Staging of carotid and coronary operations resulted in low global perioperative mortality and morbidity rates in these high-risk patients and is a good alternative therapeutic option.

Objective: To evaluate perioperative results and long term survival in patients with severe left ventricular (LV) dysfunction undergoing coronary artery bypass grafting (CABG) using non-cardioplegic methods. Methods: From April 1990 through December 1999, 4100 consecutive patients underwent isolated CABG using hypothermic ventricular fibrillation. Of these, 141 (3.4%) had severe LV dysfunction (ejection fraction < 30%). Mean age was 58.3 (9.6) years. 64 patients (45.4%) were in Canadian Cardiovascular Society class III or IV and 16 (11.3%) were subjected to urgent or emergent surgery. A previous myocardial infarction was recorded in 127 (90.1%). The majority (89.4%) had triple vessel and 26 (18.4%) had left main disease. The mean number of grafts per patient was 3.1. At least one internal thoracic artery was used in all patients and 21 (14.8%) had bilateral internal thoracic artery grafts (1.2 arterial grafts per patient). Results: Perioperative mortality was 2.8% (4 patients) and the incidence of acute myocardial infarction 2.8%. 50 (35.5%) patients required inotropes but only 16 (11.3%) required it for longer than 24 hours; 5 patients (3.5%) needed mechanical support. The incidence of renal failure was 3.5%. Mean duration of hospital stay was 9.6 (8.3) days. Follow up was 95% complete and extended for a mean of 57 (30) months. Late mortality was 11.5%. Actuarial survival rates at 1, 3, and 5 years were 96%, 91%, and 86%, respectively. Conclusions: Non-cardioplegic techniques are safe and effective in preserving the myocardium during CABG in patients with coronary artery disease and poor LV function, with low operative mortality and morbidity, and encouraging medium to long term survival rates.

F or the majority of surgeons, mitral valve repair has become the method of choice for surgical correction of mitral regurgitation. However, the feasibility of repair depends not only on the pathology but also on the experience of the surgeon and/or team. Success rates may reach almost 100% in the most common form of isolated prolapse of the middle scallop of the posterior leaflet. Nevertheless, mitral repair is still subject to a pronounced, sometimes painful, learning curve. The durability of the repair also depends on the type of pathology and on many other factors, including the technique used.Since its inception in the 1970s, the techniques of mitral valve repair have been the subject of many modifications and improvements which have made it a more predictable and reproducible method. One area where much improvement was made was ischaemic regurgitation, which was initially considered refractory to repair and for which there is now a growing experience and much improved results. Also, advancements have occurred in the treatment of regurgitation related to cardiomyopathy, previously considered a contraindication for repair. By contrast, repair for rheumatic disease still carries the worst results, although the characteristics of the usually underdeveloped and young population may still make it preferable to mitral valve replacement.In this work, we analyse the state of the art of mitral valve repair and its results according to our experience and in the light of recent reports. MITRAL VALVE REPAIR: ACCEPTED ALTERNATIVE TO PROSTHETIC REPLACEMENTc After an initial period of distrust, in the late 1970s and early 1980s, when it was developed mainly through the efforts of Carpentier, 1 Duran, 2 and others, mitral valve repair has since become a generally accepted alternative to prosthetic replacement for surgical treatment of virtually all forms of mitral valve disease; indeed, most surgeons now recognise its superiority, in terms of both early and late results. The feasibility of mitral valvoplasty varies with the different types of pathology ( fig 1) and from centre to centre, with global values that range from , 10% to nearly 90%. In many centres the use of this method is still the exception rather than the norm.The advantages of mitral valvoplasty parallel the disadvantages of prosthetic valve replacement. Valvoplasty does not require lifelong anticoagulation, compared with mechanical prostheses, especially in patients who have no other reason for anticoagulation, such as the presence of atrial fibrillation. It is also essential to keep in mind that the incidence of thromboembolic complications of mechanical prostheses and of degradation of bioprostheses, another important complication of valve replacement, is more frequent in the mitral than in the aortic position. ANATOMY AND PHYSIOLOGY OF THE MITRAL VALVEThe normal function of the mitral valve results from synchronised movement of all its components: the annulus, the leaflets, the commissures, the chordae tendineae, and the papillary muscles. Together, these...

Necrotizing Fasciitis is a rapidly progressive, potentially fatal infection of superficial fasciae and subcutaneous tissue, usually resulting from an inciting trauma to the skin. Medical literature refers few cases of necrotizing fasciitis related to intra-articular infiltrations, that often lead to patients death. This report describes the clinical events on a 55 year-old diabetic patient who developed upper extremity Necrotizing Fasciitis, 18 days after shoulder mobilization and intra-articular infiltration, due to Staphylococcus epidermidis. An early surgical debridement was performed and antibiotherapy was established, resulting in a successful outcome, despite the functional disability. We point out, through this case, the possibility of intra-articular injections of drugs causing Necrotizing Fasciitis, especially in risk patients.

Transvenous explantion or extraction of CIED leads was highly effective. A high level of experience is an essential factor in the success and safety of the procedure.