[Slide tracheoplasty in congenital tracheal stenosis]

OBJECTIVES

Slide Tracheoplasty has progressively become the gold standard in the management of long-segment tracheal stenosis in children and infants. However, in certain situations this operation might become difficult and others techniques might be preferred.

MATERIAL AND METHODS

Five patients, 1 to 6 month old had surgery by our team, for complex tracheal stenosis between 2001 and 2005. Tracheal hypoplasia was considered complex because it was associated to either: an acquired critical stenosis, a cricoid stenosis, a bronchial stenosis, a tracheal bronchus or associated to oesophageal atresia and severe tracheomalacia. All of them have been treated by a modified slide tracheoplasty.

RESULTS

The postoperative status required an average of 15 days in ICU, including 8 days of ventilation. Two patients had laryngeal nerve injury. Medium term follow up (27 months) demonstrated no need for re-intervention, good potential growth and normal child activity.

CONCLUSIONS

Slide tracheoplasty can provide good results in certain cases of severe and complex tracheal hypoplasia in infants.

[Results of heart surgery with extracorporeal circulation in octogenarians]

Cardiac surgery in the octogenarians is increasing in the industrialized countries and therefore represents a growing population. In order to better define the benefits of cardiac surgery in this population, we reviewed all consecutive octogenarians patients operated during the last 10 years. Out of 3,409 patients operated between January 1990 and December 1999, we identified 215 patients (6.3%) aged 80 years or more. Median age was 82.4 +/- 2.45 years, and 52.6% were males. Preoperatively, 52% were in New York Heart Association functional class II, 19.3% in class III, and 28.3% in class IV, with a mean Euroscore score of 7.5 +/- 2.6. Among them, 113 patients (52.5%) had isolated aortic valve replacement, 66 patients (30.6%) had isolated coronary artery bypass graft, 22 patients (10.2%) had aortic valve replacement combined with CABG, and 14 patients (6.5%) had mitral valve operation. The overall hospital mortality was 8%, and multivariate analysis revealed as risk factor for mortality aortic valve replacement combined with coronary artery bypass graft. Median follow up was 36.7 months, with 86% survival at 1 year, 59% at 5 years, and 40% at 7 years. Survival was reduced when aortic valve was combined with revascularisation. Quality of life was improved in 72% of patients. We conclude that for selected octogenarians cardiac surgery can be performed with an acceptable mortality and improves both survival and quality of life.

[3D-transthoracic echocardiography: a selection method prior to percutaneous closure of atrial septal defects]

Prior to putting in place a percutaneous device, the assessment of the atrial septal defect anatomy is mandatory. The 3D transthoracic echocardiography is a non-invasive method bringing an imaging of the septal defect surface and its borders. Fifty-two patients ageing from 3 to 16 years old had a rotational 3D transthoracic echocardiography. Thirty-six (69%) were selected for a percutaneous closure (borders > 7 mm and a septal surface/atrial septal defect ratio > 2). Thirty-two of these selected patients (89%) benefited from the Amplatz prosthesis implantation with success. The maximal 3D diameter of the septal defect was 20 + 4 mm (14-30) compared to the mean size of prosthesis at 22 mm (18-30). Four of the 36 patients (aneurismal septum or a borderline septal surface/atrial septal defect ratio) were secondarily oriented to surgeons. Sixteen patients (31%) were selected directly to a surgical closure. The lack of borders or septal surface were confirmed by the surgical view. The 3D transthoracic echocardiography allows to define new criteria for the selection of patients prior to a percutaneous closure of atrial septal defects. This prospective study demonstrates that 9 out of 10 patients who had the 3D criteria had a percutaneous closure of the septal defect.

A new percutaneously adjustable, thoracoscopically implantable, pulmonary artery banding: an experimental study

BACKGROUND

In patients who undergo left ventricular retraining, multiple reoperations are often necessary to adjust the pulmonary artery banding. The availability of a percutaneously adjustable band would be very useful.

METHODS

Ten lambs (10 to 25 kg) underwent pulmonary artery banding using a new device, 7 by thoracotomy and 3 by thoracoscopy. The possibility of percutaneously adjusting the band was evaluated immediately after operation in 10 animals and at 3 months in 8 animals.

RESULTS

One death occurred on the day of the procedure from displacement of the device and another death was from infection. Immediate hemodynamic studies proved the feasibility of increasing right ventricular afterload in a precise and reversible way. After 3 months the band could still be precisely loosened or tightened in all but 1 animal. Autopsy revealed that all the devices were in the correct position and no fibrosis or adhesions were present around the devices, and there was no residual stenosis noted on the pulmonary artery.

CONCLUSIONS

This new device may be a valuable alternative to the repeated pulmonary artery banding needed for ventricular preparation.

Pericarbon pericardial bioprosthesis: an experience based on the lessons of the past

BACKGROUND

The Pericarbon pericardial bioprosthesis, at the time of its creation, showed a breakthrough in terms of low calcification deposit rate, absence of valvular tears, and durability. The purpose of this study was to evaluate results after 10 years.

METHODS

From September 1988 to December 1997, 277 patients received a total of 287 Pericarbon pericardial valves. There were 224 (80.8%) isolated aortic valve replacements (AVR), 39 isolated mitral valve replacements (MVR), 1 tricuspid valve replacement, 3 pulmonary valve replacements, and 10 aortic and mitral valve replacements. The total cumulative follow-up was 1,221.42 patient-years (mean 4.9+/-2.6 years).

RESULTS

Overall hospital mortality was 10.1%. The overall patient survival at 10.8 years was 55.8%+/-4.2%, for AVR it was 60.0%+/-4.5%, and for MVR it was 46.5%+/-11.9%. The freedom from valve-related death for the overall population at 10.8 years was 98.0%+/-1.0%, for AVR 97.6%+/-1.1%, and for MVR 100%. The overall freedom from structural valve deterioration was 96.6%+/-2.4%, for AVR 96.1%+/-2.7%, and for MVR 100%. The overall freedom from embolic events was 96.0%+/-1.5%, for AVR 96.0%+/-1.6%, and for MVR 100%. The overall freedom from reoperation was 88.1%+/-3.8%, for AVR 89.9%+/-4.2%, and for MVR 80.6%+/-7.3%.

CONCLUSIONS

These results show that over a period of up to 10 years, the Pericarbon pericardial bioprosthesis is an excellent and safe valve substitute. Developing a detoxification process aimed at improving the biological behavior of the glutaraldehyde-tanned valve may increase those advantages.

[Use of Organon, a synthetic heparinoid, in two cardiopulmonary bypass procedures in the same patient sensitive to heparin]

We report the case of a patient who underwent two cardiopulmonary bypass (CPB) procedures with Orgaran because of heparin-induced thrombocytopenia. A 38 years-old man with ischemic mitral insufficiency was operated for coronary artery bypass and valvular replacement. The CPB was carried out with heparin. Heparin-induced thrombocytopenia occured and was proven immunologically. Two months later, a new valvular replacement was performed because of paravalvular leak due to endocarditis. The Orgaran-CPB protocol was as follows: 5,000 units before cardiopulmonary bypass, 5,000 units in the priming volume, anti-Xa level between 0.9 and 1.1 units/mL, with injection of 1,500 units if necessary, no administration of protamine. One month later, a new valvular replacement was necessary and performed with the same protocol using Orgaran. No bleeding or thrombotic complication occurred. Orgaran is a safe and reliable anti-thrombotic substitute if anti-Xa activity is closely monitored.

Ten-years' clinical experience with the Sorin Pericarbon valve

BACKGROUND AND AIM OF THE STUDY

The study aim was to evaluate 10 years' results obtained with the Pericarbon pericardial bioprosthesis.

METHODS

Between September 1988 and December 1997, 277 patients (mean age 75.8 +/- 8.5 years) received a total of 287 Pericarbon pericardial valves. Of these patients, 224 (80.8%) underwent single aortic valve replacement (AVR) and 39 single mitral valve replacement (MVR); one patient had a tricuspid valve replacement (TVR), three patients had a pulmonary valve replacement (PVR) and 10 had both aortic and mitral valve replacement (DVR). Associated cardiac procedures were performed in 86 patients (31.0%), mainly coronary artery bypass graft (n = 71). Mean patient follow up was 4.9 +/- 2.6 years; total cumulative follow up was 1,221.4 patient-years.

RESULTS

The overall hospital mortality rate was 10.1%. There were 50 late deaths (20.1%), four (1.6%) being valve-related. The patient survival rate at 10.8 years was 60.0 +/- 4.5% for AVR and 46.5 +/- 11.9% for MVR. Freedom from valve-related death at 10.8 years was 97.6 +/- 1.1% for AVR and 100% for MVR. Freedom from structural valve deterioration was 96.1 +/- 2.7% for AVR and 100% for MVR. Freedom from embolic events was 96.0 +/- 1.5% for AVR and 100% for MVR. In total, 16 patients needed reoperation, three for stenosis due to dystrophic calcification, six for endocarditis and seven for paravalvular leak. Freedom from reoperation was 89.9 +/- 4.2% for AVR and 80.6 +/- 7.3% for MVR.

CONCLUSION

These results show that, over a period of up to 10 years, the Pericarbon pericardial bioprosthesis constitutes an excellent and safe replacement valve.

[Harvesting of an internal saphenous graft for aorto-coronary bypass using video-surgery]

Classical excision of saphenous vein grafts requires a continuous incision on the leg or the thigh or both. To minimise the trauma due to this method, an endoscopic method has been recently developed. The aim of this paper was to assess the benefits of this new method compared with the classical technique. One hundred and twenty patients requiring aorto-coronary grafts were included in this prospective study and divided into two groups according to the method of saphenous vein harvesting. Group A comprised 60 patients who underwent the classical method os saphenous vein harvesting and Group B 60 patients who benefited from the endoscopic method. No difference was observed between the two groups with respect to mean age, sex ratio, history of diabetes and obliterative arterial disease of the lower limbs. Parsonnet index number of bypass grafts and length of vein excised. The length of the skin wound in group A was 30.8 +/- 8.5 cm compared with only 4.1 +/- 1 cm in Group B (p = 0.006) but the harvesting time was longer by endoscopy (55.7 +/- 23.7 minutes: 72.5 +/- 22.6 minutes for the first 10 patients, 48.5 +/- 24.7 minutes for the last 50 patients) compared with the classical technique (39.8 +/- 6.6 minutes: p = 0.001). Moreover, patients who underwent videosurgery had less operative pain (8% versus 15%) (p = 0.001). The number of infectious complications was slightly lower in Group B (3.3%, 2/60, versus 10%, 6/60), (NS). The authors conclude that harvesting of the saphenous vein by videosurgery reduces postoperative pain and gives a more aesthetic result but with a slightly longer operative time at the beginning of the experience.

"Swiss cheese" septal defects: surgical closure using a single patch with intermediate fixings

BACKGROUND

Residual ventricular septal defects and ventricular and septal dysfunctions are surgical drawbacks of "Swiss cheese" defects. We developed a technique that uses a single patch with intermediate fixings to cover the right side of the septum without producing a septal bulging, through a right atriotomy.

METHODS

Since April 1993, 5 children with "Swiss cheese" defects have been operated on using this procedure (mean age, 17 +/- 12 months). Three patients had associated lesions including tetralogy of Fallot, Taussig Bing heart, and mitral stenosis.

RESULTS

There have been no early or late deaths. The mean follow-up time is 29 +/- 18 months. All patients are asymptomatic. Echocardiography revealed either an intact septum (n = 4) or insignificant color jets at the apical portion of the septum (n = 1). The septal wall motion was preserved in 4 children and was hypokinetic in the fifth child.

CONCLUSIONS

This technique can be an additional tool to provide a secure closure of "Swiss cheese" defects even in the presence of associated cardiac lesions. Long-term consequences of this procedure on septal wall motion remain to be determined.

[Coronary surgery without extracorporeal circulation. Indications, methods and results. Apropos of 224 cases]

Coronary revascularization without cardiopulmonary bypass is evolving as an important technique. From January 1988 to September 1997, 224 patients underwent consecutively coronary artery bypass grafting without cardiopulmonary bypass in our institution. Indications for this type of revascularization were essentially: patients with a single coronary lesion and patients which presented an increased risk for extra-corporeal circulation. Follow-up was complete. The majority of patients were men (176) and the median age was 62 years. Most patients were in CCS III and IV (79%). Unstable angina was found in 19%, 4% had a recent trans mural infarction (< or = 48 hr), and 36% had an older infarct (> 48 hr). 8% were operated in emergency, 29% presented a restenosis following angioplasty, with 4% having a complication from angioplasty, and 0.8% were operated in cardiogenic shock. Redo surgery was seen in 4% of patients. 12% of patients had an ejection fraction less than 30%, 47% an ejection fraction between 30 et 49%, and 40% patients an ejection fraction greater than 50%. Mean Parsonnet score was 10. 185 patients (82.5%) underwent single bypass, and 39 patients (17%) multiple bypasses. Ten patients (4.4%) underwent hybrid revascularization with primarily surgical grafting followed by angioplasty. Postoperative outcome included: myocardial infarction in 16 patients (7.1%), 8 patients (3.5%) were reoperated for tamponade or bleeding, 2 patients (0.8%) developed a mediastinitis, and 1 patient (0.4%) had a neurological event. Hospital mortality was 4% (9 patients). Univariate and multivariate analysis identified two risks factors: age greater than 70 (OR 4.2, CI 1-18.4), and an ejection fraction less than 30% (OR 5, CI 1.2-21.6). Survival was 99.1% at 1 year, 94% at 3 years and 83.2% at 7 years. Post operative angina occurred in 33 patients, linked to a coronary anastomosis dysfunction in 9 patients (4.1%). A significant reduction of cost was found, compared to patients operated with extra-corporeal circulation. We conclude that coronary revascularization without cardiopulmonary bypass can provide satisfactory results, for patients with single coronary lesion, or for patients with an increased risk and multiple coronary lesions.

[Aorto-coronary bypass]

OBJECTIVES

Saphenous grafts used for coronary artery bypass are classically dissected via a continuous incision of the leg, the thigh or both. Recently, a new video-surgery technique has been introduced in an attempt to reduce the trauma of saphenous vein dissection. The aim of this work was to evaluate the possible benefits of this new technique compared with classical dissection.

PATIENTS AND METHODS

Sixty patients requiring coronary artery bypass grafts were included in this study and randomly divided into two groups. In group I (30 patients) the saphenous vein was dissected according to the classical technique. The video-surgery technique was used for the other 30 patients in group II. The two groups were not significantly different for mean age, sex ratio, or history of diabetes or lower limb arteriopathy. The same number of bypasses was performed in both groups (2.6 +/- 0.7). Outcome was compared for: dissection related complications (hematomas, infections), length of the skin incision over the length of the dissected vein, duration of the dissection procedure, and post-operative pain.

RESULTS

A leg incision was used in 28 cases out of 30 cases in both groups. The length of the saphenous vein dissected was 27.6 cm in group I and 21.8 cm in group II. The length of the skin incision was 27 cm in group I and only 4.7 cm in the video-surgery group II, giving an incision/vein ratio of 97% and 21% respectively. Operative time was however 37.9 min for group I and 48.5 min for group II. There was no significant difference between the groups for hematoma formation or infection but the patients in the video-surgery group experienced less post-operative pain.

CONCLUSION

Besides an improvement in the esthetic result, video-surgery dissection of the saphenous vein reduces post-operative pain at the cost of a slightly longer operative procedure.

Endoscopic saphenous vein harvesting versus 'open' technique. A prospective study

OBJECTIVE

Preparation of the great saphenous vein for coronary artery bypass grafts is usually performed through one or many cutaneous incisions. A technique of endoscopic harvesting is now available. An aim of the study was to compare both methods, prospectively.

METHODS

Sixty coronary artery bypass grafting patients were randomly assigned to two groups according to saphenous vein harvesting technique: 30 patients to group 1 -- open harvesting technique (OHT) and 30 patients to group 2 -- endoscopic harvesting technique (EHT). The results were assessed on the basis of (1) clinical outcome (hematomas, inflammations), (2) length of the cutaneous incisions compared to length of the segment of vein harvested, (3) time of harvesting, (4) postoperative pain.

RESULTS

Both groups were comparable in terms of: age, sex, diabetes, peripheral artery disease, site of harvesting, number of anastomoses, and length of the vein harvested. Both the length of the cutaneous incisions and the postoperative pain were decreased in the EHT group. Harvesting time was increased in the OHT group.

CONCLUSIONS

Endoscopic saphenous vein harvesting allows improved aesthetic aspect, less postoperative discomfort, with an increased time in harvesting in the beginning.

[Value of the spiral angio-scanner with three-dimensional reconstruction in the surgical strategy of unifocalization. Apropos of a case]

One of the difficulties of surgical treatment of pulmonary atresia with patent septum by unifocalisation resides in the accurate diagnosis of the different collateral vessels to the lung in order to optimise the surgical approach: anterior or posterolateral thoracotomy, and to determine the type of operation: one or two stages repair. Conventional angiography, even using different views, cannot always give an accurate representation of the anatomy of the different collateral vessels, especially their relationship to the bronchial structures. The authors report the contribution of spiral angioscanner with three dimensional reconstruction in the determination of the operative strategy of a case of pulmonary atresia with patent septum.

Videothoracoscopic surgical interruption of patent ductus arteriosus

A videothoracoscopic surgical technique for closure of patent ductus arteriosus in children is described. Only three ports of access are necessary to dissect the patent ductus arteriosus from the surrounding tissues and to apply the two titanium clips. The advantages given are the technique's low morbidity, lack of mortality, and reliable closure. We believe that the videothoracoscopic surgical approach is the technique of choice for patent ductus arteriosus closure in children.

Video-assisted aortofemoral bypass: results in seven cases

Between September 1995 and February 1996 we attempted to perform video-assisted aortofemoral bypass in nine patients. All patients were male with a mean age of 58.7 years, mean weight of 64.7 kg, and mean height of 1.69 m. In two patients it was necessary to switch to open laparotomy due to inadequate aortic exposure in one and extensive aortic calcification in the other. Aortobifemoral bypass was performed by the transperitoneal approach in three patients and unilateral aortofemoral bypass by the retroperitoneal approach in four patients. Exposure was more difficult by the transperitoneal approach. Postoperative graft patency was excellent in all patients. Video-assisted surgery did not shorten the delay to resumption of intestinal transit but it did reduce the duration of hospitalization and need for postoperative analgesia. Our experience suggests that video-assisted aortofemoral bypass without laparotomy can be performed and that it allows more rapid patient recovery.

[Open heart operation under videosurgery and minithoracotomy. First case (mitral valvuloplasty) operated with success]

The development of "less invasive surgery" using small incisions and videoscopic techniques may change, in the near future, our attitude towards "traditional" surgery. This is because of specific advantages such as skin limited incisions, reduced perioperative disability and lower cost. Up to now, only abdominal, thoracic and coronary artery surgery which do not imply the opening of the heart, or closure of simple atrial septal defects, have benefitted from this new approach. This article reports the first case of open heart surgery for complex lesions of the left heart through a minithoracotomy (5 x 4 cm) with the use of videotransmission and peripheral extracorporeal circulation. The patient, a 30-year-old female, was operated upon for a combined mitral valve stenosis and insufficiency of rheumatic origin unsuccessfully treated by a previous percutaneous valve dilatation. The 2.5 h open heart procedure comprised commissurotomy, repair of torn leaflets, chordal transposition and Carpentier-Edwards prosthetic ring implantation. The patient left the hospital 12 days after the operation. Transesophageal echocardiography at discharge showed normal valve function with no residual stenosis or residual leak.

[Influence of anatomo-pathological involvement of the aorta on results of Bentall's operation]

The results of 51 patients undergoing the Bentall procedure for aneurysmal pathology of the ascending aorta during the last 10 years are analysed with respect to the nature of the pathology of the lesions of the arterial wall. The study population comprised 39 men and 12 women with a mean age of 47 +/- 17 years (range 2-76 years). They were divided into two groups, Group I (n = 38) with degenerative cystic medianecrosis, Group II (n = 13) with atheromatous lesions. The overall results were satisfactory with a hospital mortality of 3.9% and 5 and 10 year survival rates of 94 and 74% respectively. No difference in results was observed with respect to the anatomical site of the aneurysm, the presence of dissection or the technique used for repair. The results in degenerative lesions (Group I) were excellent but the accent should be placed on prevention to reduce the number of patients operated in a context of acute dissection. The presence of atheromatous lesions identifies a high risk group (Group II) due to advanced age, hypertension and associated vascular and coronary lesions. The hospital mortality in this group was 15.4% compared to almost nil when the aneurysmal pathology was due to degenerative lesions of the media. The extramortality of this group is directly related to the presence of atheromatous lesions (mesenteric infarction due to atheromatous embolism) and incites special attention to the mesenteric sphere in the postoperative period. The preoperative work-up should include transoesophageal echocardiography of the thoracic aortic wall, probably the source of the postoperative emboli.