Abstract: Single lung transplantation for cystic fibrosis is an uncommon therapy. Contralateral pneumonectomy is, in these cases, rarely done before transplantation. Herein, we report the case of a single lung transplantation in a patient who had previously a contralateral pneumonectomy.
Abstract: OBJECTIVE: To evaluate the risks and benefits of a systematic reimplantation valve sparing procedure in the surgical treatment of type A aortic dissection (TAAD). PATIENTS AND METHODS: From February December 2005, 15 consecutive patients (mean age 61+/-12 years) who underwent surgery for TAAD were analyzed prospectively. Eleven had a preoperative CT-scan and all had an echography. Eight patients presented with a preoperative aortic insufficiency>2/4 and seven had an ascending aortic aneurysm over 50mm. In 11 cases, arterial cannulation was performed directly into the ascending aorta. Surgical technique included complete resection and replacement of the ascending aorta using a reimplantation valve sparing technique (David), associated in 12 patients with an arch replacement, under mild (29.7+/-3.0 degrees C) hypothermia and cerebral selective antegrade perfusion. RESULTS: Aortic clamping, cerebral perfusion and cardiopulmonary bypass (CPB) times were respectively 93+/-29, 18+/-9, and 131+/-38min. Mean bleeding at 24h was 1165+/-846ml. Troponin I level at 24h was 21+/-30 microg/l. One patient had a right coronary artery bypass for a chronically occluded coronary. Another had a triple arterial revascularisation for pre-existing coronary dissection. One patient presented with a postoperative regressive right hemiparesia (normal CT-scan). Two patients underwent revision for bleeding (one was undergoing treatment by clopidogrel). One patient had at day 7 an implantation of a covered stentgraft on the descending aorta for a concomitant penetrating aortic ulcer. One patient died suddenly on POD 7 during a tracheal aspiration. Intubation and ICU times were respectively 9.5+/-16.3 and 16.2+/-20.9 days. Four patients with severe preoperative co morbidities had long intubations. Echographic and CT-scan control, done in postoperative and after a mean follow up of 11.0+/-4.8 months, did not show any residual aortic insufficiency (actuarial survival rate at 2 years of 93.3%). CONCLUSION: A reimplantation valve sparing procedure in the TAAD seems to be reliable and should be proposed systematically without emphasizing perioperative morbidity.
Abstract: A prospective 'analysis of operative risk and results in video-assisted mitral valve surgery performed in a non selected population is reported. Seventy two consecutive patients (1997-2004) with mean age 60 +/- 12 years underwent a video-assisted mitral valve procedure using a femoral CPB. A transthoracic direct aortic clamping was done in 28 patients (TT) and an endo-aortic occlusion balloon was used in 44 patients (Endo). The surgical approach was a right lateral minithoracotomy in all cases; 16 patients had a previous cardiac surgery. The expected mitral operation (39 repairs, 33 replacements) was done in all cases, without conversion. There were 4 early deaths (1 st month), all in Endo group: 1 aortic dissection, 1 heart failure and 2 sudden deaths. Postoperative complication occurred in 17 patients with 5 reoperations for hemostasis of the thoracic wall. Cumulative rate of mortality and morbidity was 29% in Endo and 28% in TT (ns). Hospital stay was 8 +/- 2 days. At discharge, 4 patients had a residual grade 2 echocardiographic mitral regurgitation after valve repair. In January 2005, with a 1.8 years follow-up, there were 4 late deaths, 3 patients underwent a valve reoperation, 2 patients were still in NYHA class 3 and 5 patients had a residual grade 1 or 2 mitral regurgitation. The 3-year actuarial survival was 86 +/- 10% and the 3-year probability to be free of reoperation was 95 +/- 6%. In mitral valve surgery, video-assisted approach is reliable, the operative risk is controlled and midterm results are not compromised. Video-assisted mitral valve surgery is a new less invasive standard; it is the procedure of choice in valve replacement, in reoperation and in non complex valve repair with good cosmetic results.
Abstract: BACKGROUND: Aortic valve decalcification by ultrasound was given up. We evaluated a new ultrasound microhandpiece (Dissectron Penstyle) to rehabilitate this alternative treatment. METHODS: We used under magnifying lenses the ultrasound microhandpiece to decalcify 30 explanted aortic valves. In the cases with embedded calcifications the thin top of the probe could be introduced into the thickness of the leaflet preserving covering layers. RESULTS: The leaflets were totally decalcified and flexible, and surrounding structures were preserved as assessed by histological examination. CONCLUSION: This new approach of ultrasonic aortic valve decalcification gives good in vitro results which allow to consider a clinical evaluation of this procedure.
Abstract: OBJECTIVES: To assess histological traumatic effects of aortic clamps used in video-assisted surgery, an experimental study was undertaken in a pig model, comparing the Portaclamp, Endoclamp, and a metallic clamp. MATERIAL AND METHODS: In 3 groups of 5 pigs each, the descending aorta was exposed through a posterolateral left thoracotomy. External clamps (Portaclamp and metallic clamp) were positioned at the middle of the aorta. Endoclamps were inserted at the top of the descending aorta through a small purse and inflated lower. After 60 minutes of clamping, the clamp was removed and the animal reperfused for 60 minutes. It was then sacrificed and the descending aorta was harvested for blind histological study using hemotoxylin-eosin staining of 4 samples per animal: A, before the clamping spot; B, at the clamping spot; C, after the clamping spot; D, a remote sample as control. RESULTS: In the Portaclamp and metallic clamp groups, there were no lesions of the intima in all aortic samples. In the Endoclamp group, severe lesions of the intima were observed on the clamping spot: endothelium crushing with flattening of cell nucleus (3/5) or endothelium stripping with vanishing of cell nucleus all gathered in 1 point (2/5). Only spongy lesions (clearance between fibers) located on the external third of the media and moderate inflammatory lesions of the adventice were observed with a random distribution in aortic samples without difference between groups. CONCLUSIONS: This study reveals the impressive lesions of the aortic intima due to the Endoclamp. The nonspecific lesions observed in media or adventice may be related to the surgical trauma of the procedure.
Abstract: We report the case of a 40-year-old woman who presented with an ulcer of the descending aorta 9 months after ascending aortic surgery for intramural aortic hematoma, which was treated surgically with a supra-coronary aortic replacement. Treatment of the second aortic lesion and the choice between endovascular or surgical approaches are discussed.
Abstract: BACKGROUND: A simplified alternative to the Cox maze procedure to treat atrial fibrillation with epicardial high-intensity focused ultrasound was evaluated clinically, and the initial clinical results were assessed at the 6-month follow-up visit. METHODS: From September 2002 through February 2004, 103 patients were prospectively enrolled in a multicenter study. Atrial fibrillation duration ranged from 6 to 240 months (mean, 44 months) and was permanent in 76 (74%) patients, paroxysmal in 22 (21%) patients, and persistent in 5 (5%) patients. All patients had concomitant operations, and ablation was performed epicardially on the beating heart before the concomitant procedure. The device automatically created a circumferential left atrial ablation around the pulmonary veins in an average of 10 minutes, and an additional mitral line was created epicardially in 35 (34%) patients with a handheld device by using the same technology. RESULTS: No complications or deaths were device or procedure related. There were 4 (3.8%) early deaths and 2 late extracardiac deaths. The 6-month follow-up was complete in all survivors. At the 6-month visit, freedom from atrial fibrillation was 85% in the entire study group (80% in patients with permanent atrial fibrillation, 88% in the 35 patients who had the additional mitral line, and 100% in patients with paroxysmal atrial fibrillation). A pacemaker was implanted in 8 patients. Only the duration and type of atrial fibrillation significantly increased the risk of recurrence. CONCLUSION: Epicardial, off-pump, beating-heart ablation with acoustic energy is safe and cures 80% of patients with permanent atrial fibrillation associated with long-standing structural heart disease.
Abstract: Aortic valvular surgery is often challenging in patients with coronary artery bypass (CABG) using in situ right internal thoracic artery (RITA) crossing in front of the aorta to the left anterior descending artery (LAD). Full sternotomy and aortic dissection result sometimes in graft injury and subsequent myocardial ischemia. The benefit of an inferior T hemisternotomy through the second intercostal space is discussed. The grafts are neither dissected nor clamped, and the access to the aortic root is excellent. Graft lesions are avoided. The absence of graft clamping does not seem to impair the myocardial function.
Abstract: A 55-year-old male with a history of positive HIV serology and Polycytemia vera underwent coronary artery bypass graft surgery with normothermic extracorporeal circulation. Following heparin administration the activated clotting time (ACT) was 633 seconds (Hemocron) with kaolin). Lower than expected arterial and venous oxygen partial pressures together with high pressure (350 mmHg) in the arterial line upstream of the oxygenator were observed. Because of these signs the oxygenator was changed during the procedure. The outcome was uneventful. Electronic microscopic examination of the oxygenator membrane and thermic exchanger revealed fibrin and platelet deposits.
Abstract: BACKGROUND: We report a clinical study to demonstrate the feasibility and safety of a new aortic crossclamping concept for use in port-access cardiac surgery. The limited access to the aorta in minimally invasive cardiac surgery mandates specific clamping modalities, which entail specific limitations, drawbacks, and costs. Therefore a new autoguided, extravascular, and atraumatic clamping system (PortaClamp) was developed to facilitate port-access surgery while potentially avoiding the complications and costs inherent to endoluminal clamping or "blind" crossclamping. METHODS: Twenty patients underwent various cardiac operations under cardiopulmonary bypass and aortic crossclamping with the PortaClamp between February and September 2003. The method of aortic clamping is described and the operative course and clinical outcome of the patients are reported as surrogates of feasibility and safety. RESULTS: The average time to position the clamp was 196 +/- 75 seconds. Crossclamping through a 10-mm port or incision was achieved successfully, enabling cardiac arrest throughout the procedure in every patient. No patient presented with cardiovascular accident or transient ischemic attack, aortic dissection, or hematoma. Intensive care unit times were 12 +/- 3 hours; length of stay was 7.2 +/- 1.1 days. CONCLUSION: From this early experience we conclude that the PortaClamp system is safe and can effectively be used to crossclamp the aorta inexpensively to facilitate port-access cardiac surgery. Further comparative studies with the existing systems are warranted to confirm that the atraumatic design provides further benefit.
Abstract: Ministernotomy (MS) is a well-known procedure developed in the past ten years along with the rise of minimally invasive cardiac surgery. Upper, mid, or inferior partial sternotomies allow coronary surgery, as well as aortic and mitral valve approaches. Contrary to anterior thoracotomy, access to the great vessels is sometimes easy, which renders central cannulation possible. In opposition to total sternotomy (TS), MS could procure better postoperative stability that would aide in reduction of wound infections. Nevertheless, upper MS can be responsible for the lesion of the internal thoracic arteries (ITAs). Moreover, little evidence exists regarding blood sparing in MS approaches. MS presents the problem of hiding a part of the cardiac structures. For example, in the case of aortic surgery by way of upper sternotomy for example, left venting is risky or even impossible. However, partial inferior sternotomy can be interesting for aortic valve surgery in patients with in situ right ITA passing in front of the aorta, protecting the grafts during dissection. In coronary surgery, inferior T sternotomy and C sternotomy allow perfect access to the coronary network. Some authors also have described inferior "T" sternotomy for various congenital lesions. If mini-invasive cardiac surgery can offer reduced postoperative morbidity and faster rehabilitation, the advantages of MS upon TS--except for cosmetic aspects--remain to be defined. Thus, this approach should be reserved for selected patients and lesions.
Abstract: Coronary artery bypass surgery with beating heart (off-pump) has become more common in the last ten years allowing seven randomized studies with at least 60 patients, comparing off-pump and on-pump coronary bypass. Anaesthesia, monitoring and haemodynamic complications are described. Randomized studies concluded to less elevation of biochemical markers of myocardial and renal injury, less hydric inflation, less cerebral microemboli, reduction of homologous blood transfusions, of hospital stay and global costs. However in low risk patients no reduction in myocardial infarction, atrial fibrillation, stroke, acute renal failure, early reoperation, surgical site infection and mortality were observed. Non-randomized studies suggest a benefit in stroke and mortality in elderly patients but the possibility of incomplete revascularization remains.
Abstract: The introduction of robotic assistance has enabled totally endoscopic closed chest procedures, most often by left internal thoracic artery to left (LITA) anterior descending. Endoscopic stabilizers have made off-pump surgery feasible. We report the first case of a totally endoscopic off-pump bilateral ITA grafting in a 58-year-old patient.
Abstract: OBJECTIVE: To determine factors predictive of mortality in patients undergoing emergency mitral valve surgery in the setting of severe post-infarction regurgitation. METHODS: Patients admitted for an acute myocardial infarction who required urgent mitral valve surgery for severe regurgitation were studied. Factors predictive of outcome were analysed. RESULTS: Fifty-five consecutive patients (mean 65+/-10 years, 37 males) were included. The infarct was inferior in 31 patients, posterior in 10, anterior in 9 and lateral in 5. Thirty-four patients (62%) were in Killip class IV. Peroperative findings confirmed total papillary muscle rupture in 25 patients (posteromedial in 21, anterolateral in 4), and partial rupture in 12 patients (posteromedial in 10, anterolateral in 2). Papillary muscle dysfunction without rupture was responsible for regurgitation in 18 patients (posteromedial in 15, anterolateral in 3). The mitral valve was replaced by a prosthesis in all but 4 patients, who had valvuloplasty. Coronary angiography was done in 32 patients, of whom 18 underwent concomitant coronary artery bypass grafting and 2 balloon angioplasty. Surgery was performed on average 7 days after infarction. Thirteen patients (24%) died during the perioperative period. Absence of coronary revascularisation was significantly associated with increased perioperative mortality (34% vs. 9%, P = 0.02). Of the 42 surviving patients, there were 5 deaths during a mean follow-up of 4.0+/-3.7 years. CONCLUSION: In patients with acute post-infarction mitral regurgitation, perioperative mortality is high, but can be improved with concomitant CABG in addition to valve surgery. Long-term outcome of survivors is favourable.
Abstract: A prospective study of myocardial blood perfusion after coronary artery bypass graft (CABG) was conducted in two groups of patients. In group 1, a two-year assessment by exercise thallium myocardial scintigraphy without medical treatment was performed in 122 patients who consecutively underwent CABG with exclusive use of both internal mammary arteries (IMA) and gastroepiploic artery (GEA). In group 2, myocardial function and perfusion were determined by radionuclide investigations performed before and one year after CABG in 100 patients with preoperative LV dysfunction (defined as LV ejection fraction (LVEF) less than 0.40), comparing results of myocardial revascularization performed with either exclusive arterial grafts (arterial group, 54 patients) or one arterial graft (IMA) associated with a sequential vein graft (vein group, 46 patients). In group 1, 21% of patients presented silent residual electric ischemia during exercise stress testing and 26% had reversible scintigraphic ischemic defect despite complete revascularization, 18% of those in the inferior wall bypassed with GEA and 8% in the anterior wall bypassed with the right IMA. In group 2, the significant preoperative ischemia significantly decreased in both the vein group and the arterial group. LV function was significantly improved in the vein group; in contrast there was no modification of LV function in the arterial group. A multivariate analysis showed that the surgical technique used and the preoperative LVEF were independent prognostic factors of the postoperative myocardial outcome, with a positive impact of the vein use on the postoperative myocardial function recovery. It is important to recognize that arterial grafts have some limitations in the ability to supply blood flow for coronary circulation that may induce postoperatively silent residual myocardial ischemia and a lack of LV function recovery.
Abstract: AIM: To compare in a prospective randomized study chest tube (CT) and redon drains (RD) for effectiveness, cost, pain and complications after heart surgery using cardiopulmonary bypass. METHODS: Forty patients undergoing heart surgery were analyzed prospectively. Twenty patients had small RD with strong (-700 mmHg) vacuum and 20 others standard CT. All patients had patient controlled analgesia in the postoperative period and pain was noted. Residual pericardial effusion (RPE) was controlled and quantified at postoperative day 7 with transthoracic echocardiography. Drainage complications were noted and compared in both groups. RESULTS: Surgical statistics were comparable in both groups. Two patients underwent reoperation in CT for clotting, and 1 in RD for active surgical bleeding. One patient had orifice infection in CT. Drainage volumes and times were comparable in both groups at removal (992+/-507 ml in RD, 1154+/-571 ml in CT, p=ns). Morphine consumption and pain estimation were comparable in both groups in the postoperative period and at drainage removal. Echographic control showed important RPE for 3 patients in both groups. System cost was higher in CT compared to RD (up to 7 times). CONCLUSION: RD are comparable to CT in terms of drainage, pain and complications. Nevertheless, they offer better handling and removal conditions and limited cost.
Abstract: A patient with asymptomatic left main coronary artery stenosis 10 years after heart transplantation was treated successfully with off-pump coronary bypass surgery using both mammary arteries. New advances in bypass surgery may decrease the risk of revascularization in cardiac transplant recipients.
Abstract: Ministernotomy (MS) is an alternative for total sternotomy (TS) in aortic valve replacement. We compared these two approaches for results and adverse effects in a prospective study. From January to December 2000, 100 patients who underwent aortic valve replacement were included in two groups of 50 according to the surgical approach that used MS or TS; one senior surgeon performed all cases in each group. Valvular pathologies were either stenosis or insufficiency. Mean age was 63 +/- 14 years in MS, 67 +/- 12 in TS (p = ns). NYHA class was 2.7 +/- 0.5 in MS, 2.8 +/- 0.6 in TS (p = ns). Left ventricular ejection fraction was 58 +/- 12% in MS, 57 +/- 12% in TS (p = ns). There was a significant difference between MS and TS in aortic cross-clamping (66 +/- 14 min vs 48 +/- 9 min) and cardiopulmonary bypass (88 +/- 18 min vs 69 +/- 10 min, p < 0.01), but not in intervention times (2.8 +/- 0.4 hours vs 2.7 +/- 0.4 hours). Mean intensive care stay was reduced in MS (1.7 +/- 1.6 days vs 2.6 +/- 6 days, p < 0.05). Intubation times (12 +/- 7 hours vs 14 +/- 9 hours), 24 hours bleeding (394 +/- 219 mL vs 465 +/- 318), reintervention for hemostasis (4% vs 2%), rhythmic complications (14% vs 14%), and mortality at 1 month (2% vs 2%) were comparable in MS and TS. In aortic valve surgery, ministernotomy is technically more demanding and needs more time. It is as safe and as effective as conventional sternotomy but its eventual benefits, excepting upon cosmesis, are still to be defined.
Abstract: OBJECTIVE: To evaluate the important points in carotid endarterectomy. METHODS: Carotid endarterectomy was performed upon 43 cases of carotid artery stenosis under cervical plexus anaesthesia. The operation was performed with shunting between the common carotid artery and the internal carotid artery in 2 cases. RESULTS: The average clamping time of carotid artery was 27 min +/- 7 min. There were one case suffering from transient ischemic attack (TIA), 7 cases suffering from hypertension and 2 cases suffering from light edema of the wound. All of the patients recovered uneventfully. Twenty-six patients who had suffered from TIA before operation felt much better after operation. The follow-up of one month to one year showed a better condition among all patients. CONCLUSION: Cervial plexus anaesthesia helps diagnose stroke during operation. Shunting between the common carotid artery and internal carotid artery helps avoid ischemic brain injury. The effect of operation depends upon complete removal of the residual tunica intima, complete exsufflation, and control of hypertension postoperationally.
Abstract: OBJECTIVE: The aim of this study was to evaluate the preservation of the lung using the cold flushing technique in association with continuous perfusion of the organ during static hypothermic storage. METHODS: In the first phase, the hearts and lungs of 5 New Zealand rabbits were removed three hours after establishing brain death. The left lungs were each conserved in 200 ml of low-potassium UW solution at 10 degrees C for 3 hours of cold ischemia (control group I). The right lungs were also placed in cold storage but were perfused continuously for three hours with low-potassium UW solution at 10 degrees C (group II). In the second phase, ten rabbits underwent a right lung auto-transplant.Lungs were conserved using two techniques. Histoenzymatic and pathological tests were performed: lung function was evaluated. RESULTS: In the first phase the histopathological examination carried out at the end of storage revealed fewer ischemic alterations in the second group compared to the first. In the second phase a significant hypoxia was observed in group I when both lungs and the right lung only were perfused. The histopathological examination revealed ischaemia/reperfusion lesions in both groups though mainly in group I and a good level of ATPase activity in group II though these results were not significant. CONCLUSIONS: Cold flushing of the pulmonary artery and continuous perfusion during static hypothermic storage appears to guarantee a better partial arterial pressure of oxygen in this model of auto-transplant compared to the classical cold storage method.
Abstract: Diaspirin cross-linked haemoglobin (DCLHb) is a haemoglobin-based oxygen carrier which had been proposed as a resuscitative solution to replace red cell transfusion in many clinical situations. The present study was designed to evaluate the effect of different volumes of DCLHb 10% (1, 5 and 10 mL kg-1) on the cardiovascular system during cardiopulmonary bypass (CPB), and to determine the effect of DCLHb (18 mL kg-1) when added directly to the CPB prime in anaesthetized swine. DCLHb, when used as a priming solution, induced a significant increase (around 20%) in mean arterial pressure (MAP), which persisted during the entire period of CPB (P < 0.05) as compared with controls. Administration of increasing doses of DCLHb during the time course of CPB resulted in a progressive increase in MAP (P < 0.05), suggesting a linear dose-response relationship. Nicardipine, a calcium channel blocker, returned MAP to baseline. Finally, weaning of CPB was easier in animals that received DCLHb, thereby suggesting a potential protective effect of free haemoglobin in this particular clinical situation.
Abstract: OBJECTIVE: The aim of the study was to assess the quality of lung preservation offered by Euro-Collins solution (EC), Cold Modified Blood solution (CMB) and low potassium University of Wisconsin solution (UWLP). METHOD: Fifteen right lung auto-transplantations (five for each solution) in the pig (Large White) were performed after 2 h of cold ischaemic storage in physiological solution at 4 degrees C. Right lung biopsies were performed before ischaemia and 30 min after reperfusion, for histoenzymatic, histopathological and electron microscope studies. RESULTS: After reperfusion, significant alterations were observed in the haemodynamics with only the right lung perfused; pulmonary arteriolar resistance increased by a factor of 5 in the EC group, by a factor of 4 in the CMB group and by a factor of 1.2 in the UWLP group; the right ventricular ejection fraction fell by 60% in the EC group, by 50% in the CMB group and by 31% in the UWLP group. Haemodynamic impairment was lower in the UWLP group (P<0.05; P<0.001) as was ischaemic-reperfusion injury (P<0.05). Oedema was observed in the EC group and extensive alveolar wall damage in the CMB group. Hypoxaemia was observed in all groups but the differences in the degree of hypoxaemia were not significant. CONCLUSIONS: The authors concluded that UWLP solution was the most effective of the three in this transplant model.
Abstract: Nicorandil is a K(ATP) channel opener used to treat angina. It is cardioprotective and a vasodilator. We conducted a prospective, randomized, double-blind, placebo-controlled study to assess oral nicorandil in patients undergoing coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB). Twenty-two patients received nicorandil (10 mg twice a day) and 23 patients received placebo. Haemodynamic data were recorded before induction of anaesthesia (T0), 5 and 20 min after starting mechanical ventilation (T1, T2), before aortic cannulation (T3), after 30 min of CPB (T4), 10 min after CPB (T5) and after 3, 8 and 18 h in the intensive care unit (T6, T7, T8). Serum proteins (creatine kinase metabolite and cardiac troponin I) were measured before and 8 and 18 h after surgery. Haemodynamic values did not differ between the two groups. There was no tachycardia during the study, no significant difference in hypotensive episodes, ST segment changes and no changes in cardiac enzymes. Myocardial infarction after surgery was similar in the two groups. Vasoactive therapy was similar in the two groups. Nicorandil can be continued safely up to premedication without deleterious haemodynamic consequences, but a myocardial protective effect of nicorandil in CABG surgery was not found.
Abstract: BACKGROUND: The physiopathology of hemodynamic instability that occurs after brain death remains unknown. The aim of this study was to examine the initial response to brain death induction. METHODS: After anesthesia and monitoring, 16 pigs were randomized into a control group (C, n = 8) and a brain death group (BD, n = 8). We inflated a subdural catheter balloon to induce brain death. We analyzed hemodynamic and plasmatic biochemical data for 180 minutes after brain death induction. Energetic compounds were measured. We expressed the results in comparison with the C group. RESULTS: The C group remained stable. One minute after brain death, the Cushing reflex appeared, with a hyperdynamic response to plasma catecholamines levels increasing (norepinephrine and epinephrine, 3.1-fold, p = 0. 02, and 3.8-fold, p = 0.07, respectively). After a return to baseline, we recorded a second hyperdynamic profile 120 minutes later. At this time, a second peak of catecholamines appeared (6. 3-fold, p = 0.04, and 9.1-fold, p = 0.02, concerning norepinephrine and epinephrine). At the same time, we observed brief myocardial lactate production (+175%, p < 0.01), with a rise of troponine I (+64%, p = 0.03). The energetic index was similar in both groups: 0. 85 (+/-0.02) in the C group vs 0.87 (+/-0.02) in the BD group. CONCLUSIONS: In this model, biphasic plasmatic catecholamine release appears to primarily explain the physiopathology of the hemodynamic response to brain death induction.
Abstract: OBJECTIVE: To assess the blood flow supply offered to the myocardium by surgical revascularization using bilateral internal mammary (IMAs) and gastroepiploic (GEA) arteries. METHODS: Two-year assessment by exercise thallium myocardial scintigraphy without medical treatment was performed in 122 patients (mean age 61 +/- 9 years) who underwent coronary artery bypass grafting (CABG) with exclusive use of IMAs and GEA. Usually, the right IMA was used to bypass the left anterior descending coronary artery, and the left IMA to bypass the diagonal and the marginal arteries as a sequential graft if required. The GEA was used to bypass the right coronary artery (RCA) in 50 patients and its posterior branches in 72 patients. RESULTS: During maximal or submaximal exercise stress testing, 119 patients (98%) were asymptomatic and 26 patients (21%) exhibited moderate ischemic ECG modifications which were correlated (P < 0.01) with incomplete revascularization and with the use of GEA to bypass the RCA. A third of patients had moderate ischemic thallium defects on exercise reversible after redistribution (anterior, 10; lateral, 2; inferior, 28). Silent residual myocardial ischemia detected by thallium scintigraphy was correlated (P < 0.001) with ECG modifications and incomplete revascularization; and inferior thallium defects were more frequent when GEA bypassed the RCA (P < 0.05). However, 26% of patients had residual ischemia despite a complete revascularization, and in at least 18% of cases for GEA and 8% for right IMA, arterial graft blood flow was insufficient at maximum exercise level and caused silent residual myocardial ischemia detected by thallium scintigraphy. CONCLUSIONS: Myocardial revascularization using bilateral IMAs and GEA offers a satisfactory myocardial perfusion in the majority of cases; however silent residual myocardial ischemia was detected in a third of patients and was related to incomplete revascularization and to insufficient blood flow supply probably due to small diameter of the arterial grafts.
Abstract: AIMS: To develop a predictive clinical risk score of post-operative morbidity after coronary artery bypass grafting. METHODS AND RESULTS: Data were collected retrospectively from 679 patients undergoing emergency or planned bypass surgery between 1 January and 31 December 1996. The incidence of morbidity was 23%. Multivariate stepwise logistic regression analysis on two-thirds of the patients identified eight independent risk factors for severe morbidity. Six of these were pre-operative: symptomatic right heart failure, previous ventricular arrhythmias, previous coronary bypass surgery, chronic pulmonary disease, ST changes on pre-operative electrocardiogram, body mass index <24 kg. m-2, and two were intra-operative factors: the surgeon who operated, and the cardiopulmonary bypass time. A predictive clinical risk score was developed with the six pre-operative risk factors. The negative predictive value of the model is 87% and the area under the receiver operating characteristic curve is 0.77. When tested on the remaining patients not used for developing the model, the area under the curve is 0.65. CONCLUSION: This pre-operative risk score provides a simple method of risk stratification for patients undergoing coronary artery surgery. However, as for all predictive models, the performance of the score decreases when applied to a population other than that used to develop it.
Abstract: OBJECTIVE: To review current data on minimally invasive cardiac surgery. DATA SOURCES: Search through the Medline data base of French or English articles. DATA EXTRACTION: The articles were analysed to make a synthesis of the various techniques with their main indications and contra-indications. DATA SYNTHESIS: Minimally invasive cardiac surgery includes various surgical procedures. The usual techniques are described, their major benefits and drawbacks are discussed. The main goals of anaesthetic management are preservation of ventricular function and systemic perfusion, detection and treatment of myocardial ischaemia, prevention of hypothermia in case of coronary artery bypass grafting on the beating heart via sternotomy, intermittent selective ventilation of the collapsed lung using CPAP in case of limited thoracotomy. Expertise in transoesophageal echocardiography is essential for insertion and checking the accurate positioning of the various catheters of the endovascular CPB Heartport system (pulmonary vent, endosinus catheter, venous cannula, endoaortic clamp) allowing coronary artery bypass grafting and mitral valve surgery through limited thoracotomy and finally, detection of retained intracardiac air and assessment of complete clearing of cardiac cavities after mitral valve surgery through limited thoracotomy and aortic valve surgery via ministernotomy. Short-acting anaesthetic agents allow rapid recovery from anaesthesia, early extubation and discharge to the surgical ward within 24 h, whereas overall time spent in the operating room is often longer than with conventional cardiac surgery.
Abstract: BACKGROUND: The functional improvements resulting from coronary revascularization (CABG) in patients with depressed ventricular function may be described by the use of a model combining global or local quantification of myocardial perfusion, viability, and contraction. An illustration of this model, with data provided by conventional radionuclide studies as they are performed routinely in many centers, is presented and the limitations of this approach for predicting the results of CABG are discussed. METHODS AND RESULTS: The model is based on three independent variables, which can be approximated in this preliminary study by parameters derived from standard stress and redistribution/reinjection thallium-201 single-photon emission computed tomography (SPECT) acquisitions with quantification of the tracer uptake defects and from a planar gated blood pool left ventricular ejection fraction (LVEF) measurement: Perfusion is assumed to correspond to 100-stress defect (in percentage), viability is 100-redistribution/reinjection defect, and contraction is 100(LVEF/70), assuming that a normal 70% LVEF corresponds to 100% contraction. In a group of 30 patients prospectively evaluated with this protocol and included in the study on the basis of a pre-CABG LVEF <40%, a significant improvement in LVEF was demonstrated (28.2% +/- 8.5% before CABG vs 35.8% +/- 7.3% after CABG), which is accompanied by a significant decrease of the stress thallium defects (34.8% +/- 13.8% vs 25.6% +/- 10.6%), whereas the average (but not the individual) redistribution/reinjection defects remain almost stable (27.7% +/- 10.9% vs 25.7% +/- 10.1%). As reported in the three-dimensional model, pre-CABG and post-CABG representative points clearly demonstrate the functional improvements for the main variables, but there is a large spectrum of responses to revascularization. It appears that the border between reversible and nonreversible thallium defects does not match the limit between ischemic myocardium (with no contraction alteration and therefore without contraction improvement potential) and hibernating myocardium, which is able to recover mechanical function and therefore is responsible for the improvement of global LVEF. CONCLUSIONS: Thallium SPECT is far from ideal for use as an independent characterization of perfusion and viability because hibernating myocardium may be present in both the fixed and reversible parts of thallium defects. Prediction of functional recovery is conditioned by an accurate identification of viable but underperfused and noncontracting myocardium. In the future, with the use of adequate study protocols that are able to measure viability without interference of perfusion and perfusion independent of viability, the proposed model may be able to characterize regional function as a cluster of representative points for each territory and to delineate areas of the theoretical volume corresponding to a potentially recoverable situation.
Abstract: Between January 1984 and December 1994, 130 patients underwent mitral valvuloplasty for pure dystrophic mitral regurgitation. There were 94 men and 36 women with a mean age of 61 +/- 9 years: 52 patients were in atrial fibrillation; 91% of patients were in NYHA Classes III or IV. At preoperative echocardiography, the regurgitation was assessed as Grade III or IV and classified using the Carpentier classification according to type I (dilatation of the annulus) or II (mitral valve prolapse); 95% of patients had isolated prolapse of the posterior leaflet, 3% had isolated prolapse of the anterior leaflet and 2% had prolapse of the two leaflets. After valvuloplasty, a prosthetic ring was implanted in 124 patients (95%). The early mortality was 3%; 5.3% of patients had early complications. All patients underwent control transthoracic echocardiography in the first postoperative week. They were reviewed with a second transthoracic echocardiography after a mean follow-up of 5 +/- 0.3 years and a cumulative follow-up of 657 years-patients. At the immediate postoperative echocardiography, 24 minimal residual regurgitations were observed; at long-term, 20 new mitral regurgitations developed, all mild without any clinical symptoms and 98% of patients were in the NYHA Classes I or II. At 10 years, the actuarial survival was 73 +/- 16%; absence of thromboembolic complications 95 +/- 3%, absence of reoperation 95 +/- 5%. This study confirms the efficacy of mitral valvuloplasty and the postoperative stability of repaired valvular lesions. These results suggest that the operative indications should be considered at an earlier stage.
Abstract: OBJECTIVE: To assess the prognostic factors of myocardial recovery expected after coronary bypass surgery and the impact of surgical technique used, a prospective non-randomized study including a 1-year postoperative evaluation of left ventricular function was performed in patients with left ventricular dysfunction (left ventricular ejection fraction (LVEF) < 0.40). METHODS: From 1993 to 1996, 110 patients (mean age 61+/-11 years) were included in the study. The mean LVEF was 31+/-6%. All patients had preoperative radionuclide investigations based on the combination of stress/reinjection thallium single photon emission computed tomography (SPECT) and planar evaluation of LVEF; 88% of patients had reversible ischemic thallium defects. Two surgical technique were used: 53 patients received the left internal mammary artery with associated sequential vein graft, and 57 patients received only arterial grafts, internal mammary and gastroepiploic arteries. The mean number of distal anastomoses was 3.2+/-0.8 and 54% of patients had complete revascularization. At 1 year, all survivors had clinical evaluation and the same radionuclide investigations. RESULTS: The early mortality was 2.7%. At 1 year, 100 patients were surviving; on average, NYHA class decreased 1.9+/-0.8 to 1.4+/-0.6 (P < 0.01) and CCS class from 2.8+/-0.6 to 1+/-0.3 (P < 0.01). The mean LVEF increase from 31+/-9 to 34+/-10% (P < 0.01) and the mean LV end-diastolic volume decreased from 317+/-112 to 285+/-108 ml (n.s.). The postoperative improvement in LV function was higher in patients in NYHA class 3 or 4 before surgery (P < 0.05), when associated sequential vein graft had been used (P < 0.01), and in patients with low preoperative LVEF (P < 0.01). The postoperative LVEF improvement observed was significantly correlated with the improvement in left ventricular end-diastolic (LVED) volume and the improvement in redistribution/reinjection thallium uptake. Multivariate analysis showed that the surgical technique used and the preoperative LVEF were independent prognostic factors of the postoperative myocardial function recovery, with a significant positive impact of the vein use. CONCLUSION: This study confirms the excellent clinical results of coronary artery bypass grafting (CABG) in patients with coronary artery disease and LV dysfunction; improvement in LV function can be documented objectively and is correlated with reperfusion of hibernating myocardium. However, the extended use of arterial grafts does not allow to achieve the significant myocardial recovery observed with the use of one internal mammary artery (IMA) and associated sequential vein graft; it seems to be related to the preoperative selection of patients, but a direct negative impact of arterial grafts was documented and leads to be cautious in patients with severe LV dysfunction.
Abstract: Authors report on one patient with cholesterol embolization following cardiac catheterization and coronary by-pass surgery. During the immediate post-operative period, neurological and renal complications occurred because of recurrent cholesterol embolization. One month after surgery the patient died from a sudden neurological coma. Cholesterol crystal embolization appears to be a contra-indication to heart surgery, even in a strongly symptomatic patient, when the spontaneous course of the existing cardiac disease is not life-threatening in the short term.
Abstract: BACKGROUND: The aim of this study was to elucidate whether beneficial effects of cardiomyoplasty (CMP) in patients with dilated cardiomyopathy are the result of a decrease in existing ventricular dilatation or a prevention of further dilatation. METHODS AND RESULTS: Combined micromanometer-conductance catheters were used to evaluate left ventricular pressure-volume relationships in six patients with dilated cardiomyopathy before and at 6 and 12 months after CMP. Acute changes in preload and afterload were induced by a standardized leg-tilting intervention and a bolus infusion of nitroglycerin. After CMP, end-diastolic volume (EDV) decreased from 138+/-10 to 103+/-18 mL/m2 (P<.01) at 6 months and to 83+/-17 mL/m2 (P<.01) at 12 months. End-diastolic pressure (EDP) decreased from 20.2+/-6.4 to 13.9+/-7.7 mm Hg (P<.01) at 6 months after CMP. Peak ejection rate and ejection fraction increased at 6 months after CMP from 594+/-214 to 799+/-214 mL/s (P<.05) and from 26.6+/-4.7% to 40.1+/-8.3% (P<.05), respectively. Peak dP/dt decreased at 12 months after CMP from -842+/-142 to -712+/-168 mm Hg/s (P<.05). Leg-tilting before CMP increased EDP from 20.2+/-6.4 to 25.6+/-5.2 mm Hg (P<.01), end-systolic pressure (ESP) from 118+/-17 to 122+/-17 mm Hg (P<.05), and tau from 50.8+/-2.8 to 53.8+/-2.3 ms (P<.05). Six months after CMP, leg-tilting also increased EDV from 103+/-18 to 110+/-22 mL/m2 (P<.05) and ESV from 62+/-14 to 66+/-14 mL/m2 (P<.05). Before CMP, nitroglycerin decreased EDP from 20.2+/-6.4 to 10.4+/-3.8 mm Hg (P<.01), ESP from 118+/-17 to 96+/-11 mm Hg (P<.05), ESV from 100+/-11 to 89+/-7 mL/m2 (P<.05), and tau from 50.8+/-2.8 to 44.5+/-3.7 ms (P<.05). Six months after CMP, nitroglycerin decreased EDP, ESP, and tau to similar values. CONCLUSIONS: Our findings show that up to 1 year after CMP, marked decreases in left ventricular volume are present. Our measurements suggest that CMP actively reduced the dilated ventricle but did not prevent a higher EDV on an increased venous return. The latissimus dorsi muscle wrap contraction results in better synchronization of contraction and more rapid emptying of the left ventricle.
Abstract: BACKGROUND AND AIMS OF THE STUDY: Air embolism during open heart surgery seems to be a common occurrence and may be responsible for neuropsychological deficit or myocardial damage. MATERIAL AND METHODS: Forty-two consecutive patients undergoing valvular surgery were studied using the long axis view of the heart by two dimensional transesophageal echocardiography (TEE). The patients were randomized into two groups of 21 each. In group 1, the routine air evacuation method was used. In group 2, the same air evacuation method was used and controlled with a Doppler ultrasonic probe adjusted around the root of the aorta. At the end of air evacuation, intracardiac microbubbles and retained air were analyzed with TEE and when air was founded, its location was communicated to the surgeons who tried to remove it by shaking the heart and tilting the operating table for 15 minutes. The patients were assessed for detection of cardiac or neurological postoperative complications. RESULTS: The incidences of microbubbles and retained air were 57% and 43% in group 1, and 62% and 38% in group 2 respectively (ns). The mean grade of microbubbles was lower in group 2: 1.4 +/- 0.8 vs. 2.2 +/- 0.9, p < 0.05. TEE allowed to significantly decrease (p < 0.05) retained air and mean grade of microbubbles to 14% and 1.3 +/- 0.8 in group 1, and to 10% and 0.8 +/- 0.8 in group 2, without statistical difference between the two groups. Despite the help of TEE, manual attempts to eradicate retained air were unsuccessful in five patients (three in group 1, two in group 2). CONCLUSIONS: The use of aortic ultrasonic probe allowed to reduce the amount of microbubbles. TEE was a useful tool not only for the detection of retained air but also for locating it, and guiding the procedure to eliminate it.
Abstract: Lambl's excrescences are filliform aortic or mitral valve tumours. They do not usually cause any clinical problems and are autopsy findings. The authors report a case of a 64 year old female with an invalidating angina in whom echo and angiographic investigations suggested obstruction of the right coronary ostium by a valvular tumour. This was confirmed at surgery and tumorectomy was followed by regression of the anginal syndrome.
Abstract: From January 1990 to February 1994, 400 patients (mean age 59 +/- 9 years) underwent myocardial revascularization using the right gastroepiploic artery (GEA) to bypass the right coronary artery trunk or branches. They represented 40% of all patients undergoing isolated coronary surgery during the same period, from 19% in 1990 to 54% in 1994. Left ventricular function was normal in 32% of patients, moderately impaired in 62% and severely impaired in 6%. The GEA was used alone in six patients, associated with one internal mammary artery (IMA) in 111 patients (two arterial grafts, 2.2 +/- 0.4 anastomoses) and with both IMAs in 283 patients (three arterial grafts, 3.4 +/- 0.6 anastomoses); no vein graft was used. The rate of complete myocardial revascularization was 79%. Early mortality was 1.7% and influenced by left ventricular ejection fraction (P < 0.05). Complications occurred in 37 patients: myocardial infarction 4%, intra-aortic balloon pump 0.5%, reoperation for bleeding 0.5%, mediastinitis 0.25%. Early (15th postoperative day) angiographic control of the GEA graft was performed in 104 patients operated from January 1990 to December 1991 and the patency rate was 92%; anomalies of GEA were three occlusions, five stenoses, three competitive flow, no string or slender sign. Early functional results (3 +/- 1 months postoperatively) were studied in 192 patients during exercise test with medical treatment: 99% were symptom-free and 14% had electrocardiographic (ECG) ischemic modification significantly correlated with incomplete revascularization (P < 0.01). The 2- and 4-year actuarial survival rate was 96.7 +/- 1.9%. The rate of late cardiac events was 2% patient/year; Angioplasty for GEA graft failure was required in four patients. A 2-year postoperative functional assessment without medical treatment was performed during exercise test in 66 patients who had received three arterial grafts: 98% were symptom-free and 26% had ECG ischemic modification significantly correlated with incomplete revascularization (P < 0.01); during the same procedure, thallium myocardial scintigraphy was obtained in 50 patients: 18 patients (36%) had asymptomatic ischemic defects on exercise significantly correlated with incomplete revascularization and ECG ischemic changes (P < 0.01). However, posterior thallium defects demonstrated limited GEA flow at the maximum level of exercise in at least 8% of patients. Myocardial revascularization using the GEA can be achieved with minimal operative risk and offers satisfactory functional results and midterm survival rate.
Abstract: The metabolic effects of combined antegrade/retrograde and antegrade cardioplegia on myocardial protection were evaluated and compared in 30 patients who underwent myocardial revascularization. All patients had three-vessel coronary artery disease, and the revascularization was done with exclusive use of arterial grafts (internal mammary artery, gastroepiploic artery). Myocardial protection consisted of oxygenated crystalloid cardioplegia, topical slushed ice, and moderate systemic hypothermia (34 degrees C). The patients were randomly separated into two groups: group A (n = 15), who received antegrade cardioplegia, and group A/R (n = 15), who received combined antegrade/retrograde cardioplegia. There was no significant difference between the two groups concerning preoperative and intraoperative data. After the first dose of cardioplegia, right ventricular temperature was significantly lower in group A/R (15 +/- 2 degrees versus 19 +/- 5 degrees C; p < 0.05), and there was no significant difference between the two groups in left ventricular temperature. Coronary sinus blood samples were obtained before bypass and 5, 10, and 15 minutes after reperfusion; there was no difference between the two groups concerning lactates, superoxide dismutase, and glutathione peroxidase. After reperfusion, malondialdehyde levels increased significantly in group A and there was no change in group A/R, with a significant difference between the two groups (at 10 minutes after reperfusion, 0.80 +/- 0.20 versus 0.53 +/- 0.16 mumol/L; p < 0.05). Right and left ventricular myocardial biopsies were performed before bypass and 15 minutes after reperfusion; there was no significant difference between the two groups concerning adenosine triphosphate and creatine phosphate myocardial concentrations.(ABSTRACT TRUNCATED AT 250 WORDS)
Abstract: From January 1990 to June 1994, 240 patients (mean age, 60 +/- 10 years) underwent myocardial revascularization with the exclusive use of in situ bilateral internal mammary and right gastroepiploic arteries. Left ventricular function was normal in 34% of patients, moderately impaired in 58.5%, and severely impaired in 7.5%. The mean number of distal anastomoses was 3.5 +/- 0.7 and the rate of complete myocardial revascularization was 80%. Early mortality was 0.4%, and complications occurred in 20 patients: myocardial infarction, 1.6%; intraaortic balloon pump, 0.8%; reoperation for bleeding, 0.8%; and mediastinitis, 0.4%. Early (15th postoperative day) angiographic control of grafts was performed in 51 patients; the rate of functional and patent anastomoses was 100% for internal mammary arteries and 96% for gastroepiploic arteries. Early functional results (3 +/- 1 postoperative months) were studied in 141 patients during exercise test with medical treatment: 99% were symptom-free and 14% had ischemic modification of electrocardiograms. A 2-year postoperative functional assessment without medical treatment was performed during exercise test in 66 patients: 98% were symptom-free and 26% had ischemic modification of electrocardiograms; during the same procedure, thallium myocardial scintigraphy was obtained in 50 patients and 18 patients had moderate ischemic defect on exercise. Ischemic modifications of electrocardiograms and defects seen on thallium scintigraphy were correlated significantly with incomplete revascularization (p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)
Abstract: BACKGROUND: Since the clinical introduction of dynamic cardiomyoplasty, a discrepancy has been observed between unchanged measurements of cardiac function and improved clinical outcome. METHODS AND RESULTS: We performed a beat-to-beat analysis of cardiac performance at rest in nine cardiomyoplasty patients 6 to 24 months after operation. Conductance and micromanometer catheters were placed in left ventricle and aorta and used for measurements over a 15-second period, during which the wrapped latissimus dorsi (LD) muscle was stimulated for 10 seconds in a 1:2 synchronization mode followed by a 5-second period without LD stimulation. The synchronization delay between start of the QRS complex and the LD contraction was changed from 4 up to 125 ms at the patient's clinical stimulation strength and at an increased supramaximal amplitude. Comparing the LD assisted period to the unassisted period, at the clinical settings no significant changes in stroke volume (SV) as measured by the conductance technique and the aortic Modelflow technique were observed. A significant (P < .05) rise in left ventricular end-diastolic pressure (LVEDP) was observed directly after the assisted 10-second period. The peak ejection rate (PER) of left ventricular volume increased (P < .05), with a mean of 28 +/- 23% during the LD stimulated beats. At the patient's individual best setting, SV of the stimulated beats increased (P < .01) by a mean of 20 +/- 15%. Systolic aortic pressure increased (P < .01) by a mean of 7 mm Hg, peak negative dP/dt increased (P < .01), and PER increased, with a mean of 68 +/- 24% (P < .01). LVEDP was similar in stimulated and unstimulated beats and increased (P < .05) in the nonpaced 5-second period. The delay for the best setting ranged from 25 to 125 ms; the stimulus strength was 1.5 to 3 V higher than the clinical setting. At the patient's individual worst setting, SV remained unchanged and PER was higher, with a mean of 30 +/- 25% (P < .05). The worst setting was observed at the 1.5- to 3-V-higher stimulus strength; in six patients, it was at a short delay (4 to 25 ms) and in three patients, at the longest delay (100 to 125 ms). CONCLUSIONS: By the left ventricular conductance catheter and aortic Modelflow methods, improvement in cardiac function by dynamic cardiomyoplasty was demonstrated in this patient group. The synchronization interval, stimulus strength, and stimulus duration appeared to be critical for obtaining optimal improvement.
Abstract: Between November 1989 and September 1990, a cardiomyoplasty procedure was performed in 12 male patients with a mean age of 59 years. All patients were in New York Heart Association class III. Reinforcement cardiomyoplasty was isolated in 4 patients and associated with a cardiac procedure in 8. There were no perioperative deaths. Failure of cardiomyoplasty occurred in 5 patients because of recurrence of disabling congestive heart failure: 3 patients died late, and 2 had heart transplantation. The actuarial survival rate was 83% at 1 year and 73% at 2 years. Hemodynamic studies were done preoperatively in all patients, at 6 months postoperatively in 11 patients, at 1 year in 8, and at 2 years in 7. At the 2-year follow-up, 6 of the 7 survivors who did not have transplantation were functionally improved with reduced medical treatment. The following indices improved significantly at the 2-year evaluation compared with baseline: exercise capacity (63 +/- 13 W versus 83 +/- 17 W); left ventricular (LV) end-diastolic pressure (20 +/- 7 mm Hg versus 11 +/- 5 mm Hg); and angiographic LV ejection fraction (0.25 +/- 0.09 versus 0.40 +/- 0.15). Pulmonary artery pressure, pulmonary capillary wedge pressure, and cardiac index remained unchanged. Four patients underwent beat-to-beat analysis of LV function at 2 years; during skeletal muscle stimulation, stroke volume increased by 7% to 35% and LV end-systolic pressure, by 5% to 9%. In the 5 patients with failed cardiomyoplasty, mean pulmonary artery pressure and LV end-diastolic volume were higher preoperatively than in the 7 survivors.(ABSTRACT TRUNCATED AT 250 WORDS)
Abstract: The authors report the case of a 25 year old man with unexplained pulmonary hypertension during his first hospital admission. However, a past medical history suggesting right arm vein thrombosis was obtained. Venography showed signs of thoraco-brachial compression. After heart-lung transplantation, pathological studies of the explanted organs showed changes of thrombo-embolic pulmonary hypertension. A spontaneous right arm venous thrombosis occurred during convalescence. The possibility of post-embolic pulmonary hypertension caused by venous thrombosis of the upper limbs is discussed.
Abstract: Sixty consecutive coronary patients operated on by the same team in 1992 were divided into two groups: group 1 (30 patients) using intermittent oxygenated cold Fresenius solution antegrade and retrograde (FR), group 2 (30 patients) using warm retrograde blood cardioplegia (WRC) with the Fremes solution initially antegrade and retrograde (high potassium solution) then continuous retrograde low potassium solution. All patients were submitted to only arterial grafts (3 to 4) using both internal mammary arteries and the the right gastroepiploic artery. There were no differences in mean preoperative data between the 2 groups. The times of aortic cross-clamping (P < 0.05) and bypass after release of the aortic clamp (P < 0.01) were significantly higher in the WRC group. No significant difference was observed in the number of postoperative supraventricular arrhythmias or electrocardiographic infarctions. A significant difference was observed with higher values of the enzymes (aspartate amino transferase, creatine kinase) for the WRC group on the first (P < 0.05) and the second postoperative days (P < 0.01). More patients in the WRC group received vasoactive or inotropic drugs in the intensive care unit, where they stayed a longer time because of hemodynamic instability or enzyme elevation (P < 0.05). In conclusion, for coronary arterial revascularization, WRC is technically more demanding and does not appear to afford optimal myocardial protection.
Abstract: The inclusion criteria of this study were a left ventricular ejection fraction of less than 40% with global left ventricular hypokinesis; left ventricular aneurysms and valvular lesions were excluded. From January 1970 to December 1990, 155 patients fulfilling these criteria had Class III or IV angina and 49 patients had Class II or III dyspnoea. The average left ventricular ejection fraction was 31 +/- 7%. Over this 20 year period two surgical techniques were used: Group I (79 patients operated between 1970 and 1981) myocardial revascularisation with intermittent aortic clamping by an internal mammary artery pedicle on the left anterior descending artery and simple venous bypass grafts; Group II (76 patients operated between 1982 and 1990) myocardial revascularisation under oxygenated cardioplegia by internal mammary artery pedicle on the left anterior descending artery associated with sequential venous bypass grafts. The average number of bypass grafts was 1.6 in Group I and 3.7 in Group II (p = 0.001). The early postoperative mortality (first month) was 5.2% it was lower in Group II (2.6%) than in Group I (7.6%) (p = 0.01). After 79 +/- 14 months follow-up, 6 patients were lost to follow-up, 51 patients had died secondarily and there were 90 survivors. Globally, 80% of deaths were of cardiac origin, 38% from cardiac failure. The actuarial 5, 10 and 15 year survival rates were 79 +/- 7%, 63 +/- 10% and 36 +/- 15% respectively. The 5 year survival in Group I was 71 +/- 10% compared with 88 +/- 8% in Group II (p = 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)
Abstract: Coronary patients with left ventricular ejection fraction (LVEF) < 40% and abnormal motion of all left ventricular walls on cineangiography but without significant valve disease or left ventricular aneurysm were selected for this study. From January 1970 to December 1990, 155 patients meeting the above criteria consecutively underwent coronary by-pass surgery; preoperatively, 149 patients had angina class III or IV, and 49 patients had dyspnea class II or III. LVEF was 31 +/- 7%. During this 20-year period, two different surgical techniques have been used: from 1970 to 1981, 79 patients (group I) received internal mammary artery upon left anterior descending artery with associated simple saphenous grafts, under intermittent aortic cross clamping; from 1982 to 1990, 76 patients (group II) received internal mammary artery upon left anterior descending artery with associated sequential saphenous vein graft, under oxygenated cardioplegic myocardial protection. The mean number of by-pass was 1.6 in group I and 3.7 in group II (p = 0.001). Early mortality rate was lower in group II than in group I: 2.6% vs 7.6% (p = 0.01). After a follow-up of 79 +/- 14 months, there were 51 late deaths, 6 patients were lost to follow-up and 90 patients were still alive; 80% of all deaths were from cardiac causes, including 38% due to heart failure. Actuarial survival rate at 5, 10, 15 years was 79 +/- 7%, 63 +/- 10%, and 36 +/- 15% respectively. The 5-year survival rate was 71 +/- 10% in group I and 88 +/- 8% in group II (p = 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)
Abstract: AIM: To test the value of surgical angioplasty of the coronary trunks as an alternative to bypass techniques. PATIENTS AND METHODS: Surgical angioplasty of the coronary trunks was performed in 12 patients (mean age 59 +/- 9 years), of whom nine underwent right coronary trunk angioplasty, five underwent left main coronary artery angioplasty, and two patients underwent bilateral coronary trunk angioplasty. A transpulmonary approach to the left main coronary artery was used. The patch consisted of saphenous vein in the first two patients but in the rest pericardium was preferred. Associated bypass procedures to the other coronary network using internal mammary or gastroepiploic arteries were performed in six patients, and one patient had a concomitant aortic valve replacement. RESULTS: No early mortality (30-day) or morbidity was observed and all procedures were successful. A 15-day angiographic study revealed an excellent result in all 14 angioplasties. After 6 months, all patients were free of symptoms during exercise stress testing (maximum level of exercise 140 +/- 20 W). One patient with a recurrence of angina underwent a second operation after 1 year because of left anterior descending coronary artery occlusion after bilateral angioplasty. Another angiographic study was obtained after 1 year in three other patients, which showed excellent results (four angioplasties controlled). After a mean follow-up period of 17 +/- 7 months (range 6-31), all patients were symptom-free, and with the exception of the one reoperation, no cardiac events were reported. CONCLUSIONS: Provided that contraindications (calcifications, involvement of the distal bifurcation) are respected, surgical angioplasty of the coronary trunks is safe, restores physiologic coronary perfusion, is economical with bypass material, and provides good results.
Abstract: The authors report the cases of two patients who underwent surgery of atrial fibrillation by Cox's technique. In one case, it was associated with mitral valvuloplasty for atrial fibrillation of 4 years' duration; sinus rhythm was restored on the 19th postoperative day; it persisted at 11 months without antiarrhythmic drugs. On the other case, it was associated with mitral valve replacement for atrial fibrillation of 7 years' duration in a patient with dilated cardiomyopathy and a poor left ventricle; sinus rhythm was restored by electrical cardioversion during the 4th postoperative month; it persisted at 9 months with antiarrhythmic therapy. Cox's technique allows: 1) definitive suppression of atrial fibrillation, 2) restoration of atrioventricular synchronisation, 3) preservation of atrial transport function. The indications are paroxysmal or permanent atrial fibrillation, invalidating and resistant to medical therapy; atrial fibrillation of over 3 years' duration associated with mitral regurgitation requiring valvular repair and atrial fibrillation of invalidating primary cardiomyopathy.
Abstract: From January 1979 to December 1990, 397 consecutive patients (mean age, 55 +/- 11 years) underwent mitral valve replacement with the St. Jude Medical valve. Associated procedures performed were 174 multiple valve replacements, 24 coronary artery bypass graftings, 25 tricuspid repairs, and 13 left ventricular myectomies. The continuous intravenous administration of heparin was started on the first postoperative day and maintained until effective oral anticoagulation, started on the seventh day, was achieved (INR, 3 to 4.5). Follow-up consisted of 2,402 patient-years (pt-y) (mean, 6.1 +/- 0.2 years) and was 97% complete. The early (30-day) mortality was 3.5%; the 5-year and 10-year actuarial survivals were 86% +/- 4% and 73% +/- 6%, respectively. Survival was less in patients who had been in an advanced preoperative functional class (p = 0.02) and in those who underwent multiple valve replacements (p = 0.05). The 5-year and 10-year survivals in patients who underwent isolated mitral valve replacement and who were in preoperative New York Heart Association functional class II and III, were 90% +/- 5% and 82% +/- 7%, respectively. The early and late mortality and the incidence of deaths resulting from heart failure and sudden deaths were higher in patients who had undergone multiple valve replacements (p = 0.05). In terms of all deaths, 47% (36/77) were valve related (including 12 sudden deaths, 0.50%/pt-y). Thromboembolic complications occurred in 44 patients, and these were broken down as follows: embolism, 1.46%/pt-y, and valve thrombosis, 0.37%/pt-y.(ABSTRACT TRUNCATED AT 250 WORDS)
Abstract: Between January 1991 and December 1993, surgical coronary angioplasty was performed in 12 patients with an average age of 59 years: right coronary artery (17), left main coronary artery (3) and bilateral angioplasty (2). Internal mammary or gastroepiploic artery bypass grafts were associated on another vessel in 5 patients and 1 patient also underwent aortic valve replacement. There was no early mortality (1 month), or perioperative myocardial infarction. At the 15th postoperative day, the angiographic result was satisfactory in all patients. At 6 months, exercise testing was negative in all cases (maximum load 140 +/- 20 watts). Reoperation for bypass surgery was necessary in 1 patient because of symptomatic occlusion of the left anterior descending left anterior descending artery, one year after angioplasty of the left main coronary extending to the proximal left anterior descending. With a mean postoperative follow-up of 19 +/- 7 months (6 to 31 months), all patients are asymptomatic: 5 of the 6 angioplasties controlled angiographically at 1 year were patent without any signs of progression (1 occlusion/reoperation). Surgical angioplasty of the main coronary vessels is a sure and reliable procedure: it restores physiological coronary perfusion, economises venous and arterial vessels and is no obstacle to percutaneous transluminal coronary angioplasty.
Abstract: Several surgical techniques have been proposed for obstructive hypertrophic cardiomyopathy (OHCM): myotomy, mitral valve replacement (MVR), or myotomy-myomectomy (MM). We reviewed our series of 47 patients who had undergone surgery in order to determine their prognosis and to know whether MVR+MM was better than MM only. Left intraventricular gradient decreased from 86 +/- 34 mmHg to 15 +/- 20 mmHg (P < 0.0001). Postoperatively, three patients died from low cardiac output (6.4%); five died later. Annual mortality (including postoperative deaths) was 3.0%. Follow-up was 5.7 +/- 0.7 years. Survival was 87 +/- 11% at 12 years. After operation, 91% had NYHA class I or II dyspnoea (before surgery this had been 28%); chest pain was CCS class I in 88% (vs 47%); 12% had had syncope since operation (vs 53%). The gradient decrease was larger in the MM+MVR group (P < 0.05). Survival and functional improvement were similar in the two groups. Mitral regurgitation decreased from 2.7 to 0 in the MM+MVR group (P < 0.0001), whereas it decreased from 1.5 to 1.2 in the MM group (ns). MM appears to be the procedure of choice. When mitral regurgitation is important or when an intrinsic disease of the mitral valve exists, the addition of MVR should be considered.
Abstract: Thirty-four patients underwent isolated aortic valve replacement with mean pulmonary artery pressures greater than 40 mmHg between 1972 and 1988. The aortic valve disease was stenotic in 10 cases, regurgitant in 14 cases and mixed in 10 cases. Thirty patients (88%) had invalidating cardiac failure (NYHA Classes III and IV). The mean preoperative ejection fraction was 44 +/- 15%. The hospital mortality was 17.6%. Ten patients died secondarily, five with terminal cardiac failure. The 5 year actuarial survival was 70 +/- 16%; the 10 year survival was 60 +/- 18% with an average follow-up of 115 +/- 61 months. None of the patients was lost to follow-up. Fifteen of the 18 survivors (83%) are asymptomatic or pauci-symptomatic after a follow-up of 126 +/- 62 months. Doppler echocardiography (n = 12) showed normal prosthetic valve function in 11 cases and aortic regurgitation in 1 case. Eight patients had tricuspid regurgitation with pulmonary artery systolic pressures less than 30 mmHg in 6 cases and between 30 and 40 mmHg in 2 cases. Severe pulmonary hypertension is therefore a poor early postoperative prognostic factor in aortic valve replacement surgery due to the associated left ventricular dysfunction. However, the long-term results are satisfactory: clinical improvement is usually related to a reduction of pulmonary hypertension.
Abstract: Stimulated skeletal muscle grafts have been proposed to improve left ventricle function in patients with severe myocardial failure. In 1 particular case reported here, however, the postoperative functional improvement was only transient and disabling heart failure recurred after 9 months in spite of a vigorous latissimus muscle contraction. Heart transplantation was proposed to this patient and performed successfully. Technically, the key to heart removal depends on the retrograde dissection of the ventricular cavities, starting from the right atrioventricular groove. The intraoperative observations confirmed the viability of the latissimus dorsi muscle, inefficient on a highly dilated cardiomyopathy. Histopathological examination of the latissimus dorsi muscles showed that the transformation process of the stimulated muscle was good. Thus, severe cardiac dilatation seems to be one of the limitations of cardiomyoplasty. Cardiomyoplasty, when it fails, does not preclude heart transplantation. The histochemical studies confirm the electrophysiologic principle of cardiomyoplasty in humans.
Abstract: Between 1974 and 1990, 58 patients underwent tricuspid valve replacement with porcine bioprostheses (Hancock 42, Carpentier-Edwards 16) during multiple valve replacement (double, 21; triple, 37). Perioperative mortality was 12%; 16 patients died later, mostly from cardiac causes. Actuarial survival (1 patient lost to follow-up) was 81% +/- 11% at 5 years, and 60 +/- 17% at 10 years. Reoperation because of Hancock prosthesis deterioration was performed in 2 patients at 11 and 15 years, respectively. At last follow-up (mean 108 +/- 48 months), 82% of survivors (28/34) were functionally improved. Doppler echocardiography was performed in 29 patients in February 1991. In 21 patients, after 88 +/- 40 months of follow-up, the bioprosthesis was normal, there was no leaflet malformation, no significant tricuspid regurgitation and the mean diastolic transprosthetic gradient (DTPG) was 3.8 +/- 1.7 mmHg. In 7 patients (follow-up: 129 +/- 40 months, P less than 0.05), there was moderate dysfunction (all Hancock prostheses) with leaflet sclerosis, tricuspid regurgitation grade 2, and mean DTPG 5.7 +/- 1.8 mmHg (P less than 0.05). Only 1 patient (Hancock prosthesis implanted in 1981) had severe tricuspid prosthesis stenosis with very thickened leaflets and mean DTPG 13 mmHg. Pulmonary artery hypertension (most often fixed) was present in 11 patients, associated with a poor functional result and a significantly higher DTPG. We conclude that porcine bioprostheses in tricuspid position have an acceptable long-term durability and satisfactory performance. Prosthetic dysfunction correlates with the length of follow-up of patients and with the presence of fixed pulmonary artery hypertension.
Abstract: Ninety patients undergoing cardiac surgery were randomly divided into three groups of 30 patients to compare the effects on bleeding and transfusion requirements of either intraoperative infusion of high-dose aprotinin (GpI) or reinfusion of autologous fresh whole blood (GpII) versus a control group (GpIII). Standardized anesthetic, perfusion, and surgical techniques were used. Platelet counts, hemoglobin concentration, hematocrit, fibrinogen, and Ivy-Nelson bleeding times determined at fixed times perioperatively did not differ among the three groups. The total loss from the chest drains was significantly reduced in GpI (328 +/- 28 mL; mean +/- SEM) as compared with the loss in GpII and GpIII (775 +/- 75 mL and 834 +/- 68 mL, respectively). There was a threefold difference in the total hemoglobin loss (GpI, 14.2 +/- 1.7 g; GpII, 50.1 +/- 5.0 g; GpIII, 45.0 +/- 5.2 g). GpI patients also received less banked blood: 250 +/- 53 mL versus 507 +/- 95 mL in GpII and 557 +/- 75 mL in GpIII. No GpI patient required transfusion of platelets or fresh frozen plasma. Fresh whole autologous blood transfusions had no significant hemostatic effect and failed to reduce the homologous blood requirement. Conversely, high-dose aprotinin reduced blood loss and transfusion requirements.
Abstract: Between 1974 and 1990, 58 patients underwent tricuspid valve replacement with a porcine bioprosthesis (Hancock 42, Carpentier-Edwards 16) in the course of polyvalvular replacement (double 21, triple 37). Early postoperative mortality was 12%: 16 patients died secondarily, usually of cardiac causes. The actuarial survival (1 patient lost to follow-up) was 81 +/- 11% at 5 years and 60 +/- 17% at 10 years. Two patients were reoperated for dysfunction of a Hancock bioprosthesis, 11 and 15 years after implantation. At long-term, with an average follow-up of 108 +/- 48 months, 82% of survivors (28/34) were clinically improved. Doppler echocardiography was performed in 29 patients in February 1991. In 21 cases, with a follow-up of 88 +/- 40 months, the bioprosthesis was normal with an average diastolic transprosthetic pressure gradient of 3.8 +/- 1.7 mmHg. In 7 patients followed up for 129 +/- 40 months (p < 0.05) moderate dysfunction of the Hancock prosthesis was observed with a mean diastolic pressure. Severe dysfunction of a Hancock prosthesis was observed in 1 case. Fixed pulmonary hypertension was noted in 11 cases and was associated with a poor clinical result and a raised mean diastolic transprosthetic pressure gradient. The durability and haemodynamic performance of tricuspid porcine bioprostheses are satisfactory in the long term. Prosthetic dysfunction is correlated to the duration of implantation of the bioprosthesis and to persistent pulmonary hypertension.
Abstract: Between 1970 and 1985, 596 patients underwent isolated aortic valve replacement with a Björk-Shiley prosthesis: 448 men and 148 women, average age 52 +/- 13 years (range 10-78 years). The valve lesion was aortic stenosis in 158 cases, aortic regurgitation in 218 cases and mixed valve disease in 220 cases. Fifty-four per cent of patients had invalidating cardiac failure (Stage III of the NYHA Classification). Thirteen per cent of patients had an associated non valvular surgical procedure. The hospital mortality was 5.7% and 77% of the early deaths were of cardiac origin. Results were analysed after an average follow-up period of 90 +/- 15 months, a total of 3817 patient-years. The late mortality was 94 (16.7%). Actuarial survival was 87 +/- 1% at 5 years and 79 +/- 2% at 10 years. A prognostic score was established from a multifactorial analysis: Cox = 0.44 (NYHA Stage 1, 2, 3, 4) + 5.29 C/T (absolute value) + 1.15 associated procedure (0.1) + 0.65 (RBBB) (0.1). In the long-term, 84.8% of survivors were asymptomatic (NYHA Stages I and II). The incidence of thrombo-embolism was 0.5/100 patient-years. At 10 years, 95% of patients had no thromboembolic complication. The incidence of ineffective endocarditis was 0.3/100 patient-years and that of complications of anticoagulant therapy was 0.4/100 patient-years. The incidence of valve dehiscence was 0.1/100 patient-years and the reoperation rate was 0.4/100 patient-years but there were no cases of valve dysfunction. The global complication rate in this series was 1.35/100 patient-years. These results confirm the good results of aortic valve replacement with a mechanical prosthesis.(ABSTRACT TRUNCATED AT 250 WORDS)
Abstract: We report a case illustrating the therapeutic consequences of an intravenous metastasis to the left superior pulmonary vein following resection of a voluminous primary lung carcinoma. Arterial spread of malignant cells occurred because the size of the tumor did not allow immediate clamping of the left superior pulmonary vein. The embolism was situated at the aortic bifurcation and lower limb ischemia persisted despite also emergency embolectomy. Distal (lower popliteal) embolectomy was also unsuccessful, and lower limb amputation was inevitable. This case illustrates the problems encountered in surgical treatment of pulmonary vein invasion by lung carcinoma and the role of adjuvant chemotherapy and radiotherapy.
Abstract: Between 1970 and 1984, 386 mitral valve replacements with the SE 6120 prosthesis were performed with a mean post-operative follow-up of 75 +/- 44 months or a total follow-up of 2520 patient years (PY). Rapid post-operative mortality was 6.7 percent and the delayed mortality 26.5 percent, the 5-year actuarial survival rate was 80 +/- 2% and that at 10 years 67 +/- 2% (including early mortality). There was no significant difference for survival between single-valve replacements (n = 183) and multiple-valve replacements (n = 203). Multifactorial prognosis analysis (Cox) gave two post-operative prognosis: X (n = 386) = 0.0391 (age) + 0.2421 (NYHA stage); Y (n = 147) = 0.8561 (X) + 0.6299 (VG type). The incidence of complications related to the prosthesis is 4.16 per 100 PY, including sudden deaths. The current actuarial analysis shows that at 5 years 91 +/- 1% at 10 years 78 +/- 2% of the operated subjects are devoid of any such complication and of thrombosis of the valve. Statistically, it was found that permanent atrial fibrillation (p = 0.03), the size of the right atrium (p = 0.02) played a promoting role. With a post-operative follow-up in excess of 8 years. 79% of the survivors are symptom-free or present few symptoms and the myocardial response is poor in 52 patients (NYHA stage III or IV).
Abstract: We report a case illustrating the therapeutic consequences of an intravenous metastasis to the left superior pulmonary vein following resection of a voluminous primary lung carcinoma. Arterial spread of malignant cells occurred because the size of the tumor did not allow immediate clamping of the left superior pulmonary vein. The embolism was situated at the aortic bifurcation and lower limb ischemia persisted despite also emergency embolectomy. Distal (lower popliteal) embolectomy was also unsuccessful, and lower limb amputation was inevitable. This case illustrates the problems encountered in surgical treatment of pulmonary vein invasion by lung carcinoma and the role of adjuvant chemotherapy and radiotherapy.
Abstract: We evaluated myocardial protection with Hamburg oxygenated crystalloid cardioplegic solution in a double study. Part I was a prospective metabolic study, measuring myocardial adenosine triphosphate (ATP) and creatine phosphate (CP) contents before and after ischemia in 30 coronary bypass (CABG) patients. During ischemia, CP levels decreased significantly, whereas ATP did not. After 10 minute of reperfusion, mean ATP contents were 90% of preischemic values and CP levels increased to 85% of preischemic values. Spontaneous myocardial defibrillation was seen in 93.3% of patients. Part II included evaluation of early postischemic myocardial function in 228 patients, 48 with multiple valve replacement (MUVR) and 180 with CABG. Spontaneous myocardial defibrillation was seen in 90.3%. Cardiac index, measured before and 1 and 12 hours after surgery, increased significantly in the postischemic period (from 1.95 +/- 0.9 to 2.5 +/- 0.7 l/min m2 in MUVR, p 0.04; from 2.2 +/- 0.6 to 2.7 +/- 0.7 l/min/m2 in CABG, p 0.01). Myocardial infarction frequency was 3% among CABG patients, and unrelated to the number of distal anastomosis or to aortic cross-clamp time. Early postoperative mortality was 6.2% for MUVR and 0.5% for CABG. Thus, oxygenated cardioplegia with Hamburg solution preserves high-energy phosphate compounds and prevents ischemic injury, with excellent short-term clinical results.
Abstract: Between 1972 and 1987, 43 patients underwent isolated mitral valve replacement with mean pulmonary arterial pressures greater than 50 mmHg. The valve disease was stenosis in 13 cases, regurgitation in 15 cases and mixed mitral valve disease in 15 cases. Forty-one patients (95 %) had invalidating cardiac failure (Stages III and IV of the NYHA Classification). The hospital mortality was 2.3%. Thirteen patients died during follow-up, 8 of cardiac failure, 3 of sudden death and 2 died of non-cardiac causes. The 8 year actuarial survival was 82 +/- 7% with an average postoperative follow-up of 96 +/- 41 months. No patients were lost to follow-up. Eighty six per cent of survivors (25/29) are asymptomatic or paucisymptomatic. Doppler studies were performed in 22 patients, showing normal prosthetic function in 18 cases and an obstructive prosthesis in 4 cases. Seventeen patients had tricuspid regurgitation showing normal pulmonary artery systolic pressures in 9 cases and less than 55 mmHg in 5 cases. On average, systolic pulmonary artery pressure fell from 88 +/- 11 mmHg before to 33 +/- 9 mmHg after surgery (p = 0.01). These results show that severe pulmonary hypertension is not prohibitive for mitral valve replacement. The long-term results are good with functional improvement and reduction of pulmonary hypertension.
Abstract: Eleven male patients, New York Heart Association (NYHA) Class III, have undergone cardiomyoplasty (Chachques and Carpentier technique). There were no deaths. Two patients suffered from low cardiac output, one patient suffered a massive aortic bifurcation embolism, and one patient had a Legionella pneumonia. All patients recovered well. The follow-up was 6.9 +/- 2.3 months. One patient had a Cardiomyostimulator Pulse Train Generator failure and had it replaced. The first seven patients were evaluated 6 months after surgery. They all improved (Class II) except for one, who was transplanted. The maximal level of exercise was improved (92 +/- 18 W vs 60 +/- 24 W), as was the heart rate-systolic blood pressure product (30,262 +/- 3,119 vs 19,908 +/- 4,190), mainly due to an increase in systolic blood pressure (200.0 +/- 25.5 vs 141.5 +/- 20.3 mmHg). Echographic parameters, maximal oxygen consumption, left ventricular ejection fraction (LVEF), cardiac index, oxygen arteriovenous difference, and cardiac filling pressures did not change. The left ventricular (LV) angiography always showed good contraction of the latissimus dorsi. A problem needing investigation is the principle of cardiomyoplasty (CMP) itself, as the muscle acts more as a lift than as pincers. Our patients, and patients from other series, improved functionally, and they exercised more. Improvement in survival can be studied only by a randomized clinical trial.
Abstract: Other valvular lesions associated with pure MS were studied in 202 consecutive patients whose mean age was 43.4 +/- 12.7 years; 76.7% were females. MS was isolated in 63.4%, associated with aortic regurgitation (AR) in 27.7%, aortic stenosis in 1.0%, tricuspid stenosis (+aortic valve lesion) in 1.0%. In isolated MS, 42.4% were NYHA class III or IV, compared with 49.0% in MS + aortic valve lesion. One hundred and sixty-nine (85.4%) patients were operated on; 23.1% had mitral valve replacement, 76.9% had closed (31.4%) or open (45.6%) mitral commissurotomy; 7.1% had associated aortic valve replacement. There were perioperative complications in 20.4%, and the perioperative death rate was 4.1%. Two patients were reoperated in the postoperative course, and 28 patients after this period. The follow-up was 13.3 +/- 4.5 years. The survival rate was 77.7 +/- 4.6% (SE) for isolated MS, and 71.1 +/- 6.3% for MS associated with an aortic valve lesion (NS). The prognosis of MS is very good: the survival rate at 20 years follow-up is 75%. The association of aortic stenosis or tricuspid stenosis does not appear to alter this survival, but numbers are small. Important aortic regurgitation is a significant predictor of higher mortality in patients with MS.
Abstract: Between january 1987 and january 1990, 115 patients aged over 70 (mean: 75 +/- 3 years) underwent heart surgery performed by our team. Fifty-three had coronary artery bypass graft surgery alone, 44 had cardiac valve surgery alone and 18 had combined coronary and cardiac valve surgery; 88 percent of the patients were in NYHA functional class III or IV, and 79 percent presented with left ventricular dysfunction. The early postoperative mortality rate was 7 percent: 5.6 percent in coronary bypass surgery alone, 8 percent in cardiac valve surgery alone and 22 percent in combined coronary and valve surgery. After a mean follow-up period of 22 +/- 8 months, 85 percent of the patients are asymptomatic or exhibit few symptoms. The actuarial survival rate at 3 years is 78 +/- 10 percent. Thus, in 1990 age is lo longer an obstacle to heart surgery. In most cases the operative risk is controlled by a surgical strategy where the physiopathology of the elderly is taken into account and the appropriate surgical techniques are applied.
Abstract: The aim of this study was to confront preoperative echocardiographic data with the anatomic operative findings in patients with mitral insufficiency (MI) undergoing Carpentier's mitral valvuloplasty in order to determine the mechanism(s) of the regurgitation, to classify MI by the echocardiographic changes and to thereby answer the question as to whether echocardiography can identify the patients likely to benefit from this operation. Between February 1985 and November 1987, 66 patients (47 men, 19 women, average age 58 +/- 9 years) with pure MI were referred for surgery with a view to mitral valvuloplasty. This operation was possible in 49 patients (2 of 6 rheumatic MI and 47 of 60 dystrophic MI). The sensitivity of echocardiography was excellent and its specificity very good in diagnosing prolapse of one or the other mitral leaflets. Echocardiography was not as good in distinguishing rupture from elongation of the chordae tendinae and myxoid degeneration from fibro-elastic leaflets. Echocardiography allowed preoperative classification of MI in 4 groups: Group 1 (n = 46) with prolapse of the posterior leaflet; Group 2 (n = 4) with prolapse of the anterior leaflet; Group 3 (n = 8) with prolapse of both mitral leaflets; Group 4 (n = 2) with abnormalities of the mitral annulus alone. Carpentier's valvuloplasty was possible in 43/46 patients in Group 1, 2/4 patients in Group 2, 1/8 patients in Group 3 and 1/2 patients in Group 4. In conclusion, echocardiography is a good tool for selecting patients with dystrophic MI for Carpentier's valvuloplasty.
Abstract: Between January 1986 and November 1987, 156 carotid endarterectomies for atheromatous stenosis of the carotid bifurcation were performed in 137 patients; 118 were unilateral and 19 were bilateral. The lesions were asymptomatic in 47 cases and symptomatic in 109 cases. Contralateral carotid stenosis was observed in 66 patients and cerebral infarction was noted on preoperative CT scans in 34 patients. A morphological study of operative atheromatous carotid specimens divided the lesions into non complicated plaques (n = 40) and complicated plaques (n = 116), the complications being intraplaque haemorrhage (n = 64), intraluminal thrombus (n = 29) and rupture of the intima (n = 72). Intima rupture was observed in 64 per cent of asymptomatic lesions and 76 per cent of lesions with cerebral infarction (P = 0.04). Intraplaque haemorrhage was observed in 50 per cent of symptomatic lesions (P = 0.0001), and 86 per cent of lesions with intraplaque haemorrhage were symptomatic. These results confirm the embolic, but often asymptomatic, character of intima ruptures and the correlation between intraplaque haemorrhage and preoperative neurological symptoms. Our findings are in favour of a haemodynamic rather than embolic mechanism of the neurological symptoms associated with carotid stenosis. They also enable potentially dangerous and therefore surgical lesions to be determined.
Abstract: In 1990, by consensus, the elderly patient in terms of cardiac surgery is a patient aged over 70. The special features of this population include the severity of symptomatology, the high incidence of left ventricular dysfunction and the high incidence of concomitant pathology. In the majority of cases the operative risk is controlled by a surgical strategy which takes into account the pathophysiology of the elderly patient and surgical techniques appropriate in the elderly. Over a 3 year period (1987-1990), 115 patients aged over 70 underwent cardiac surgery at the hands of our team with an early postoperative mortality rate of 7%: 5.6% following coronary surgery only, 8% following valve surgery only, 22% following combined surgery. Improved life expectancy and quality of life of patients was the rule in the majority of cases, thus fulfilling the aims of surgery.
Abstract: Coronary bypass surgery was performed on forty-eight patients with LVD from 1970 to 1979. Mean age was 53 +/- 9 years. All patients had abnormal motion of all walls on cineangiography and three vessel disease. Mean LVEF was 27.7%. Mean of distal anastomoses was 1.6 per patient with internal mammary artery graft to LAD. Six patients died early postoperatively (7.5%) and there were 31 late deaths. Actuarial survival including early deaths is 71.5 (+/- 6)% 5 years and 49% 10 years postoperatively. LVEF has a significant influence upon late survival (p 0.01). Because of incomplete revascularization, 55% of the 40 surviving patients, have recurrence of angina with a mean follow-up of 103 months. We have subsequently increased the mean number of bypass grafts in these patients.
Abstract: In a series of 885 resections for lung carcinoma performed between 1976 and 1986, 48 (5.5%) were for large size tumors of 8 cm and over. Pneumonectomy was performed in 28 patients (58.3%), lobectomy in 17 (35.5%) and bilobectomy in 3 (6.2). Histological type of tumor was squamous cell in 27, adenocarcinoma in 9, large cell carcinoma in 10, and adenosquamous carcinoma in 2. The stage of the disease was stage I in 16 cases, stage II in 3 cases, and stage III in 29 cases. Total survival rate including perioperative mortality (3 deaths) was 30.5% at 3 years and 16.3% at 5 years. The best prognostic factors are: age under 60 (23% survival at 5 years, and no survival over 60, (p = 0.01), absence of weight loss (24% survival at 3 years, and 14% at 3 years in case of weight loss (p = 0.02), absence of symptoms (44% at 3 years) but no survival in case of symptoms (p = 0.02), no invasion of mediastinal lymph nodes (N0 and N1), and stage I and II of the disease (50% of survival at 3 years against 20% for stage III (p = 0.04). There was no relation to survival rate between T2 and T3, squamous and adenocarcinoma, and between lobectomy and pneumonectomy. Most of our patients died of post-operative metastasis (52%), related to the large size of the tumor.
Abstract: Myocardial protection by the Hamburg oxygenated crystalloid cardioplegic solution was evaluated. A prospective metabolic study was conducted by measuring the myocardial adenosine triphosphate (ATP) and creatine phosphate (CP) contents by enzymatic techniques in 30 coronary bypass patients with a mean of 3.5 (+/- 0.9) aorto-coronary bypass grafts. Mean aortic cross clamp time was 48.4 (+/- 9.8) min. Myocardial samples were obtained from the left anterolateral ventricular wall: 1 = before CPB, 2 = before aortic cross clamp removal, 3 = 10 min following reperfusion. During ischemia, there was no statistically significant decrease in myocardial ATP contents [3.26 (+/- 0.82) vs 3.01 (+/- 0.92) mumol/g of frozen weight]; in contrast myocardial CP contents decreased significantly [2.71 (+/- 1.44) vs 1.87 (+/- 1.19) mumol/g; p = 0.01]. Following 10 min of reperfusion, the mean ATP level [2.96 (+/- 0.84) mumol/g] was 90% of the preischemic value, and myocardial CP levels (2.32 (+/- 0.92) mumol/g] increased to 85% of preischemic levels. Spontaneous myocardial defibrillation was observed in 93.3% of cases. Early postischemic myocardial function was studied in 228 cardiac operations using the same myocardial protection. 48 patients underwent multiple valve replacement (MUVR), and 180 patients had 4 or more aorto-coronary bypass grafts (CABG). Spontaneous myocardial defibrillation was observed in 90.3% of all; cases; mean CPB time after aortic cross clamp removal was 10.3 (+/- 8) min. Cardiac index by Swan-Ganz thermodilution catheter were measured just before cardiopulmonary bypass and one and twelve hours later.(ABSTRACT TRUNCATED AT 250 WORDS)
Abstract: Authors studied two groups of patients, in which a cardiac valvular prosthesis was reimplanted within 15 years. Data of patients reoperated on (group A) were used to estimate indications, surgical methods, postoperative course and late results. Data of patients which underwent surgery and then requiring reoperation (group B) were used to evaluate the percentage of reoperation falling to 1 patient/1 year according to a primary implanted valvular prosthesis: 42 patients were divided into two groups. 3 perioperative and 12 late deaths (totally 28.3%) were stated in the group A. 5- and 10-year survival rates were 83.3% and 65.6%, respectively. In the group B the lowest percentage of reoperation (1 patient/1 year) were stated in patients with mitral Starr-Edwards 6120 valve (029) and Björk-Shiley aortic valve (0.13). The highest percentage of reoperation was observed in patients with biological prosthetic valves (homograft or heterograft--4.64) and in comparison with patients with primary implanted mechanical prostheses (0.24). Those differences were statistically significant (p less than 0.001).
Abstract: During a 5 year period (January 1979-December 1983) 357 patients were submitted to mitral valve replacement. These were performed by the same surgeon and were randomized in 2 groups: Group A consisted of 179 patients who received a St Jude Medical (SJM) prosthesis in the mitral position. Group B comprised 178 patients with a Björk-Shiley valve (BSM) initially (113 patients from 1979 to December 1981 matched with 111 SJM) and later a Starr-Edwards 6120 valve prosthesis (65 patients matched with 63 SJM). Analysis of 21 preoperative clinical, hemodynamic data and operative variables showed the groups to be well randomized. All patients were anticoagulated postoperatively. A follow-up study was performed each year postop: at the end of 1986 there was a 35 to 95 months follow-up with a mean of 64.7 months (1596 patient years follow-up). Fifteen patients were lost to follow-up. There were 8.4% deaths related to the prosthesis in group A and 20.2% in group B (p less than 0.001). The difference was due mainly to deaths from thromboembolic complications and sudden deaths. The rate of peripheral arterial embolic complications was 2.3% in group A and 4.3% in group B per patient year (NS). The difference between the 2 groups is significant for all thromboembolic events including sudden deaths: 3.1% in group A and 7.9% per patient year in group B (p less than 0.001). There were no statistical differences in the rates of endocarditis per patient year (0.3% in group A, 0.9% in group B), reoperation (0.75% in group A, 0.89% in group B), or anticoagulant related hemorrhage (1.6% in group A, 2.4% in group B). Actuarial survival rate, including all postoperative deaths, is significantly different (p less than 0.05) at 5 years, 87.6% +/- 4.5 (group A) versus 77.4% +/- 6 (group B) and at 7 years follow-up, 83.4% +/- 6.5 (group A) versus 73.2% +/- 7.2 (group B). The probability of freedom from death and complications related to the prosthesis is significantly different (p less than 0.001) at 5 years postoperatively: 79% +/- 6.5 for group A versus 54% +/- 7.5 for group B and at 7 years: 72% +/- 7.5 (group A) versus 46% +/- 8.5 (group B). Comparison of subgroups, 113 BSM versus 111 SJM (1979-81) and 65 SE 6120 versus 63 SJM (1982-83) showed similar significant differences in the results: however there were more early deaths, valve thrombosis, valve dysfunctions and sudden late deaths in the BSM group and more peripheral arterial emboli in the SE 6120 group.(ABSTRACT TRUNCATED AT 400 WORDS)
Abstract: In the present study Doppler-echocardiography was used to evaluate the quality of mitral valve regurgitation (MVR) repair by Carpentier valvuloplasty. Between January, 1984 and June, 1987, this operation was performed in 51 patients (39 men, 12 women; mean age 58 +/- 10.9 years) presenting with mitral valve regurgitation; 25 were in class III and 14 in class IV of the NYHA classification. Two patients died soon after the operation and 2 others some time later. The 47 survivors were followed up for a mean period of 20.5 +/- 11.2 months: 3 of them required mitral valve replacement for residual MVR or mitral stenosis, one developed cerebral embolism. At the latest control, 18 patients were in NYHA class I and 26 in NYHA class II. Doppler velocimetry showed no or little mitral valve dysfunction; the residual MVR was below grade 1 in 37 of the 44 survivors who were not reoperated upon. Mitral function was satisfactory after Carpentier valvuloplasty, with a mean transmitral gradient of 3.3 +/- 1.3 mmHg and a mean mitral valve area of 2.9 +/- 0.98 cm2. In 3 patients an intraventricular gradient of 10 to 20 mmHg, reflecting moderate ventricular obstruction, was detected by Doppler velocimetry. These data obtained with the combined Doppler-echocardiographic method confirm that the quality of mitral function is excellent after Carpentier mitral valvuloplasty.
Abstract: Over this 15-year period, 322 combined aortic and mitral valve replacements were performed by the same surgeon. Bioprostheses were used in only 4 patients, 318 received a double mechanical prosthesis. The Bjork-Shiley valve was always used for the aortic orifice. For the mitral orifice, three types of valve were implanted: 160 Starr-Edwards 6120 valves, 59 Bjork-Shiley valves and 99 St-Jude Medical valves. The early post-operative mortality was 5.9 p. 100. It was due to cardiac causes in 73.7 p. 100 of the cases and was significantly influenced by the myocardial protection technique (p less than 0.05). A long-term review of the survivors was carried out in november-december, 1986: 15 patients were lost sight of; there were 63 late deaths 77.8 p. 100 of which were either of cardiac origin or due to the prosthesis. 225 patients have survived with a mean follow-up of 79.1 months. The actuarial survival rate (early post-operative mortality included) was 78.2 p. 100 at 5 years and 70.2 p. 100 at 10 years. The incidence of peripheral arterial embolism was 1.9 p. 100 per patient-year, while that of all thromboembolic complications (sudden deaths included) was 3.4 p. 100 per patient-year. The percentages per patient-year of the other complications observed were: haemorrhages 2.2 p. 100, infective endocarditis 0.40 p. 100, reoperation 0.47 p. 100. The proportions of patients free of any complication were 84.8 p. 100 at 5 years and 79.7 p. 100 after 10 years.(ABSTRACT TRUNCATED AT 250 WORDS)
Abstract: Hypertrophic obstructive cardiomyopathy, the pathogenesis of which is controverted, exposes the patient to the risk of sudden death and often evolves towards heart failure. When medical treatment is inadequate, surgery may be considered. The authors report their experience of myectomy performed in 28 subjects with pure obstructive cardiomyopathy. Despite a medical treatment based, in most cases, on beta-blockers, all patients showed severe symptoms, with syncopes in 39 p. 100 of the cases, stage 2 or over angina (Canadian Cardiovascular Society grading) in 57 p. 100 of the cases, and stage 3 or over dyspnoea (New York Heart Association grading) in 61 p. 100 of the cases. The intraventricular pressure gradient, measured in 25 patients, was 81.7 +/- 44.9 mmHg. The operation always consisted of myectomy according to the Morrow procedure, i.e. double myotomy of the subaortic septum extended on a length of at least 4 cm, with excision of the muscle between the two incisions. In addition, mitral valve replacement was performed in 13 patients who had severe mitral regurgitation. Three patients (7 p. 100) died with low cardiac output in the peri-operative period; pre-operatively, these patients were in a particularly poor condition. One patient died suddenly during the 4th post-operative month. The annual mortality rate therefore was 2.3 p. 100, and the actuarial survival rate at 8 years was 89.3 p. 100.(ABSTRACT TRUNCATED AT 250 WORDS)
Abstract: In this retrospective study 161 aortic valve replacements performed between January, 1970 and December, 1975 in patients with chronic aortic valve disease are reviewed with a minimum post-operative follow-up of 10 years. Patients' mean age at the time of surgery was 49 +/- 13 years. There were 61 cases of aortic valve regurgitation, 61 cases of aortic valve stenosis and 39 cases of combined aortic valve stenosis and regurgitation. Pre-operative values representative of left ventricular enlargement and systolic dysfunction were: mean cardiothoracic ratio 0.56 +/- 0.06; mean cardiac index 2.4 +/- 0.6 1/min/m2; mean ejection fraction 49 +/- 10 p. 100. Early (1st month) post-operative mortality was 5 p. 100 and late mortality 34.6 p. 100. Death was either sudden (37 p. 100) or due to poor myocardial results (21 p. 100). The actuarial survival rate was 89 +/- 2 p. 100 at 5 years and 78 +/- 3 p. 100 at 10 years. It was significantly influenced by the patient's pre-operative functional status (p less than 0.017) and by a cardiothoracic ratio greater than 0.55 (p = 0.05). Survival at 10 years was altered, though not significantly, in the aortic valve regurgitation group. Ninety-five patients have survived with a mean post-operative follow-up of 142 +/- 14 months; 82p. 100 have few or no symptoms, and the percentage of poor myocardial results is 20 p. 100. Ten years after surgery, 96 p. 100 of the patients were free from thromboembolic accidents and 90 p. 100 had not required reoperation.(ABSTRACT TRUNCATED AT 250 WORDS)
Abstract: We report 2 cases of severe hypertension and acute onset of anuria after renal transplantation in which angiography revealed renal artery stenosis. After renal artery reconstructive surgery renal function returned to normal and the hypertension improved. A high index of suspicion is needed to make the diagnosis. Only by heightened awareness of this important entity will patients with post-transplantation anuria secondary to renal artery stenosis be identified. Such patients may benefit from renal artery revascularization to reverse this type of renal failure.
Abstract: From 1972 to 1986, 22 patients underwent surgical treatment for severe renovascular hypertension and rapidly progressive renal failure caused by atherosclerotic disease of the renal artery or dysplasia (group A), or by post-transplant renal artery stenosis (group B). 1. Group A (n = 16): These patients were assessed preoperatively with the measurement of serum creatinine and blood-urea levels (means 271 +/- 204 mumol/l and 15.6 +/- 10.3 mmol/l respectively) and renal clearances. 5 patients underwent aorto-renal bypass (bilateral in one case) and 11 patients were treated by autotransplantation of the kidney. Operative mortality was 6.2%. Improvement in renal function was statistically significant at 1 and 6 months postoperatively (p less than 0.05). After a mean follow-up of 31 +/- 12 months, renal function was normal in 8 patients, improved in 4, unchanged in 1 and worse in 2. At short and long-term, 81% of the patients were normotensive without medication of with an improved blood pressure (p less than 0.001). 2. Group B (n = 6): Transplant revascularisation was performed on average 10 +/- 8 months after renal transplantation. 5 patients had renal function impairment (mean serum creatinine 241 +/- 96 mumol/l, mean blood-urea 16 +/- 17 mumol/l) and 1 patient a posttransplant anuria. Resection of anastomotic (n = 2) or post-anastomotic (n = 4) lesions was carried out in all case with a new anastomosis (n = 2) or a "crossed" anastomosis (n = 4). On the 24th hour one patient underwent a second revascularization because of immediate postoperative anuria secondary to another anastomotic stenosis.(ABSTRACT TRUNCATED AT 250 WORDS)
Abstract: Sixteen patients underwent surgical treatment for severe renovascular hypertension with rapidly progressive renal failure. These patients were assessed preoperatively with the measurement of serum creatinine and blood-urea levels (means 271 +/- 204 mumol/l and 15.6 +/- 10.3 mmol/l respectively), and renal clearances. 5 patients underwent aorto-renal bypass (bilateral in one case) and 11 patients were treated by autotransplantation of the kidney. Operative mortality was 6.2%. Early results were assessed at 1 and 6 months postoperatively. Renal function was normal in 8 patients, improved in 5 (p less than 0.05), unchanged in 1 and worse in 1 by aorto-renal bypass thrombosis. At long-term with a minimum follow-up of 12 months (mean 31 +/- 12 months), the initial improvement in renal function remained steady in 12 patients whilst 1 patient has gone on to hemodialysis. At middle and long-term, 81% of the patients were normotensive without medication or had improved blood pressure (p less than 0.001). These good results confirm the reversibility of renal ischemic lesions and support an aggressive attitude towards the use of revascularization in the surgical treatment of such patients with renovascular hypertension and renal failure.
Abstract: Between 1970 and 1984, 37 patients underwent simultaneous triple valve replacement by the same surgeon, all for rheumatic valve disease. Björk-prosthesis were used for aortic, Starr, Björk or St. Jude for mitral and bioprosthesis for tricuspid replacements. The median follow-up was 68 months (range, 2 months to 9.6 years). Two patients died in the first postoperative month (5.4%). Most late deaths were of cardiac origin. 85% of all deaths were in Functional Class IV. Five and ten year actuarial survival rate was 75% and 58% for the entire group. Twenty three long-term survivors were followed; all were improved for at least one Functional Class (p = 0.001). Moderate but significant (p = 0.05) cardiothoracic ratio regression was observed. Seven patients had postoperative non lethal complications. In summary, when necessary, triple valve replacement carried an excellent symptomatic improvement. Surgical intervention before patients reach Functional Class IV is preferable. The use of bioprosthesis in tricuspid position is suggested.
Abstract: Between January 1970 and December 1982, seventy-one patients in functional Stage IV of the NYHA classification underwent isolated aortic valve replacement for aortic incompetence (27 cases), aortic stenosis (18 cases) or mixed aortic valve disease (26 cases). Three haemodynamic criteria were chosen: left ventricular ejection fraction less than 40% (average 34 +/- 2%); arteriovenous difference greater than 6 volumes per 100 ml (average 6.7 +/- 0.2 vol.); left ventricular end diastolic pressure greater than 20 mmHg (average 26 +/- 1.3 mmHg). Analysis of the preoperative data defined the clinical profile of these patients: average cardiac index 2.2 +/- 0.07 l/min/m2; 75% had a cardiothoracic index greater than 0.50%; 61% had at least one conduction defect. The average Sokolow index was 50 +/- 2 mm. Twenty seven of the 71 patients died (36%); there were 7 early postoperative deaths (1st month) (10%), mainly due to ventricular arrhythmias (6 out of 7). There were 20 late deaths (31%) on average 52 +/- 8 months after surgery: 70% were of cardiac origin with a predominance of sudden deaths. There were no deaths in the group of patients operated after 1977, probably because of improved techniques of peroperative myocardial protection. The actuarial survival was 72% at 5 years and 63% at 10 years: long term survival was lower in aortic incompetence (25% at 10 years) compared with aortic stenosis (68%) and mixed aortic valve disease (78%). There was a significant relationship between long term survival and cardiothoracic ratio, ejection fraction, the duration of symptoms before surgery and the presence of atrioventricular or left bundle branch block.(ABSTRACT TRUNCATED AT 250 WORDS)
Abstract: The 10-year follow-up of consecutive series of 126 patients who underwent coronary bypass surgery from January 1970 through December 1972 without associated procedures is reported. There were 112 men and 14 women with a mean age of 50.3 +/- 8.0 years. Indications for operation were stable angina pectoris in 35 cases and unstable angina in 91 cases. Eleven patients had one-vessel disease, 55 patients had two-vessel disease and 60 patients had three-vessel disease. The mean number of grafts per patient was 1.8. Graft patency rate was 78.4% at the time of early angiographic control (from one to 24 months). There were two early deaths and 47 late deaths. One patient was last to follow-up. Twenty-six of the late deaths were cardiac in nature (57.7%). The overall 10-year survival rate was 68.0 +/- 4.1%. The factors most clearly related to survival rate were: age (p less than 0.05) ischaemic ST-segment depressions on resting preoperative electrocardiogram (p less than 0.005), preoperative electrocardiographic evidence of anterior, septal or lateral myocardial infarction (p less than 0.05), ventricular function as assessed by preoperative left ventriculography (p less than 0.05). During the follow-up period 35.1% of survivors had had no recurrence of angina and 64.9% had experienced at least one episode of angina. At the ten-year evaluation 33 surviving patients considered themselves free of angina, 27 patients considered the angina to be less severe than before the operation and four considered it to be the same or more severe. A significant positive correlation was noted between clinical response and completeness of revascularization (p less than 0.05).
Abstract: Between 1970 and 1985, 194 patients underwent one or several reoperations after conservative valvular surgery (Group A) or valvular replacement surgery (Group B). Group A: comprised 141 patients with a previous history of closed heart mitral commissurotomy (114 cases), open heart mitral commissurotomy (20 cases), mitral valvuloplasty (5 cases) or aortic commissurotomy (2 cases) reoperated after an average period of 153 +/- 44 months. At reoperation, prosthetic valve replacement of the previously operated valve was systematic and another valvular procedure was also performed in 66 cases. Hospital mortality was 7.8 p. 100. Mortality was high in patients reoperated in functional Class IV of the NYHA classification, after closed heart mitral commissurotomy performed over 10 years before hand. The global mortality rate was 17 p. 100 (average postoperative follow-up of 70 +/- 44 months). The actuarial 5 year survival rate was 85 +/- 6 p. 100 and the 10 year survival was 70 +/- 13 p. 100; NYHA Class IV cardiac failure was a significant poor prognostic factor (p less than 0.05). The prognosis of reoperation after commissurotomy depended mainly on the interval between the relapse of symptoms and reoperation. Group B: comprised 53 patients with valvular prostheses reoperated after an average period of 58 +/- 41 months. The indications of reoperation were prosthetic valve dysfunction (31 cases), perivalvular leak (5 cases), prosthetic valve thrombosis (6 cases), infective endocarditis (7 cases), haemolysis (1 case) and associated valvular disease (10 cases). Reoperation concerned mechanical prostheses in 26 cases and bioprostheses in 24 cases. It consisted in valvular replacement (51 cases) or reinsertion (2 cases). Eight patients underwent second reoperation.(ABSTRACT TRUNCATED AT 250 WORDS)
Abstract: The results of saphenous vein coronary bypass alone were assessed in 126 patients operated between 1970 and 1972 with a postoperative follow-up period of 10 to 12 years. Spontaneous or unstable angina was observed in 72% and incapacitating effort angina in 27.7%. An average of 1.8 grafts per patient was carried out but revascularisation remained incomplete in 51.6% of cases. The early postoperative mortality was 1.58%; the early postoperative infarct rate was 12.7%. There were 47 late deaths, most of which were of cardiac origin (53.2%) or due to cerebrovascular accidents (12.8%). Actuarial survival studies showed an annual mortality rate of 3.2%. The overall 10 to 12 year survival rate was 68.4. The secondary infarction rate was 13.7%, an annual rate of less than 1.5%. Control coronary angiography was carried out in 112 patients; 78% of the grafts remained patent at 2 years. Age (p less than 0.008), basal ECG changes (p less than 0.003) and left ventricular function (p less than 0.05) were significant prognostic factors for survival. One year after surgery, 63.5% of patients were angina free. Thereafter, the annual recurrence rate for angina was 3.1%. After 10 years, 35.4% of patients remained free of angina. A statistical analysis of the factors influencing the recurrence of angina showed that the number of coronary stenoses (p less than 0.02) and the quality of revascularisation (p less than 0.001) were significant factors. After an average follow-up of 75.7 months, 9 patients were reoperated using the internal mammary to revascularize the left anterior descending artery. Sixty per cent of the operated patients were able to return to work.
Abstract: A case of 3 contiguous diverticula of the right posterior wall of the upper trachea is reported. The earlier literature on this subject and the different classifications described are studied. Congenital genesis of the tracheal diverticula is suggested by their localisation and histologic bronchial elements, and by embryogenesis and anomalies of the trachea. They are presumed to correspond to a rudimentary, extra, apical bronchis.
Abstract: 39 cases of congenital anomalies in the origin and/or in the distribution of the coronary arteries arisen from the aorta, without associated cardiac abnormality, seen in the course of 6 525 selective coronary arteriographies in adults, are reported and integrated into a general classification of coronary arteries abnormalities. The clinical correlation of these anomalies is specified. The authors emphasize the importance of their diagnosis in the surgery of valve replacement or of myocardial revascularization.
Abstract: We report the case of a still-born baby girl who had a rare craniostenosis known as the "clover leaf skull syndrome". The 125 previously reported cases were reviewed allowing us to better define the principal features of this condition.
