[Different approaches to chest drainage in the management of primary spontaneous pneumothorax]

Drainage of primary spontaneous pneumothorax (PSP) may be managed by different techniques and with different types of drain. It is mainly performed in the pneumology department or in the emergency department. The aim of the study was to evaluate the factors that influence the success of PSP drainage. This retrospective, monocentric study performed in University Hospital of Toulouse, included patients with a first episode of PSP requiring drainage. The primary outcome was the rate of success according to the techniques of drainage. Data on the size of the drain (>14F or<14F), the drainage technique (small bore catheter or chest tube drainage) and the drainage department (pneumology or emergency) were collected. One hundred and twenty-four patients had a drainage between 2014 and 2016: the late recurrence free success rate was 59% (n=73). Compared with emergency, drainage in pneumology increased the success rate threefold regardless of the drainage technique (P=0.0001) The success rate was similar whatever the technique used (Seldinger or classic technique) (P=0.31). Success and complications rates were similar whether the drain was large (>14F) or small (<14F) (respectively P=0.99 and P=0.58). In our study, the drainage of PSP in the pneumology department, with a small caliber inserted by the Seldinger technique, was associated with a significantly higher success rate.

Biodegradable Polymer (D,L-Lactide-ε-Caprolactone) in Aortic Vascular Prosthesis: Morphological Evaluation in an Animal Model

Biodegradable D,L-Lactide-ε-caprolactone copolymer was used in substitution to bovine collagen to seal porosity in nine Dacron vascular Sorin Carbografts®. One served as control and 8 were implanted in mini-pigs as vascular by-pass in the thoracic aorta. The grafts were explanted at 7 days (4 animals), 30 (2 animals) and at 90 days (2 animals), and submitted to gross examination, X-ray, histology and electron microscopy.

Aim of the study was to assess the safety and the reliability of these polyester vascular prostheses impregnated with the copolymer in terms of containment of the bleeding in the perioperative period, host inflammatory response, copolymer biodegradation and prostheses “healing”.

All the grafts were patent at angiographic and X-ray examination. At 7 days blood infiltration between Dacron and copolymer lining was detected. Inflammatory granulocyte infiltrates and granulomatous reaction with polymer degradation was observed at 30 days and fibrous tissue healing at 90 days. Luminal surface was covered by thin thrombi at 7 and by a neointima at 30 and 90 days.

We conclude that D,L-Lactide-ε-caprolactone copolymer is effective in preventing perigraft bleeding, even though an early hematoma between Dacron and the copolymer coating occurs. Copolymer is degraded through a mild inflammatory reaction, with eventual evolution to fibrous healing.

[Pulmonary vein leiomyosarcoma extending into the left atrium]

In this paper, the authors report the case of a 28-year-old man with pulmonary vein leiomyosarcoma presenting subacute respiratory distress. Thoracic computed tomography and transoesophagal ultrasonographic examination of the heart suggested the diagnosis of a heart tumour revealed by the obstruction of the mitral valve and pulmonary oedema. Emergency cardiac surgery revealed the mass to be a leiomyosarcoma, probably extending from the right inferior pulmonary vein and extending into the left atrium. The clinical evolution was complicated because of a sudden local relapse. The patient underwent a second cardiac intervention involving lower right lobectomy followed by adjuvant chemotherapy with an ifosfamide-adriamycin combination. This treatment failed to control the disease and a third cardiac intervention was necessary with second-line gemcitabine-paclitaxel adjuvant chemotherapy. Further recurrences were observed with metastases first in the scalp and then in the spine and adrenal glands leading to the death of the patient 2 years after the diagnosis.

Pressure-suit combined with pelvic stop-flow: A feasibility study in a bovine model

BACKGROUND

Isolated pelvic perfusion exposes tissue to high drug doses and may benefit patients with advanced malignancy. However, leakage is a limit to this technique.

AIMS

The aim of the study is to increase the perfusion ratio between local and systemic compartments on isolated pelvic perfusion. We hypothesised that an inflated pressure-suit placed above the level of aortic and caval stop flow could decrease leakage from the regional to the systemic blood compartment in a bovine model.

METHOD

As the size of the pressure-suit was adapted for use in humans, we performed our experimental study on 6 calves which are big enough to fit into the suit. We used an inflated pressure-suit placed at low (40mmHg) and high pressures (125mmHg) above the level of aortic and caval stop-flow. A pharmacokinetic study with cisplatinum was performed in both compartments.

RESULTS

After injection of the drug, the mean ratio of drug concentration in the locoregional/systemic compartment was 43.1. After 30min, this mean ratio was 4 and 9.7 for a pressure-suit pressure of 40mmHg and 125mmHg, respectively. At pressure-suit pressures of 40mmHg and 125mmHg, pelvic perfusion achieved pelvic/systemic exposure ratios of 5.9 and 14.9 at 30min, respectively. Leakage at 30min was higher when the pressure-suit was inflated at low pressure (40mmHg, mean 18%). When the pressure-suit was inflated at high pressure, leakage was lower (125mmHg, mean 7%).

CONCLUSIONS

The pressure-suit increased the perfusion ratio between pelvic and systemic compartments in a bovine model.

[Development and evaluation of a prosthetic valved conduit dilated by percutaneous approach: experimental study in the lamb]

This study was undertaken to develop a dilated valved conduit for reconstruction of the right ventricular outflow tract in the animal. The conduits were made by sewing a valved tube (Medtronic Inc) inside a vascular stent (Numed Inc). After preparation, they were inserted surgically in five lambs. The conduits were then dilated 6 weeks and 3 months after their implantation. Before sacrificing the animals at 3 months, a 22 mm valved stent was implanted percutaneously inside the surgical conduits. One animal died suddenly due to kinking of the conduit. Balloon dilatation was performed in the surviving animals. The first dilatation only had a modest impact on valvular function but it was much aggravated after the second dilatation. A valved stent was successfully inserted percutaneously. At sacrifice, all the conduits were completely engulfed in an intense fibrosis. In conclusion, a valved biological conduit for reconstruction of the right ventricular ejection tract has been developed and can be dilated sequentially to follow growth. The new product could have an important role to play in the management of congenital malformations involving the right ventricular outflow tract.

[Effects of video information in patients undergoing coronary angiography]

BACKGROUND

informed consent is a fundamental and legal obligation for each interventional cardiologist. The effect of consent form describing risks of invasive procedure on anxiety is controversial. This trial was aimed to assess the added value of video information to the standard informed consent process.

METHODS

200 consecutive patients undergoing coronary angiography were enrolled. The first one hundred were assigned to conventional education conducted by the physician (no video group) and the second one hundred had consent obtained in the conventional manner assisted by video information (video group). The outcome variables for this comparison consisted of a standard anxiety score (Spielberger Statement Anxiety Inventory questionnary) plus hemodynamics measurements of heart rate, systolic and diastolic blood pressure obtained at baseline and immediately after written informed consent In addition, before discharge, patients graded the tolerability and satisfaction on a 4-point scale.

RESULTS

The groups were similar with regard to their baseline characteristics and anxity score (37+23 vs 37+23). Patients who had not had prior experience of catheterization had higher baseline anxiety than those who had prior angiography (45 + 22 vs 31 + 20; p = 0.027). Patients who watched the video were significantly less anxious after informed consent (28 + 21 vs 34 + 22; p = 0.048) and had a significantly lower heart rate (65 + 10 vs 71 + 12; p = 0.03). The benefits of video information were especially prominent in those with higher anxiety scores at baseline (score after 45 + 24 vs 57 + 26; p = 0.046). Tolerability were higher in the video group compared with no video group (98% vs 86%; p = 0.003). Finally, satisfaction of information for informed consent process was higher in video group than in no video group (99% vs 76%; p = 0.001).

CONCLUSION

a video information decreased anxiety level after written informed consent and improved tolerability and satisfaction scales in patients undergoing coronary angiography. The most likely to benefit from video information are patients with higher anxiety level at baseline. Beneficial effect on informed refusal should be investigated in larger population.

[Management of acute coronary syndromes in a new French coronary intensive care unit. The first four years of activity in the GRACE registry (Global Registry of Acute Coronary Events)]

The GRACE registry provides the opportunity to analyse management of acute coronary syndromes in the real word and the impact of hospital characteristics. In this setting, we compare the activity of a new coronary intensive care unit with regional data.

METHODS

From January 2000 to December 2003, 376 eligible patients were involved (22% of regional inclusion). GRACE standard diagnosis were the following, for our centrer (for the cluster): ST elevation myocardial infarction 28% (37%), non-ST elevation myocardial infarction 32% (31%), unstable angina 33% (24%). Demographic characteristics were similar with a median age of 64 (vs 66) and a large majority of male (74 vs 81%). Medical history and cardiovascular risk factors were comparable. Predictors of hospital mortality were observed at the same rate: cardiogenic shock (3 vs 3%), congestive heart failure > Killip 2 (4 vs 4%), left ventricular ejection fraction (LVEF) lower than 40% (17 vs 16%), recurrent ischemic symptoms (8 vs 8%). Coronary artery bypass grafts were required in 5% (vs 2%).

RESULTS

Drugs prescription rates were similar: aspirin at admission (95%) and at discharge (95%), betablocker at admission (70%) and at discharge (85%), statin at admission (< 30% in 2000, > 60% in 2003) and at discharge (< 60% in 2000 and > 80% in 2003), ticlopidin-clopidogrel at admission (< 20% in 2000 and > 40% in 2003), ACE inhibitor for LVEF < 40%, intravenous GPIIblIIa, and low molecular weight heparin (90%). Cardiac catheterisation (90%) and percutaneous coronary interventions (80%) were performed at the same rates in our center and in the cluster. Hospital death was similar (2 vs 4%). Discharge status was home for a large majority of patients (63 vs 76%). The median length of stay was five days and shorter than three days for patients with unstable angina.

CONCLUSION

Based on GRACE registry data, the present evaluation revealed that our new center offered evidence-based medical and interventional therapy in patients with acute coronary syndromes at the same level than experienced institutions with similar results for hospital death and length of stay.

Successful Surgical Treatment of Mitral Valve Stenosis in a Dog

OBJECTIVE

To report the successful surgical management (open mitral commissurotomy, OMC) of mitral stenosis (MS), incorporating heart-beating cardiopulmonary bypass (CPB), in a 1-year-old dog.

STUDY DESIGN

Clinical case.

ANIMALS

One-year-old Cairn Terrier with MS.

MATERIALS AND METHODS

Diagnosis of MS was confirmed by means of 2-dimensional, continuous-wave and color-flow Doppler echocardiography. Surgery was performed through a left intercostal thoracotomy. CPB was initiated and the heart was kept beating. The fused commissures of the mitral valve were incised to free the cusps of the valve.

RESULTS

Left intercostal thoracotomy allowed easy observation of the mitral orifice during heart-beating OMC. Persistent bleeding from the atriotomy site required a second surgical procedure after which the dog had an uneventful recovery. Echocardiography at 2 weeks and 1 year postoperatively indicated substantial improvement in left ventricular filling (pressure half-time=187 ms before surgery, 105 ms [2 weeks] and 110 ms [1 year] after surgery). Enlargement of the left atrium resolved; however, moderate mitral valve regurgitation was still present.

CONCLUSIONS

MS can be successfully treated by OMC, facilitated by use of CPB. Substantial improvement in cardiac function was evident by ultrasound and Doppler examination postoperatively.

CLINICAL RELEVANCE

OMC under heart-beating CPB should be considered for the treatment of MS in the dog.

Factors influencing fluoroscopy time and dose-area product values during ad hoc one-vessel percutaneous coronary angioplasty

X-ray exposure during radiologically guided interventional procedures may have some deleterious effects. The aim of our study was to analyse the factors affecting patient dose during percutaneous coronary angioplasty (PTCA). We evaluated radiation dose during coronary angiography followed by one-vessel PTCA in 402 consecutive patients who were treated by three experienced physicians using both femoral and radial techniques. Fluoroscopy time (t) and patient dose measured by a dose-area product (DAP) meter were recorded. A good correlation was observed between t and the DAP (r=0.78, p<0.001). To assess the factors affecting radiation exposure, we studied the differences between operators, arterial catheterization access and stenting strategy. Median (25th to 75th percentiles) values for t were 19 (13 to 26) min and for DAP were 191 (145 to 256) Gy cm(2) for operator 3 compared with t=12 (9 to 18) min and DAP=137 (91 to 208) Gy cm(2) for operator 2 (p<0.005 versus operator 3) and t=13 (9 to 17) min, and DAP=134 (93 to 190) Gy cm(2) for operator 1 (p<0.001 versus operator 3). Differences between the radial and the femoral techniques were: t=17 (13 to 24) min versus 12 (8 to 17) min, (p<0.001) and DAP=175 (128 to 246) Gy cm(2) versus 138 (93 to 197) Gy cm(2), (p<0.001). In comparison with stenting without pre-dilation, direct stenting significantly reduced t and DAP [t=12 (9 to 16) min versus 16 (11 to 22) min, (p<0.001) and DAP=130 (95 to 186) Gy cm(2) versus 163 (119 to 230) Gy cm(2), respectively, (p<0.01)]. Radiation exposure to patients and staff are strongly dependent on operators, stenting strategy and the arterial access chosen for ad hoc one-vessel PTCA.

[Percutaneous artificial heart valves: from animal experimentation to the first human implantation in a case of calcified aortic stenosis]

The development of artificial cardiac valves capable of being positioned by catheter has become an important subject for research, with the objective of treating valvular patients who are not operable or at very high surgical risk. We tested an artificial valve implantable by the percutaneous route, consisting of three leaflets of bovine pericardium sutured to the inside of a stainless steel stent, deployable by inflating a balloon. Following laboratory evaluation, this valve was implanted with success in animals, then for the first time in man, in a case of calcified aortic stenosis. The patient, a 57 year old male in cardiogenic shock, had associated multiple non-cardiac pathology and could not be operated on. Implantation was carried out by the trans-septal anterograde route, the only route available due to severe end stage arteritis. The artificial valve was deposited in the centre of the native aortic valve, without obstructing the coronaries nor reaching the mitral valve. The result was spectacular with instantaneous haemodynamic improvement and excellent valvular function confirmed by transoesophageal echocardiography every 15 days after implantation. Non-cardiac complications marred the progress, dominated by aggravation of pre-existing leg ischaemia, necessitating amputation for which the consequences were fatal at 4 months. This case demonstrates that implantation of a cardiac valve by the percutaneous route is possible in calcified aortic stenosis, and that it brings rapid clinical improvement. This technique could in future constitute an important alternative therapeutic approach for selected patients.

[Comparison between radial and femoral approaches in ad hoc coronary angioplasty]

Between September 1999 and June 2001, 591 patients required ad hoc coronary angioplasty. The authors compared the group of patients in whom the approach of first intent was radial (n = 328, 55%) with those in whom the femoral approach had been used (n = 263), in terms of immediate local (haematoma or thrombosis requiring surgical intervention or transfusion) and general complications (myocardial infarction, cerebrovascular accident), and major adverse cardiovascular events (infarction, angioplasty, bypass and death) at 1 year. The dose of ionising radiation during the procedures was also compared prospectively. The conversion rate from the radial (R) to the humeral or femoral (F) approach was 10%. The angioplasty, stenting, and stenting without dilatation failure rates were identical in the two groups (5% versus 5%, 0.6% versus 1.9%, 3% versus 4%, respectively). The average irradiation time was greater in the R group than in the F group (23 +/- 12 min vs 17 +/- 4 min, p < 0.001) as was the irradiation per surface unit (242 +/- 137 Gy.cm2 vs 185 +/- 117 Gy.cm2, p < 0.001). The immediate complication rate was comparable in the two groups (2.5% in group R vs 3.6% in group F) as was the major adverse cardiovascular event rate at 1 year (13% in both groups). The authors observed the same rate of immediate complications and late adverse cardiac events in patients undergoing coronary angioplasty followed by immediate angioplasty by the radial or femoral approaches with an acceptable conversion rate from the radial to the femoral approach. The procedures by the radial approach seem to be associated with a greater time and dosage of ionising radiation.

[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.

[Iatrogenic lesions of the left main coronary artery]

Reoccurrence of ischemic events several months after a percutaneous transcutaneous coronary angioplasty is usually due to a restenosis. Coronary angiography rarely shows a new stenosis on another site or on the left main coronary artery. In this series, we report 5 cases of left main coronary artery stenosis which have occurred from 3 to 12 months after a prior percutaneous angioplasty. This phenomenon which has previously been described after direct cannulation of the coronaries ostia during aortic valve replacement in the 70'. This complication is related to intimal damage caused by traumatic manipulation of the left main, which can be either already minimally altered or normal. This complication is rare after percutaneous transcutaneous coronary angioplasty (0.2-1.7%) according to various series. We compare our cases to the published cases in the literature.

[Perforation of the aorta after percutaneous closure of an atrial septal defect with an Amplatz prosthesis, presenting with acute severe hemolysis]

We report a case of aortic perforation three weeks after transcatheter occlusion of an atrial septal defect (ASD) by an Amplatzer device. Revealed by acute hemolysis, this complication needed an emergency surgical operation. The fistula between the no coronary Valsalva sinus of the aorta and the left atrium was repaired. The ASD was closed by patch. This serious accident should consider a short antero-superior rim as a risk factor for aortic perforation in transcatheter closure for ASD.

The effect of a systemic arteriovenous fistula on the pulmonary arterial blood pressure in the fetal sheep

In order to investigate whether systemic arteriovenous fistula occurring during the fetal period could induce pulmonary hypertension at birth, a fistula was surgically created between the carotid artery and jugular vein of fetal lambs at 120 days' gestation. Mean pressures in the left pulmonary artery, aorta, atrium and ventricles were measured at birth in seven experimental animals and in five control animals. Mean left pulmonary pressure was significantly higher in the lambs with fistula as compared with the control group, suggesting that prenatal occurrence of systemic arteriovenous fistula may induce fetal pulmonary hypertension. The present study provides a new animal model that could be relevant for the study of mechanisms regulating pulmonary vascular tone in the perinatal period.

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.

Feasibility, safety, cost-effectiveness and 1 year follow-up of coronary stenting without predilation: a matched comparison with the standard approach

BACKGROUND

We evaluated the feasibility, safety, procedural cost-effectiveness, radiation dose and time and 1-year target vessel revascularization rate of direct unprotected mounted stenting without previous balloon dilatation (DS) in native coronary artery lesions.

METHODS

DS was attempted in 119 patients; 39 had a recent myocardial infarction, 62 had unstable angina, and 18 had stable angina. The clinical follow-up was obtained at 14+/-5 months (range 6 to 24 months). These results were compared with those for a consecutive group of 160 patients matched for type and length of lesions and who had a stent only if the post-balloon residual stenosis was >30%.

RESULTS

The feasibility of DS was 112/119 (94%). The number of inflations, the length of the stent/length of the lesion ratio, the time and the dose of radiation were dramatically lower in the DS group (P<0.001). DS conferred a slight reduction in procedure-related cost [$820+/-157 for DS vs. 894+/-427 for standard dilatation (SD) per patient]. The 1-year target vessel revascularization rate was similar in both groups [nine (8%) for DS vs. 17 (11%) patients for SD, ns].

CONCLUSIONS

DS is feasible and safe in selected coronary lesions. This method provides a low rate of repeat revascularization and reduces the time and the dose of radiation compared with the standard approach.

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.

[Coronary subclavian steal syndrome after internal mammary artery bypass grafting. A cause of severe postoperative recurrent myocardial ischemia]

A 65-year-old underwent a triple bypass: internal artery mammary-descending coronary artery, aorta diagonal-lateral coronary (sequential). Three weeks later he started to have severe angina pectoris with ST depression in anterior EKG leads. A left transradial coronary angiography was performed. The examination showed a total occlusion of the left subclavian artery 2 cm after the aortic arch and a retrograde flow in the internal mammary artery (IMA). Via transfemoral approach, angiography showed the patency of the aorto-veinous sequential graft and a retrograde flow through anastomosis in the left mammary artery. The patient underwent a reimplantation of the IMA on the brachiocephalic artery. One month later the patient is doing well without chest pain. A coronary subclavian steal syndrome should be suspected in case of recurrent ischaemia after IMA bypass, particularly if there is more than 20 mmHg systolic pressure differential between the arms. Left transradial approach achieved diagnostic in case of total left subclavian artery occlusion.

[Iatrogenic dissection of the left main artery treated by direct stenting]

A 70-year-old woman was referred to the department due to a symptomatic severe calcific-aortic stenosis. During pre-operative trans-radial approach coronagraphy occurred a iatrogenic dissection of the left main artery with total occlusion and cardiac arrest (asystole). Successful resuscitation is achieved with an emergency strategy of percutaneous direct stenting revascularization combined with cardiopulmonary resuscitation manoeuvres.

[Leiomyosarcoma of the superior vena cava: diagnosis by endovascular biopsy]

We report the case of a 69-year-old woman with leiomyosarcoma of the superior vena cava presenting with acute superior vena cava syndrome (SVCS). CT and MRI failed to fully characterize the endovascular process. Percutaneous endovascular biopsy, followed by metallic stent placement to treat the SVCS, confirmed the diagnosis. Symptoms resolved within 48 hours and surgical resection of the tumor was performed one month later. Unfortunately the patient died two weeks later because of intracranial hemorrhage.

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.

[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.

Bicarbon valve -- European multicenter clinical evaluation

OBJECTIVE

Fifteen collaborating centers in eight countries present their pooled experience with the new Bicarbon bileaflet valve.

METHODS

Between 4/90 and 4/96, 1351 patients, 806 males and 545 females, aged 10 to 83, mean 58.4 +/- 12.4, underwent valve implantation.

OPERATIONS

aortic valve replacement (AVR), 726; mitral valve replacement (MVR), 475; double valve replacement (DVR), 150. Additional procedures: CABG, 211; TV repair, 64; other, 152.

RESULTS

Mortality: 67 early (seven valve related) and 56 late (40 valve related). Valve thrombosis: six obstructive, three non-obstructive; embolism: nine major cerebral, 37 other. Major bleeding: 29. Hemolysis: two clinically significant. Non-structural dysfunction: 24 paravalvular leaks, one leaflet interference. No structural failure! Endocarditis: 24. Reoperation 48: 22 non-structural dysfunctions, 14 endocarditis, seven thrombosis and embolism, five other. Estimated 5-year freedom from valve-related deaths is 97.2% for AVR and 92.4% for MVR; 4-year freedom from valve related deaths for DVR is 90.5%. Mean calculated NYHA improvement is 1.24.

CONCLUSIONS

The Bicarbon mechanical prosthesis is well designed, durable, has good hemodynamic features and an acceptably low incidence of complications.

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.

Long-term results with the Sorin Pericarbon valve in the aortic position: a multicenter study

BACKGROUND AND AIM OF THE STUDY

A multicenter study was designed to evaluate the Pericarbon pericardial bioprosthesis for up 10 years after implantation in the aortic position.

METHODS

Between January 1986 and November 1996, 321 patients (mean age 75.8 +/- 7.3 years) received 325 Pericarbon pericardial valves in the aortic position. Four patients underwent redo surgery and each received a second Pericarbon prosthesis. Associated cardiac procedures in 80 patients were mainly coronary bypass (n = 66). Follow up extended up to 10 years (cumulative follow up of 931.0 patient-years; mean follow up 3.1 +/- 2.2 years).

RESULTS

There were 19 late deaths, with seven valve-related. Twelve patients suffered an embolic complication (transient cerebral attack in four, peripheral in six and induction of a myocardial infarction in two). Of these complications, five occurred within 30 days of surgery and seven beyond the first year. Ten patients were reoperated on, six for primary tissue failure, two for prosthetic endocarditis and two for paraprosthetic leak. Primary failure was due in all cases to leaflet mineralization. No primary tear of the leaflet was reported. Actuarial freedom after 10 years from primary tissue failure was 83.9 +/- 7.4% and from major embolic events 97.6 +/- 1.0%. Freedom from valve-related mortality at 10 years was 92.1 +/- 4.9%.

CONCLUSIONS

These results indicate that, over a period of up to 10 years, the Pericarbon pericardial bioprosthesis compares favorably with other replacement valves.

In vivo evaluation of a retrievable vena cava filter--the Dibie-Musset filter: experimental results

PURPOSE

To evaluate, in an animal model, the efficacy and safety of a 7 Fr percutaneous vena cava filter for temporary or permanent use.

METHODS

The Dibie-Musset (DM) filter is a wire preformed into a double-spiral shape with a spring effect. The experiment was performed in 15 adult sheep and consisted of the insertion of 45 filters, clot trapping tests, and filter retrieval. Follow-up in all sheep consisted of radiologic (abdominal radiograph, inferior vena cavogram, abdominal computed tomography), macroscopic, and microscopic examinations between days 8 and 386 after filter placement.

RESULTS

Of the 45 filters implanted in 15 sheep, 29 were retrieved between day 0 and day 15. Filtration efficiency was 100% for clots 4 x 4 x 20 mm. No long-term (1 year) side-effects were detectable. Microscopic examination of the vein wall showed only a dense intimal fibrosis without signs of acute inflammation at 1 year.

CONCLUSION

These results support the efficiency and safety of the DM filter in an animal model.

Video surgical technique for interruption of patent ductus arteriosus in children and neonates

Classical surgical interruption of PDA has partially been replaced by trans catheter endovascular closure since 1971. We describe a new technique for PDA closure by video surgery. With the patient under general anesthesia and intubated, two 5 mm holes were made through the left thoracic wall. A video camera and specially devised surgical tools were introduced, such as scissors, dissecting forceps, clip appliers. The ductus was dissected and two titanium clips were applied, completely interrupting the ductus. 282 patients were operated on from April 1991. Mean age was 20 months (range 1 month to 17 years) and mean weight was 13 kg (range 1.2 to 65 kg) Twenty-one had associated lesions not necessitating immediate surgical treatment. All had successful closure of the patent ductus with the video-assisted technique. 6 patients had recurrent laryngeal nerve injury (5 transient, 1 permanent). The usual hospital stay was from 48h to 72h. There were no other complications and no deaths. Video surgery is a rapid, safe and successful technique for closure of the patient ductus arteriosus. The technique is feasible in low-weight and premature infants.

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-thoracoscopic surgical interruption of patent ductus arteriosus. Routine experience in 332 pediatric cases

OBJECTIVE

Pediatric video-assisted thoracic surgery closure of patent ductus arteriosus can now be performed on a routine basis. We review here our entire experience with this technique.

METHODS

Three hundred and thirty two consecutive patients underwent video-assisted closure of patent ductus arteriosus from September 1991 to September 1996. Indications were symptomatic ductus or failure of closure in older children. All complications were carefully noted, as well as intensive care unit stay, and operating room time.

RESULTS

Patients were divided in three age groups: less than 6 months (101 patients, 31%), 6-48 months (179 patients, 54%), greater than 48 months (52 patients, 16%). The mean weight was 12.6 kg (range 1.2-65 kg). Associated cardiac anomalies were atrial septal defect (3), ventricular septal defect (5), anomalous pulmonary venous return (1). Six patients had a residual shunt following video-assisted interruption. Five patients had successful immediate clip repositioning (three via video-assisted interruption, two via thoracotomy). One patient continued to have a small shunt, which is followed medically. Complications included recurrent laryngeal nerve dysfunction in six patients (1.8%) (five transient, one persistent). Mean operating time was 20 +/- 1.5 mn and hospital stay averaged 48 h (> 6 months), 72 h (< 6 months).

CONCLUSIONS

Interruption of patent ductus can be safely performed by video-assisted technique with minimal morbidity and no mortality. It can be performed in all age group with minimal hospital stay.

Coronary artery revascularisation without extracorporeal circulation. Indications and results

OBJECTIVE

Coronary artery revascularisation without extracorporeal circulation is a technique which can be performed in selected patients in need of a coronary artery bypass graft.

METHODS

Consecutive patients (210) underwent coronary artery bypass graft without extracorporeal circulation. Indications were high risk patients, or single coronary artery lesion. To predict perioperative mortality, preoperative risk factors were reviewed, and Parsonnet score was calculated.

RESULTS

There were seven deaths (3.3%), and univariate analysis revealed greater age, NYHA, and poor ejection fraction to be the only predictors of early mortality. Perioperative myocardial infarction included 15 patients (7.1%), most of them seen in the multiple bypass group (10/39, 26%). Patients were divided into low risk (Parsonnet score < 15) 155 patients with two deaths (1.2%), and high risk (Parsonnet score > 15) 55 patients with five deaths (9%). Complete revascularisation was performed in the low risk group, while in the high risk only the symptomatic vessel was bypassed and other angiographic lesions treated with postoperative angioplasty (10 patients). A total of 12 patients developed early postoperative angina (5.7%), 9 presented an anastomosis dysfunction which was treated by angioplasty (5) and surgery (4), and 188 patients (85.7%) did not receive transfusions while 190 patients (90.4%) did not need postoperative inotropes. Length of stay, operating room time, and medical costs were all significantly reduced.

CONCLUSIONS

Myocardial revascularisation without extracorporeal circulation can be performed with a low operative mortality, and minimal morbidity only in patients undergoing single bypass revascularisation. It can also be performed as part of a multiple revascularisation strategy in association with angioplasty in high risks patients.