Italian Referral Hospital Research Articles

Risk of Congenital Toxoplasmosis in Newborns from Mothers with Documented Infection: Experience from Two Referral Centres

During pregnancy, primary Toxoplasma gondii infection can cause congenital toxoplasmosis (CT). We described the newborns’ outcomes from a multicentre cohort of mothers with seroconversion (SC) at different gestational ages. This retrospective observational study (from 2007 to 2018) was conducted in two Italian referral hospitals: Fondazione IRCCS Policlinico San Matteo in Pavia and Spedali Civili in Brescia. In total, 247 pregnant women were enrolled: seroconversions were enrolled: seroconversions documented as having occurred in the two months preceding pregnancy in 12 cases (4.9%; 95% CI 2.2–7.5%), and during pregnancy in 235 cases (95.1%; 95% CI 92.5–97.8%). SC is defined as the appearance of specific anti-Toxoplasma antibodies (IgM/IgG) during pregnancy in a previously seronegative woman. A total of 56 (22.5%; 95% CI 17.3–27.7%) newborns were lost to follow-up; thus, the outcome of 193 (77.5%; 95% CI 72.3–82.7%) newborns was analyzed. The overall transmission rate of T. gondii infection was 23.8% (95% CI 17.8–29.8%), 0% (95% CI 0.0–11.9%) among the 1st trimester SCs, 12.5% (95% CI 5.6–19.4%) among the 2nd trimester SCs, 53.8% (95% CI 41.7–66.0%) among the 3rd trimester ones. No CT were found in the group of periconceptional infection. Among the infected newborns, clinically manifest cases were 12 (26.1%; 95% CI 13.4–38.8%), including 1 case (2.2%; 95% CI 2.0–6.4%) of stillbirth and 11 symptomatic neonates (23.9%; 95% CI 11.6–36.2%). A total of 83 amniocentesis were performed (33.6%; 95% CI 27.7–39.5%), no complication was recorded and no false positive or false negative results were registered. The results are in line with the fetal risks reported in literature for T. gondii infection during pregnancy, even if at a lower percentage probably due to a prompt treatment.

Treatment Sequencing and Independent Outcomes of First- and Second-Line Chemotherapy in a Retrospective Series of Patients with Biliary Tract Cancer.

Background/Objectives: Biliary tract cancers (BTCs) are aggressive neoplasms with limited therapeutic options. The amount of prospective evidence is poor, and limited data are available on the impact of treatment sequencing on survival. Here we report a real-world experience of patients with advanced BTC treated with at least three lines of therapy. We evaluated the impact of sequential treatments, and we further compared the efficacy of Gemcitabine/Cisplatin (GemCis) and mFOLFOX to other first- and second-line chemotherapy regimens, respectively. Methods: Data on 60 patients with locally advanced or metastatic BTC under the care of a single Italian referral hospital and treated with at least three lines of chemotherapy were retrospectively collected. Data from 56 patients were included in the analysis. Survival analyses were performed using R software (v1.2.5042). Results: We compared the outcomes of patients treated according to the "standard" pre-immunotherapy sequence (GemCis and mFOLFOX in the first and second lines, respectively) versus those treated with all other combinations ("control" group). Our analysis did not show significant survival differences between the two groups. However, it should be noted that we selected long-survival patients by including only those who received at least three or more lines of chemotherapy. Focusing on the first-line setting, no significant differences in both mPFS and mOS emerged by comparing GemCis versus other doublets (mainly Gemcitabine/Oxaliplatin). Similarly, mPFS and mOS from second-line treatment did not statistically differ between patients treated with mFOLFOX versus those treated with other regimens (71% chemotherapy doublets). Conclusions: Our series provides real-world outcomes of patients with advanced BTC before the approval of immunotherapy. Even considering the monocentric and retrospective design, our study represents one of the first analyses on the impact of sequential treatment strategies in patients with BTC.

Safety of endoscopist-directed nurse-administered sedation in an Italian referral hospital: An audit of 2 years and 19,407 procedures

Background and study aimsBalanced propofol sedation (BPS) administered by adequately trained non-anaesthesiologist personnel has gained popularity in GI endoscopy because of its shorter procedure and recovery time, high patient satisfaction, and low rate of adverse events (AEs), despite being considered controversial. We report data from an audit of endoscopist-directed (ED) nurse-administered sedation in an Italian referral hospital. Patients and methodsConsecutive endoscopic procedures performed between 2020 and 2022 were considered. Under the guidance of the endoscopist, the nurse administered midazolam/fentanyl, followed by a progressive top-up dosage of a 10–20 mg bolus of propofol to achieve moderate to deep sedation. The endoscopists and nurses were all certified in our hospital with a continuous and scheduled training from 2006. ResultsDuring the study period, a total of 19,407 examinations (7,803 EGDS, 10,439 colonoscopies, 77 PEG, 697 EUS, and 365 ERCP) and 14,415 patients were included. Of these, 29.4 % of patients were classified as ASA I, 66.5 % as ASA II, and 5.1 % as ASA III. Hypotension was recorded in 1,293 (6 %) examinations and bradycardia in 176 (0.9 %) patients. Eleven patients (0.06 %) had minor respiratory adverse events. Two patients (0.01 %) had major AEs requiring orotracheal intubation. ConclusionsED-BPS is safe in low-risk patients. Major AEs occurred in 0.01 % of procedures.

Effectiveness and safety of bimekizumab for the treatment of plaque psoriasis: a real-life multicenter study-IL PSO (Italian landscape psoriasis).

Bimekizumab is a monoclonal antibody that targets Interleukin-17 A and F, approved for the treatment of moderate-to-severe plaque psoriasis. While bimekizumab has been evaluated in several phase-III clinical trials, real-world evidence is still very limited. This multicenter retrospective study included patients affected by plaque psoriasis treated with bimekizumab from May 1, 2022 to April 30, 2023, at 19 Italian referral hospitals. Patients affected by moderate-to-severe plaque psoriasis eligible for systemic treatments were included. The effectiveness of bimekizumab was evaluated in terms of reduction in psoriasis area and severity index (PASI) compared with baseline at weeks 4 and 16. The main outcomes were the percentages of patients achieving an improvement of at least 75% (PASI75), 90% (PASI90) and 100% (PASI100) in PASI score. The study included 237 patients who received at least one injection of bimekizumab. One hundred and seventy-one patients and 114 reached four and 16 weeks of follow-up, respectively. Complete skin clearance was achieved by 43.3% and 75.4% of patients at weeks 4 and 16, respectively. At week 16, 86.8% of patients reported no impact on their quality of life. At week 16, there were no significant differences between bio-naïve and bio-experienced patients in terms of PASI75, PASI90 and PASI100. The most commonly reported adverse events (AEs) were oral candidiasis (10.1%). No severe AEs or AEs leading to discontinuation were observed throughout the study. Our experience supports the effectiveness and tolerability of bimekizumab in a real-world setting with similar results compared with phase-III clinical trials.

Real-Life Effectiveness and Safety of Upadacitinib in Adults and Adolescents with Moderate-to-Severe Atopic Dermatitis: A Single-Center 16-Week Study.

The treatment of severe atopic dermatitis (AD) includes cyclosporine and recently approved biologics and small molecules. Among these, upadacitinib is a selective inhibitor of Janus kinase 1, approved for the treatment of severe AD in adolescents/adults. Upadacitinib has shown efficacy and safety in several phase 3 clinical trials, but data on real-life patients are still lacking. We conducted a retrospective real-life observational study to evaluate the effectiveness and safety of upadacitinib up to week 16 in a cohort of both bio-naïve and bio-experienced patients. This study was carried out by analyzing the AD database records of an Italian referral hospital. Thirty-eight patients were included in this study, and 35 completed 16weeks of treatment. At week 16, out of 35 patients, the percentages of Eczema Area and Severity Index (EASI) 50, EASI 75, EASI 90 and EASI 100 responses were 94.29, 91.43, 74.29, and 60%, respectively. A decrease of at least 4 points from baseline of itch-NRS was reported by 94.74 and 91.43% of patients at weeks 8 and 16. Regarding the safety of upadacitinib, 26.32% of patients experienced at least one adverse event (AE), and a total of 13 AEs were recorded, including blood test abnormalities and papulopustular acne. None of our patients interrupted the drug because of an AE. We observed higher rates of EASI75/EASI90/EASI100 responses at week 16, compared with data from clinical trials. The safety profile of upadacitinib was favorable, as no AEs leading to discontinuation were experienced by our patients up to week 16.

Predictors for Pulmonary Tuberculosis Outcome and Adverse Events in an Italian Referral Hospital: A Nine-Year Retrospective Study (2013-2021).

Background:The COVID-19 pandemic has undone years of progress in providing essential TB services and controlling the TB burden. Italy, a low TB burden country, has an incidence of 7.1 cases per 100,000 people. To control the TB spreading in Italy is critical to investigate the characteristics of patients with the worst outcomes and the highest risk of adverse events related to antituberculosis therapy. Therefore, we conducted a large retrospective study in TB patients admitted to the Clinic of Infectious Diseases University of Bari, Italy, in order to describe the clinical presentation and the factors associated with adverse events and outcomes.Methods:We retrospectively evaluated the patients admitted to the Clinic of Infectious Diseases from January 2013 to 15 December 2021. We stratified our cohort into two groups: <65 years of age and ≥65 years in order to assess any differences between the two groups. Two logistic regression models were implemented considering the dependent variables as: (I) the adverse events; and (II) the unsuccessful treatments.Results:In total, 206 consecutive patients [60% (n = 124) M, median age 39 years, range 16–92] were diagnosed and admitted with TB at Clinic of Infectious Diseases. Of the whole sample, 151 (74%) were <65 years and 55 (26%) were ≥65. Statistically significant differences between the two groups were detected (p-value < 0.05) for nationality (p-value = 0.01), previous contact with TB patient (p-value = 0.00), type of TB (p-value = 0.00), unsuccessful treatment (p-value = 0.00), length of hospitalization (p-value = 0.02) and diagnostic delay (p-value = 0.01). Adverse events related to TB drug regimen were reported in 24% (n = 49). Age < 65 years (O.R. = 3.91; 95% CI 1.72–4.21), non-Italian nationality (O.R. = 4.45; 95% CI 2.22–4.98.), homeless (O.R. = 3.23; 95% CI 2.58–4.54), presence of respiratory symptoms (O.R. = 1.23; 95% CI 1.10–1.90), diagnostic delay (O.R = 2.55; 95% CI 1.98–3.77) resulted associated with unsuccessful treatment outcome (death, failure or lost to follow up). Finally, age < 65 years (O.R. = 1.73; 95% CI 1.31–2.49), presence of pulmonary TB (O.R. = 1.15; 95% CI 1.02–1.35), length of hospitalization (O.R. = 1.82; 95% CI 1.35–2.57) and TB culture positive (O.R. = 1.35; 95% CI 1.12–1.82) were associated with adverse events in our populations.Conclusions:The pharmacological approach alone seems insufficient to treat and cure a disease whose ethiopathogenesis is not only due to the Mycobacterium tuberculosis, but also to the poverty or the social fragility. Our data suggest that young foreigners, the homeless, and the people with low social and economic status are at higher risk of an unfavorable outcome in low incidence TB countries. Targeted actions to support this highly vulnerable population both in terms of outcome and occurrence of adverse events are needed.

Vitamin D 25OH deficiency in COVID-19 patients admitted to a tertiary referral hospital

Background & aimsGreat interest has been raised by the possible protective role of vitamin D in coronavirus disease 2019 (COVID-19), but objective data on 25(OH)vitamin D deficiency in hospitalized COVID-19 patients are not conclusive.The aim of this study was to determine the prevalence of 25(OH)vitamin D deficiency in COVID-19 patients admitted to an Italian referral hospital and explore its association with clinical outcomes and the markers of disease severity.MethodsIn this single-center cohort study, 129 consecutive adult COVID-19 patients hospitalized in an Italian referral center were enrolled from March to April 2020. 25(OH)Vitamin D serum levels were assessed 48 h since hospital admission and categorized into: normal (≥30 ng/mL), insufficient (<30 - ≥20 ng/mL), moderately deficient (<20 - ≥10 ng/mL), severely deficient (<10 ng/mL).ResultsThe prevalence of 25(OH)vitamin D insufficiency, moderate deficiency and severe deficiency was 13.2%, 22.5% and 54.3%, respectively.25(OH)Vitamin D deficiency (<20 ng/mL) was not associated with COVID-19 clinical features and outcomes. Unexpectedly, after adjusting for major confounders, a significant positive association between increasing 25(OH)vitamin D levels and in-hospital mortality (on a continuous logarithmic scale, odds ratio = 1.73 [95% CI, 1.11 to 2.69]; P = .016) was observed.ConclusionsVery low 25(OH)vitamin D levels were highly prevalent and suggestive of deficiency among our hospitalized severe COVID-19 patients, but low 25(OH)vitamin D levels were not associated with outcome variables. Whether 25(OH)vitamin D adequacy may influence clinical outcomes in COVID-19 and the unexpected correlation between higher 25(OH)vitamin D levels and mortality require further investigations by large intervention trials.

Active Pulmonary Tuberculosis in Elderly Patients: A 2016-2019 Retrospective Analysis from an Italian Referral Hospital.

Tuberculosis (TB) in the elderly (>65 years old) has increasingly become a global health problem. It has long been recognized that older people are vulnerable to developing tuberculosis. We retrospectively evaluated data from patients older than 65 years diagnosed with pulmonary TB admitted to the National Institute for Infectious Diseases L. Spallanzani, Rome, Italy, from 1 January 2016 to 31 December 2019. One hundred and six consecutive patients were diagnosed with pulmonary TB and 68% reported at least one comorbidity and 44% at least one of the TB risk-factors. Out of the 26 elderly patients who reported an adverse event, having risk factors for TB (O.R. (Odds Ratios) = 1.45; 95% CI 1.12–3.65) and the presence of cavities on Chest X-rays (O.R. = 1.42; 95% CI 1.08–2.73) resulted in being more likely to be associated with adverse events in elderly patients. Having weight loss (O.R. = 1.31; 95% CI 1.08–1.55) and dyspnea (O.R. = 1.23; 95% CI 1.13–1.41) resulted in being significant predictors of unsuccessful treatment outcome in elderly patients. Older people with TB represent a vulnerable group, with high mortality rate, with a challenging diagnosis. Hospitalizations in tertiary referral hospital with clinical expertise in TB management can be useful to improve the outcome of these fragile patients.

Minimally Invasive Techniques for Hirschsprung Disease

Background: Surgical treatment of Hirschsprung disease (HD) evolved in the last decades with the introduction of new innovative minimally invasive techniques. The aim of present study is to compare the results from two centers, applying similar minimal access approaches, total transanal endorectal pull-through (TEPT) and laparoscopic-assisted transanal pull-through (LA-TAPT). Materials and Methods: Data of all patients admitted between January 2011 and December 2016 in two Italian referral Hospitals for HD were retrospectively collected and analyzed. Exclusion criteria were as follows: redo procedure, patients with total colonic aganglionosis (ileostomy), patients lost at follow-up, or missing data. Patients who underwent TEPT and LA-TAPT were compared for gestational age, birth weight, age and weight at surgery, associated malformation, genetic syndrome, length of hospital stay, and early postoperative complications (within 30 days). Statistical analysis: Fisher's test and Mann-Whitney test; statistical significance set at P < .05. Results: None of the patients who underwent TEPT required laparotomy or laparoscopic assistance. Patients who underwent TEPT had lower age (P = .001), lower body weight (P < .0001), a significant higher rate of associated congenital heart disease (P = .006), and longer postoperative stay. In addition, the prevalence of perianal dermatitis was higher in TEPT patients (17/61 [28%] versus 2/46 [4%], P = .001). The two groups were similar in terms of postoperative enterocolitis, redo surgery, anastomotic stenosis, and other infective complications. Conclusion: Both minimally invasive techniques allow surgical advantages and outcomes; TEPT avoids pneumoperitoneum and the transperitoneal approach, with no need for laparoscopic instrumentation. TEPT group had longer postoperative stay, probably due to the higher prevalence of associated cardiac anomalies, and higher prevalence of perianal dermatitis, probably due to the lower age at operation.

Persistent left ventricular dysfunction after acute lymphocytic myocarditis: Frequency and predictors.

BackgroundPersistent left ventricular (LV) systolic dysfunction in patients with acute lymphocytic myocarditis (LM) is widely unexplored.ObjectivesTo assess the frequency and predictors of persistent LV dysfunction in patients with LM and reduced LVEF at admission.Methods and resultsWe retrospectively evaluated 89 consecutive patients with histologically-proven acute myocarditis enrolled at three Italian referral hospitals. A subgroup of 48 patients with LM, baseline systolic impairment and an available echocardiographic assessment at 12 months (6–18) from discharge constituted the study population. The primary study end-point was persistent LV dysfunction, defined as LVEF <50% at 1-year, and was observed in 27/48 patients (56.3%). Higher LV end-diastolic diameter at admission (odds ratio [OR] 1.22, 95% confidence interval [CI] 1.04–1.43, p = 0.002), non-fulminant presentation (OR 8.46, 95% CI 1.28–55.75, p = 0.013) and presence of a poor lymphocytic infiltrate (OR 12.40, 95% CI 1.23–124.97, p = 0.010) emerged as independent predictors of persistent LV dysfunction at multivariate analysis (area under the curve 0.91, 95% CI 0.82–0.99). Pre-discharge LVEF was lower in patients with persistent LV dysfunction compared to the others (32%±8 vs. 53%±8, p <0.001), and this single variable showed the best accuracy in predicting the study end-point (area under the curve 0.95, 95% CI 0.89–1.00).ConclusionsMore than half of patients presenting with acute LM and LVEF <50% who survive the acute phase show persistent LV dysfunction after 1-year from hospital discharge. Features of subacute inflammatory process and of established myocardial damage at initial hospitalization emerged as predictors of this end-point.

Aseptic central nervous system infections in adults: what predictor for unknown etiological diagnosis?

Despite the availability of nucleic acid amplification tests (NAATs), most of aseptic acute meningitides, encephalitides, and meningoencephalitides (AAMEMs) in adults remain of unknown etiology so far. To shed light on such topic, we aimed to evaluate potential predictors for AAMEMs of unknown origin. We collected retrospectively data from all consecutive cases of AAMEMs in adults discharged from an Italian referral hospital, from January 2004 to December 2016. Laboratory analysis included common immunometric methods and NAATs. Potential predictors for unknown etiology (age, seasonality, serum C-reactive protein value, antibiotic use before lumbar puncture, immunodeficiency conditions, clinical symptoms and signs) were evaluated by a logistic regression analysis model. A p value ≤ 0.05 was considered to indicate statistical significance. The study included 92 patients (median age 39years; 54.3% males) affected by meningitis (n = 57), encephalitis (n = 25), and meningoencephalitis (n = 10). The identified agents that cause AAMEMs were herpesviruses (20.7%), enteroviruses (5.4%), tick-borne encephalitis virus (3.3%), influenza virus A (2.2%), West Nile virus (1.1%), and parvovirus B19 (1.1%), while 66.3% of cases were of unknown etiology. No predictor was found to be significantly associated with AAMEMs of unknown etiology. We suggest that potential infectious agents causing undiagnosed cases should be investigated among non-bacterial, non-opportunistic, and non-seasonal organisms.

Spread of Vancomycin-ResistantEnterococcus faeciumIsolates Despite Validated Infection Control Measures in an Italian Hospital: Antibiotic Resistance and Genotypic Characterization of the Endemic Strain

An alarming increase of vancomycin-resistant Enterococcus faecium (VREfm) isolates was detected in an Italian referral hospital subjected to policies of infection control validated by the Joint Commission International. Analysis of the population structure of 122 consecutive, nonreplicate VREfm isolates collected over an 18-month period identified a single major clone that spread around the whole hospital, rapidly establishing an endemic state. It belonged to sequence type (ST) 17 and showed a highly multidrug-resistant phenotype, being resistant to all antimicrobial classes for the carriage of several resistance determinants. Furthermore, some strains with decreased susceptibility to daptomycin were detected. Eighteen out of the 122 isolates did not group in the major clone. They showed a low spreading potential inside the hospital wards, even if most of them displayed a multidrug-resistant phenotype and belonged to a hospital-adapted lineage. Causes that led to the VREfm endemic state have not been fully elucidated. However, it is conceivable that the increase in systemic antibiotic consumption and the use of selective digestive tract decontamination, including vancomycin in critically ill patients during the period before 2014, may have played a role in the ST17 clone dissemination, but additional traits conferring high fitness in hospital environment cannot be excluded.

The Surgical Checklist

Surgical safety checklists (SSCs) are associated with reductions in postoperativemorbidity andmortality and have now achievedwidespread implementation, although thequalityof implementation remainsunclear inmanysettings.1,2 In this issue of JAMA Surgery, Bock and colleagues3 evaluate the effect of introducing an SSC in a single Italian referral hospital on30-and90-dayall-causemortality,30-dayreadmissionrate, and hospital length of stay. Bock et al3 demonstrate a statistically significant decrease inoverall surgicalmortality at90daysafter surgeryand a reduction in hospital length of stay after implementation of anSSC.Mostpreviouspublications thatexaminedsurgicalmortality focusedonthemoretraditional andwidely accepted 30-daypostoperativemortality and readmission rates. Historically, the 30-day outcomes were chosen because of difficulties with long-term follow-up and issueswith attributing death in the 30to 90-daypostoperative period to the primary surgical procedure.3 We commend the authors for choosing to focus on the 90-day postoperative all-cause mortality rate, and we are reassured that they saw a statistically significant decrease. However, we should also considerwhyno statistically significant change in the 30-day postoperative all-cause mortality rates was observed. This finding could be attributable to inherent differences in the population studied, to the case mix, or to insufficient power to detect change related to sample size. This article also highlights the ongoing challenges of checklist implementation and measurement of the impact of the SSC. First, whether SSC performance underwent direct observation during implementation and whether that observation compared with reported performance are unclear. Checklist performance appears to be measured primarily by checking whether a form was completed. Significant discordance between paper checklist completion and actual completion has been described.4 Second, 80% completion was considered the threshold for complete implementation in this study, whereas recent literature supports that full rather than partial checklist completion provides an opportunity for significant improvement of the effect of the SSC on the quality of patient care and surgical safety.5 With more effective implementation and full SSC use in every case, the improvement in outcomes seen could have been even. If the SSC is not used, it cannot help. Although some investigators question the actual impact of checklists, despite the proliferation of evidence regarding improved patient outcomes and quality of care across countries, these arguments fail to acknowledge fully the difficulty of effectively implementingSSCs ina complexhealth system.6 A focus on the systems of care and promotion of a culture of safety at the institutional level is necessary tooptimize checklist implementation and realize its full potential. Effective implementation is critical tomeaningfuluseofSSCs,whichcan lead to maximally improved outcomes.

Surgical Treatment of Ventricular Septal Defect Complicating Acute Myocardial Infarction. Experience of a North Italian Referral Hospital

The purpose of our study was to evaluate the clinical outcome of postinfarction ventricular septal defect (VSD) of patients referred to our institution for surgical treatment, by assessing the role of several operative, pre- and post-operative variables on mortality. The medical records of 58 consecutive patients (mean age 73±7 years), operated on after 14±12 days from the acute myocardial infarction were retrospectively reviewed and the data were analyzed. Associated procedures were left ventricular reconstruction in 13 patients and aortocoronary bypass grafting in 47 (81%). The overall operative, in-hospital mortality rate was 52% (75% in patients operated on within the first week and 16% if time from infarct to surgery was &gt;3 weeks). Time from AMI to surgery and time from hospital admission to operation were significantly shorter in nonsurvivors ( p=0.003 and 0.012, respectively). Other pre-operative variables significantly associated with mortality were: cardiogenic shock, pulmonary pressure, VSD diameter. In conclusion, time from AMI to operation appears to be a very important prognostic factor. However, size of VSD and hemodynamic conditions significantly influence the mortality. Moreover, concomitant procedures of revascularization can be safely performed, when required, as actually occurs in most cases.

Surgical treatment of ventricular septal defect complicating acute myocardial infarction. Experience of a north Italian referral hospital

The purpose of our study was to evaluate the clinical outcome of postinfarction ventricular septal defect (VSD) of patients referred to our institution for surgical treatment, by assessing the role of several operative, pre- and post-operative variables on mortality. The medical records of 58 consecutive patients (mean age 73±7 years), operated on after 14±12 days from the acute myocardial infarction were retrospectively reviewed and the data were analyzed. Associated procedures were left ventricular reconstruction in 13 patients and aortocoronary bypass grafting in 47 (81%). The overall operative, in-hospital mortality rate was 52% (75% in patients operated on within the first week and 16% if time from infarct to surgery was >3 weeks). Time from AMI to surgery and time from hospital admission to operation were significantly shorter in non-survivors ( p=0.003 and 0.012, respectively). Other pre-operative variables significantly associated with mortality were: cardiogenic shock, pulmonary pressure, VSD diameter. In conclusion, time from AMI to operation appears to be a very important prognostic factor. However, size of VSD and hemodynamic conditions significantly influence the mortality. Moreover, concomitant procedures of revascularization can be safely performed, when required, as actually occurs in most cases.