A cerebrovascular accident (CVA) is a devastating complication of coronary artery bypass grafting (CABG) and a major cause for morbidity and mortality. Aortic manipulation, cannulation, and clamping ...during CABG may lead to release of atheromatous material from the ascending aorta, which may cause a CVA. This study assessed the hypothesis that the use of intraoperative epiaortic ultrasonography (EAUS) would supplement imaging information with that derived from manual aortic palpation and influence the surgical decision-making approach accordingly.
After undergoing a mid-sternotomy for CABG, 105 patients underwent EAUS with an 8-MHz transducer ordinarily used for conventional transthoracic echocardiography. The surgical strategy was decided on at three stages: preoperatively, after manual aortic palpation, and following EAUS.
The preoperative strategy had assigned 105 patients to the “touched aorta” group that was planned for either on-pump or off-pump CABG (OPCAB) with proximal anastomosis to the aorta. Pathologic lesions of the atheromatotic ascending aorta were evident in 40 patients (38%), with the lesions detected in 22 patients (21%) by both palpation and EAUS, and in 18 patients (17%) by EAUS alone. The planned surgical strategy was changed in 29 patients (28%): 25 patients (24%) were converted from on-pump CABG to OPCAB, and the EAUS influenced the choice of the aortic cannulation, cross-clamping, and proximal anastomosis site in 4 patients (4%). Among the changes in surgical decision making, changes in 11 patients (10%) were based on lesion detection by both manual palpation and EAUS; in 18 patients (17%), changes resulted from pathologic evidence provided by EAUS alone.
This study showed EAUS to be more sensitive in detecting atherosclerotic lesions than manual intraoperative palpation of the ascending aorta. This investigation contributes new data on the effect of EAUS on intraoperative surgical approach in the era of OPCAB. The use of EAUS has emerged as an important tool in intraoperative decision making, and we recommend its use routinely in CABG procedures.
Background. Incidence of tricuspid prosthesis replacement was 1.9% of all valvular operations performed between June 6, 1966 and April 18, 1996. Many series report similar figures, but institutional ...experience is limited and the consensus on treatment modalities is lacking.
Methods. One hundred tricuspid operations were performed on 83 patients (46 female). A primary operation was performed in 64 cases, 13 patients had one previous operation, 4 patients had two previous operations, and 2 patients had three previous operations. Seventeen patients required a tricuspid prosthetic valve rereplacement. There were 2 emergent and 17 urgent operations. The New York Heart Association class was IV in 13 patients (mean pulmonary artery pressure, 41 mm Hg), III in 66 patients (mean pressure, 38 mm Hg), and II in 21 patients. The most frequent operation was simultaneous replacement of the mitral and tricuspid valve (41 patients). Seventy biological and 30 mechanical prostheses were used. Total follow-up time was 613 years, mean 7.4 years (median 4.2 years), with a maximum of 27.8 years, and was 92% complete.
Results. Operative mortality was 24%. Survival was 0.54 (0.48 to 0.59, n = 39) at 5 years, 0.38 (0.32 to 0.44, n = 27) at 10 years, 0.31 (0.25 to 0.36, n = 19) at 15 years, 0.29 (0.23 to 0.34, n = 11) at 20 years, and 0.17 (0.098 to 0.26, n = 3) at 25 years. Early mortality was increased from higher New York Heart Association class (hazard ratio = 2.2), congenital disease (hazard ratio = 6.9), and valvuloplasty failure (hazard ratio = 4.3). The constant risk phase (4%/patient-year) after 2 years was enhanced by older operative age (hazard ratio = 1.4). Prosthetic type had no independent effect. Biological prostheses were at risk for 300 years and had a reoperation incidence of 4.7%/patient-year (14 events); mechanical prosthesis were at risk for 137 years with a rate of 2.2%/patient-year (3 events) (
p = 0.21). Three valve thromboses were observed in old-design mechanical prosthesis. Bioprosthetic degeneration showed a steeper rate after 7 years.
Conclusions. This study does not show a clear superiority of biological versus mechanical prostheses. In the long run survival with mechanical prostheses could be superior, given the high rate of bioprosthetic degeneration after 7 years.
Background. Results of valvular reoperations depend on extrinsic and patients’ intrinsic risk factors. New prosthetic substitutes continue to appear and the clinical effect is difficult to evaluate. ...Randomized studies are limited by patient selection and follow-up time. We followed the patient-centric outcome research applied to a large database of valvular operations.
Methods. Between January 1, 1970 and January 1, 1995 755 patients underwent one reoperation, 96 a second reoperation, and 12 a third reoperation. On January 1, 1996 a common closing date follow-up was obtained in 98.7% of reoperated patients. Multivariable analysis in the hazard domain was applied to obtain an upgradable model of survival that could be used for predictions and treatment comparison.
Results. Postoperative death hazard showed an early phase merging within 6 months with a constant low hazard phase. The survival proportion was 0.65 (70% CL, 0.63 to 0.67) at 5 years, 0.51 (70% CL, 0.49 to 0.53) at 10 years, 0.47 (range, 0.44 to 0.49) at 15 years, 0.42 (70% CL, 0.39 to 0.46) at 20 and 25 years. Significant incremental risk factors for early mortality were reoperative era 1970 to 1980 (hazard ratio = 2.8), reoperation number (hazard ratio = 1.9), heart penetration on surgery (hazard ratio = 7.6), emergent operation (hazard ratio = 5.8), urgent operation (hazard ratio = 2.1), prosthetic thrombosis (hazard ratio = 2.4), acute prosthetic endocarditis (hazard ratio = 3.0), acute endocarditis of the natural valve at antecedent operation (hazard ratio = 3.2), original floppy valve pathology (hazard ratio = 3.2), and mitroaortic replacement (hazard ratio = 5.7). Isolated mitral reoperation had a lower risk (hazard ratio = 0.5). Significant incremental risk factors for constant phase were: operative era (1970 to 1980) (hazard ratio = 2.0), congestive heart failure (hazard ratio = 2.6), reoperation on tricuspid valve after previous mitral insertion (hazard ratio = 4.9), reoperation for recurring dehiscence (hazard ratio = 4.6), double-valve procedure (hazard ratio = 1.6), coronary artery bypass graft (hazard ratio = 2.7), aortic root disease at original operation (hazard ratio = 2.1), older operative age (hazard ratio = 1.1). Use of bileaflet prosthesis was found to decrease significantly (
p = 0.0002) the death risk (hazard ratio = 0.2).
Conclusions. There is no late uprising hazard, and surviving patients remain exposed to a low risk of death (4% of patients per year). Considering simultaneously the confounding from operative age and operative era and the many concomitant risk factors, survival appears favorably influenced by use of bileaflet valves on reoperation.
With this work we present the activity and performance optimization of the Italian computing centers supporting the ATLAS experiment forming the so-called Italian Cloud. We describe the activities of ...the ATLAS Italian Tier-2s Federation inside the ATLAS computing model and present some Italian original contributions. We describe StoRM, a new Storage Resource Manager developed by INFN, as a replacement of Castor at CNAF - the Italian Tier-1- and under test at the Tier-2 centers. We also show the failover solution for the ATLAS LFC, based on Oracle DataGuard, load-balancing DNS and LFC daemon reconfiguration, realized between CNAF and the Tier-2 in Roma. Finally we describe the sharing of resources between Analysis and Production, recently implemented in the ATLAS Italian Cloud with the Job Priority mechanism.
