Pulmonary Artery Aneurysm : A Case Report and Management of this Uncommon Pathology

Pulmonary artery aneurysm is a rare pathology and the optimal treatment approach remains unclear in the absence of clear guidelines. We report a case of pulmonary aneurysm and discuss the treatment options.

Efficacy of TachoSil® as a sutureless hemostatic patch to repair a perforation of the interventricular groove during endocardial radiofrequency ablation

Catheter ablation is a well-established therapeutic option for management of recurrent ventricular tachycardia in patients with ischemic/non-ischemic heart disease and procedural complications include a mortality rate of up to 3% and a risk of major complications up to 10%. Cardiac perforation following a catheter ablation is rare but serious complication and occurs in 1% of ventricular ablation procedures. The appropriate surgical repair may be challenging and need cardiopulmonary bypass support according to the location of the lesion and the hemodynamic status of the patient. We report the case of a free wall right ventricular perforation of the interventricular groove with cardiac tamponade following catheter ablation for recurrent ventricular tachycardia. Due to the proximity of the left anterior descending artery and the extreme fragility of tissues, the patient was treated successfully by a sutureless patch technique using a fibrin tissue-adhesive collagen fleece (TachoSil®). This technique is a safe and effective surgical option to repair a ventricular perforation especially when the ventricular tissues are fragile. It is simple and enable to realize surgical repair also if the localization of tear is difficult to access and without the need for cardiopulmonary bypass support if hemodynamic conditions are stable.

Telomere length in vascular tissues from patients with atherosclerotic disease

OBJECTIVES

The present study was aimed at evaluating telomere length in blood and in different vascular tissues with or without atheroma, in 3 groups of subjects: a group of atherosclerotic subjects who underwent surgery (Atherosclerosis-Surgery), a second group of subjects with asymptomatic atherosclerotic carotid plaques but who did not undergo cardiovascular surgery (Atherosclerosis-No surgery), and a third group of subjects without atherosclerotic disease (Controls). The main objective was to determine if there is in vivo regulation of telomere length in situ by atherosclerotic lesions.

METHODS

A total of 84 subjects (mean age 69 ± 8 years) were studied. Blood and arterial tissue telomere lengths were determined by Southern blotting. Personal medical history (diabetes, hypertension, cardiovascular disease, dyslipidemia), family medical history, drug intake, and lifestyle were evaluated in the entire population through the use of a questionnaire.

RESULTS AND CONCLUSION

Arterial segments which did not develop atherosclerosis such as the saphenous vein and internal mammary artery, had longer telomere length than aortic segments. On the other hand, telomere length was shorter in aortic tissues which presented atherosclerotic lesions compared to corresponding tissues without atherosclerotic lesions. These results also suggest tissue regulation of telomere size by local factors likely related to oxidative stress responses.

Ultrasound-guided radiofrequency-driven umbilical cord occlusion: an in-vitro study

OBJECTIVES

To assess the ability and safety of radiofrequency (RF) to induce cord thermal lesions using in-vitro perfused umbilical cords.

METHODS

Nineteen human term umbilical cords were cannulated at both ends and perfused continuously with saline serum in a saline serum bath (37 degrees C). The RF electrode was then inserted into the cord close to the umbilical vein. Different RF power and temperature controls were applied to determine the optimal RF procedure in terms of cord tissue injury and safety in nine experiments. The safety of RF procedures was investigated in ten cords by measuring temperature changes at different sites close to the RF electrode insertion and the impact of RF on cord narrowing was evaluated by continuous monitoring of intraluminal pressure. Subsequent histopathological analysis was carried out in all cases.

RESULTS

The optimal RF procedure reached a temperature of 100 degrees C in 10 min. RF produced a significant increase in intraluminal pressure (from 54.2 +/- 16.4 mmHg at baseline to 118.3 +/- 42.7 mmHg after 10 min, P < 0.05). There was no significant increase in temperature next to the site of insertion during the RF procedure. Histopathological analysis confirmed a > 30% decrease in cord and vein diameter. Cord tissue lesions were characterized by damage in the vessel walls and in the surrounding Wharton's jelly.

CONCLUSION

Our results suggest that RF might be a feasible and safe technique to induce occlusion of umbilical vessels. Further in-vivo experiments are needed to assess its ability to induce a complete occlusion of the umbilical cord.

Superior prevention of acute rejection by tacrolimus vs. cyclosporine in heart transplant recipients--a large European trial

We compared efficacy and safety of tacrolimus (Tac)-based vs. cyclosporine (CyA) microemulsion-based immunosuppression in combination with azathioprine (Aza) and corticosteroids in heart transplant recipients. During antibody induction, patients were randomized (1:1) to oral treatment with Tac or CyA. Episodes of acute rejection were assessed by protocol biopsies, which underwent local and blinded central evaluation. The full analysis set comprised 157 patients per group. Patient/graft survival was 92.9% for Tac and 89.8% for CyA at 18 months. The primary end point, incidence of first biopsy proven acute rejection (BPAR) of grade >/= 1B at month 6, was 54.0% for Tac vs. 66.4% for CyA (p = 0.029) according to central assessment. Also, incidence of first BPAR of grade >/= 3A at month 6 was significantly lower for Tac vs. CyA; 28.0% vs. 42.0%, respectively (p = 0.013). Significant differences (p < 0.05) emerged between groups for these clinically relevant adverse events: new-onset diabetes mellitus (20.3% vs. 10.5%); post-transplant arterial hypertension (65.6% vs. 77.7%); and dyslipidemia (28.7% vs. 40.1%) for Tac vs. CyA, respectively. Incidence and pattern of infections over 18 months were comparable between groups, as was renal function. Primary use of Tac during antibody induction resulted in superior prevention of acute rejection without an associated increase in infections.

Telerobotic-assisted laparoscopic hysterectomy for benign and oncologic pathologies: initial clinical experience with 30 patients

BACKGROUND

Telerobotic-assisted laparoscopic attempts to provide technological solutions to the inherent limitations of traditional laparoscopic surgery. The aim of this study is to report the first experience of two teams concerning telerobotic-assisted laparoscopic hysterectomy for benign and malignant pathologies.

METHODS

This study included 14 patients at the University Hospital Saint Pierre of Brussels (Belgium) and 16 patients at the Cancer Center of Nancy (France) from September 1999 to July 2003.

RESULTS

The indications for surgery were uterine malignant diseases in 12 cases (stade I) (41%), and benign pathologies of the uterus in 18 cases (59%). Five postoperative complications (17%) occurred, none related to the robotic system.

CONCLUSION

Robotic surgery can be safely performed in gynecologic and gynecologic-oncologic surgery with no increase in complication rates. A significant advance is represented by the surgeon's ergonomic improvement.

Biliary lesions during radiofrequency ablation in liver. Study on the pig

BACKGROUND

Radiofrequency (RF) is a method of in situ destruction of liver tumor. Biliary complications are bile ducts stenosis or biliary abcess. The aim of this work was to study consequences of liver RF on bile ducts.

METHODS

A porcine model of biliary lesions was created using radiofrequency ablation liver. Twenty-two pigs were used for the study. The RF RITA 1500 generator (RITA Medical Systems, Mountain View, Calif., USA) was used for all experiments. The needle was positioned under sonographic control in liver parenchyma beside bile ducts. Two lesions were performed in left liver. Four groups of 5 pigs were treated. The pigs were sacrificed 1 or 3 weeks after the procedure. Pringle maneuver was utilized in half of the RF procedures. An ex vivo cholangiogram was obtained by direct injection into the main bile duct. Samples of RF lesions of liver parenchyma near and at a distance from the RF lesions were taken for pathological studies.

RESULTS

Radiological lesions were biliary stenosis, with or without upstream bile duct dilatation, or complete interruption of the bile duct, or extravasation of the radiological contrast agent. Histological lesions of bile ducts were observed near RF lesions and at distance of the RF lesions when a Pringle maneuver was used or when the liver was removed after 3 weeks.

CONCLUSIONS

RF ablation in contact of the intrahepatic bile duct induced biliary lesions. Therefore, it is required to stay away from the bile duct or to protect it when performing RF ablation.

Laparoscopic computer-assisted pyeloplasty: the results of experimental surgery in pigs

OBJECTIVE

To evaluate the experimental feasibility of laparoscopic computer-assisted pyeloplasty for pelvi-ureteric junction obstruction.

MATERIALS AND METHODS

Fourteen pyeloplasties were undertaken in pigs using a laparoscopic transperitoneal approach and the robotic surgical system (da Vinci, Intuitive Surgical Inc., Sunnyvale, CA, USA).

RESULTS

The robotic surgical system provides real-time three-dimensional stereoscopic vision. Manipulating the intracorporeal endo-wristed instruments from a remote console allows laparoscopic manoeuvres that are as easy as those during open surgery. Surgeons with no particular experience in laparoscopic surgery could learn complex surgery easily and quickly.

CONCLUSION

This technique provides faster training and the possibility of undertaking complex laparoscopic procedures, especially reconstructive, with less fatigue for the surgeon.

Antithrombotic therapy is associated with better survival in patients with severe heart failure and left ventricular systolic dysfunction (EPICAL study)

BACKGROUND

In patients with congestive heart failure (CHF), clinical trials have demonstrated the benefit of a number of drugs on morbidity and mortality. Nevertheless so far, there is no published controlled study of long-term antithrombotic therapy in patients with CHF. The aim of this work was to identify the relationship between cardiovascular drug use, especially antithrombotic therapy, and survival of CHF patients in current clinical practice, using an observational, population-based database.

METHODS

The EPICAL study (Epidémiologie de l'Insuffisance Cardiaque Avancée en Lorraine) has identified prospectively all patients with severe CHF in the community of Lorraine. Inclusion criteria were age 20-80 years in 1994, at least one hospitalisation for cardiac decompensation, NYHA III/IV HF, ventricular ejection fraction < or =30% or cardiothoracic index > or =60% and arterial hypotension or peripheral and/or pulmonary oedema. A total of 417 consecutive patients surviving at hospital discharge were included in the database. The average follow-up period was 5 years. Univariate Cox models were used to test the relationship of baseline biological and clinical factors to survival. Cardiovascular drug prescriptions were tested in a multivariate Cox model adjusted by other known predictive factors.

RESULTS

Duration of disease >1 year, renal failure, serum sodium > or =138 mmol/l, old age, serious comorbidity, previous decompensation, high doses of furosemide and vasodilators use were independently associated with poor prognosis at 1 and 5 years. Oral anticoagulants, aspirin, lipid lowering drugs and beta-blockers use were associated with better survival. There was no interaction between aspirin and angiotensin converting enzyme inhibitor use on survival.

CONCLUSION

Antithrombotic therapy was associated with a better long-term survival in our study population of severe CHF. These results together with other previously published circumstantial evidence urge for a prospective, controlled and randomised trial specifically designed to evaluate optimal oral anticoagulants and aspirin in patients with congestive heart failure.

Ovarian strumal carcinoid tumor responsible for carcinoid heart disease

We report a case of right ovarian strumal carcinoid tumor responsible for tricuspid regurgitation. Valve replacement and salpingo-oophorectomy were performed. Serotonin level and tomodensitometry were normal at 3-year follow-up. Rarity of strumal carcinoid tumor explains why this tumor has never been reported with carcinoid heart disease before.

Activation of metalloproteinase-2, loss of matrix scleroprotein content and coronary artery calcification

Plaques from the coronary arteries of explanted hearts showed massive calcification (15-fold increase) with a loss of scleroproteins (-36%), an increase in the collagen to elastin ratio (twofold) and activation (+15%) of matrix metalloproteinase-2 (MMP-2). Plaque-free portions of the coronary artery gave results similar to those obtained with the internal mammary artery. There was a significant correlation between plaque calcification and MMP-2 activation, suggesting that the two processes may be linked.

Detection and prediction of acute heart transplant rejection with the myocardial T2 determination provided by a black-blood magnetic resonance imaging sequence

OBJECTIVES

This study aimed to determine whether the myocardial T2 relaxation time, determined using a black-blood magnetic resonance imaging (MRI) sequence, could predict acute heart transplant rejection.

BACKGROUND

The use of black-blood MRI sequences allows suppression of the confusing influence of blood signal when myocardial T2 is calculated to detect myocardial edema.

METHODS

A total of 123 investigations, including cardiac MRI and myocardial biopsy, were performed 8 +/- 11 months after heart transplantation. Myocardial T2 was determined using an original inversion-recovery/spin-echo sequence.

RESULTS

A higher than normal T2 (> or = 56 ms) allowed an accurate detection of the moderate acute rejections evidenced at baseline biopsy (> or = International Society for Heart and Lung Transplantation grade 2): sensitivity, 89% and specificity, 70% (p < 0.0001). T2 was increased in grade 2 (n = 11) compared with grade 0 (n = 49, p < 0.05), grade 1A (n = 34, p < 0.05) and grade 1B (n = 21, p < 0.05); T2 was further increased in grade 3 (n = 8) compared with grade 2 (p < 0.05). In addition, in patients without rejection equal to or greater than grade 2 at baseline, a T2 higher than normal (> or = 56 ms) was correlated with the subsequent occurrence of equal or greater than grade 2 rejection within the next three months: sensitivity 63% (12/19) and specificity 78% (64/82) (p = 0.001).

CONCLUSIONS

Myocardial T2 determined using a black-blood MRI sequence, is sufficiently sensitive to identify most of the moderate acute rejections documented with biopsy at the same time, but is also a predictor of the subsequent occurrence of such biopsy-defined rejections.

[Advanced cardiac failure. New surgical approaches]

THERAPEUTIC OPTIONS

Prognosis of advanced heart failure is ominous since survival rate is less than 65% one year after an acute and severe cardiac episode. Medical therapy has proven to be efficient in reducing fatal complications and in delaying critical evolution. Depending on the etiology and the myocardial status, new surgical approaches can also be proposed for repair or substitution. SURGICAL REPAIR: The beneficial effect of myocardial revascularization on severe ischemic cardiomyopathy, the relevance of mitral valve repair in dilated cardiomyopathy, and the advantage of ventricular remodeling in patients with major ventricular dyskinesia has been clearly demonstrated. All these surgical techniques improve ventricular function and enhance survival rate by about 70% after three years. SUBSTITUTION PROCEDURES: The best therapeutic option to recover heart function for normal life and reduced mortality remains, when possible, cardiac transplantation. Ventricular cardiac assist devices are planned as a temporary option to bridge the waiting period to transplantation or for myocardial recovery but can also be proposed as a chronic implantation in an outpatient care scheme. Cardiomyoplasty for therapeutic management of advanced cardiac failure is still a controversial surgical approach. Other clinical strategies such as transmyocardial laser revascularization, myocardial angiogenesis and myocardial cell therapy are being investigated or developed. ADAPTED TREATMENT: Optimal management of each patient with advanced heart failure requires an adequate treatment selected among a wide range of medical and/or surgical strategies.

High-performance liquid chromatographic analysis of muscular interstitial arginine and norepinephrine kinetics. A microdialysis study in rats

Complex interactions between the L-arginine/nitric oxide synthase (NOS) pathway and the sympathetic nervous system have been reported. Methods capable of measuring L-arginine and norepinephrine (NE) have mainly been reported for plasma. We report the use of the microdialysis technique combined with high-performance liquid chromatography (HPLC) for measurement of both L-arginine and NE within the same tissue microdialysis sample. The microdialysis probe consisted of linear flexible probes (membrane length: 10 mm, outside diameter: 290 microm, molecular weight cut-off 50 kDa). The method used for L-arginine measurement was HPLC with fluorescence detection, giving a within-run and a between-day coefficient of variation of 2.9 and 12.8%, respectively. The detection limit was 0.5 pM/20 microl injected for L-/D-arginine. The method used for NE measurement was HPLC with electrochemical detection. The coefficients of variation were 4% for within-assay precision and 7.5% for between-assay precision. The detection limit for NE was 1 fmol/20 microl injected. The microdialysis technique coupled with HPLC system was validated in vivo to measure muscular interstitial concentrations of both arginine and NE under baseline conditions and after intravenous infusion of 500 mg/kg of L-arginine or D-arginine. In conclusion, the microdialysis technique coupled to HPLC allows the simultaneous measurements of both L-arginine and NE within the same tissue microenvironment and will enable the study of the complex interactions between the L-arginine/NO pathway and sympathetic nervous system within the interstitial space of different organs.

Differential clinical prognostic classifications in dilated and ischemic advanced heart failure: the EPICAL study

BACKGROUND

The clinical management of severe congestive heart failure (CHF) should be graded according to the prognosis of each individual patient. Our objective was to elaborate a prognostic rating system for severe CHF.

METHODS

The EPICAL program (Epidémiologie de l'Insuffisance Cardiaque Avancée en Lorraine) identified patients with severe CHF defined by hospitalization accompanied by class III/IV dyspnea, edema, or hypertension; an ejection fraction </=30% or a cardiothoracic index >/=60%. Baseline variables were tested in Cox multivariate models.

RESULTS

Patients with ischemic heart disease (n = 219) had a lower 1-year survival rate (57.6%) than patients with dilated cardiomyopathy (n = 182) (69. 1%). Multivariate analysis identified 5 prognostic factors for ischemic CHF and 7 for CHF caused by dilated cardiomyopathy. These variables were used to classify patients within prognostic subgroups of good (>75%), intermediate, or poor (</=25%) 1-year survival.

CONCLUSION

A score for prognostic prediction was further derived from readily available data to help physicians improve decision making and to assist in clinical trials as a stratification tool.

Determinants of angiotensin-converting enzyme inhibitor prescription in severe heart failure with left ventricular systolic dysfunction: the EPICAL study

BACKGROUND

Angiotensin-converting enzyme (ACE) inhibitors have been demonstrated to reduce morbidity and mortality rates in patients with heart failure with left ventricular systolic dysfunction. Nevertheless, these drugs are underutilized in current practice and prescribed at doses below those usually recommended. The aim of this work was to identify the social, demographic, laboratory, clinical, and therapeutic factors associated with nonprescription of ACE inhibitors and/or their prescription at doses below those recommended in the treatment of severe long-term congestive heart failure (CHF).

METHODS AND RESULTS

An epidemiologic observational study, EPICAL (EPidémiologie de l'Insuffisance Cardiaque Avancée en Lorraine), studied 417 patients with severe CHF surviving after the index hospitalization. Multivariate logistic regression determined the factors associated with ACE inhibitor nonprescription and with their prescription at lower-than-recommended doses. ACE inhibitors were taken by 75% of the patients but 38% took lower-than-recommended doses. Factors shown to be associated with nonprescription included patients >65 years of age with renal impairment (odds ratio 19.5, confidence interval [CI] 7.9-48.0), nonsinus cardiac rhythm (odds ratio 2.0, CI 1.2-3.2), and prescription of potassium-sparing diuretics (odds ratio 2.4, CI 1. 2-4.7). Renal impairment was the single most important factor associated with prescription of lower-than-recommended doses, particularly in elderly patients.

CONCLUSIONS

Our results underline the need for optimal and better use of ACE inhibitor therapy. CHF treatment guidelines must be more uniformly applied by all physicians caring for patients with heart failure.

Consequences of inspired oxygen fraction manipulation on myocardial oxygen pressure, adenosine and lactate concentrations: a combined myocardial microdialysis and sensitive oxygen electrode study in pigs

Adenosine is a potent vasodilator whose concentration has been shown to increase in cardiac tissue in response to hypoxia. However, the time-dependent relationship between the levels of myocardial interstitial adenosine and tissue oxygenation has not yet been completely established. Therefore, the purpose of this study was to investigate the complex relationship between tissue myocardial oxygen tension (PtiO(2)) and interstitial myocardial adenosine and lactate concentrations by developing a new technique which combines a cardiac microdialysis probe and a Clark-type P O(2)electrode. The combined and the single microdialysis probes were implanted in the left ventricular myocardium of anesthetized pigs. The consequences of the combined use of microdialysis and P O(2)probes on myocardial PtiO(2)and microdialysis performances against glucose were evaluated. A moderate but significant reduction in the relative recovery against glucose of the combined probe was observed when compared to that of the single microdialysis probe (42+/-2 v 32+/-1%, mean+/-S.E. M.n=5 P<0.05), at 2microl/min microdialysis probe perfusion flow. Similarly, myocardial oxygen enrichment, measured by the P O(2)electrode, was negligible when microdialysis probe perfusion flow was 2microl/min. Systemic hypoxia (FiO(2)=0.08) resulted in a significant decrease in PtiO(2)from 30+/-4 to 11+/-2 mmHg, limited increase in coronary blood flow (CBF), and a significant increase in myocardial adenosine and lactate concentrations from 0.34+/-0.05 to 0.98+/-0.06micromol/l and from 0.45+/-0.05 to 0.97+/-0.06 mmol/l respectively (P<0.05). Increasing the FiO(2)to 0.3 restored the PtiO(2)and hemodynamic parameters to baseline values with no changes in interstitial adenosine and lactate concentrations. Nevertheless, myocardial interstitial adenosine remained significantly higher than baseline values. In conclusion, this study demonstrates the ability of a combined probe to measure simultaneously regional myocardial PtiO(2)and metabolite concentration during hypoxia. The hypoxia-induced increase in myocardial adenosine persists after correction of hypoxia. The physiological significance of this observation requires further studies.

Consequences of static and pulsatile pressure on transmembrane exchanges during in vitro microdialysis: implication for studies in cardiac physiology

Microdialysis is an established technique for measuring the kinetics of various neurotransmitters within the extracellular space in the field of neurochemistry. Recently, its use has been extended to sampling in other tissues, including liver, kidney and the heart. A persistent problem in cardiac microdialysis concerns two parameters related to myocardial function: pressure and frequency (heart rate). The aim of the study is to evaluate the consequences of pressure and frequency on transmembrane exchanges. Linear flexible microdialysis probes (membrane length: 12 mm, outside diameter: 390 microns, MWCO 50,000 Daltons) were designed in our laboratory. The probes, perfused at 2 microL/min with sterile water, were placed in a system filled with a glucose solution (2 g/L) and able to generate either static: 0 to 400 mmHg (0 to 53.31 kPa) or pulsatile pressure: 0-100; 0-200; 0-300 mmHg (0-13.32; 0-26.65; 0-39.98 kPa) at different frequencies: 1, 2 and 3 Hz. At 2 mu litre min-1 perfusion rate, the pressure inside the probe is estimated to be 80 mmHg (10.66 kPa). Under static pressure conditions, the glucose recovery rate can be expressed as an exponential function, and the outflow rate can be expressed as a linear function of the external pressure level. Under dynamic conditions, the external mean pressure must be accounted for. When external mean pressure exceeds 80 mmHg (10.66 kPa) (pressure generated by the flow rate of perfusion inside the probe), the recovery rate increases with frequency. Conversely, if the outer mean pressure is lower than 80 mmHg (10.66 kPa), the recovery rate decreases with frequency. Theoretical and experimental modelling results in a nomogram that can be used to estimate in vivo recovery. In conclusion, mass transfer across a microdialysis membrane is dependent on the direction of the transmembrane pressure gradient and increases with heart rate. These findings must be taken into account when in vivo recovery rates during cardiac microdialysis are determined.

Acute pulmonary hypertension after cardiopulmonary bypass in pig: the role of endogenous endothelin

BACKGROUND

Acute pulmonary hypertension occurring after cardiopulmonary bypass can be a cause of post-operative morbidity and mortality. The purpose of this study was to investigate whether bosentan, a non-peptidic mixed endothelin antagonist affected the pulmonary hypertension induced by experimental cardiopulmonary bypass.

METHODS

Pigs were anesthetized and instrumented to determine hemodynamic measurements. Pigs were randomized to receive either 3 mg/kg bolus + 7 mg/kg per h bosentan (n = 8) or saline (n = 7). All pigs underwent 90 min of cardiopulmonary bypass and were further observed for a 120-min period.

RESULTS

In the control group, cardiopulmonary bypass induced a dramatic pulmonary hypertension (+78 +/- 13%, P < 0.005) and accompanied an increase of pulmonary vascular resistance (+228 +/- 50%, P < 0.005), whereas, in the treated group, bosentan completely prevented these deleterious effects of cardiopulmonary bypass with only a moderate decrease of systemic vascular resistance (-19 +/- 14.6%, P < 0.05).

CONCLUSIONS

The present findings support the hypothesis that endogenous endothelin is a mediator of acute pulmonary hypertension occurring after cardiopulmonary bypass. Bosentan, a mixed endothelin antagonist completely prevented pulmonary hypertension after cardiopulmonary bypass and may, therefore, have therapeutic applications in the management of patients following cardiac surgery.

Incidence, clinical and etiologic features, and outcomes of advanced chronic heart failure: the EPICAL Study. Epidémiologie de l'Insuffisance Cardiaque Avancée en Lorraine

OBJECTIVES

Characterize the incidence, clinical and etiologic features and outcomes of advanced congestive heart failure.

BACKGROUND

This condition is frequent, severe and costly, yet no population-based epidemiological data are available that take into account modern advances in diagnosis and therapy.

METHODS

The EPICAL (Epidémiologie de l'Insuffisance Cardiaque Avancée en Lorraine) study was based on a comprehensive registration of patients with ACHF (defined as hospital admission for presence of NYHA class III or IV symptoms, radiological and/or clinical signs of pulmonary congestion and/or signs of peripheral edema, left ventricular ejection fraction <30% or a cardiothoracic ratio >60%) in patients aged 20-80 years during year 1994, in the community of the Lorraine region in France (n = 1,592,263). Average follow-up for readmission to hospital and mortality was 18 months (12-24 months).

RESULTS

From 2,576 registered patients, 499 were enrolled into the study among which, 358 were new presentations. This represents a crude incidence rate of 225 per million. 46.3% had a coronary heart disease. One-year mortality rate was 35.4% and the rate of mortality and/or readmission to hospital was 81%. Patients were admitted to hospital 2.05 times per year (64% of these for worsening heart failure), spending 27.6 days per year in hospital. Twenty received a heart transplant (4%). On discharge, 74.8% were using ACE inhibitors and 49.6% digitalis.

CONCLUSIONS

Mortality and hospitalization rate of advanced CHF remain very high despite recent therapeutic progress. Major therapeutic and managed-care research is required.

Comparison of long term outcome in patients with or without aortic ring abscess treated surgically for aortic valve infective endocarditis

OBJECTIVE

To assess the long term prognostic significance of aortic valve ring abscess in patients with aortic endocarditis.

PATIENTS

A consecutive series of 75 patients who had surgery for aortic infective endocarditis between 1981 and 1989; 35 had aortic ring abscesses (group 1) and 40 did not (group 2). Mean age did not differ between the two groups. Prosthetic valve endocarditis was present in 17% of group 1 and 5% of group 2. Pneumococcal or beta haemolytic streptococcal endocarditis was more common in patients with native valve endocarditis who had aortic ring abscesses (20% v 5%).

DESIGN

Cohort analysis.

RESULTS

In-hospital mortality (11.4% v 7.5%) and 10 year survival (56% v 66%) were not significantly different between groups 1 and 2. In patients with native valve endocarditis, 10 year survival was 62% and 66%, respectively for patients with or without ring abscess, and 10 year reintervention-free survival was 38% v 58% (p = 0.11). In these patients, the presence of an intercurrent illness, severe congestive heart failure before surgery, and use of valved conduits for surgical treatment were predictors of poorer long term survival. At follow up residual aortic regurgitation was documented in 72% of patients in group 1 and 26% in group 2 (p < 0.01).

CONCLUSIONS

Aortic valve ring abscess is not an independent marker of poor long term outcome in patients with infective endocarditis. However, as residual aortic regurgitation appears frequent at follow up, specific surgical techniques should be considered in patients with paravalvar abscesses.

Increase in myocardial interstitial adenosine and net lactate production in brain-dead pigs: an in vivo microdialysis study

BACKGROUND

Brain death-related cardiovascular dysfunction has been documented; however, its mechanisms remain poorly understood. We investigated changes in myocardial function and metabolism in brain-dead and control pigs.

METHODS

Heart rate, systolic (SAP) and mean (MAP) arterial pressure, left ventricular (LV) dP/dtmax, rate-pressure product, cardiac output (CO), left anterior descending coronary artery blood flow, lactate metabolism, and interstitial myocardial purine metabolite concentrations, monitored by cardiac microdialysis, were studied. A volume expansion protocol was performed at the end of the study.

RESULTS

After brain death, a transient increase in heart rate (from 90 [67-120] to 158 [120-200] beats/min) (median, with range in brackets), MAP (82 [74-103] to 117 [85-142] mmHg), LV dP/dtmax (1750 [1100-2100] to 5150 [4000-62,000] mmHg x sec(-1), rate-pressure product (9100 [7700-9700] beats mmHg/min to 22,750 [20,000-26,000] beats mmHg/min), CO (2.2 [2.0-4.0] to 3.3 [3.0-6.0] L/min), and a limited increase in left anterior descending coronary artery blood flow (40 [30-60] to 72 [50-85] ml/min) were observed. Net myocardial lactate production occurred (27 [4-40] to -22 [-28, -11] mg/L, P<0.05) and persisted for 2 hr. A 6-7-fold increase in adenosine dialysate concentration was observed after brain death induction (2.9 [1.0-5.8] to 15.8 [7.0-50.7] micromol/L), followed by a slow decline. Volume expansion significantly increased MAP, CO, and LV dP/dtmax in control animals, but decreased LV dP/dtmax and slightly increased CO in brain-dead animals. A significant increase in adenosine concentration was observed in both groups, with higher levels (P<0.05) in brain-dead animals.

CONCLUSIONS

Brain death increased oxygen demand in the presence of a limited increase in coronary blood flow, resulting in net myocardial lactate production and increased interstitial adenosine concentration consistent with an imbalance between myocardial oxygen demand and supply. This may have contributed to the early impairment of cardiac function in brain-dead animals revealed by rapid volume infusion.

Treatment of end-stage renal failure after heart transplantation

BACKGROUND

Five to 10% of heart-transplant recipients develop end-stage renal failure (ESRF). Little is known about the outcome of these patients under renal replacement therapy.

METHODS

We conducted a retrospective study in 16 men (mean age 52.8+/-7.4 years at heart transplantation) who developed ESRF 5.3+/-2.1 years later. Results. Haemodialysis (HD) was the first-line treatment (mean Kt/V 1.35+/-0.4). Vascular access was unsuccessful in six patients (37.5%) due to peripheral arteriopathy and they were treated with tunnelled catheters for an average 15 months without bacterial infection. Mean weight was 68.4+/-10 kg at onset of HD and 61.7+/-9 kg one month later. Despite this reduction in extracellular overload, one antihypertensive drug was required in 75% of patients and two drugs in 12.5%. One patient tolerated automated peritoneal dialysis (PD) for 16 months (weekly Kt/V 2.1) despite persistent anuria. Renal transplantation (RT) was contraindicated in eight patients because of aortoiliac arteriopathy (n=5), poor general status (n=2), or ischaemic heart disease (n=1). RT was performed in eight patients with no acute episode of heart or renal graft rejection. There were no serious infectious complications. Three months after RT, mean serum creatinine was 115 micromol/l. One patient developed post-transplant lymphoproliferative disorder 3.5 months after RT and was successfully treated with transplant nephrectomy. Sudden death occurred in two patients 18 and 33 months after RT. Overall patient survival was 100, 78, and 59%, 1, 2 and 3 years after HD onset respectively. Using a time-dependent variable, the Cox model analysis demonstrated that heart-transplant recipients with ESRF have a relative risk of death 3.2 times higher than those without ESRF (95% CI = 1.3-7.8).

CONCLUSIONS

HD, PD, and RT can be useful for the treatment of ESRF after heart transplantation. After initiating HD, patient survival is nearly the same as that reported in patients in Europe undergoing HD for other causes. But ESRF seems to reduce life expectancy in heart-transplant recipients.

[Protective effect of labetalol on cardiovascular consequences of brain death in the swine]

OBJECTIVE

Assessment of the preventive effect on cardiovascular changes following experimental brain death (BD) in the pig by pretreatment with labetalol, an alpha and beta adrenoreceptor blocking agent.

STUDY DESIGN

Experimental study.

ANIMALS

Ten 25-35 kg domestic pigs allocated either in the control group (n = 5) or the labetalol group (n = 5).

METHODS

BD was achieved in anaesthetized animals by the rapid inflation of a Foley catheter inserted into the sub-dural space. In the labetalol group, the agent (total: 10 +/- 3 mg.kg-1) was administered immediately before BD and thereafter over a 20-min period, in order to maintain haemodynamic parameters at control values. The following haemodynamic data were recorded over a 3 hour period after BD: heart rate (HR), dP/dtmax, mean arterial pressure (MAP), pulmonary capillary wedge pressure (PCWP), cardiac output (CO) and left anterior descending coronary artery blood flow (CBF). Afterwards, a dynamic loading test with 500 mL of dextran over 20 min was performed.

RESULTS

In the control group, BD elicited a significant increase in HR (from de 96 +/- 9 to 176 +/- 11 b.min-1), dP/dtmax (from 1,960 +/- 123 to 4,904 +/- 930 mmHg.s-1), MAP (from 88 +/- 5 to 119 +/- 11 mmHg), CO (from 2.4 +/- 0.2 to 3.6 +/- 0.7 L.min-1) and CBF (from 45 +/- 6 to 73 +/- 7 mL.min-1) respectively. Apart from a slight increase in HR and a significant increase in CBF (from 34 +/- 4 to 55 +/- 6 mL.min-1), no other modifications occurred in the labetalol group. Following volume expansion, the labetalol group animals experienced a significant increase in CO (from 2.3 +/- 0.3 to 3.7 +/- 0.2 L.min-1), dP/dtmax (from 1,400 +/- 91 to 2,100 +/- 212 mmHg.s-1) and MAP (from 55 +/- 5 to 70 +/- 5 mmHg). In the opposite, a significant decrease in dP/dtmax (from 1,645 +/- 450 to 628 +/- 152 mmHg.s-1) occurred in the control group.

CONCLUSION

The protective effect of labetalol confirms the role played by the activation of the cardiac sympathetic nervous system in the cardiocirculatory changes following BD.

[Alteration of sinus variability after cardiac surgery]

Sinus tachycardia is frequent after cardiac surgery and this tachycardia is probably due to changes of the autonomic nervous system. The objective of this study was to evaluate the changes possibly induced by cardiac surgery, by studying sinus variability (SV) during a 24-hour Holter monitoring. The examination was performed in 28 patients who had undergone cardiac surgery 1 to 6 weeks previously. These patients had no alteration of left ventricular function, or any causes likely to modify SV and they had a normal postoperative course. Their results were compared to those of 4 subjects developing a postoperative complication (1 case of ventricular tachycardia and 3 cases of resuscitated cardiac arrest). The results were also compared to those of 24 age-matched adult controls without heart disease (control group). The study of SV included temporal and spectral analysis of SV with measurement of the standard deviation of normal RR intervals (SD), mean heart rate (HR), percentage of RR intervals differing by more than 50 m/sec from the adjacent interval (pNN50), coefficient of variability (CV) (SD/RR), square root of the differences between successive RR (rMSSD), spectral properties of low frequencies (LF) and high frequencies (HF) and the fractionated spectral property (LF/HF).

RESULTS

(see tables, page 151 and 152). An alteration of SV was therefore observed in the surgical group, and lasted 4 to 6 months after surgery. No difference was observed between subjects without cardiac events and those presenting a cardiac event.

IN CONCLUSION

cardiac surgery decreases all parameters of SV during the first few postoperative months. Certain unexpected cardiac accidents during this period could be explained by these changes.

[Measurement of functional inability and quality of life in cardiac failure. Transcultural adaptation and validation of the Goldman, Minnesota and Duke questionnaires]

Cardiac failure has a big impact on the daily life of patients and this can be evaluated using quality of life questionnaires. The aim of this study was to translate and adapt for the French population and test the validity of two quality of life self-administered-questionnaires: the Duke health Profile, the Minnesota Quality of Life Questionnaire in Cardiac Failure and one function capacity questionnaire, the Goldman Specific Activity Scale. The questionnaires were translated and retranslated then submitted to a committee of experts: the final version was presented to 30 patients. The study of the quantitative properties of the three instruments was performed on a sample of 74 patients with cardiac failure to assess their validity and 26 stable patients after cardiac transplantation to test reproducibility. The results of this study show that these three instruments are valid and reproducible and are comparable to the original documents: Cronbach's Alpha ranging from 0.54 to 0.78 for the Duke, except for the social dimension, and from 0.73 to 0.93 for the Minnesota, except for its incapacity dimension, intraclass correlation coefficient > 0.6 in all dimensions. The validity of convergence with LVEF and the NYHA measured during hospitalisation for decompensation was poor, except for the Goldman. The three instruments provided coherent information. The authors conclude that a structured method allows transcultural adaptation of instruments of evaluation of quality of life, the French version having comparable properties to the original documents: they may be used for clinical research.

[Reflections on external circulatory assistance. Apropos of 8 patients treated with the MEDOS system]

Mechanical circulatory support is required when cardiogenic shock is unresponsive to well conducted medical therapy. In this hemodynamic situation, when the patient's life is in danger, within hours, several questions should be answered quickly. These questions take into consideration the etiologies of cardiogenic shock and are related to the possibility of improvement of myocardial function, cardiac transplantation, the choice of uni- or biventricular support and surgical techniques of left ventricular assistance (left atrium to aorta or left ventricular apex to aorta). The follow-up of patients with circulatory support is complex. It requires to take into consideration hemodynamic, mechanical and hemobiological parameters as well as the peripheric organ function. We report in this article our clinical experience with eight patients that underwent circulatory support with Medos external ventricular assist device.

[Uni- or biventricular circulatory assist devices. Selection criteria and patients' follow-up, choice of device]

Therapy of patients presenting with cardiogenic shock refractory to medical treatment can be undertaken with uni or biventricular circulatory assist devices. Pre implantation evaluation of patients is aimed at defining the etiology as well as the extent of uni versus biventricular heart failure, the possibility of recovery of myocardial function improvement of vital organ function and the possibility of cardiac transplantation. Circulatory assist devices must provide efficient support of the failing ventricles, allow recovery of myocardial function or cardiac transplantation under optimal circumstances. The choice of uni-biventricular support of total artificial heart is discussed as well as criteria useful in defining a therapeutic strategy.

Consequences of coronary occlusion on changes in regional interstitial myocardial neuropeptide Y and norepinephrine concentrations

An attempt to determine the consequences of prolonged ischemia on simultaneous regional changes in norepinephrine (NE) and neuropeptide Y (NPY) interstitial myocardial concentrations in a pig model in vivo was made. The aim of the authors was to investigate further the mechanism of the major NE release previously observed in perfused hearts preserved using a Langendorff technique. Regional myocardial ischemia was induced by ligation of the left anterior descending coronary artery (LAD) in ten anesthetized pigs. NE and NPY release was studied using interstitial microdialysis, a technique initially used to monitor neurotransmitter kinetics in brain dialysate samples. Four dialysis probes were implanted into the left ventricular wall of the beating heart. Two were implanted into the ischemic region (LAD) (for NE and NPY determinations, respectively) and the remaining two into the non-ischemic left circumflex coronary artery region (LCX). Dialysate NE and NPY concentrations, as indices of interstitial myocardial NE and NPY concentrations, were measured by HPLC and RLA, respectively. A slight but significant increase in NPY levels was observed in both territories (LAD: from 190 +/- 27 to 349 +/- 62 pmol/l, LCX: 146 +/- 30 to 257 +/- 52 pmol/l) suggesting moderate stimulation of cardiac sympathetic nerve activity following LAD occlusion. On the contrary, a marked but progressive increase in NE release was observed in the ischemic region (from 8.8 +/- 1.0 to 251.4 +/- 44.8 nmol/l), when NE levels in the non-ischemic region remained stable (from 10.3 +/- 2.1 to 11.0 +/- 1.9 nmol/l). These results demonstrate the utility of regional in-vivo myocardial NE and NPY monitoring using microdialysis. The strong and sustained NE accumulation occurring in the ischemic region is consistent with the hypothesis of a local non-exocytotic metabolic NE release in case of prolonged myocardial ischemia, when exocytotic release remain only minimal as attested by the slight increase in NPY observed.

[Antiaggregant effect and tolerance of calcium carbasalate administrated immediately after aorto-coronary bypass. Results of a double-blind versus placebo study]

The patency of aorto-coronary bypasses is greatly influenced by platelet aggregability, and there is an associated risk of thrombosis which may occur very early during surgery. It is in this context that aspirin has been the subject of successful clinical studies. When administering aspirin, it is preferable to choose formulations that are well tolerated by the gastro-intestinal tract. This was the reason for carrying out the present randomised single-centre double-blind parallel-group study aimed at confirming the platelet anti-aggregant effect and tolerability of calcium carbasalate administered during the immediate postoperative period. The dose prescribed was equivalent to aspirin 325 mg daily, and was given as a single dose 6 hours after the end of the operation and repeated for 7 days, versus placebo, in 56 patients undergoing aorto-coronary bypass grafts. A clinical assessment, ECG, platelet count and measurements of CPK and CPK-MB were carried out daily for the 7 days of the study. Tests of platelet aggregation (to arachidonic acid, ADP and collagen), assays of serum thromboxane B2, MDA and PDF, and urinary assays for beta-thromboglobulin and 6-keto-PGF-1 were carried out before treatment, then 1 and 7 days after the start of treatment. Fifty males (89%) and 6 females, mean age 58.3 years, received treatment with either calcium carbasalate (group C, n = 28) or placebo (group P, n = 28). The atheromatous lesions present in most cases represented triple-vessel disease (37 cases), and most operations were triple bypasses (23 cases) or double bypasses (20 cases). A significant reduction in platelet aggregation to arachidonic acid and collagen on D1 (p = 0.05) and D7 (p < 0.001), and to ADP on D7 (p < 0.01) was observed in group C as compared with group P. Group C also showed significant reductions as compared with group P in respect of serum thromboxane B2 levels on D1 (p < 0.01) and D7 (p < 0.001) and MDA levels on D1 and D7 (p < 0.001). No significant difference was demonstrated between the two groups in respect of urinary 6-keto-PFG-1 excretion. The number of patients showing a rise in CPK was lower in group C but this difference did not reach statistical significance. ST segments change were comparable in the two groups, and no patient complained of anginal pain during the study. These results show that calcium carbasalate administered at a dose equivalent to 325 mg aspirin daily caused very early inhibition of platelet aggregation, specifically inhibiting platelet production of thromboxane B2 without altering prostacyclin levels. In addition, calcium carbasalate was found to be well tolerated. This study confirms the value of early administration of aspirin at a dose of 325 mg daily during the hours immediately following aorto-coronary bypass graft surgery.

[Primary liposarcoma of the left ventricle. Apropos of a case and review of the literature]

Primary malignant myocardial tumours are rare and essentially sarcomas. The authors report a case of primary left ventricular liposarcoma which is the 18th reported case. The presenting signs were of cardiac failure. Metastases are common by the time of diagnosis. Surgical ablation, though rarely complete because of its myocardial localisation, is justified for precise histological diagnosis. The prognosis of these lesions is poor. Complementary treatment is rarely used. However, it should be proposed as surgery alone has been shown to have limited curative applications.

Inhaled nitric oxide as an adjunct to pulmonary thromboendarterectomy

In chronic pulmonary vascular thrombotic disease, pulmonary thromboendarterectomy has proved to be effective in reducing pulmonary hypertension and improving gas exchange. However, persistent pulmonary hypertension and unrelenting reperfusion edema are the main causes of death. We report a case of pulmonary thromboendarterectomy followed by an immediate unfavorable postoperative course with acute and persistent pulmonary hypertension, gas exchange impairment, and heart dysfunction. In this particular case, inhaled nitric oxide was successfully administered.

Myocardial effects of experimental acute brain death: evaluation by hemodynamic and biological studies

BACKGROUND

Because of problems concerning the functional quality of heart transplants, more and more interest has been focused on the physiologic changes occurring during brain death, one of the major possible contributing factors to the myocardial alterations.

METHODS

The aim of this study was to describe the link between acute experimental brain death and myocardial metabolism. This was achieved by in vivo 3-hour hemodynamic and biological (myocardial lactate production) studies and then in vitro 6-hour phosphorus-31 nuclear magnetic resonance spectroscopy. Two groups of pigs were involved in the study: group I (n = 10) as control and group II (n = 10) as brain-dead animals.

RESULTS

Within the first hour, we observed a strong increase in myocardial activity associated with the onset of myocardial lactate production, lasting 2 hours and corresponding to a myocardial anaerobic metabolism period. Despite the apparent normalization before excision of the hearts, phosphorus-31 nuclear magnetic resonance spectroscopy revealed a significant decrease in adenosine triphosphate levels in group II when compared with group I.

CONCLUSIONS

We conclude that, in our study, acute experimental brain death is associated with an early and transient period of myocardial anaerobic metabolism and adenosine triphosphate consumption. These myocardial consequences of brain death could partially explain some observations of heart graft dysfunction.

[On the use of the gastroepiploic artery in myocardial revascularization]

Between 1985 and 1992, the gastroepiploic artery was used for coronary bypass surgery in 80 consecutive patients. Revascularisation was totally arterial in 62.5% of cases, the gastroepiploic being associated with single or double internal mammary artery grafts. The gastroepiploic graft was used to revascularise the inferior myocardial regions. The postoperative morbidity was essentially due to respiratory complications: 6 patients had objective pulmonary complications and 11 patients had relative transient postoperative hypoxia. The early gastrointestinal complications were related to ulceration (5 patients) complicated by haemorrhage in 2 patients. This morbidity was responsible for a significant increase in the period of intensive care. The hospital mortality was 6.2%, observed mainly in the first third of the author's experience and in patients with preoperative poor prognostic factors. These relatively high morbidity and mortality rates have led to a cautious use of the right gastroepiploic artery for coronary bypass surgery in patients over 70 years of age, in those with unstable angina operated as an emergency and in those with associated pathology, especially respiratory problems. The choice of a complex surgical option should not be synonimous with an increased postoperative mortality.

Evaluation of the Duke criteria versus the Beth Israel criteria for the diagnosis of infective endocarditis

New diagnostic criteria for infective endocarditis (IE) have been proposed by the Duke University Endocarditis Service (Durham, NC) to update the widely used Beth Israel (Boston) criteria. We compared the Duke criteria with the Beth Israel criteria in a series of 115 consecutive patients with suspected IE who were hospitalized in a referral center. The diagnosis of IE was histologically and/or bacteriologically confirmed for 27 operated patients. If surgery had not been performed on these 27 patients, 22 vs. 12 would have been classified as having ¿clinically definite¿ and ¿probable¿ IE by the Duke vs. the Beth Israel criteria, respectively, whereas 0 vs. 5 would have been ¿rejected¿ by the Duke vs. the Beth Israel criteria, respectively. The improvement in sensitivity of the criteria from 44% (Beth Israel) to 82% (Duke) was statistically significant (P < .01). We confirm that the Duke criteria improve the sensitivity of diagnosis of IE. The specificity of these criteria should be further evaluated.

[Comparative outcome of aortic valve endocarditis with or without annular abscess]

Annular abscess is a not uncommon but serious complication of aortic valve endocarditis. The aim of this retrospective study was to evaluate the prognosis of aortic valve endocarditis with and without annular abscess. Between January 1981 and 1989, 122 consecutive cases of aortic endocarditis fulfilling the diagnostic criteria of Duke University were admitted to hospital. Group I included 40 cases with aortic ring abscess confirmed at surgery, in 35 patients; group II comprised 43 cases of operated aortic valve endocarditis without annular abscess in 41 patients and group III comprised 38 cases of aortic valve endocarditis treated medically without echocardiographic or angiographic signs of annular abscess in 36 patients. The patients in group III were significantly older than those in group I (57 +/- 14 years vs 44 +/- 17 years; p < 0.001). From the clinical point of view, endocarditis of prosthetic valves was slightly more common, but without reaching statistical significance, in group I, but the abscess was associated with more severe cardiac failure. Systemic embolism, atrioventricular block and pericardial effusion were equally common in the three groups. On the other hand, endocarditis with annular abscess was more often the result of infection with streptococci A, B, C or pneumoniae, than forms without abscess (22.5% vs 5% and 3% respectively in the 3 groups; p < 0.05). Of the patients treated surgically, destructive lesions of the valves were more common in cases of abscess (57.5% vs 35%; p < 0.05): the hospital mortality was higher in cases of abscess (17.5% vs 7%).(ABSTRACT TRUNCATED AT 250 WORDS)

Mitral valve tumor revealed by stroke

Valvular tumors are uncommon and usually benign lesions, discovered accidentally or when neurological or cardiological complications occur. We report a case of mitral valve papillary fibroelastoma measuring less than 1 cm and revealed by stroke. Transesophageal echocardiography was the best method to establish the diagnosis as it provided higher discriminative power than the transthoracic echocardiography or nuclear magnetic resonance. The embolic risks justify the surgical treatment of these lesions while anticoagulation therapy can be suggested as a substitute to surgery for the high risk patients.