[Extracorporeal circulation: an extraordinary tool that is not just for cardiac surgeons]

Extracorporeal circulation (ECC) is not only used for open heart surgery. There are also other surgical and medical applications. ECC can be used for encephalic arteries surgery to induce hypothermia and maximally protect the brain. Femoro-femoral ECC may be needful for urgent traumatologic surgery of the supra-aortic trunci. Intracranial aneurysm repair can occasionally necessitate deep hypothermia and circulatory arrest with ECC. Renal cell carcinomas may metastasize to the right atrium and surgery with ECC is mandatory for complete excision. Some reports in the literature mention use of ECC for hepatic surgery of intra-hepatic aneurysms. With acute peripheral ischemia, metabolites in the affected limb can be washed out with good results. Medical indications for ECC are numerous with pulmonary assistance as one of the foremost when mechanical ventilation failed. Homogeneous and rapid rewarming of hypothermic patients can be achieved with ECC. Finally, some groups have reported the use of ECC to administer chemotherapy in limb melanoma.

[Impact of psychiatric disturbances on the outcome of coronary bypass surgery]

The influence of anxiety and depression on the development and prognosis of coronary disease seems to be well established but there are few studies of the effects of these disturbances on the postoperative outcome of coronary surgery. The object of this review of the literature was to present recent data on this subject and to suggest therapeutic strategies for patients referred for coronary bypass surgery to improve their quality of life and even cardiovascular prognosis.

Simple surgical technique to prevent direct secondary aortoenteric fistulas

To prevent direct secondary aortoenteric fistulas, a devastating complication of abdominal aortic surgery, we describe here a rapid, very easy to perform and no cost operating technique. A part about 4 cm long of the vascular prosthesis was cut to obtain a partial tailored ring which was passed through the prosthesis. After the anastomosis was realized, the tailored ring was hitched up to totally cover proximal anastomosis and prevent direct contact between aorto-prosthetic anastomosis and the bowel.

[Chronic constrictive pericarditis in African children: report of a case]

The chronic constrictive pericarditis is a rare affection, with multiple etiologies and concerning especially the adult. We report a case of chronic constrictive pericarditis in an African child in whom no etiology was found. A review of the literature raises the characteristics of chronic constrictive pericarditis for a better therapeutic management.

[Results of coronary artery surgery in octogenarians]

Over an 11 year period from January 1990 to December 2000, 3282 patients underwent isolated or combined surgical myocardial revascularisation. In this group, 42 were aged 80 or over (maximum 87 years), 1.3% of the total patient population. The mean age of this subgroup was 81.8 +/- 1.75 years) with a male predominance (61.9%). All patients were autonomous and considered to be in good general and psychological health. Preoperative coronary angiography showed 33.3% of left main stem lesions either alone or associated with a right coronary lesion. The ejection fraction was over 50% in 78.6% of cases. Saphenous vein grafts were used in all but 5 patients who also had left internal mammary artery grafts. Thirteen patients (31%) underwent combined valvular surgery (11 aortic and 2 mitral valve) and 2 patients underwent combined vascular surgery. Three patients were operated as an emergency. A total of 5 patients died in the first 30 postoperative days, a hospital mortality of 11.9%. There were 2 postoperative hemiplegias and 2 cases of renal failure which were aggravated in the postoperative period. The other patients were discharged from hospital with a satisfactory cardiac and functional status. The global mortality was 14% at 3 years and 18% at 5 years. The main bad prognostic factor for survival was the association of aortic valve surgery. In selected octogenarians in good general and psychological health without severe co-morbid conditions, surgical myocardial revascularisation may be considered with an acceptable operative risk.

Using VAC to treat a vascular bypass site infection

Vacuum-assisted closure is becoming an increasingly popular adjunctive therapy. The following evidence suggests it can be used to treat an infected groin incision over a patent vascular bypass.

Aspergillus flavus mitral valve endocarditis after lung abscess

A 16-year-old male with bone marrow failure due to chemotherapy for recurrent acute lymphoblastic leukemia developed an abscess in the lower lobe of the left lung draining through a bronchogastric fistula, as well as mitral valve endocarditis with large vegetations. After a course of antifungal therapy, the left lobe was removed and the fistula closed. The mitral valve was then replaced, after a failed attempt at valve repair, by a mechanical, double-leaflet prosthesis. Microscopy of the lung and heart specimens disclosed hyphae. Cultures of both specimens on Sabouraud's medium recovered a fungus, which was identified by culturing on Czapek's medium as Aspergillus flavus. Despite further antifungal therapy, fatal embolism developed. The emboli contained the same A. flavus as the valve and lung specimens. This case confirms the grim prognosis of primary Aspergillus endocarditis in immunocompromised patients, and suggests that delayed surgical treatment and the presence of another focus of Aspergillus infection may increase the risk of death.

Postoperative exercise tolerance after aortic valve replacement by small-size prosthesis: functional consequence of small-size aortic prosthesis

OBJECTIVES

The objective of this study was to determine whether a small-size valve prosthesis contributes to exercise intolerance, as assessed by VO2 measurement during an exhaustive cycle ergometer exercise.

BACKGROUND

The determinants of exercise capacity after mechanical aortic replacement are not well known. The selection of small valve sizes has, however, been described as an independent predictor of exercise intolerance as assessed by exercise duration. Maximal oxygen uptake (VO2max) is a good index of exercise tolerance.

METHODS

Fourteen patients were eligible, with a mean age of 62 +/- 6 years. Before surgery, the mean left ventricular ejection fraction (LVEF) was 73 +/- 8%. Two valve types with small diameter (19 to 21 mm) were used: Medtronic Hall and St Jude Medical. A healthy sedentary control group (n = 14) paired for age, weight and size was constituted. After one year of follow-up, cardiorespiratory tests were performed. In addition, the gradients through the prostheses were determined by continuous pulse Doppler at rest and immediately after the cardiorespiratory test. RESULTS The exercise tolerance was not significantly different between the control group and patient group: VO2 peak (21.7 vs. 20.4 ml/kg/min; p = 0.42), workloads (115 vs. 93 W; p = 0.13) and ventilatory parameters were similar. The mean and peak gradients at rest and during exercise were not correlated with VO2max.

CONCLUSIONS

Valve replacement by small aortic prosthesis does not seem to be a factor of exercise intolerance as assessed by VO2max in patients without LVEF dysfunction before surgery.

Vertebral artery surgery with cardiopulmonary bypass and deep hypothermia

Deep hypothermia was proposed to prevent neuronal ischemia and stroke during surgical procedures on arteries that supply the brain, especially with extended occlusive lesions on both internal carotid arteries. The interest of this therapeutic option is still under discussion, even in the case of combined cardiac and cerebrovascular surgery. We report the case of a 53-year-old male who was admitted to our institution for symptomatic vertebrobasilar insufficiency. Angiography showed a thrombosis of both internal carotid arteries, stenosis of both external carotid arteries, and a tight proximal stenosis of a dominant right vertebral artery. Endarterectomy and angioplasty of the origin of the right external carotid artery was done first to increase the blood supply to the brain via collateral arteries connecting the extra- and intracranial networks. Six weeks after this, a right-sided vertebral-to-carotid artery anastomosis was performed during cardiopulmonary bypass (CPB)-induced deep hypothermia for optimal neuronal protection, with good results. However, early thrombosis of the right vertebral artery requiring reintervention in normothermia, without any stroke, indicate that deep hypothermia was unnecessary in this case, probably because of the previous natural and surgical development of collateral circulation. However, there was no means of predicting this in a reliable manner before the procedure and deep hypothermia appeared a safe technique for neuronal protection without any specific postoperative complications.

Malignant ventricular arrhythmias revealing anomalous origin of the left coronary artery from the pulmonary artery in two adults

We report two cases of anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA), revealed by malignant ventricular arrhythmias in adult patients. A two coronary system was re-established in both patients, and cryotherapy was performed on one of the patients who, in addition, presented ventricular aneurysm triggering ventricular tachycardia.

Large encircling cryoablation without mapping for ventricular tachycardia after anterior myocardial infarction: long-term outcome

OBJECTIVE

Map-guided procedures have been the accepted standard for ventricular tachycardia surgery. However, promising results of visually guided resections without mapping have been reported. The goal of this study was to evaluate the efficacy of large encircling cryoablation without mapping for ventricular tachycardia after anterior myocardial infarction.

METHODS

Between 1985 and 1996, this procedure, along with aneurysmectomy, was performed on 38 patients for malignant ventricular tachycardia. The mean interval between the operation and myocardial infarction was 59.2 months; 7 patients (18.4%) were operated on within 1 month of myocardial infarction. The mean patient age was 62.1 +/-7.3 years and the mean left ventricular ejection fraction was 29.0% +/-7.2%.

RESULTS

Hospital mortality was 2.6% (1 patient). The electrical success rate based on postoperative electrophysiologic studies was 94.5%. Overall electrical success rate was 89.1%. Freedom from ventricular tachycardia was 77% (95% CI 61%-94%) at both 5 and 7 years. Freedom from sudden cardiac death was 91% (95% CI 80%-100%) at both 5 and 7 years, with overall actuarial survivals at 5 and 7 years of 63% (95% CI 47%-80%) and 42% (95% CI 22%-63%), respectively. The main cause of late death was congestive heart failure in 62.6% of these patients.

CONCLUSIONS

One can achieve good results without intraoperative mapping in the treatment of patients with ventricular tachycardia after anterior myocardial infarction by using large encircling cryoablation.

Prognostic value of myocardial lactate dehydrogenase subunit ratio in heart transplant recipients

BACKGROUND

Allograft coronary artery disease (CAD) is a major long-term complication in heart transplant recipients. Unfortunately, methods for early estimation of the likelihood of development of the disease are not currently available. Lactate dehydrogenase (LDH) is composed of heart and muscle subunits. The prevalence of these subunits in LDH isoenzymes (LDH1 through LDH5) is an accurate indicator of myocardial metabolism and allows indirect estimation of oxygen availability to cardiocytes. This study investigated the prognostic value of myocardial LDH composition for the occurrence of morbid events in patients with severe allograft CAD.

METHODS

Eighty-eight heart transplant recipients were followed up for a median of 4.3 years. The isoenzymes of LDH and the ratio of the heart and muscle subunits (H/M) were determined in 526 endomyocardial biopsy samples.

RESULTS

Eleven patients (12%) died from allograft CAD during follow-up. They had significantly lower H/M ratios compared with event-free patients, with clear differences as early as 6 months after operation. A threshold value of 2.75 was derived from receiver operating characteristic curve analysis. Patients showing H/M values < or =2.75 had a significantly higher mortality rate than did those with higher values (p=.0003). Importantly, the H/M ratio emerged as the most powerful independent prognostic factor of death by allograft CAD (p=.001) in a multivariate model.

CONCLUSIONS

Poor myocardial aerobic metabolism estimated through low H/M values was highly predictive of cardiac death resulting from severe allograft CAD. Analysis of LDH isoenzyme profile in routine endomyocardial biopsies might be of clinical value.

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.

[Extracorporeal circulation for warming in severe accidental hypothermia. 3 cases]

BACKGROUND

Severe accidental hypothermia with central temperature below 28 degrees C can result from prolonged cold exposure and lead to a fatal outcome by spontaneous or provoked ventricular fibrillation.

CASE REPORT

Three patients were referred for central temperature below 24 degrees C. At admission, the patients had major ventricular rythm disorders (two were in a state of circulatory arrest and the third had auricular fibrillation and circulatory collapse). Emergency care associated internal warning using extracorporeal circulation via the femoro-femoral route with a centrifuge pump. Outcome was favorable in 2 cases.

DISCUSSION

Prognosis is very poor in patients who experience severe accidental hypothermia (< 28 degrees C) with circulatory collapse. Death often results from major rhythm disorders. Optimal emergency rewarming and oxygenation using extracorporeal circulatory assistance can be successful.

[Outcome of type I acute aortic dissection operated after 70 years of age. A retrospective study of operated dissection of the aorta in the over 70 years old]

The aim of this study was to assess the perioperative mortality and long-term outcome of Type I dissection of the aorta operated in patients over 70 years age. Of the 87 dissections of the aorta operated between 1988 and 1995, 19 concerned patients aged 71 to 79 (average 74.1 +/- 2.4 years). The procedure was replacement of the ascending aorta with gluing of the false lumen in call ases. Two patients also underwent aortic valve replacement and three also had replacement or repair of the aortic arch. Eleven patients (56%) had circulatory arrests lasting an average of 33 minutes (10-86 minutes). The mortality rate at 30 days was 31.5% (6/19): 3 deaths were due to bleeding, 1 to mesenteric infarction, 1 to cardiac arrhythmia and 1 to a cerebrovascular accident. The morbidity was 53%, mainly due to neurological complications, chest infection and renal failure. After an average period of 36.8 months (range: 3 to 75 months) with no patient lost to follow-up, the late mortality was 23% (3/13), giving actuarial survival rates at 1.5 and 6 years of 63%, 47.5% and 32%, respectively (including the operative mortality). Or the survivors, 9 were in NYHA Classes I-II and 1 in class III. One patient developed a hemiparesis. The authors conclude that, despite high mortality and morbidity at 30 days, long-term survival and its quality are arguments in favour of surgical management, even in elderly patients.

Mycotic aneurysm of the extracranial carotid artery: an uncommon complication of bacterial endocarditis

This report describes a case involving mycotic aneurysm of the extracranial internal carotid artery occurring as a complication of staphylococcal endocarditis in a patient with systemic lupus erythematosus. Three main points are emphasized: (1) this complication occurred in an immunodepressed patient; (2) surgical treatment consisted of aneurysmorraphy using absorbable suture; (3) the outcome was successful with a follow-up of 24 months.

Preservation of three-dimensional annular movement with the SJM-Seguin mitral annuloplasty ring

BACKGROUND AND AIMS OF THE STUDY

In order to achieve optimal annuloplasty during mitral valve repair, we developed a new device, the SJM-Seguin annuloplasty ring, with the aim of remodeling, correcting dilatation, and preserving physiologic annulus function. This ring has variable flexibility; that is, it is sufficiently rigid in its anterior region to maintain intercommissural distance, yet sufficiently flexible in its posterior region so as not to interfere with left ventricular function and to permit the natural three-dimensional annular mobility.

METHODS

Following successful studies in animals, 75 patients were operated on for mitral regurgitation between January 1994 and May 1996. The patients' mean age was 60.4 +/- 13.2 years; 53.8% were men. The cause of mitral insufficiency was degenerative in 77.4% of patients, rheumatic in 12%, ischemic in 5.3%, and infectious in 5.3%. Associated procedures were carried out in 36% of the cases.

RESULTS

There were no intraoperative deaths, but two in-hospital deaths and one late death, all of which were unrelated to the annuloplasty ring. Mitral regurgitation, monitored by transesophageal echocardiography decreased from +3.42 +/- 0.6 before repair to +0.31 +/- 0.12 after repair (p < 0.005). Follow up was 100% at a mean of 14.2 months (range: 3 to 26 months). There were no annuloplasty-related complications, and especially no echocardiographically discernible systolic anterior motion. There were no transient ischemic attacks. One reoperation was performed due to endocarditis at nine months after initial repair. The average transmitral gradient was 1.94 mmHg.

CONCLUSIONS

This new annuloplasty ring provides, with the absence of any valve-related complications, correction of annular dilatation and remodeling of the annulus while respecting physiologic annulus function such as natural three-dimensional mobility.

Advance in mitral valve repair using a device flexible in three dimensions. The St Jude Medical-Séguin annuloplasty ring

To allow remodeling of the annulus while respecting natural three dimensional annular movements during mitral valve repair, a new annuloplasty ring (St Jude Medical [SJM]-Séguin annuloplasty ring) was developed. This ring has variable flexibility; that is, it is sufficiently rigid on the anterior portion to maintain intercommissural distance, and sufficiently flexible on the posterior portion to respect left ventricular function and natural three dimensional annular mobility. Fifty patients operated on for pure mitral regurgitation between January, 1994 and June, 1995 were studied. Mean age was 58 years. The cause of mitral insufficiency was degenerative in 80% of the patients, rheumatic in 12%, ischemic in 4%, and infectious in 4%. The operative technique to restore normal valve coaptation was quadrangular resection in 31 cases, commissurotomy and chordal fenestration in 8, use of polytetrafluoroethylene chordae in 6, and chordal shortening or transposition in 5. Annuloplasty with a SJM-Séguin annuloplasty ring was realized in all 50 cases. Transesophageal echocardiographic mitral regurgitation decreased from 3.6 +/- 0.8 to 0.3 +/- 0.2 after repair (p < 0.005). Two post operative deaths due to non valve related complications, were observed. There were no ring related complications, especially no left ventricular outflow tract obstruction due to systolic anterior motion. Patients were all reviewed at a mean follow-up of 12.1 months (range, 9-27 months). All are well, in New York Heart Association functional Class I. Echocardiography showed a mean 0.4 +/- 0.3 mitral regurgitation, absence of any systolic anterior motion, and satisfactory mobility of the annuloplasty ring after the movements of the natural annulus, including non planar deviation. These preliminary results suggest that this annuloplasty ring 1) provides excellent correction of annular dilatation and remodeling of the annulus, 2) avoids systolic anterior motion observed with rigid rings, and 3) preserves physiologic three dimensional annulus motion.

[Paraplegia after surgical treatment of primary aorto-duodenal fistula]

A 68-year-old patient with chronic cirrhosis underwent surgical repair of the subrenal abdominal aorta presenting an aorto-duodenal fistula. The fistula was considered to be a primary fistula because it occurred without prior surgery and because the aorta had ruptured without formation of an aneurysm. The postoperative period was complicated by paraplegia further compromising the outcome in this severe condition. In general, there are several problems involved in the management of aorto-duodenal fistulae. Neither computed tomography of the abdomen nor gastroduodenal endoscopy are able to provide the diagnosis in all cases before surgery. Surgical treatment is most often conducted in an emergency setting requiring repair of both the digestive tract and of the vascular lesions. It is also important to recognize the risk of neurological events occurring intra-operatively. Prognosis is usually poor.

Myocardial lactate dehydrogenase subunit ratio in cardiac allograft recipients

BACKGROUND

Allograft coronary artery disease (CAD) is a major long-term complication in heart transplanted patients. However, the metabolic basis of allograft CAD remains to be fully elucidated. We analyzed the lactate dehydrogenase heart (H) and muscle (M) isoenzyme pattern in endomyocardial biopsy specimens and the evolution of the H/M ratio to test whether changes in this ratio could be the earliest manifestation of allograft CAD.

METHODS

Twenty-four heart transplant recipients were followed up for 12 months. Endomyocardial biopsy was performed at 1, 2, 3, 6, and 12 months after transplantation. Lactate dehydrogenase 1 through 5 isoenzymes were separated by electrophoresis, and the H/M ratio was calculated. Two groups of patients were identified: group 1 (n = 20), patients without allograft CAD; and group 2 (n = 4), patients with poor outcome (three deaths, 1 case of low cardiac output) and angiographic and histologic evidence of allograft CAD.

RESULTS

Both groups had similar H/M baseline values. The H/M ratio was higher (p = 0.01) in group 1 at 6 months (3.48 +/- 0.64 versus 2.17 +/- 0.43) and 12 months (3.76 +/- 0.92 versus 2.18 +/- 0.45) when compared with group 2. The H/M ratio increased from 2.78 +/- 0.89 at 1 month to 3.76 +/- 0.92 at 12 months (p = 0.02) in group 1 and decreased in group 2 (2.86 +/- 0.49 versus 2.18 +/- 0.45; not significant).

CONCLUSIONS

Changes in H/M ratio reflect an anaerobic shift in the lactate dehydrogenase isoenzyme composition and can be taken as an early indicator of allograft CAD.

Short-term development of transplant-related coronary artery disease in orthotopic cardiac allograft recipients

Transplant-related coronary artery disease is the main cause of death in orthotopic heart transplant recipients one year or more after operation. We report our own experience with chronic vascular rejection occurring 4, 10, and 15 months after transplantation in 3 of 71 consecutive patients. Immunosuppressive regimen included perioperative lymphocyte antibody therapy, cyclosporine, azathioprine and methylprednisolone. All 3 patients received cardiac allografts from donors not the same ABO blood type and developed cytomegalovirus infection (one primary phase infection and two reactivations). Death occurred in all of them. Histologic signs of both cellular and vascular rejection were found in one patient and two had pure vascular rejection. These observations support the potential role of cytomegalovirus infection and donor-recipient partial ABO blood type group incompatibility in the development of allograft vasculopathy as a short-term complication in heart transplant recipients.

Use of active shunt for surgical repair of intrapericardial inferior vena caval injury

We report a case of intrapericardial inferior vena caval disruption due to goring by a bull, and we describe the surgical repair of this uncommon penetrating cardiac injury. Review of the literature indicates that, as with other penetrating cardiac injuries, this rare lesion requires aggressive treatment involving an emergency thoracotomy. The use of an atrial caval active shunt was necessary for successful surgical management, and therefore we conclude that surgical treatment of this lesion is comparable with surgical repair of hepatic veins and retrohepatic vena caval injuries incurred during blunt vascular trauma or penetrating abdominal injuries.

Repair of the aortic arch with fibrin glue in type A aortic dissection

Location of the intimal tear in the aortic arch in type A aortic dissection is for many authors an indication for replacement of the aortic arch, but this operation has a high in-hospital mortality rate: 20% to 40%. Instead, we suggest repairing the aortic arch by injecting fibrin glue, which contains a human sealer protein concentrate, between the two dissected layers under circulatory arrest while replacing the ascending aorta. To evaluate this technique, we reviewed 45 successive patients operated on for type A acute aortic dissection between January 1989 and July 1993, of which 6 had the intimal tear located on or extending into the aortic arch. Mean age was 71 +/- 4.2 years (range 68 to 74). After proximal supracoronary anastomosis with a collagen-impregnated graft, aortic arch repair was achieved by injecting fibrin glue between the two layers, using circulatory arrest at a mean temperature of 22 degrees C, with a mean duration of 24 minutes. This obliterated the dissection in the arch and also the intimal flap. The distal part of the graft was then anastomosed to the proximal portion of the aortic arch at the origin of the innominate artery under circulatory arrest. There were no early or late deaths. All patients were asymptomatic at a mean follow-up of 2.6 years. Follow-up angioscan showed obliteration of the dissection in the aortic arch in all patients; there were two patients with dilatation of the distal aortic arch of 40 and 45 mm.(ABSTRACT TRUNCATED AT 250 WORDS)

Aortic valve repair with fibrin glue for type A acute aortic dissection

Repair of the acute aortic insufficiency associated with type A aortic dissection is now preferred to valve replacement. This is generally achieved by resuspending the aortic valve using different types of suturing techniques, with sutures usually passing through the aortic wall, which causes bleeding at the suture sites. We suggest, instead, simply injecting fibrin glue between the two dissected layers of the aortic annulus, which achieves resuspension of the aortic valve and reinforces the proximal stump without the need for any sutures. To evaluate the efficacy of this simple technique, the cases of 15 consecutive patients who underwent operative intervention for the treatment of the type A aortic dissection associated with acute aortic insufficiency between January 1989 and July 1993 were reviewed. The mean patient age was 63 +/- 11.2 years (range, 43 to 74 years). All had massive 3+ or 4+ aortic insufficiency, documented pre-operatively by transesophageal echocardiography. None had any history of aortic regurgitation. In all patients, the aortic repair was done in conjunction with a supracoronary replacement of the ascending aorta with a collagen-impregnated graft attached using a running suture, after reinforcement of the dissected tissues with glue. There was one non-valve-related early death (6.7%) and no late mortality. At a mean follow-up of 2.3 years, all patients were in New York Heart Association functional class I and had a mean aortic insufficiency grade of 0.3 (range, 0 to 1+). Follow-up computed tomography in all patients showed closure of the dissecting process on the proximal ascending aorta.(ABSTRACT TRUNCATED AT 250 WORDS)

[Value of the superior trans-septal approach in mitral valve replacements]

Mitral valve exposure is widely improved by the superior-transseptal approach (STS). The diffusion of this technique has been restricted because of the possibility of detrimental effects of sino-atrial arrhythmias, especially in patients in sinus rhythm preoperatively. Between April 1991 and December 1992, we performed mitral valve replacement (MVR) on 55 patients by an STS approach. The mean age was 57.7 +/- 11.3 years (38-75 years). 21 were reoperations and 1 patient had been operated twice. The procedure consisted in 10 MVR with a bioprosthetic valve and 45 with a mechanical valve. Associated procedures were 5 tricuspid annuloplasties, 13 aortic valve replacements, 1 tricuspid valve replacement, 4 CABG, and 1 aneurysm resection. Overall hospital mortality was 9.1 +/- 3.8% (5/55). Mortality for isolated MVR was 6.2 +/- 4.2% (2/32). 51% (28/55) were in sinus rhythm (SR) preoperatively, 43% (12/28) of them had never presented atrial fibrillation. Postoperatively among those 28 patients in SR, 20 remained in SR, 7 were in atrial fibrillation, and 1 in atrial flutter. 3.6% (2/55) needed transient electrosystolic pacing for very slow atrial fibrillation 20% (11/55) have presented a transient sino-atrial dysfunction; None of these rhythmic events had any adverse effect. Finally, the very good visibility and accessibility are the major advantages of this approach, especially in mitro-tricuspid combined procedures, in small left atrium and repeat surgery. As sino-atrial arrhythmias are transient, we think this approach can be routinely employed in MVR.

Static morphometric bases for CT identification and evaluation of the outflow chamber of the left ventricle. Preliminary study in formalin-fixed heart

A static morphometric study of the outflow chamber of the left ventricle (OCLV) was investigated in a series of 10 formalin-fixed hearts. A spatial reconstruction of the shape and the volume of the OCLV was carried out by means of a Somaton Plus TR4 Tomodensitometer (Siemens). The technic allows evaluation of the surface of the aortic and the mitral orifices and visualization of the three-dimensional OCLV and LV morphology, as well as calculation of their volumes. The limits of the technic in the dynamic study of the OCLV are presented.

Fibrin sealant for early repair of acquired ventricular septal defect

The trend toward early operation for acquired ventricular septal defects exposes the patient to major perioperative bleeding and residual shunt because of the fragility of the recently necrosed myocardium. To reduce these complications we have used a fibrin sealant to reinforce the cardiac tissues in addition to the usual closure of the defect with a Dacron patch through a left ventricular septum around the defect, area. During cardiac arrest fibrin sealant is applied on the ventricular septum around the defect, between the septum and the patch, and on the edges of the ventriculotomy. This technique was used in three patients (mean age 68.2 years) operated on for an acquired ventricular septal defect within 4 days of the infarction and within 24 hours of the occurrence of the defect. Low postoperative bleeding, absence of recurrent shunt, and good ventricular function indicated satisfactory surgical result in all three patients. We suggest that the use of fibrin sealant during operations for acquired ventricular septal defects, by reinforcing the necrotic and fragile tissues, may reduce perioperative bleeding and assure a more solid implantation of the patch.

Hemodynamic effect of calcium channel blockade during anesthesia for coronary artery surgery

Because the choice of anesthetic technique does not influence the incidence of perioperative myocardial ischemia, reduction of ischemic risk may require specific antianginal therapy. Calcium entry blockers are effective drugs in antianginal therapy. Diltiazem reduces myocardial oxygen demand through decreases in heart rate, inotropy, and systolic function, while increasing myocardial oxygen delivery through coronary vasodilation. These potentially beneficial effects of diltiazem were evaluated in 15 of 29 patients (diltiazem v placebo, double-blind study) scheduled for coronary artery bypass graft surgery. Continuous infusion of diltiazem (0.15 mg/kg bolus followed by 2 micrograms/kg/min), during anesthesia and surgery before cardiopulmonary bypass, significantly reduced the major MVO2 determinants during anesthesia with moderate doses of fentanyl and a benzodiazepine (midazolam in 8 of 14 control patients and 9 of 15 treated patients, or flunitrazepam in the others). Heart rate, mean arterial pressure, and inotropy were decreased during the most stressful events of surgery when plasma diltiazem concentrations were in the therapeutic range (greater than 96 ng/mL). The number of patients with perioperative ischemia was 2 of 15 in the treated group and 4 of 14 in the control group. Provided that diltiazem plasma concentrations are sufficient, it can contribute to lowering the ischemic burden during anesthesia for coronary artery surgery.

Hemodynamic effects of anesthesia in patients chronically treated with angiotensin-converting enzyme inhibitors

Angiotensin-converting enzyme inhibitors (ACEIs) are increasingly used in the treatment of cardiovascular disease, but recent reports have warned of some hemodynamic risk (hypotension and bradycardia) when associated with anesthesia. To assess the hemodynamic effects of induction of anesthesia in patients chronically treated with ACEIs, 16 hypertensive patients scheduled for coronary artery bypass graft surgery (n = 12) or vascular surgery (n = 4) were studied. Eight of them were chronically treated (for at least 1 mo) with ACEIs (ACEI group), and the remaining eight (control group) were treated with other classes of antihypertensive drugs. Induction of anesthesia, which consisted of flunitrazepam (0.03 mg/kg), fentanyl (0.006 mg/kg), and pancuronium (0.1 mg/kg) IV, was followed by a significant decrease in mean arterial blood pressure from baseline in both groups (by 16.8% in controls [P = 0.001] and 33.5% in ACEI-treated patients [P = 0.001] [P = 0.041 between groups]). In control patients, mean arterial blood pressure decrease was only associated with a significant decrease in cardiac index (-18%, P = 0.014). In ACEI-treated patients, the arterial blood pressure decreases were associated with consistent reductions in pulmonary capillary wedge pressure (-26.4%; P = 0.035) and cardiac index (-23.9%; P = 0.001). Systemic vascular resistance index and heart rate were moderately changed (-14.2% and -4.5%, respectively). Rapid restoration of arterial blood pressure was obtained in all ACEI-treated patients, mainly with the intravenous administration of 0.4 to 0.7 L of lactated Ringer's solution. Phenylephrine (0.38 +/- 0.9 mg) was, however, required in four patients when mean arterial blood pressure was less than 60 mm Hg.(ABSTRACT TRUNCATED AT 250 WORDS)

Myocardial depressant effect of nitrous oxide after coronary artery bypass graft surgery

We have studied the cardiovascular effects of nitrous oxide after cardiac ischaemia-reperfusion injury caused by aortic cross-clamping and unclamping during coronary artery bypass grafting (CABG). At the time of chest closure, 20 patients were allocated randomly to receive oxygen and air (FIO2 = 0.5) or 50% nitrous oxide in oxygen in addition to anaesthesia with fentanyl. Nitrous oxide significantly decreased mean arterial pressure (P less than 0.01) and cardiac index (P less than 0.05), which suggests that nitrous oxide with fentanyl may significantly depress left ventricular performance after CABG. Although ischaemia-reperfusion cardiac injury did not appear to increase the myocardial depressant effect of nitrous oxide, the use of nitrous oxide is not recommended immediately after CABG.

Fibrin sealant improves surgical results of type A acute aortic dissections

From January 1984 to July 1990, 63 patients were operated on for type A acute aortic dissection. Forty-two patients (aged 22 to 80 years) had isolated replacement of the ascending aorta with the following techniques: group 1 (n = 10) had replacement of the ascending aorta with an intraluminal sutureless graft, group 2 (n = 14) had a Dacron prosthesis sutured to the aorta, and in group 3 (n = 18) the proximal and distal aortic stumps were glued together and reinforced at the suture sites with fibrin sealant before implantation of the Dacron prosthesis. There were no significant differences between the three groups with respect to age, sex, or preoperative clinical and anatomical data. Three (30%) intraoperative deaths occurred in group 1, 4 (29%) in group 2, and none in group 3. Cross-clamp and extracorporeal circulation time were significantly lower in group 1 when compared with groups 2 and 3. Perioperative blood loss during the first 24 hours was significantly lower in group 3 (372 +/- 155 mL) when compared with group 1 (755 +/- 210 mL; p less than 0.05) or group 2 (1,055 +/- 370 mL; p less than 0.01). Total hospital mortality was 7 (70%) in group 1, 6 (43%) in group 2, and 1 (5.5%) in group 3. All patients were reviewed: one late death occurred in group 2 and none in the other groups. All survivors were in good clinical condition. In conclusion, intraluminal sutureless grafts allowed shorter cross-clamp and extracorporeal circulation time but did not improve surgical results for treatment of type A acute aortic dissections.(ABSTRACT TRUNCATED AT 250 WORDS)

Properties and Modulation of Ca channels in adult human atrial cells

Ca-channel currents have been investigated in single cells isolated from adult human atrium using the whole-cell patch clamp technique. Ca-channel currents are activated at voltage positive to -40 mV, peak between -10 and 0 mV and inactivate with a slow decay when Ba2+ ions (5 mM) are used as charges carrier. These properties correspond to those of the high voltage activated, DHP-sensitive, (L-type) Ca channel. No low voltage activated (T-type) currents have been evidenced. The present work also provides the first report about the modulation of Ca channels in adult human atrial cells by beta-adrenergic agonists and dihydropyridines (agonists and antagonists). Electrophysiological and pharmacological properties of these Ca channels are qualitatively similar to those of the L-type Ca currents recorded from cardiac animal cells. However, at a physiological calcium concentration (2 mM), basal Ca currents are often very small or even absent but are revealed following the addition of the dihydropyridine (DHP) agonist Bay K 8644. Whether the decrease of the basal Ca current amplitude may be related to the chronic pretreatment of the patients by Ca channel blockers or to the pathology is discussed.

[Vascular effects of adenosine-triphosphate]

This study assessed the effects of adenosine triphosphate (ATP) on systemic vascular resistances during the hypothermic cardiopulmonary bypass phase of cardiac surgery. Twenty patients scheduled for cardiac surgery were randomly divided into an ATP group (n = 10), and a placebo group (n = 10). Anaesthesia was similar for all the patients (diazepam, fentanyl and pancuronium). During the heart arrest phase, and as soon as the arterial pressure, the level in the venous return reservoir, and the pump flow rate had all been in steady state for 5 min, ATP or placebo was injected into the venous line of the oxygenator. Injection speed was doubled every three minutes, twice. The following ATP doses were administered: 0.012, 0.025 and 0.05 mg.kg-1.min-1. The level in the venous return reservoir was kept constant. Mean arterial pressure (MAP) and pump flow rate (DP) were assessed every half minute. Systemic vascular resistances were calculated with the relationship MAP/DP. Changes in vascular capacitance were directly proportional to changes in DP as the heart had been excluded, and all the blood returned to the pump, the blood volume being kept constant. MAP and DP remained unchanged in the placebo group. In the opposite ATP induced a dose-related systemic vasodilation: MAP decreased from 82.8 +/- 12.5 mmHg (control) to 66.0 +/- 14.8 mmHg, 59.8 +/- 10.6 mmHg, and 49.0 +/- 4.7 mmHg with 0.012, 0.025 and 0.05 mg.kg-1.min-1 ATP respectively. The MAP returned to preinfusion control levels when the ATP infusion was discontinued (90.0 +/- 17.8 mmHg). The DP, and therefore venous return, did not change, neither during ATP infusion, nor after its discontinuation.(ABSTRACT TRUNCATED AT 250 WORDS)

Constitutive production of interleukin-6 and immunologic features in cardiac myxomas

The constitutive production of interleukin-6 (IL-6), a potent hepatocyte-stimulating factor and B cell-differentiating factor, was demonstrated in 3 patients with cardiac myxomas. Tumor cells from the only patient who presented with immunologic features produced 14-23-fold higher levels of IL-6 than those from the 2 patients who lacked such features. A significant serum IL-6 level (56 pg/ml), greater than that observed in patients with active rheumatoid arthritis, was also observed only in this patient, with a subsequent return to an undetectable level after surgical removal of the tumor. This was associated with a regression of the immunologic features. This same patient was observed to have an IL-6-dependent, proliferative polyclonal plasmacytosis of the bone marrow. These observations demonstrate that an overproduction of IL-6 by cardiac myxoma cells, in association with a systemic passage of this IL-6, may be responsible for the immunologic features similar to those observed in true autoimmune diseases such as rheumatoid arthritis.

Myosin: a highly sensitive indicator of myocardial necrosis after cardiac operations

Plasma levels of ventricular myosin fragments, determined with monoclonal antibodies to myosin heavy chains, were studied in 27 patients after cardiac operations (17 aorta-coronary bypass grafts and 10 valve replacements) to assess their possible role as a marker of perioperative myocardial necrosis. Five patients had perioperative myocardial necrosis after aorta-coronary bypass grafts as indicated by changes in the electrocardiogram and elevated levels of the MB isoenzyme of creatine kinase. Six more patients were also studied after thoracic operations performed by the same sternotomy approach. After cardiac operations, myosin levels increased from postoperative day 3 and reached peak values on day 7. Peak myosin values in patients with perioperative myocardial necrosis after aorta-coronary bypass grafting were significantly higher than in patients after an identical operation but without perioperative myocardial infarction (3793 +/- 592 versus 369 +/- 47 ng/ml; p less than 0.001). These results suggest that plasma myosin is a sensitive marker of myocardial necrosis. Furthermore, peak plasma levels of ventricular myosin after coronary bypass grafting without myocardial infarction (mean value 369 +/- 47 ng/ml) were not significantly different from peak levels after thoracic operations (mean value 253 +/- 52 ng/ml), whereas they were significantly higher after valve replacement (mean value 794 +/- 149 ng/ml; p less than 0.01). These results indicate that a certain degree of myocardial necrosis occurs during value replacement that is undetectable by the usual diagnostic criteria for perioperative myocardial infarction. We conclude that the plasma level of ventricular myosin fragments is a more specific and accurate marker of perioperative myocardial necrosis than changes in the electrocardiogram or elevated creatine kinase MB levels. Therefore the detection of myosin fragments, which appear in the serum on the third day after cardiac operations, may be useful for precise comparisons of different techniques of myocardial protection.

[Extracardiac malformations in tetralogy of Fallot]

The purpose of our study was to determine the incidence and type of malformations associated with tetralogy of Fallot (TF). Among 133 patients followed up for 12 years, 30 who had either complete TF (n = 26) or pulmonary atresia and interventricular septal defect (n = 4) presented with another, extracardiac malformation. These malformations were part of a malformative syndrome in 21/30 patients, including 4 trisomies 21, 6 embryofoetopathies unquestionably (antiepileptics n = 2, alcohol n = 1) or possibly (hormonal treatment n = 1) of environmental origin, 6 branchial arch pathologies and 5 miscellaneous syndromes. The extracardiac malformation was isolated in the remaining 9 patients, including 5 cases of skeletal anomaly and one case each of omphalocele and microcephaly. Altogether, in these 30 patients skeletal and neurosensory anomalies were largely predominant. Skeletal anomalies involved the vertebral column in 8 cases (cervical 3, thoracic 4, lumbar 1) and the limbs in 5 cases (2 of which were phocomelias). The 4 patients with pulmonary atresia and interventricular septal defect also presented with an early embryopathy: Shprinzen's velocardiofacial syndrome (n = 2), DiGeorge syndrome (n = 1) and situs inversus (n = 1). We compared TF with other congenital heart diseases in our population and found that the incidence of associated malformations was about average. The various associations are discussed. In genetic syndromes, trisomy 21 predominates and TF is less frequent than atrioventricular canal. In syndromes of environmental origin, the role of antiepileptic drugs (chiefly phenytoin and trimethadione) is well-known, alcohol is less often responsible and the TF-phocomelia association is suggestive of progesterone. In branchial arch syndromes, TF is the usual cardiopathy.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of preoperative renin-angiotensin system blockade on hypertension following coronary surgery

Renin-angiotensin system activation is suspected of being involved in postcoronary surgery hypertension, but appears to be useful in maintaining blood pressure during anesthesia and cardiopulmonary bypass. To clarify these points, 19 patients were compared: ten as a control group and nine who received captopril during two days before surgery. Anesthesia was the same for the two groups, and cardiopulmonary bypass ensured nonpulsatile flow rates. Anesthesia induced a slight decrease in the mean arterial blood pressure of the treated group (91.1 +/- 3.3 mm Hg to 83.3 +/- 3.9 mm Hg), which did not occur in the control group (89.9 +/- 5.8 mm Hg to 89.7 +/- 4.9 mm Hg). During cardiopulmonary bypass, the mean arterial blood pressure was maintained at comparable levels in the two groups (65.6 +/- 3.5 mm Hg in the control group, 72.6 +/- 3.0 mm Hg in the treated group), with same pump flow rates. After cardiopulmonary bypass, the mean arterial blood pressure returned nearly to prebypass values. Postoperatively, three patients in the control group and four in the treated group developed hypertension. Thus, preoperative renin-angiotensin system blockade by a converting-enzyme inhibitor did not impair blood pressure regulation during anesthesia and cardiopulmonary bypass, but failed to prevent hypertension following coronary surgery.

Comparison of myoglobin and creatine kinase MB levels in the evaluation of myocardial injury after cardiac operations

Myoglobin was studied in 40 patients before, during, and after cardiac operations and was compared to the MB isoenzyme of creatine kinase to identify its possible role as a marker of perioperative myocardial damage. Myoglobin reached peak values during cardiac arrest in all patients and was significantly higher immediately after administration of the anesthetics, during cardiac arrest, and until the sixth postoperative hour in eight patients with a perioperative myocardial infarction. By contrast, the MB isoenzyme of creatine kinase reached peak values at the fourth postoperative hour and was significantly higher in patients with perioperative myocardial infarction from the fourth to the tenth postoperative hours. We conclude that myoglobin is a valuable marker of perioperative myocardial damage and is an earlier and more specific marker of perioperative myocardial infarction than creatine kinase MB.

[Surgery of coronary revascularization in patients over 70. Apropos of 40 cases]

40 of the 900 patients operated upon for aorto-coronary bypass grafting between January 1980 and October 1984, were over 70 years old (mean 71.1; range: 70-76 years old). 25 had severe angina pectoris (class III or IV) and 15 of them had emergency surgery. An average of 2 grafts per patient was performed with 3 deaths and 3 myocardial infarcts in the peri-operative period. Patients had an average of 21 months follow-up (range 5 years, 3 months); in that period 2 deaths due to myocardial infarction, 3 persistent angina pectoris (class II) and 32 asymptomatic patients were observed. These results illustrate advances in cardiac surgery, anesthesia and postoperative management. Coronary surgery may therefore be performed in patients over 70 years old with an acceptable operative risk and satisfactory longterm results.