Continuous electroencephalogram patterns are suggestive of eventual neurologic outcomes in post-cardiac arrest patients treated with therapeutic hypothermia

INTRODUCTION

Therapeutic hypothermia (TH) after cardiac arrest (CA) resuscitation is the first therapy proven to increase survival to discharge and neurologic recovery. Methods for neurologic and mortality prognostication after CA resuscitation have been called into question because they were developed based on evidence that was developed prior to the advent of TH. This study examines the relationship between electroencephalogram (EEG) patterns and mortality and neurologic outcomes in post-CA patients undergoing TH.

METHODS

Eighty-three of 732 patients who had continuous EEG (cEEG) monitoring during TH were included. Continuous EEG tracings were classified as isoelectric, low voltage, burst suppression, epileptic form, and diffuse slowing. Primary outcomes are survival to discharge and Cerebral Performance Categories (CPCs) at hospital discharge.

RESULTS

Among patients with favorable neurologic outcomes (CPC1 and CPC2), the duration cardiopulmonary resuscitation and time until return of spontaneous circulation were shorter than observed in patients with poorer neurologic outcomes (CPC3, CPC4, and CPC5). The time to target temperature was equivalent among neurologic outcome groups (499.5 minutes vs 431.0 minutes, P = .09). Favorable neurologic outcome was associated with initial presentation with ventricular tachycardia or ventricular fibrillation and had cEEG patterns suggestive of diffuse slowing and epileptiform waves.

DISCUSSION

The use of cEEG can provide prognostication information otherwise not obtainable by clinical examination. Specific cEEG patterns predicted probability of mortality for patients according to their initial rhythm of CA as a function of cardiopulmonary resuscitation time.

[Prevention of venous thromboembolism following cardiac, vascular or thoracic surgery]

In the absence of thromboprophylaxis, coronary artery bypass graft surgery (CABG), intrathoracic surgery (thoracotomy or video-assisted thoracoscopy), abdominal aortic surgery and infrainguinal vascular surgery are high-risk surgeries for the development of venous thromboembolic events (VTE). The incidence of VTE following surgery of the intrathoracic aorta, carotid endarterectomy or mediastinoscopy is unknown. Data from the litterature are lacking to draw evidence-based recommandations for venous thromboprophylaxis after these three types of surgeries, and the following guidelines are but experts'opinions (Grade D recommendations). Thromboprophylaxis is recommended after CABG (Grade D), with either subcutaneous (SC) low molecular weight heparin (LMWH) or SC or intravenous (i.v.) unfractioned heparin (UH) (PTT target = 1.1-1.5 time control value) (both grade D). This may be combined with the use of intermittent pneumatic compression device (Grade B). After valve surgery. The anticoagulation recommended to prevent valve thrombosis is sufficient in order to prevent VTE. We recommend thromboprophylaxis with either LMWH or low dose UH to prevent VTE after aortic or lower limbs infrainguinal vascular surgery (both grade B and D). Vitamine K antagonists (VKA) are not recommended in this indication (Grade D). We recommend thromprophylaxis following intrathoracic surgery via thoracotomy or videoassisted thoracoscopy (grade C). Either subcutaneous LMWH or subcutaneous or i.v. low dose UH may be used (Grade C). Efficacy of intermittent pneumatic compression device has been demonstrated in a study (grade C). VKA are not recommended (grade D). No further recommendation regarding the duration of thromboprophylaxis after these three types of surgeries can be made.

Outpatient video-mediastinoscopy

We reviewed our experience with video-mediastinoscopy as an outpatient procedure. From November 2002 to May 2003, 20 video-mediastinoscopies were performed on an out-patient basis. There were no operative deaths. No surgical complication is reported in a patient requiring readmission and antibiotic therapy for left pneumonia. In conclusion, video-mediastinoscopy can be safely performed on an out-patient basis in selected patients with mediastinal involvement.

Forearm arteries entrapment syndrome: a rare cause of recurrent angioaccess thrombosis

Entrapment syndrome below or just above the elbow is uncommon. These rare causes of neurologic or vascular entrapment are linked to anomalous anatomical structures. No case of entrapment syndrome has been reported in patients with angioaccess for hemodialysis. We report, for the first time, forearm arteries entrapment in two patients presenting with recurrent angioaccess for hemodialysis thrombosis. Anatomical, radiologic, and surgical features of these uncommon syndromes are discussed.

Morphometric study of the pulmonary trunk: implications for a new approach of the Ross procedure

A pulmonary valve autograft may be proposed to replace diseased aortic valves. The explanted pulmonary valve is replaced with a pulmonary homograft with the inherent risk of calcified degeneration. A monocusp valve using the anterior pulmonary trunk has been proposed to reconstruct the right ventricular outflow tract. The aim of this study was to determine the feasibility of this technique. In hearts from 17 adult cadavers, we measured: pulmonary trunk diameter at the leaflet tops (D1). H1 and H2 were respectively from leaflet top to lower and upper levels of the pulmonary trunk bifurcation. D2 = 1.4 D1 was calculated as the monocusp size allowing a 45 degrees opening of the valve and thus permitting good valvular efficacy. G = H1 - D2 determined the feasibility of the technique: G greater than 10 mm, appeared the most favorable, G between 0 and 10 mm, appeared possible, and G less than 0, appeared to be impossible. Mean values of D1, H1 and H2 were respectively: 20.19 mm, 37 mm and 57 mm. The technique was possible in 16 cases (94%) and impossible in 1 case (6%). Preoperative determination of these parameters, by echocardiography or magnetic resonance imaging, appears necessary before applying this new surgical technique.

Management of pseudoaneurysm of the ascending aorta performed under circulatory arrest by port-access

Pseudoaneurysms of the ascending aorta following previous thoracic surgery pose a difficult surgical management problem. In this report, we present a case of a patient with aortic insufficiency and a pseudoaneurysm of the ascending aorta at the site of a previous anastomosis. The particularity of this case is in the atypical use of Port-Access technology (Heartport, Redwood City, CA) to overcome surgical concerns [1].

Continuous infusion of remifentanil and target-controlled infusion of propofol for patients undergoing cardiac surgery: a new approach for scheduled early extubation

OBJECTIVE

To assess hemodynamic stability, postoperative pain management, and the control and timing of early extubation of a total intravenous anesthetic technique using propofol target-controlled infusion (TCI) and remifentanil in cardiac surgery.

DESIGN

Prospective study.

SETTING

University hospital.

PARTICIPANTS

Fifty patients scheduled for elective cardiac surgery.

INTERVENTIONS

Premedication consisted of oral midazolam, 0.1 mg/kg. Anesthesia was induced with propofol TCI at a target concentration of 1.5 to 2 microg/mL; remifentanil, 1 microg/kg; and rocuronium. Anesthesia was maintained with propofol at the same target concentration and remifentanil titrated between 0.25 and 1 microg/kg/min. Thirty minutes before the end of surgery, a 0.1-mg/kg bolus of morphine was administered intravenously. Postoperative sedation was achieved by maintaining the propofol infusion until the patient was deemed ready for extubation. Postoperative pain relief was evaluated using a visual analog scale. The intervals between arrival in the intensive care unit, spontaneous ventilation, and extubation were recorded.

MEASUREMENTS AND MAIN RESULTS

Included in this study were 36 men and 14 women (American Society of Anesthesiologist = III; New York Heart Association = II) scheduled for cardiac surgery. All patients remained hemodynamically stable throughout the perioperative period. Thirty-seven patients were successfully extubated during the first 4 postoperative hours. Spontaneous breathing was achieved at a mean interval of 15+/-5 minutes after propofol discontinuation. The mean interval to extubation was 163+/-45 minutes after arrival in the intensive care unit. Extubation was performed 48+/-12 minutes after patients were considered ready to awaken. During spontaneous ventilation, 36 patients received additional boluses of morphine (mean, 2.5+/-1 mg). Subsequently, all patients achieved a visual analog scale less than 40 mm.

CONCLUSION

The combination of remifentanil and propofol TCI resulted in hemodynamic stability and good postoperative analgesia. This technique allows physicians to schedule the time of extubation in patients undergoing cardiac anesthesia.

Comparison of the acute hemodynamic effects of hypertonic or colloid infusions immediately after mitral valve repair

OBJECTIVE

To determine the acute hemodynamic effect of hypertonic saline and/or colloid solutions as volume resuscitation in postoperative mitral valve repair patients.

DESIGN

Prospective, randomized trial.

SETTING

Postoperative cardiac intensive care unit of Broussais Hospital.

PATIENTS

Twenty-six patients who underwent mitral valve repair were prospectively studied. Two patients were excluded during the study.

INTERVENTIONS

During the immediate postoperative period, when wedge pressure decreases to <8 mm Hg, patients were randomly assigned to receive 250 mL of either hypertonic saline 7.2%-hydroxyethyl starch 6% (molecular weight, 200,000; hydroxyethylation ratio, 0.5) solution (HS-HES group), hypertonic saline 7.2% solution (HS group), or hydroxyethyl starch 6% solution (HES group). The infusion was completed within 15 mins. No additional volume was infused throughout the study.

MEASUREMENTS AND MAIN RESULTS

Standard hemodynamic measurements and echocardiographic data demonstrated that HS-HES and HS induced a higher increase in left ventricular end-diastolic area than HES. In the HS-HES and HS groups, systemic vascular resistances decreased significantly and end-systolic area tended to decrease. In the HES group, systemic vascular resistances did not change and end-systolic area tended to increase. Accordingly, ejection fraction increased significantly by 21% and 18% with HS-HES (from 50.5 +/- 5.5 to 61.2 +/- 4.8) and HS (from 49.7 +/- 3.6 to 58.8 +/- 3.3), respectively, and did not change with HES. A major increase in cardiac index was observed after hypertonic solutions infusion, from 2.9 +/- 0.3 to 4.1 +/- 0.4 L/min/m2 in the HS-HES group and from 2.7 +/- 0.3 to 3.8 +/- 0.4 L/min/m2 in the HS group. Then, cardiac index progressively returned to baseline values within the 3 hrs after the infusion. No significant difference was observed between HS-HES and HS. In these groups, plasma sodium increased significantly after the infusion and remained higher than baseline values throughout the study. Adverse events were observed only with hypertonic solution administration: hypotensive episodes, sudden increases in pulmonary capillary wedge pressure, and ventricular arrhythmias. These side effects are likely attributable to a too-high dose and/or rate of infusion. All patients included in the study were discharged from the hospital before the 10th postoperative day.

CONCLUSION

We conclude that in patients who have undergone mitral valve repair, postoperative infusion of hypertonic saline solutions increases left ventricular preload and left ventricular ejection fraction. The use of these hypertonic solutions may be of interest in patients with valvular cardiomyopathy. A titrated dose and a low rate of infusion may substantially improve the safety.

[The pericardium: a heterogeneous tissue. Anatomic and morphometric considerations]

BACKGROUND AND AIMS OF THE STUDY

Short-term glutaraldehyde fixed autologous pericardium is widely used in cardiac valve repair or in autologous pericardial bioprosthesis construction. The thinner the tissue, the better the fixation. The aim of this study was to determine thickness and useful surface area of pericardium in relation to harvesting site using a digital thickness counter (0.01 mm precision). Parietal pericardium fragments were obtained from the pericardial sac of six fresh cadavers (group I). In the other groups, pericardial strips (80 x 30 mm) were obtained from patients undergoing surgery: group II patients (n = 5 females) and group III (n = 10 males) were non-cardiomegalic (cardiothoracic ratio (CTR) < 0.5)), while group IV patients (n = 5) were all cardiomegalic (CTR > 0.5). Results were reported on a coloric scale according to measurement position. In group I, mean surface area was 93 +/- 18 cm2, and thickness gradually increased from 0.1 to 0.6 mm, maximally on the diaphragm, along the left heart side. In other groups, a gradual increase in thickness was identified towards the diaphragmatic zone. Significant differences in tissue thickness appear as a result of cardiomegaly, but are not related to the sex of the patients. Pericardium taken from the right anterior aspect of the pericardial sac in patients without cardiomegaly is the most appropriate tissue for valve reconstructive surgery, due to its thin nature and hence better fixation properties.

Continuous infusion versus bolus administration of sufentanil and midazolam for mitral valve surgery

OBJECTIVE

In the present study, the authors compared continuous infusion to bolus administration of sufentanil and midazolam in patients undergoing mitral valve surgery. The purpose of the study was to evaluate the hemodynamic variability, total dose, effective plasma drug concentrations, and simplicity of the two anesthetic techniques.

DESIGN

Prospective, randomized study.

SETTING

University hospital.

PARTICIPANTS

Thirty patients scheduled for elective mitral valve surgery.

INTERVENTIONS

Induction of anesthesia was similar in both groups and consisted of sufentanil, up to 2 microg/kg, and midazolam, 0.05 to 0.15 mg/kg, followed by atracurium, 0.5 mg/kg. Anesthesia was maintained in the bolus group with predetermined boluses of sufentanil, 2 microg/kg, and midazolam, 0.03 mg/kg. Boluses were not administered if blood pressure was within 20% of baseline. The continuous-infusion group received sufentanil, 3.6 microg/kg/h, and midazolam, 0.08 mg/kg/h, started immediately after induction. The infusion rate was reduced to sufentanil, 1.8 microg/kg/h, and midazolam, 0.04 mg/kg/h, after sternotomy and was discontinued at skin closure. Atracurium was infused at a rate of 0.5 mg/kg/h up to sternal closure in both groups. No inhalation agents were used.

MEASUREMENTS AND MAIN RESULTS

Hemodynamic variability between the groups was not significant. Total sufentanil dose was 773 +/- 186 microg in the continuous-infusion group and 610 +/- 184 microg in the bolus group (p = 0.01). Total midazolam dose was 14.4 +/- 3 mg and 11.2 +/- 3 mg in the continuous-infusion and bolus groups, respectively. There were 3.46 (range, 0 to 7) additional bolus injections in the bolus group and 0.31 (range, 0 to 1) in the continuous-infusion group (p < 0.001). Plasma sufentanil concentrations at extubation were similar in both groups (0.5 ng/mL). Plasma midazolam concentrations at extubation in the bolus group (17 +/- 6.7 ng/mL) were similar to those in the continuous-infusion group (23 +/- 5 ng/mL).

CONCLUSION

The simplicity of the continuous infusion is a major advantage. This technique provides hemodynamically safe and stable conditions similar to those of bolus administration.

Cardiac valve papillary fibroelastoma: surgical excision for revealed or potential embolization

OBJECTIVE

We have reviewed the case histories of 4 patients who underwent operations between September 1994 and November 1997 at Broussais Hospital for cardiac valvular papillary fibroelastoma.

METHODS

Diagnosis was strongly suggested by echocardiography. Tumor locations were mitral (1), tricuspid (1), and aortic (2). Indications for operation were previous stroke for the mitral tumor, prophylaxis for the tricuspid tumor, syncopal episodes for the first aortic tumor, and transient ischemic attack and mesenteric ischemia for the second aortic tumor.

RESULTS

Surgical excision with a conservative, valve-sparing approach was performed in all cases. For the first aortic tumor, aortic valve reconstruction was achieved with part of a cryopreserved aortic homograft cusp. Intraoperative transesophageal echocardiography showed no evidence of valvular regurgitation after excision in all cases. All patients had uneventful postoperative recoveries. No evidence of regurgitation or recurrence was seen on echocardiography at follow-up.

CONCLUSIONS

Despite their histologically benign aspect, cardiac papillary fibroelastomas should be excised because of potential embolic complications. A conservative, valve-sparing approach is recommended, however, because of the absence of recurrence after total excision.

Aortic valve surgery in osteogenesis imperfecta: report of two cases and review of the literature

Aortic insufficiency is a well known but uncommon valvular dysfunction in patients with osteogenesis imperfecta. In such cases, aortic valve surgery has rarely been performed, and carries a high risk of perioperative complications. We report two patients with osteogenesis imperfecta, who underwent elective successful aortic valve replacement. The surgical problems encountered in this connective tissue disorder are also reviewed.

Autologous pericardial patch harvesting site for cardiac valve repair: anatomic and morphometric considerations

BACKGROUND AND AIMS OF THE STUDY

Short-term glutaraldehyde-fixed autologous pericardium is widely used in cardiac valve repair or in autologous pericardial bioprosthesis construction. The thinner the tissue, the better the fixation. The aim of this study was to determine thickness and useful surface area of pericardium in relation to harvesting site using a digital thickness counter (0.01 mm precision).

METHODS

Parietal pericardium fragments were obtained from the pericardial sac of six fresh cadavers (group I). In the other groups, pericardial strips (80 x 30 mm) were obtained from patients undergoing surgery: group II patients (n = 5 females) and group III (n = 10 males) were non-cardiomegalic (cardiothoracic ratio (CTR)<0.5), while group IV patients (n = 5) were all cardiomegalic (CTR >0.5).

RESULTS

Results were reported on a coloric scale according to measurement position. In group I, mean surface area was 93+/-18 cm2, and thickness gradually increased from 0.1 to 0.6 mm, maximally on the diaphragm, along the left heart side. In other groups, a gradual increase in thickness was identified towards the diaphragmatic zone. Significant differences in tissue thickness appear as a result of cardiomegaly, but are not related to the sex of the patients.

CONCLUSIONS

Pericardium taken from the right anterior aspect of the pericardial sac in patients without cardiomegaly is the most appropriate tissue for valve reconstructive surgery, due to its thin nature and hence better fixation properties.

Partial mitral homograft for tricuspid valve repair

We report a case of partial replacement of the tricuspid valve by a mitral homograft in a young drug addict with right heart endocarditis. Operation was indicated because of sudden severe tricuspid regurgitation and persistence of vegetations despite appropriate antibiotic therapy. Partial tricuspid valve replacement was performed with a segment of mitral homograft reinforced by a semirigid prosthetic ring. At 30-month postoperative follow-up the patient was in excellent clinical condition with a satisfactory echocardiographic result.

Dynamic cardiomyoplasty: clinical follow-up at 12 years

OBJECTIVE

The purpose of this study is to evaluate the long-term outcome of dynamic cardiomyoplasty. This surgical technique was conceived to assist the failing heart. The many proposed mechanisms of action of cardiomyoplasty are: (1) systolic assist; (2) limitation of ventricular dilation; (3) reduction of ventricular wall stress (sparing effect); (4) ventricular remodeling with an active girdling effect; (5) angiogenesis; and (6) a neurohumoral effect.

METHODS

We investigated 95 patients in our hospital undergoing this procedure due to severe chronic heart failure, refractory to optimal medical treatment. Patients had a mean age of 51 +/- 12 years. The etiology of heart failure was ischemic 55%, idiopathic 34%, ventricular tumor 6%, and other 5%. The mean follow-up was 44 months.

RESULTS

The mean New York Heart Association (NYHA) functional class improved postoperatively from 3.2 to 1.8. Average radioisotopic left ventricular (LV) ejection fraction increased from 17 +/- 5 to 27 +/- 4% (P < 0.05). Stroke volume index increased from 32 +/- 7 to 43 +/- 8 ml/beat per m2 (P < 0.05). The heart size remained stable over the long term. Following cardiomyoplasty, the number of hospitalizations due to congestive heart failure was reduced to 0.4 hospitalizations/patient per year (preoperative: 2.5, P < 0.05). Computed tomography scans showed at long term a preserved latissimus dorsi muscle structure in 84% of patients. Survival probability at 7 years is 54%. Six patients underwent heart transplant after cardiomyoplasty (mean delay: 25 months), due to the natural evolution of their underlying heart disease. There were no specific technical difficulties.

CONCLUSIONS

Clinically, this procedure reverses heart failure, improves functional class and ameliorates quality of life. The latissimus dorsi muscle histological structure is maintained at long-term, when postoperative electrostimulation is performed, avoiding excessive stimulation. Cardiomyoplasty may delay or prevent the progression of heart failure and the indication of cardiac transplantation.

Study of muscular and ventricular function in dynamic cardiomyoplasty: a ten-year follow-up

BACKGROUND

The basic physiologic principle underlying cardiomyoplasty is long-term electrostimulation of a latissimus dorsi muscle (LDM) wrapped around the heart to obtain a phasic activity that could be integrated with ventricular kinetics. The aim of cardiomyoplasty is to prolong survival and to improve the quality of life of patients with severe chronic and irreversible myocardial failure by improving systolic contraction and correcting diastolic dysfunction.

METHODS

To evaluate the long-term outcome of cardiomyoplasty, we investigated 82 patients electively undergoing this procedure in-our hospital. All patients had severe chronic heart failure that did not respond to optimal medical treatment. Patients had a mean age of 50 +/- 12 years (84% males). The cause of heart failure was ischemic (55%), idiopathic cardiomyopathy (34%), ventricular tumor (6%), and other (5%). The mean follow-up was 4.3 years.

RESULTS

The mean New York Heart Association functional class improved after operation from 3.2 to 1.8. Average radioisotopic left ventricular ejection fraction increased from 17% +/- 6% to 28% +/- 3% (p < 0.05). Stroke volume index increased from 35 +/- 9 to 46 +/- 8 ml/beat/m2 (p < 0.05). The heart size remained stable at long term (evaluated by echo and computed tomography scanning). After cardiomyoplasty the number of successive hospitalizations resulting from congestive heart failure was reduced to 0.4 hospitalizations/patient/year (before operation 2.5, p < 0.05). Computed tomography scans showed at long-term a preserved LDM structure in 82% of patients who underwent operation. Survival probability at 7 years was 54% for the totality of patients, and 66% for patients who underwent operation in New York Heart Association functional class 3. Five patients underwent heart transplantation after cardiomyoplasty (mean delay 29 months), principally as a result of the natural evolution of their underlying heart disease, without major technical difficulties.

CONCLUSIONS

Our 10-year clinical experience demonstrates that cardiomyoplasty increases ejection fraction, improves functional class, and ameliorates quality of life. Ventricular volumes and diameters remain stable long term. LDM structure is maintained long term if electrostimulation is performed avoiding excessive myostimulation. Patient selection is the most important determinant for early and late outcome. Late death in patients undergoing cardiomyoplasty is principally due to sudden death. Our future aim is to incorporate a cardioverter-defibrillator in the cardiomyostimulator, thus improving long-term results. Cardiomyoplasty may delay or prevent end-stage heart failure and the need for heart transplantation.

Early extubation after mitral valve surgery: a target-controlled infusion of propofol and low-dose sufentanil

OBJECTIVE

In the current study, the use of a target-controlled infusion of low-dose propofol was combined with a continuous infusion of sufentanil for patients undergoing mitral valve surgery. The purpose of the study was to evaluate the hemodynamic stability, the time to awakening and spontaneous ventilation, and the feasibility in an early extubation setting of a total intravenous anesthetic technique.

DESIGN

Prospective study.

SETTING

University hospital.

PARTICIPANTS

Fifteen patients scheduled for elective mitral valve surgery.

INTERVENTIONS

Induction of anesthesia consisted of sufentanil (1 microgram/kg), propofol (1 microgram/mL) target plasma concentration achieved over 3 minutes, and atracurium (0.5 mg/kg). The propofol target-controlled infusion was maintained at 1 microgram/mL throughout surgery and stopped at skin closure. A continuous infusion of sufentanil at 1.8 micrograms/kg/hr was started after induction and reduced to 0.9 microgram/kg/hr at the start of cardiopulmonary bypass and stopped at the end of bypass. Atracurium was infused at a rate of 0.5 mg/kg/hr up to sternal closure. No inhalation agents were used.

MEASUREMENTS AND MAIN RESULTS

Hemodynamic data were within normal limits. Six patients (40%) responded to verbal commands within 15 minutes postoperatively, 10 (67%) within the first hour, and all patients recovered within 2 hours. Four patients (27%) resumed spontaneous ventilation within the first 15 postoperative minutes. The time to successful spontaneous ventilation was 169 +/- 42 minutes. Spontaneous ventilation was associated with a 21% increase in cardiac index. Total sufentanil dose was 328 +/- 28 micrograms (4.6 +/- 0.2 microgram/kg), whereas total propofol dose was 862 +/- 44 mg (13.1 +/- 1.2 mg/kg). No patient required reintubation.

CONCLUSION

The simplicity of the method with only one change in infusion rate is a major advantage. The technique permits predictable recovery and return to spontaneous ventilation in all patients. Its use in patients entering early extubation protocols is appealing for its reproducibility, simplicity, and safety.

Mycotic aneurysm of the left subclavian artery presented with hemoptysis in an immunosuppressed man: case report and review of literature

We report the case of a 32-year-old man with a mycotic aneurysm of the left subclavian artery. This patient had immunosuppression caused by chemotherapy administered for treatment of leukemia. This aneurysm was revealed by two episodes of hemoptysis caused by a lung parenchyma fistulization. The patient was treated successfully by simple ligation and exclusion via a thoracotomy with partial lung resection. Histologic examination confirmed the presence of aspergilloma filaments in the false aneurysm. We suspect that aspergilloma could have been the cause of the mycotic aneurysm in this particular case. The literature on subclavian artery mycotic aneurysms is reviewed.

Is the incidence of recurrent carotid artery stenosis influenced by the choice of the surgical technique? Carotid endarterectomy versus saphenous vein bypass

PURPOSE

The purpose of this study is to compare the incidence of recurrent carotid artery stenosis (RCS) after carotid endartarectomy (CEA) and saphenous vein grafting (SVG) in patients with bilateral carotid artery stenosis.

METHODS

Between 1978 and 1990, 1483 patients underwent carotid artery surgery at our institution. Fifty-one patients were diagnosed with bilateral carotid artery stenosis and were included in a prospective study that consisted of performance of CEA on one side and SVG on the other. The patients consisted of 34 men and 17 women. Forty patients had symptoms, and 11 were symptom free with severe (> or = 90%) bilateral carotid artery stenosis. All patients underwent a two-stage procedure with an operative interval that ranged from 5 days to 6 months.

RESULTS

All patients survived, and no permanent postoperative neurologic deficit was observed. Follow-up was available for all patients and ranged from 6 to 150 months (mean 52 months). Serial Doppler studies were performed in all patients at 6- to 9-month intervals. Unilateral RCS (> or = 80%) occurred in two cases (two of 102); one in a CEA (one of 51) and one in the distal anastomosis of a SVG (one of 51) at 6 and 8 months, respectively, after operation. The reoperative surgical technique performed in both cases was a SVG.

CONCLUSIONS

The incidence of RCS requiring repeat operation after carotid artery surgery is not influenced by the choice of the surgical technique, namely CEA or saphenous vein bypass.

Double mitral homograft for recurrent bacterial endocarditis of the mitral and tricuspid valves

A young patient suffering from acute bacterial endocarditis underwent reconstructive surgery of the mitral and tricuspid valves. One year later a recurrent endocarditis occurred that could not be controlled with antibiotic therapy. Two separate mitral homografts were used to replace both the mitral and the tricuspid valves. The homografts' papillary muscles were sutured side to side to the recipient's and a circumferential suture of the leaflet tissue was accomplished. Homograft implantation was associated with Carpentier ring annuloplasty of the atrioventricular valves. In the right sided position, the mitral homograft was oriented in an anti-anatomical manner and an inverted semi-rigid prosthetic ring of the mitral type was inserted. Clinical and echocardiographic follow up at four months was excellent.

Gastric emptying in humans: influence of different regimens of parenteral nutrition

Intravenous administration of nutrients can suppress oral food intake. Inhibition of gastric emptying (GE) is a potential explanation for this process. Inhibition of GE during parenteral nutrition (PN) and attenuation of this by parenteral nutrition enriched with branched-chain amino acids (BCAAs) was examined in nine healthy males maintained on standard liquid diets for 6 d before each of three GE studies. GE was measured by scintigraphy after ingestion of a liquid test meal, at weekly intervals, after a 6-h infusion of Ringer lactate solution (RL), peripheral PN, or PN with half the amino acids replaced with BCAAs (BCPN). With PN, gastric emptying during the first 50 min was delayed by 38% compared with RL infusion; BCPN attenuated the effect, suggesting that postabsorptive control of food intake may act through changes in GE. These findings have clinical potential to reduce interference with appetite and to optimize food intake during PN administration.