 year and 97.3 +/- 1.9% at 10 years. Autograft function follow-up resulted in 5 patients requiring reoperation for aortic incompetence. The univariate risk factors for aortic incompetence at discharge and during follow-up were respectively annulus reinforcement (p = 0.05) and bicuspic aortic valve (p = 0.05). Reoperation for homograft failure occurred in 1 patient. During follow-up, 24 patients (25.5%) developed homograft stenosis (gradient > 20 mm Hg). Univariate analysis indicated the diameter of the homograft (p = 0.001) as factor associated with stenosis during follow-up. Cox regression identified smaller diameter of the homograft (p = 0.001) and older age of donor (p = 0.002) as independent risk factor for the development of homograft stenosis.
CONCLUSIONS:
The Ross operation can be performed with few complications. Although both the aortic autograft and the pulmonary homograft have limited durability, this has not yet resulted in considerable reoperation rates and associated morbidity and mortality.
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Aspergillus left ventricular assist device endocarditis.
Ital Heart J2004 Nov;5(11):876-80.
Barbone Alessandro, Pini Daniela, Grossi Paolo, Bandera Angelo, Manasse Eric, Citterio Enrico, Eusebio Alessandro, Silvaggio Giuseppe, Settepani Fabrizio, Municinò Annamaria, Colombo Piergiuseppe, Casari Erminia, Ornaghi Diego, Gronda Edoardo, Gallotti Roberto
Abstract
Left ventricular assist device (LVAD) support is an established therapy for patients with end-stage heart failure as a bridge to transplant; its usage as an alternative for those patients not eligible for transplant is not an established therapy yet. A 68-year-old male had a Thoratec-Heartmate LVAD implanted as destination therapy. After an uneventful (apart from early fever) recovery in the intensive care unit, the patient developed an intractable high temperature, and generalized sepsis and died 21 days following implant. The white cell blood count never exceeded the guard limits, and the patient succumbed with severe LVAD valve malfunction. At post-mortem examination friable material consisting of fungal hyphae was found on the inflow and outflow valves. According to published clinical trials, infection accounts for more than 40% of mortality in LVAD supported patients. Fungal LVAD endocarditis is a particularly deadly disease. Successful management requires a high level of suspicion and timely institution of antifungal therapy to control the infection. This has led some authors to recommend empiric antifungal therapy in LVAD recipients with culture-negative sepsis unresponsive to broad-spectrum antibiotics.
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Aortic root replacement with composite valve graft.
Ann Thorac Surg2003 Jul;76(1):90-8.
Pacini Davide, Ranocchi Federico, Angeli Emanuela, Settepani Fabrizio, Pagliaro Marco, Martin-Suarez Sofia, Di Bartolomeo Roberto, Pierangeli Angelo
Abstract
BACKGROUND:
Composite valve graft replacement is currently the treatment of choice for a wide variety of lesions of the aortic root and the ascending aorta. In this study we report our experience with aortic root replacement using a composite graft.
METHODS:
Between October 1978 and May 2001, 274 patients (79.6% male and 20.4% female) with a mean age of 53.5 years underwent composite graft replacement of the aortic root. One hundred sixty-one patients (70.8%) had annuloaortic ectasia and 46 (16.8%) aortic dissection. The classic Bentall technique was used in 94 patients (34.3%), the "button technique" in 172 patients (62.8%), and the Cabrol technique in 8 patients (2.9%).
RESULTS:
The early mortality rate was 6.9% (19 of 274 patients). Cardiopulmonary bypass time longer than 180 minutes and associated coronary artery bypass grafting were found to be independent risk factors of early mortality. The actuarial survival rate was 77.7% at 5 years and 63% at 10 years. The independent risk factors for late mortality were coronary artery disease, chronic renal failure, and postoperative dialysis. The actuarial freedom from reoperation on the remaining aorta was higher among patients without Marfan syndrome (94.6% versus 79.6% at 10 years, p = 0.008).
CONCLUSIONS:
Composite valve graft replacement can be performed with low hospital mortality and morbidity. The button technique offers some advantages and should be used whenever possible. In case of acute aortic dissection root replacement is usually not necessary. Marfan patients should be treated with early root replacement before dissection occurs.
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